Welcome to the Simplyhealth Employee Plan

Transcription

1 Welcome to the Simplyhealth Employee Plan

2 Your group policy document Congratulations on your new health cover. We care about our employees health and we like to help you look after yourself, that s why we are providing this cover. This brochure explains more about your cover, including what is and isn t covered under each module. It also explains how you can go about claiming. This policy document contains information about all modules on the Simplyhealth Employee Plan. Please read the sections appropriate to your level of cover as detailed on your membership certificate. You should read the policy document together with your membership certificate which shows any personal underwriting exclusions and excess levels that apply to your cover. These documents form your policy with us. Hopefully you ll find all the information you need, but if you don t, please feel free to call us on

3 Everything you need to know made simple Our five areas of cover 4 Voluntary upgrades 6 Module 1 The Essentials 8 Making a claim under Module 1 11 Directed Private Medical Care: Module 2 Out-patient, In-patient and Day-patient 15 Module 3 Psychiatric Treatment 16 Module 4 Heart and Cancer 17 Making a claim under Modules 2, 3 and 4 25 Module 5 Senior Manager Private Medical Insurance 27 Making a claim under Module 5 37 General terms and conditions 41 3

4 Our five areas of cover There are five different areas of cover, and your membership certificate will explain which elements you can benefit from. The five areas are: + Plus Module 2 Out-patient, in-patient and day-patient + Plus Module 5 Senior Manager Private Medical Insurance Module 1 The essentials + Plus Module 3 Psychiatric treatment + Plus Module 4 Heart and cancer cover Module 1 The Essentials Helping you meet the everyday costs of healthcare like a dental check-up or a new pair of glasses. You do not need to see your GP first, just see an appropriately qualified professional or complementary therapist, pay the bill yourself and then send in your claim with the receipt. We ll pay you back your eligible costs up to your annual limits for a whole range of treatments. This means you can get treatment when you need it rather than when you can afford it. Also we offer you support through a series of up to six counselling sessions to deal with situations like stress or bereavement. This service is completely confidential and no details of any calls will be released to Simplyhealth. You can access this service by calling Module 2 Out-patient, In-patient and Day-patient With our hospital network we will guide you to a local, private hospital to help get any medical concerns diagnosed quickly and treated expertly. It provides peace of mind throughout a period of ill health where you need surgery, from the first consultation with a specialist to the delivery of the surgery you need. See page 15. Module 3 Psychiatric Treatment If you need it, this module gives you access to psychiatric in-patient and day-patient treatment up to the policy limits. See page 16. Module 4 Heart and Cancer Cover If you are diagnosed with a heart condition or cancer, this module provides you with cover to help treat those conditions. Limits apply. See page 17. Module 5 Senior Manager Private Medical Insurance This module is for job levels C2 and D only and replaces modules 2, 3 and 4. This module includes an extensive range of benefits to support you throughout a period of ill health. This gives you access to some of the finest medical facilities. If your GP refers you for further diagnostic tests, you can have the reassurance that you will be able to see a consultant quickly, have treatment at a private hospital and if necessary, be covered for physiotherapy to help you recover. See page 27. 4

5 Employee cover provided for by Simplyhealth Annual cover (unless stated) Job levels A & B Job level C1 Job levels C2 and D Dental 120 Module 1 A Health Cash Plan - 100% payback Optical 120 Health screening 200 Physiotherapy, osteopathy, chiropody / podiatry, chiropractic, acupuncture and homeopathy Helplines and face to face counselling New child payment - subject to a 12 month qualifying period 300 six sessions (employee only) 200 (employee only) Six months from start date, full cover for employee only including pre-existing conditions From start date, full cover for employee only including pre-existing conditions From start date, full cover for employee only including pre-existing conditions Specialist consultation fees* Full cover* Module 2 A B C Out-patient, In-patient & Day Patient Treatment Diagnostic tests, including MRI, CT and PET scans Surgeons and anaesthetists fees Hospital charges Physiotherapy NHS cash benefit maximum 91 days/nights each year Parent accommodation charges Full cover Full cover Full cover Full cover if requested by a specialist for up to three months after surgery 100 each day/night Full cover for one parent staying overnight Six months from start date, full cover for employee only including pre-existing conditions From start date, full cover for employee, partner and children including pre-existing conditions Not applicable, see Module 5 Module 3 A B C Psychiatric Treatment In-patient and day-patient treatment Out-patient treatment Full cover up to 28 days up to 2,000 Six months from start date, new conditions only (Full cover for pre-existing conditions 12 months after start date or 1 Sept 2010 whichever is the later) for employee only From start date, full cover for employee, partner and children including pre-existing conditions Not applicable, see Module 5 Module 4 A B C Heart & Cancer Cover Heart cover Cancer cover 50,000 policy lifetime limit 50,000 policy lifetime limit Six months from start date, new conditions only (Full cover for pre-existing conditions 12 months after start date or 1 Sept 2010 whichever is the later) for employee only From start date, full cover for employee, partner and children including pre-existing conditions Not applicable, see Module 5 Module 5 D Senior manager private medical insurance Scale B hospitals Not available Not available From start date, full cover for employee, partner and children including pre-existing conditions Notes A Modules 1-4 have a combined annual limit of 100,000. B Modules 2-4 are provided on a directional care basis requiring all treatment to be pre-authorised. C 100 excess each person (including employee) every claiming year for the first claim for Modules 2-4 (combined) or Module 5. D Job level C2 and above. No limit on claims for private medical treatment and Scale B hospitals without directional care. 100 excess applies. * Limited to 91 days for in-patient specialist consultations. 5

6 Getting the most from your plan with voluntary upgrades The Simplyhealth Employee Plan offers an excellent level of health cover. However you have the flexibility to buy additional cover to enhance the cover offered to you as part of your employment with Simplyhealth. There are two options available to you: Option 1 Upgrade your Simplyhealth Employee Plan via direct debit You can do this only during the month of July each year (because our plan year starts 1 September), or if you have a lifestyle change (see the voluntary dependants section on this page), in which case call and our Customer Services team will be able to help you. For new employees, you can also do this when you first become eligible to join the plan. For job levels A and B this is six months after your start date, for job levels C and above this is from your start date. Just call and our Customer Services team will be able to help you. At the beginning of July each year, there will be reminders and upgrade forms on Simpl-e for all employees. Option 2 Buy an additional direct Simplyhealth policy at any time You can buy the following additional policies at any time by simply calling ext Simply Cash Plan Simply Dental Plan Simply Personal Health Voluntary dependants You can choose to add your partner or children at your own cost provided they live with you permanently. You can include up to a maximum of four of your or your partner s children on the policy. We may request your child s original birth certificate if they are to be covered on the policy. Once a child has been covered on the policy they must stay on the policy for a minimum of one year. If a child is removed from the policy, they cannot rejoin (unless taking their own policy) for a period of three years. Application forms and details of prices are available on Simpl-e. You can only add dependants when you first join the scheme or on the scheme renewal date. You can only change dependants cover on the scheme renewal date or because of a lifestyle change that necessitates a change of cover. One of the following lifestyle changes would allow you to add or remove a dependant: you marry or enter into a civil partnership you divorce or separate from a long term partner your partner is made redundant or retires you move from full to part time working or vice versa you become a parent (to include a child you will have to complete an application. If you add your child to the policy within three months of its birth, we will not apply any personal exclusions, regardless of the child s health) 6

7 Restrictions on cover for dependants Module 1 Dependants who join this policy can start claiming immediately. Modules 2, 3, and 4 Dependants have two ways of applying for cover, each of which involves a different level of medical information. You can select the underwriting option that you want to apply from the application form available on Simpl-e. These options apply whenever the dependant joins or adds additional modules. Module 5 you cannot upgrade to Module 5 if your job level is C1 or below. For more detail on how the different underwriting options work, please see the appendix at the back of this booklet. Option 1 No medical assessment (Moratorium) If you choose this option there is no need to provide any medical history. Option 2 Full medical assessment (Full Medical Underwriting) Under this option your dependant will need to complete a full medical questionnaire. We will then give a personalised membership certificate with details of any specific medical conditions that are excluded due to your dependant s medical history. Children turning 21 At the renewal date following their 21st birthday (or 24th birthday if they are in full time education) a child will no longer be covered by this plan. They may apply for a Simplyhealth policy in their own right. Leaving Simplyhealth If you leave the Group you can apply for personal membership of Simplyhealth. We will be in contact with you regarding the options available. We will not cover any pre-existing conditions which have occurred during the previous five years. However, if your dependant remains free from any symptoms, treatment, medication or advice for a pre-existing condition, or any other condition related to it, for two consecutive years after being added to the policy, we will not apply the pre-existing conditions exclusion to that condition, provided that it would normally be covered by this policy. Details of the moratorium will be shown on your personalised membership certificate. 7

8 Module 1 The Essentials Everyday health cash benefits Essentials covers you for optical and dental check-ups and treatment and also complementary therapies. You do not need to see your GP first, or get any pre authorisation of claims under this module. Just see an appropriately qualified professional, pay the bill yourself and then send in your claim form together with the receipt. We ll pay you back the cost of eligible treatment up to your annual limits. For the following benefits we will pay you up to the maximum amount of your chosen level shown below. You are required to pay the cost of the treatment and claim this back from us, up to your maximum entitlement in your claiming year. Dental We all know how hard it is to find a dentist on the NHS these days, so there s no need to suffer with toothache or put off going to the dentist because of the cost. Simplyhealth pays up to 100% of your dental bills up to your annual entitlement, whether you are treated privately or on the NHS. This includes regular check-ups as well as treatment such as fillings. To find your nearest dentist visit NHS Choices Tel: (Wales), Tel: 111 (England and Scotland), British Dental Health Foundation Tel: / , British Dental Association What is covered Dental check-ups Dental brace or gum shield provided by a dentist or orthodontist Dental crowns, bridges and white fillings Dentures Laboratory fees and dental technician fees referred by a dentist or orthodontist Dental X-rays Denture repairs or replacements by a dental technician What is not covered Dental prescription charges Dental consumables, for example toothbrushes, mouthwash and dental floss Dental practice plan payments and dental insurance premiums Dental implants and bone augmentation procedures, for example sinus lift, bone graft Cosmetic procedures, for example dental veneers, tooth whitening and the replacement of amalgam fillings with white fillings Joining fees Laboratory fees and dental technician fees not connected to dental treatment or performed by a dentist Missed appointment fees and administration fees Dental treatment provided at a hospital as a day-patient or in-patient (you may be able to claim for some dental treatment under Module 2 or for Senior Managers, Module 5) Excesses for private medical insurance plans Treatment received outside the UK Treatment provided by a dentist, periodontist or orthodontist Endodontic treatment Hygienist fees Local anaesthetic fees 8

9 Health screening Simplyhealth believes in being proactive about your health. That s why we help cover up to 100% of the cost for health screening which must include a full blood screen, urinalysis, prostate or cervical screens, a full physical examination, biometric analysis and tests. You can claim towards health screening by qualified staff at a hospital, registered health screening clinic or service, up to the annual limit. What is covered A health risk assessment undertaken for preventative reasons by a registered nurse or doctor, or by a registered health screening clinic or service provider. The health screen must include a full blood screen, urinalysis, prostate or cervical screens (as appropriate), full physical examination, biometric analysis and tests What is not covered Medical examinations Medical and radiological tests when not part of a full body health screen for preventative reasons. For example ultrasounds, scans, X-rays, cholesterol tests, bone density scans and blood tests Diagnostic tests Tests related to a symptom or condition Home testing kits Internet screening Medical screening for employment purposes Emigration examinations Excesses for private medical insurance plans Treatment received outside the UK Helplines and face to face counselling This service allows you to call for advice on a range of basic medical, health and wellbeing matters, as well as telephone counselling. Simplyhealth employees can also access six face to face counselling sessions by calling the helpline on Optical Whether you work with computers or drive a car, everyone should still get their eyes tested regularly. Simplyhealth will give up to 100% money back towards your optician bills, including sight tests, new glasses or contact lenses, up to your annual entitlement. To find your nearest optician visit NHS Direct Tel: (England & Wales), Tel: (Scotland), What is covered Sight test fees, scans or photos for an eye test Fitting fees Prescribed glasses, including frames and prescribed lenses Adding new prescribed lenses to existing frames Glasses frames Contact lenses Consumables supplied as part of an optical prescription, for example solutions and tints Repairs to glasses Sunglasses, safety glasses and swimming goggles with prescription lenses Contact lenses paid for by instalment What is not covered Eye laser surgery Optical consumables, for example contact lens cases, glasses cases and glasses chains/cords, or cleaning materials Solutions that are not part of a prescription Magnifying glasses Non prescription glasses Lenses supplied under an optical insurance plan Contact lens replacement insurance premiums Opticians insurance premiums Ophthalmic consultant charges Excesses for private medical insurance plans Treatment received outside the UK 9

10 Physiotherapy, osteopathy, chiropody or podiatry, chiropractic, acupuncture and homeopathy cover We pay up to 100% of the cost for alternative and complementary therapies to help with regular treatment and recovery. Important: In order to be able to practise in the UK: Physiotherapists must be registered with the Health and Care Professions Council (HCPC) Osteopaths must be registered with the General Osteopathic Council (GOC) Chiropractors must be registered with the General Chiropractic Council (GCC) Chiropodists or podiatrists must be registered with the Health and Care Professions Council (HCPC) What is covered Treatment provided by a physiotherapist, osteopath, chiropodist or podiatrist, chiropractor, acupuncturist or homeopath in their specific field of expertise Homeopathic medicines prescribed by a registered homeopath where payment is made directly to the homeopath Assessments, for example gait analysis, performed by a chiropodist or podiatrist Consumables prescribed and supplied by the chiropodist or podiatrist at the time of treatment, for example orthotics and dressings Consultations and treatment with a podiatric surgeon What is not covered Any other treatment that is not physiotherapy, osteopathy, chiropody or podiatry, chiropractic, acupuncture or homeopathy All other treatments, for example reflexology, aromatherapy, herbalism, sports or remedial massage, Indian head massage, reiki, and Alexander technique Internet or telephone homeopathic consultations Homeopathic medicines prescribed by or purchased from a professional who is not a registered homeopath For chiropody or podiatry, consumables not prescribed or supplied by the chiropodist or podiatrist at the time of treatment, for example corn plasters, insoles, dressings Surgical footwear, for example corrective footwear Cosmetic pedicures Excesses for private medical insurance plans Treatment received outside the UK New child payment If you have a child, or legally adopt a child under the age of 18, you will receive a cash benefit. This benefit is subject to a 12 month qualifying period and is for the employee only. What is covered The birth of your child where this occurs after the 12 month qualifying period The stillbirth of your child where this occurs after 24 weeks of pregnancy and after the 12 month qualifying period The legal adoption by you or your partner, after the 12 month qualifying period, of a child, unless that child is already related to either you or your partner What is not covered A miscarriage up to 24 weeks of pregnancy Foster children A baby born to a child who is aged under 18 and is covered under the policy Pregnancy termination A child born or adopted before or during the qualifying period X-rays and scans Appliances, for example lumbar roll, back support, TENS machine Homeopathic medicines purchased from a chemist, health food shop, by mail order or over the internet 10

11 Making a claim under Module 1 The Essentials Making a claim on your plan couldn t be easier under The Essentials module. Claiming is simple and straightforward. You pay the practitioner directly for any treatment and then reclaim money for eligible treatment from us, up to your maximum entitlement. Claims will usually be settled within a few days of receipt and the money will be paid directly into your bank account. Claims with receipts Pay your bill to the physiotherapist, dentist etc. as normal. Simplyhealth will only pay claims for treatment provided by registered healthcare professionals If you undertake a staged course of treatment you can only claim for the treatment you have received and paid for. We do not pay for treatment you have not yet received Keep your receipt see the receipt requirements below Fill in the claiming details boxes on the front of the claim form, following the guide on the following pages. Don t forget to sign and date the Declaration section You can make up to four claims on each form, if you need more claim forms or need assistance, please call Simplyhealth Customer Services on Send your claim form and receipt back to Simplyhealth in the reply envelope provided as soon as possible Receipt requirements In order for us to be able to pay a claim under Module 1 - The Essentials, we need to be satisfied that what you are claiming for is covered by the policy for example, that any treatment is given to a person covered by the policy, or that treatment is given by a person who is qualified to provide it, or that what you are claiming for is not subject to a policy exclusion. When you make a claim, you need to send us a fully completed claim form along with original supporting documentation (for example an original receipt we do not accept copies) that together should leave us with no doubt about: the name of the patient the details of the practitioner or establishment and the treatment that they have provided the date of treatment and the amount paid for that treatment. We may not be able to pay your claim if you do not send us all this information, or the claim form and supporting documentation that you send us does not give us enough detail. We will not pay your claim if we are not satisfied that what you are claiming for is covered by the policy. Simplyhealth does not accept receipts which have been altered, nor do we accept invoices, card payment receipts or photocopies of any accounts. Please note we cannot return receipts. You must send us your claim as soon as possible after the date of treatment. Claim forms need to be sent in by you and will not be accepted if they are sent directly by a healthcare professional or institution. We only make payments by direct credit directly into your bank account. It is your responsibility to keep us informed of any changes to your personal details, including bank account details. We will not pay for any treatment provided by a member of your family. If we overpay any claims, we reserve the right to recover any such overpayment. If you or anyone included on the policy holds or is covered under another insurance policy then you can claim on either or both policies up to your maximum entitlement as long as you have individual receipts to support your claim. The total paid out by all policies must not exceed the value of the costs you have incurred. New child payment claims Fill in the New child payment section on the back of the claim form Sign and date the Declaration on the front of the form Send your claim form and your child s birth certificate to Simplyhealth in the reply envelope provided as soon as possible There is a 12 month qualifying period for new child payment. 11

12 How to fill out your claim form The front for healthcare claims with a receipt We ve already included a claim form in this welcome pack. When making a claim, please complete your form in blue or black ink, and remember to enclose the original receipt for your treatment _1 SHCFV1:72053 ALL CFPV /08/ :42 Page A / 0 Claim Form If we ve got your details wrong, please correct them in this box Each person covered under your plan has their own personal code Each benefit has its own benefit code Policy no Please provide your current contact details below E mail: Tel No: Your personal details The codes shown below are for use when completing your claim form. If you need any help with your claim or any of your personal information shown is incorrect, just call us free on the number above. PERSONAL CODE Mr & Mrs Sample Sample address Sample Road Sample Town Postcode Customer Services Alan Child House Borden Gates Andover Hampshire SP10 2RT Telephone: Minicom service: (For hearing or speech impaired members only) Opening hours: 8am to 9pm weekdays 9am to 5pm weekends PERSON COVERED DATE OF BIRTH TREATMENT TREATMENT DESCRIPTION TREATMENT TREATMENT DESCRIPTION CODE CODE 100 Mrs Sample 03/10/ Optical 082 Osteopathy 201 Mr Sample 05/06/ Dental 083 Acupuncture 302 Charlie Sample 11/10/ Homeopathy 085 Chiropody/Podiatry 076 Health Screening 080 Physiotherapy 081 Chiropractic Your details For all claims under Module1 - The Essentials, except new child payment, please enter the personal code and the treatment code Enter the treatment date and the full amount paid For all claims, the policy holder must sign and date here Claiming details (See overleaf for claims not listed above) Please complete a separate line below for each treatment, selecting the PERSONAL CODE and the TREATMENT CODE from the above lists. Then enter the treatment date and if applicable the amount paid from your receipt. Please use black or blue ink and complete the form in BLOCK CAPITALS and always submit your claim within 6 months of treatment. PERSONAL CODE TREATMENT CODE TREATMENT DATE FULL AMOUNT PAID EXAMPLE (The example above shows a claim for physiotherapy for the person coded 100 who received treatment on 9th January 2008 and paid 50.95) D D M M Y Y. D D M M Y Y. D D M M Y Y. D D M M Y Y.. EXAMPLE Please enclose your original receipts in the envelope provided (do not staple them to the claim form). Please note that receipts will not be returned, only scanned images are retained on our records. Declaration I consent to Simplyhealth seeking medical information in respect of this application and any subsequent claim under this membership, from any relevant doctor, professional or hospital representative. I consent to Simplyhealth processing sensitive information about me (and anyone covered under my policy) including health information. I understand that any charges levied for completing this form are my responsibility and are not refundable by Simplyhealth. I declare that the information given is to the best of my knowledge and belief, true and complete. I understand that any false statements may disqualify me from membership and/or reimbursement of any claim. Customer s signature: Date: All claims under Module 1 - The Essentials (except new child payment) Your signature 12

13 The back for new child payment The reverse of this form is for new child payment claims only. This claim form is only to be used for Module 1. Any claims under Module 2, 3 and 4 must be via the Helpline on Under this plan hospital claims are covered under either Module 2, 3 or _1 SHCFV1:72053 ALL CFPV /08/ :42 Page 2 For a new child payment, fill in this section, enclose your child s birth certificate, then sign and date the declaration Patient s details Please note that you may only claim for cover that is specified in the Policy Document of your Plan New-child payment For New-child payment just complete below and enclose each child s birth certificate/adoption papers, then simply sign the declaration overleaf. If a hospital stay of more than 14 nights was needed, also ask a hospital representative to complete the Hospital claims section below. I wish to claim for New-child payment (4) Hospital claims Number of birth certificates/adoption papers enclosed To assist the hospital in completing this form, please complete the Patient s details yourself, then ask the hospital representative to complete the Admission details where appropriate. New child payment only First name Personal code (see front of form) Surname Date of birth D D M M Y Y Admission details I certify that the above patient was admitted to this establishment for the period and reason shown below: Your establishment (4) Hospital Establishment stamp and details of representative Convalescent Home Nursing Home Duration of admission As a day case: admitted on D D M M Y Y As an in-patient: admitted on D D M M Y Y discharged on D D M M Y Y number of nights (Excluding home visits) Reason for admission (4) Care for the elderly Mental/Psychiatric Ante/Post natal Other Signature: Position: Date: Please always confirm nature of condition/procedure below If a parent stayed with a child Parent s first name Personal code (see front of form) Parent s surname Stayed from D D M M Y Y to D D M M Y Y Number of nights Simplyhealth Data Protection Notice: We will keep information about you confidential and as the data controller we will store and process your data in accordance with the Data Protection Act However, we may give information about you and how you use our products to fraud prevention agencies, regulatory bodies or other specified groups as set out in our Terms and Conditions. Simplyhealth is a trading name of Simplyhealth Access, registered and incorporated in England and Wales, No Registered office: Hambleden House, Waterloo Court, Andover, Hampshire SP10 1LQ. Authorised and regulated by the Financial Services Authority. Your calls may be recorded and monitored for training and quality assurance purposes. SHCFV1 09/09 13

14 Directed Private Medical Care Modules 2, 3 and 4 Your health cover benefits explained The policy is designed to provide cover to diagnose and treat acute conditions. These are medical conditions that are likely to respond quickly to treatment, leading to your full recovery and returning you to your previous state of health. Your Directed Private Medical Care gives you access to some of the finest medical facilities. If your GP refers you for further diagnostic tests or consultations you can have the reassurance that you will be able to see a consultant quickly and have treatment at a private hospital. As all treatment needs to be authorised and arranged by us, you must call the Helpline before arranging treatment*. We select your treatment provider and will only pay for treatment arranged through our Helpline. Prior to any treatment being arranged you must ensure that your GP has referred you for further treatment or investigation. Please see page 25 for further details on the claiming process. Where we have stated full cover this is subject to the terms of the policy. Treatment expenses must, in our opinion, be reasonable and exclusively for the treatment of an eligible acute condition. Directed Private Medical Care will not pay for treatment of a chronic condition. We may refuse to pay any expenses in excess of those normally charged for similar treatment in the UK. We pay specialists fees based on a fixed fee schedule for the treatment that you have. You can find out more about the Simplyhealth fee schedule by calling We will not pay for fees that are greater than those detailed within our fee schedule. For the assessment of all in-patient claims the days of admission and discharge count as one day. For all benefits we will only pay for treatment that is normally provided under the NHS or approved by the National Institute of Health and Care Excellence (NICE). Benefits paid under Directed Private Medical Care are subject to the combined overall maximum benefit limit of 100,000 each person every claiming year that applies to Modules 1, 2, 3 and 4. *NHS Cash benefit Your NHS cash benefit is for when you receive in-patient or day-patient treatment as an NHS patient. To make a claim, please call the Helpline and we will explain how to claim. We don t arrange the treatment for you. As with any other claim, we may need details of the medical condition that you have and the treatment that you have received in order to validate your claim. 14

15 Module 2 In-patient, out-patient and day-patient treatment what is covered Specialists consultation fees Diagnostic tests as an out-patient Full cover Full cover GP referred specialist out-patient consultations. For specialist physician fees as an in-patient or day-patient you must be under the regular care of a specialist. In respect of in-patient treatment, we would not normally pay unless the specialist attends you on at least five days each week. Paid for up to 91 days in any one claiming year. GP or specialist referred out-patient diagnostic tests, including MRI, CT and PET scans. Surgery fees Full cover Surgeons and anaesthetists fees if you need an operation. Hospital charges Full cover Accommodation and nursing (including intensive care) Operating theatre charges Drugs and dressings prescribed for use while an in-patient or day-patient Diagnostic tests Prostheses when implanted as part of a surgical procedure If we pay for the surgery that means you need an external prosthesis, for example a false leg or a glass eye, we will pay up to 5,000 for the prosthesis NHS cash benefit Parent accommodation charges Post operative physiotherapy 100 each person every day or night Full cover Full cover If you are admitted free of charge on the NHS for treatment or diagnostic tests that we would have paid for as a private patient, we will give you 100 for: each admission you have as a day-patient or each night when you are an in-patient up to a maximum of 91 days or nights in combined total each claiming year. We will not pay NHS cash benefit for out-patient treatment (for example radiotherapy), or for treatment that we would not pay for as a private patient (for example rehabilitation / convalescence, or an admission for treatment of a chronic condition). For one parent staying overnight in a hospital while their child receives in-patient treatment covered by the policy. The child must be under the age of 12 and named on the policy. Physiotherapy treatment requested by a specialist and provided within three months of surgery that we have paid for. 15

16 In-patient, out-patient and day-patient treatment what is covered Dental surgery Full cover for specific treatment only Dental surgery carried out in a hospital by an oral and maxillofacial surgeon. We will only pay for: surgical removal of impacted/buried or unerupted teeth surgical removal of complicated buried roots removal of the tip of a tooth s root (apicectomy) surgical removal of a cyst from the jaw bone (enucleation of cyst) In-patient, out-patient and day-patient what is NOT covered Psychiatric consultations and treatment (covered under psychiatric please see your membership certificate to see whether you are covered) Consultations, treatment or surgery for diagnosed heart or cancer (covered under heart or cancer please see your membership certificate to see whether you are covered) Physiotherapy not related to surgery that we have paid for, that has not been requested by a specialist or starts more than three months after surgery that we have paid for (if you are covered under Module 1 - The Essentials cover then you may be able to claim for this please check your membership certificate to see whether you are covered) Treatment for a chronic condition see page 20 for further details Dental treatment which has not been carried out in a hospital by an oral and maxillofacial surgeon and is not specifically listed under core cover (dental surgery benefit). If you are covered under Module 1 - The Essentials, you may be able to claim for any dental treatment, please check your membership certificate to see whether you are covered Further exclusions are shown on page 19 Module 3 Psychiatric treatment what is covered In-patient and day-patient treatment Full cover up to 28 days GP or specialist referred in-patient and day-patient treatment for up to 28 days each claiming year. Out-patient treatment 2,000 limit each person every claiming year GP or specialist referred out-patient treatment under the care of a psychiatrist. Psychiatric what is NOT covered Treatment of a chronic condition see page 20 for further details Further restrictions are detailed on page 19 16

17 Module 4 Heart and Cancer cover what is covered Cancer cover 50,000 policy lifetime limit each person We will pay for surgery We will pay for one operation to reconstruct a breast that has been removed (either by mastectomy or lumpectomy), and we will pay for one further operation to improve symmetry of your breasts. We will not pay for further cosmetic operations to a reconstructed breast We will pay for radiotherapy We will pay for chemotherapy which aims to cure your cancer or induce a remission. We will not pay for chemotherapy whilst you are in remission to keep your cancer stable (this is sometimes called maintenance, or palliative, treatment) Whilst you are receiving chemotherapy or radiotherapy that we pay for, we will also pay for treatment prescribed by your specialist that you need to deal with their side effects, for example: antibiotics anti sickness drugs steroids pain killers drugs to boost your immune system blood transfusions Treatment for cancer can mean that you need a variety of services. If your specialist recommends it, we will pay for sessions with: a dietician, to stabilise your diet following surgery, chemotherapy or radiotherapy a stoma nurse, to show you how to care for your stoma a specialist nurse to show you how to manage lymphoedema NHS cash benefit If you are admitted free of charge on the NHS for treatment or diagnostic tests that we would have paid for as a private patient, we will give you 100 for: each admission you have as a day-patient or each night when you are an in-patient up to a maximum of 91 days or nights in combined total each claiming year. We will not pay NHS cash benefit for out-patient treatment (for example radiotherapy), or for treatment that we would not pay for as a private patient (for example rehabilitation / convalescence, or an admission for treatment of a chronic condition). 17

18 Heart and Cancer cover what is covered We will make a donation to a registered hospice for each night that you are admitted, up to 91 nights each claiming year We will pay for consultations and diagnostic tests to monitor your condition for five years after the last treatment for cancer that we paid for on this policy Heart cover 50,000 policy lifetime limit each person In-patient and day-patient treatment of heart conditions, for example open heart surgery or angiogram (sometimes called a cardiac catheter). We will pay for post treatment consultations and diagnostic tests as an out-patient to monitor you until your condition has been stabilised NHS cash benefit. If you are admitted free of charge on the NHS for treatment or diagnostic tests that we would have paid for as a private patient, we will give you 100 for: each admission you have as a day-patient or each night when you are an in-patient up to a maximum of 91 days or nights in combined total each claiming year. We will not pay NHS cash benefit for out-patient treatment (for example taking statins), or for treatment that we would not pay for as a private patient (for example rehabilitation / convalescence, or an admission for treatment of a chronic condition). Heart and Cancer cover what is NOT covered: Treatment of a chronic condition, please see page 20 Further restrictions are detailed on page 19 18

19 Directed Private Medical Care what is NOT covered under Modules 2, 3 and 4 Any treatment that has not been authorised and arranged by us Treatment not normally provided under the NHS or approved by National Institute of Health and Care Excellence (NICE) Pre-existing conditions which have not been disclosed to us and accepted by us for benefit (this exclusion does not apply to Simplyhealth employees) Any exclusions specific to your cover as shown on your membership certificate Treatment received abroad Charges which exceed those listed within the Simplyhealth fee schedule Dental treatment which has not been carried out in a hospital by an oral and maxillofacial surgeon and is not specifically listed within the table of cover. You may be able to claim for dental treatment under Essentials cover, please check your membership certificate to see whether you are covered Repatriation or transfer repatriation to the UK, or transfer to a hospital abroad, from a ship, oil rig, or similar offshore location Chronic conditions however, we will pay for treatment (or NHS cash benefit) for an acute flare-up of a chronic condition if: you need to be admitted to hospital as an in-patient for that treatment and the treatment aims to quickly stabilise your chronic condition Drugs and dressings you take home from hospital medical, surgical or dental appliances, for example hearing aids, glasses and contact lenses, braces or walking aids such as crutches or frames. This exclusion does not apply to a prosthesis, for example a knee or hip replacement, or an electronic device such as a pacemaker. However, even if we pay for an electronic device, we will not pay for the replacement of: consumables, for example batteries or leads or the device itself Cosmetic treatment or surgery Treatment related to developmental problems, learning difficulties or delayed speech disorders, for example, dyslexia or attention deficit hyperactivity disorder Treatment you need as a result of alcoholism, alcohol abuse, solvent abuse, drug abuse or addictive conditions or any associated condition (for example hepatitis, cirrhosis, oesophageal varices or psychiatric conditions) HIV infection, AIDS or any associated condition Preventative treatment or diagnostic tests for example sight testing, vaccination or inoculation, routine medical or dental examinations and monitoring of a condition Emergency treatment Home nursing Private ambulance costs and the flare-up was unexpected (for example we will not pay for recurring in-patient admissions which may be a natural consequence of your chronic condition, and which happen on a regular or predictable basis) See page 21 for examples of how we deal with chronic conditions. Genetic testing Treatment of low fertility or infertility, or pregnancy, or childbirth resulting from such treatment Pregnancy or childbirth, or any medical conditions relating to childbirth Termination of pregnancy Dialysis regular or long term renal dialysis 19

20 Transplantation operations or procedures for example autologous plasmapharesis, transplant of bone marrow or stem cells, kidney transplant, autologous blood transfusion or similar procedures Removal of non diseased tissue for example breast reduction Self inflicted non accidental conditions Accommodation without treatment - for example a stay in hospital wholly or partly for domestic reasons; when the patient is not undergoing active regular treatment by a specialist or where treatment could be reasonably provided elsewhere, or where the hospital has effectively become your permanent home. We also exclude stays in a convalescent home, convalescent hospital, health hydro or nature cure clinic GP or dentists fees (and fees as a result of providing further medical information which we have asked for) Unlicensed drugs or the use of drugs outside the scope of the licence issued by the European Medicines Agency (EMEA) or the National Institute for Health and Care Excellence (NICE) Treatment for injuries or illness arising out of war, invasion, act of foreign enemy, nuclear or chemical contamination, hostilities (whether war has been declared or not), civil war, riot, civil commotion, rebellion, revolution, insurrection or military or usurped power Chiropractic, osteopathy, acupuncture and homeopathy treatment Physiotherapy not related to surgery that we have paid for, that has not been requested by a specialist or that starts more than three months after surgery that we have paid for What is a chronic condition? Directed Private Medical Care does not cover any chronic conditions. A chronic condition is a disease, illness, or injury that has one or more of the following characteristics: it needs ongoing or long term monitoring through consultations, examinations, check-ups, and/or tests it needs ongoing or long term control or relief of symptoms it requires your rehabilitation or for you to be specially trained to cope with it it continues indefinitely it has no known cure it comes back or is likely to come back It is not always clear that you have a chronic condition when you visit your GP. This is why we will pay for referral to a specialist and any diagnostic tests and consultations to make a diagnosis. The aim of any treatment must be to return you to the state of health you were in immediately before suffering the disease, illness or injury, or lead to your full recovery. What does this mean in practice? If your condition has or acquires one or more of the characteristics of a chronic condition, we will not pay any benefit for this condition, unless agreed by us in advance of the treatment. Even if we have paid for previous treatment, it does not mean that we will continue to cover that condition, if we think it has become chronic. If your diagnosis is for a chronic condition, we will confirm to you that we will not pay for further consultations, diagnostic tests or treatments. What if your condition gets worse? We do not pay for ongoing treatment, consultations or diagnostic tests to maintain a chronic condition in a stable state. However, we will pay for treatment (or NHS cash benefit) for an acute flare-up of a chronic condition if: you need to be admitted to hospital as an in-patient for that treatment and the treatment aims to quickly stabilise your chronic condition and the flare-up was unexpected (for example we will not pay for recurring in-patient admissions which may be a natural consequence of your chronic condition, and which happen on a regular or predictable basis) If you have an acute flare-up of a chronic condition, please call us on We will not pay for treatment unless we have arranged it. 20

21 Examples of chronic conditions While these case studies are fictitious they are intended to illustrate how this section of the policy works in practice to support the health and wellbeing of individual members. Alan Alan has worked for Simplyhealth for many years and has private medical insurance cover under modules 2 (in-patient, day-patient and out-patient), 3 (psychiatric treatment), and 4 (heart and cancer cover). He develops chest pain and is referred by his GP to a specialist. He has a number of investigations and is diagnosed as suffering from a heart condition called angina. Alan is placed on medication to control his symptoms. The Helpline will arrange the consultations with a specialist and diagnostic tests to diagnose Alan s condition, and then pay the bills for these (provided that Alan has sufficient funds available from the 50,000 policy lifetime limit for heart conditions. If this is the first heart claim that Alan has ever made this is likely to be the case). The Employee Plan does not cover follow up consultations for long term monitoring of Alan s condition, drugs taken as an out-patient or drugs taken home from hospital, so Simplyhealth will not pay for: the drugs that Alan takes to control his symptoms, or any further consultations to monitor his condition Two years later, Alan s chest pain recurs more severely and his specialist recommends that he have a heart bypass operation. Under module 4, heart and cancer cover, the Helpline will arrange Alan s consultation with the specialist and his heart bypass operation, and then pay the bills for these provided that Alan has sufficient funds available from the 50,000 policy lifetime limit for heart conditions. Following his operation Alan will need to have further consultations to check that the operation was a success and to adjust his medication so his condition remains stable for the future. We will pay for consultations and diagnostic tests as an out-patient until Alan s condition has been stabilised, provided there is sufficient money remaining within the policy limits. Deirdre Deirdre has worked for Simplyhealth for two years when she develops symptoms that indicate she may have diabetes. She has private medical insurance cover under modules 2 (in-patient, day-patient and out-patient), 3 (psychiatric treatment) and 4 (heart and cancer cover). Her GP refers her to a specialist who organises a series of investigations to confirm the diagnosis, and she then starts on oral medication to control the diabetes. After several months of regular consultations and some adjustments made to her medication regime, the specialist confirms the condition is now well controlled and explains he would like to see her every four months to review the condition. The Helpline will arrange the consultations with a specialist and diagnostic tests to diagnose Deirdre s condition, and then pay the bills for these. We will also pay for the consultations and diagnostic tests that Deirdre s specialist needs to ensure that the condition is stabilised. Once Deirdre s diabetes has been stabilised, we will not pay for any further consultations to monitor the condition on a long term basis. One year later, Deirdre s diabetes becomes unstable and her GP arranges for her to go into hospital for treatment. The Helpline will arrange the admission, and then pay the bill for this if: Deirdre needed to be admitted to hospital as an in-patient for that treatment and the treatment aimed to quickly stabilise her condition and the flare-up was unexpected (for example we would not pay for recurring in-patient admissions which may be a natural consequence of Deirdre s condition, and which happen on a regular or predictable basis) However, we would not continue to pay benefit for Deirdre s diabetes indefinitely. We would strongly recommend that Deirdre calls us before going into hospital as a private patient so that we can advise her whether or not we will pay for the admission. 21