Live life well. Your policy summary and terms and conditions of your health insurance.

Transcription

1 Your policy summary and terms and conditions of your health insurance

2 Contents Your policy summary 3 Terms and conditions of your health insurance 7 Your policy summary This document provides a summary of the key information of your private health insurance. Please read your policy document for full terms and conditions. PruHealth Data Protection Notice 10 Your PruHealth policy terms and conditions Cover and benefits in detail Underwriting Exclusions Policy terms and conditions, general conditions, policy administration Complaints procedure Law and interpretation Currency Glossary of definitions 37 Appendix 1a Moratorium underwriting 41 Appendix 1b Moratorium underwriting 44 Appendix 2 Lifestyle surgery 47 How to contact us 51 Your insurance policy This document reflects the policy terms and conditions as agreed between PruHealth and your employer. It is an insurance policy underwritten by Prudential Health Limited that aims to cover the cost of private treatment for acute medical conditions for UK residents. You will have access to the highest standards of care and treatment as quickly as possible. The duration of cover is 12 months. Please refer to this document and your membership certificate for full details of the cover and any exclusions that may apply. You should review your cover regularly to ensure that is continues to meet your needs. You will also find reference to our Vitality programme in section 1.18 of this document. Please note that the services, discounts and rewards offered under our Vitality programme may change during the course of a policy year. Full cover Under our private medical insurance cover, all of your eligible costs will be covered in full (unless any excess applies) providing you re being treated in a hospital or other facility that is on your hospital list and by a specialist recognised by us. For example, if you need an operation, your surgeon s and anaesthetist s fees will be paid in full. What other benefits does this policy offer me? With our Vitality programme, everyone can benefit from a healthier lifestyle. If you eat well, exercise and maintain an all round healthy lifestyle, you could get greater discounts with our Vitality reward partners. For more information, please refer to section 1.18 Vitality. You could also receive a renewal reward which is based on your Vitality engagement and how much you claim. In the first year, we will work out your renewal reward using the claims that have been paid out in the first 10 months of your policy. In the years that follow, we ll look at claims for a full year. The full year will be 10 months of the current policy year and 2 months of the previous policy year. For more information, please refer to section Please also read your membership certificate. You ll earn Vitality points too for certain healthy activities such as health screens and exercising at the gym. Proof of activities must be submitted within six months of the activity. Your Vitality points increase your Vitality status. The higher your status, the greater your Vitality reward partner discounts. Terms and Conditions PruHealth 3

3 Prices with our Vitality partners may increase during the year. For more information, please refer to section 1.18 Vitality. What will this policy cover? You are covered for a wide range of acute conditions. These are diseases, illness or injuries which are likely to respond quickly to treatment with the aim of returning you to the state of health you were in before you suffered the condition. Complete your online Health Review and you ll be given your own Personal Health Fund, or PHF. This is an amount of money you can use to pay for certain services and treatments that aren t usually covered by health insurance. Your membership certificate shows the services that have been chosen and the amount of money you have available to spend on these services or treatments. By completing your Health Review, you will have access to the Vitality reward partners and, if selected, your renewal reward for the following year. For more information, please refer to section 1. Cover and benefits in detail. What our policies do not cover As with many private medical insurance policies, there are some standard treatments and conditions that we don t cover. These include: Any pre-existing conditions in the first two years of the policy, if you joined the scheme under our moratorium clause before 1 January 2013 Any medical conditions in the five years before the date of joining, if you joined the scheme under our moratorium clause on or after 1 January These conditions can become eligible for cover if you don t need treatment for them or any related medical conditions for two continuous years after your cover starts Any day-to-day monitoring or treatment of most chronic conditions. Examples of chronic conditions include diabetes and asthma Self-inflicted injuries Emergency treatment or visits to your GP Cosmetic treatment Pregnancy and childbirth Treatment for obesity (other than treatment we have authorised under our Lifestyle surgery benefit) Deafness Any other conditions explicitly excluded. For more information, please refer to section 3. Exclusions and your summary of benefits for full details on what your policy does not cover. Depending upon the policy your employer has chosen for you, there may be times when you are required to contribute towards the treatment you receive. This will be either an excess or co-payment. Please see your summary of benefits for details of any excess or co-payments that may apply. Out of hospital list co-payment An out of hospital list co-payment applies for services outside of your selected hospital list. A 40% co-payment will apply to the hospital charges for an inpatient admission outside of your selected hospital list. A 40% co-payment will apply to the hospital tariff for a diagnostic scan outside of your selected hospital list. Please see section 1.4 for further details on how these work. How do I claim? If you have the misfortune to claim, we have made this process easy for you: Step 1: Visit your GP. If they refer you for treatment, tell them you have cover with PruHealth and ask for the following: Full details of your condition/injury, diagnosis and intended treatment Full name and address of the specialist or therapist and the hospital/ clinic you ve been referred to. Step 2: Phone us on Once you have all the details, call our dedicated Claims Team for your authorisation number. Make sure you have your membership number on hand when you call. Write your authorisation number down and take it with you to the specialist. If you have treatment without having the authorisation number, it could mean you may not be covered for the treatment. It s worth remembering that you might be asked to give details of your condition over the phone, so you may want to make the call in private. Log on to the Member Zone at pruhealth.co.uk/member and click on `My cover, to double check any details of your cover. You may be able to receive an authorisation number online. Please log on to the Member Zone at pruhealth.co.uk/member to find out. Step 3: Book your appointment with the specialist and start your treatment. When you go for your treatment, make sure you take the authorisation number with you. If you need further visits, ask for a procedure code and description of the treatment or investigation. Always speak to our Claims Team to make sure you re covered for further treatment. Step 4: Settling the bill. In most cases, medical bills will be sent directly to us. If you do get a bill, forward it to us at: PruHealth Customer Services Stirling, FK9 4UE If you make a payment yourself, send us the bill with proof of payment and we ll pay you back. What happens if I complain but am not happy with the outcome? We hope this never happens but if it does you can take your complaint to the Financial Ombudsman Service once you ve received our final decision. This is a free service to you and does not affect your legal rights. You ll find contact details and information on how to make a complaint later in this document but here s their website address for your convenience: 4 5

4 What happens if I leave the company? Your cover ends on your leaving date which means we won t pay for any more treatment you have after that date even if you re in the middle of treatment at the time or we ve authorised that treatment in advance. Depending on your age and how long you ve been covered under your company scheme, you may be eligible to continue your cover with us on an individual plan with the same personal underwriting terms. Please also note that you may still be subject to the notice period of any relevant Vitality partner and to any other relevant terms and conditions of that Vitality partner. Also, there will be no refund in respect of any Vitality activities or Vitality points earned once your cover has ended. What protection is there if PruHealth goes out of business? As a PruHealth member, you re protected by the Financial Services Compensation Scheme. If we re unable to pay your claim because we ve become insolvent or are no longer in business, the scheme may arrange to transfer your plan to another insurer, or provide a new plan. If this isn t possible it will provide compensation of 90% of the claim, with no upper limit. More details can be found on their website: How to contact us Online: Via our Member Zone at pruhealth.co.uk/member and send us a secure message. By post: PruHealth Customer Services Stirling, FK9 4UE By phone: Please note that PruHealth can only give information on PruHealth products. Terms and conditions of your health insurance PruHealth is committed to a policy of full transparency and as such we highlight any important details we think you ought to pay close attention to with this icon, in order to ensure you understand your cover and don t get any surprises when you need to make a claim. Your policy terms and conditions need your close attention, which is why our Cover Check icon appears on the cover of this document. 6 Terms and Conditions PruHealth

5 About this document This document reflects the terms and conditions of the scheme as agreed between PruHealth and your employer. Please refer to this document in conjunction with your membership certificate and your summary of benefits for full details of cover and exclusions that may apply. Words in italics in this document are defined terms which have a specific meaning. You should check their meaning in the glossary at the back of this document. About PruHealth PruHealth was launched in October 2004 and is a joint venture between Prudential and Discovery Holdings, the South African health insurance leader. About Prudential UK and Discovery Holdings Established in 1848, today Prudential plc is an international financial services group with significant operations in Asia, the US and the UK. Discovery Holdings was founded in 1992 as a specialist health insurance company in South Africa. It is now the market leader in healthcare in South Africa. Important regulatory information PruHealth is the trading name of Prudential Health Limited and Prudential Health Services Limited. Prudential Health Limited, registration number is an insurer that underwrites the insurance products. Prudential Health Services Limited, registration number , is an insurance intermediary with FSA authorisation to mediate insurance business in the UK. Prudential Health Services Limited acts as an agent of Prudential Health Limited and arranges and provides administration on insurance plans underwritten by Prudential Health Limited. Our registered offices are at Laurence Pountney Hill, London EC4R 0HH. Prudential Health Limited and Prudential Health Services Limited are authorised and regulated by the Financial Services Authority (FSA). You can check our authorisation on the FSA s Register by visiting the FSA s website: or by contacting the FSA directly on The products we offer Prudential Health Services Limited only offers private medical insurance products underwritten by Prudential Health Limited and Prudential Health Insurance Limited. Prudential Health Services Limited can offer other insurance products from a specific range of insurers. A list of insurers and insurance products is available on request. Most Innovative New Product 2011 Most trusted PMI Provider 2009 & 2010 Best Individual PMI Provider 2006, 2007, 2008 & 2010 Best use of ebusiness by a Provider 2010 Health Insurance Company of the Year 2006 & 2007 Best Individual PMI Provider 2006, 2007, 2008 &

6 PruHealth Data Protection Notice Why should you read this notice? We think it is important for all our customers to be made aware of what information PruHealth Group* holds about them and to have the reassurance of knowing that we comply with the Data Protection Act. How we use your personal information The PruHealth Group will use your information (including information provided about your dependants) for underwriting and administration purposes. By taking out a policy with us, you agree to us processing your personal information and sensitive personal information (for example health information). We will also use your information for statistical data analysis, management information and fraud prevention purposes. If you wish to make a claim on your policy, this will inevitably mean that you will have to provide us with information regarding your medical condition which we will then process in order to administer your claim. Calls to PruHealth may be recorded and may be monitored. Who we may give personal information to We may disclose your personal information to our business associates, agents and service providers for the purposes above. Your information may be processed by service providers in a country outside the European Economic Area, which may not have the same standard of data protection as in the UK. We will ensure appropriate safeguards are in place to protect your information. We will pass your information to any legal or regulatory body if required to do so. We may also use your information or give it to others, for research, statistical purposes or to improve our services, but we will remove your name and address from this first. If you have appointed an insurance adviser we will send them copies of correspondence relating to the policy and any renewal documentation. We may disclose information about a claim to them, although no medical information will be provided without your consent. Your information, and that of others also covered by the policy, may be disclosed to other parties (for example other insurance companies) with a view to preventing fraudulent or improper claims. Processing claims In the event of a claim we may have to give some information to those involved in your treatment or care, and/or your representative (if you have chosen one). This will be done confidentially. Correspondence about all claims (including those made by dependants) will be addressed to the policyholder in respect of individual policies. If a dependant does not wish us to correspond with the policyholder in relation to their claim, and if they are aged 18 or over, they should take out a separate policy in their own name. If you have another insurance policy that covers the same costs that you are claiming from us, then we may also disclose your relevant personal information to that other insurer so that we can ensure we only pay our proportion of the claim. Group policies If you belong to a group policy you may want to ask your employer whether an insurance adviser has been appointed, so that you know who may have access to your personal information. We may disclose information about a claim to the administrator / Group Secretary of a group policy, but no medical information will be provided without your consent. Correspondence about any claim, (including when made by a dependant of an insured employee), will be restricted to that needed to handle the claim and will be addressed to the insured employee. Our marketing policy PruHealth, our group of companies and our business associates, service providers and agents may use your personal information to inform you of other services and products that may be of interest to you by telephone, post, or text. Please call our Customer Services Department if you would prefer not to receive details of other products. Obtaining a copy of the information we hold about you You have the right to request a copy of the information we hold about you (for which we may charge a fee) and to have any inaccurate information corrected by writing to us at the below address. Where information has been supplied by a medical practitioner, you should be aware that we need their consent before we can supply this to you, or alternatively you can request such information direct from the practitioner. Data Protection Co-ordinator Prudential Health Services Limited Marshall Point 4 Richmond Gardens Bournemouth, BH1 1JD Disposal of information We will continue to hold information about your policy for a reasonable period of time after it has ended. We will then dispose of your personal information in a responsible way to maintain your confidentiality. *PruHealth is a joint venture between Prudential in the UK and Discovery Holdings Limited in South Africa. The PruHealth Group includes Prudential Health Limited and Prudential Health Insurance Limited, both trading as PruHealth, and Prudential Health Services Limited trading as PruHealth and/ or PruProtect

7 Your PruHealth policy terms and conditions Overview This is the policy wording and benefit description for the PruHealth private medical insurance (PMI) taken out by the policyholder. The policy is a contract between Prudential Health Limited and the policyholder, to provide cover for the employees as detailed in this policy document. PruHealth expects that this policy will enable the policyholder to protect and enhance the wellbeing of their employees and of their dependants in times of illness and health. It is intended to complement rather than replace NHS services provided in the UK. Any examples contained in this policy wording are for illustrative purposes only and do not reflect the totality of the circumstances described by the relevant clause. Contacting us You can contact us for more information or further clarification on the benefits, cover, exclusions and the rules included in this policy, as follows: Online: Via our Member Zone at pruhealth.co.uk/member and send us a secure message. By post: PruHealth Customer Services Stirling FK9 4UE By phone: Or contact your adviser. How we will communicate with you We will use a member s address as the primary form of contact regarding this policy and our Vitality programme. Please note we generally do not send paper copies of our policy documentation or Vitality information to members unless specifically requested. All policy documentation can be found by logging on to our secure online Member Zone at pruhealth.co.uk/member. 1. Cover and benefits in detail Please refer to the membership certificate and summary of benefits for details of cover and exclusions that specifically apply. Subject to these documents, we will pay for the treatments and services as clearly laid out in the schedule below. Any benefit limits that may apply will be detailed in the summary of benefits. We will not pay for any other treatments or services unless we expressly agree to do so in writing. Inpatient Care Hospital charges Fees charged by PruHealth recognised consultants includes surgeons, anaesthetists and physicians fees Cancer treatment Psychiatric treatment. Outpatient Care Consultations with appropriately recognised consultants Diagnostic scans include CT, MRI and PET scans. These must be following consultant referral only and also within the member s selected hospital list. A co-payment of 40% of the hospital tariff will apply for scans undertaken outside of the member s selected hospital list. Other diagnostic tests including pathology, X-rays and physiological tests such as an ECG Physiotherapy, chiropractic and osteopathy. Cover will only apply up to the number of authorised sessions Cancer treatment Psychiatric treatment. Other Care Complementary and alternative therapies. Our list of criteria for entry for all providers is available on request or on our website Childbirth cash benefit Nursing at home Private ambulance Parental accommodation NHS hospital cash benefit Assistance at home Lifestyle surgery Your policy also provides you with cover for Lifestyle surgery for some specified medical conditions. Our general exclusion for pre-existing conditions doesn t apply to the conditions covered under this benefit but there are other rules specific to this benefit. Full details can be found in Appendix 2. Cover is available only to employees whose employer s Head Office is in the UK and is for treatment in the UK, Channel Islands and the Isle of Man. PruHealth will cover the claims from consultants who are registered as specialists with the General Medical Council. Other therapists must be registered with the appropriate regulatory body. We reserve the right to withhold or remove recognition of any specialist for reasons such as suspension of registration, fraud or unreasonable charges. Who can be covered under this policy? Subject to the agreement of the policyholder, the following people may join this scheme: any employee (including any director, partner or owner) over the age of 16 providing they meet the eligibility criteria agreed with the policyholder; the insured member s husband, wife or partner, who live at the same address as the insured member 12 13

8 the insured member s children providing they are under the age of 21 when they first join Insured employees can add up to eight dependants to their policy. An insured member must live in the UK for at least 180 days in each policy year. An insured member is only eligible for cover if they are not employed in the following occupations: working offshore in the extraction/ refinery of natural/fossil fuels professional or semi-professional sports for which a salary, sponsorship, or a benefit in kind is received armed forces personnel. If any member applying to join this policy already has cover with another insurer, we recommend they do not cancel that cover until we have confirmed in writing that we have accepted their application. Hospital list The selected hospital list where the member can be treated is specified in the membership certificate and is available on our website. PruHealth hospital lists may change from time to time. We recommend that the member check the most up-to-date version on our Member Zone before their treatment commences. Our hospital lists include some of the UK s leading private hospital groups. The member s hospital list will be able to provide most services which are available within their purchased benefits. If the member has any problems finding a service they need in the selected hospital list, they should contact us and we will help to locate a facility and/or consultants who provide that service. In certain circumstances, this may mean they will need to travel to get the service within the selected hospital list and avoid a co-payment. If the member goes to a hospital not on their selected hospital list, they will be liable to contribute 40% of the hospital charges relating to their treatment. Please note that our Lifestyle surgery benefit is subject to additional qualifying conditions and is only available at certain private hospitals, which may not always be close to your home address. Also, all procedures under this benefit must be arranged by the consultant group nominated by us. 1.1 Benefit limits Any benefit limits stated apply for each person covered under the policy. These limits also apply to the total of claims over the policy year. Where a combined limit applies, it means that the cost of any treatment paid for out of those benefits accumulates towards the overall limit. There may be sub-limits within the overall combined limit and the member should check their summary of benefits for further details. 1.2 Excesses An excess applies for each person covered under the policy. The excess relates to the amount of claims over a policy year for an individual, not to each claim event. Please note that after every renewal a new excess will apply to each person covered. A rolling excess is when the excess is only payable once every 12 months. The membership certificate will detail which type of excess the member has. The excess doesn t apply to: claims under our Lifestyle surgery benefits, but you will have to contribute 25% to the cost of consultations and package of treatment (full details can be found in Appendix 2); Childbirth cash benefit; Assistance at home benefit; NHS hospital cash benefit; and claims from your Personal Health Fund. 1.3 Co-payment A co-payment works in a similar way to an excess, as the member may not be entitled to claim the full cost of the treatment. The member has to contribute a percentage towards treatment costs, up to a maximum amount. Co-payments apply to each claim s invoice and per person covered under the policy. 1.4 Out of hospital list co-payment An out of hospital list co-payment applies for services outside of a member s selected hospital list. A 40% co-payment will apply to the hospital charges for an inpatient admission outside of the member s selected hospital list. A 40% co-payment will apply to the hospital tariff for a diagnostic scan outside of the member s selected hospital list. 1.5 Intensive and high dependency care Critical care We will pay for critical care where it is part of the expected post-operative management of the member and where the intention is to treat a disease, illness or injury which is likely to respond quickly to treatment. We will pay for unexpected care in a private hospital providing the following conditions are met: It follows an elective, non-emergency admission; It is provided in a dedicated critical care area; and It is the most appropriate setting for such treatment. We do not pay for unexpected critical care in an NHS hospital under any circumstances. We do not pay for any level of critical care which is not medically necessary for the condition being treated. 1.6 Psychiatric care PruHealth will actively manage psychiatric treatment in order to achieve the best outcome for the member on a case by case basis. Please note that due to the nature of psychiatric illness it may be that over the course of treatment, the condition will be deemed to be chronic (see Exclusions: chronic conditions). If a financial limit applies, it will apply for both inpatient and outpatient treatment or services and includes both accommodation and treatment 14 15

9 costs. The outpatient sub-limit is for outpatient treatment and accumulates to the overall psychiatric limit. 1.7 Rehabilitation Cover is available for rehabilitation, which is treatment intended to restore health or mobility or return the member to independent living, following a stroke or injury. The rehabilitation must be integral to eligible inpatient treatment, should start no more than two months after initial diagnosis or date of injury, will normally be covered for 30 days only and will be managed within our guidelines for chronic conditions. A specialist should make the referral to a rehabilitation unit for the treatment to be eligible. 1.8 Complementary and alternative therapies Where covered, this category includes healthcare systems and practices that are not presently considered to be part of conventional medicine. To be eligible for cover, these therapies must be used for treatment of an acute condition following referral by a GP or specialist. All practitioners must have adequate experience and indemnity insurance, must be registered with the appropriate authority and be a member of a speciality organisation. Our list of criteria for entry for all providers is available on request and on the Provider Zone. Treatment for pre-existing conditions, chronic conditions and associated medicines and products is not covered. 1.9 Pregnancy and childbirth Option 1: Pregnancy and childbirth benefit including caesarean section PruHealth will pay for treatment for ectopic pregnancy, hydatidiform mole, post partum haemorrhage, miscarriage, retained placenta and stillbirth. Treatment for other conditions related to pregnancy or childbirth is not included. PruHealth may, however, pay for caesarean section if it is medically necessary and the mother has been a member of the PruHealth scheme for at least 12 months before the procedure. PruHealth will need full clinical details from the consultant to assess eligibility for cover. The following fees will be paid: Obstetrician procedure and one follow-up consultation Anaesthetist procedure only No hospital fees if it takes place in an NHS facility Hospital fees as per normal benefit if in a private hospital. Option 2: Pregnancy and childbirth benefit PruHealth will pay for treatment for ectopic pregnancy, hydatidiform mole, post partum haemorrhage, miscarriage, retained placenta and stillbirth. Treatment for other conditions related to pregnancy or childbirth is not included Childbirth cash benefit This is payable on the birth of a child to a member who has been covered by a policy for at least nine months prior to the birth. In order to claim the benefit, the member must provide PruHealth with a copy of the birth certificate and request the payment of benefit within six months of the birth, unless there is a good reason why this can t be done. This benefit is also payable in the case of legal adoption. To be eligible, the child must be under 18 years of age at the time of adoption and we must be informed within six months of the adoption taking place. The member must also provide us with a copy of the necessary paperwork. The nine month waiting period required for the birth of a child does not apply to adoption Nursing at home In order to claim the nursing at home benefit, such treatment must: immediately follow a period of inpatient treatment for a medical condition covered by the policy be for treatment that would otherwise be provided in hospital as an inpatient be undertaken by a nurse; and be recommended and carried out under the supervision of the member s specialist Private ambulance Use of an ambulance is covered for private transfers between hospitals, whether NHS or private. This use is limited to paid services provided by independent companies or the NHS. It is limited to medically necessary transfers where there is a reasonable medical need for the action to be taken. Transfers for non-medical reasons will not be covered Parental accommodation benefit This benefit is paid to enable one parent to stay in the same hospital as their child when the child is admitted as an inpatient to a private hospital or an NHS private ward within an NHS Private Patient Unit (PPU). Limits on the policy are shown in the summary of benefits. Paediatric conditions are mainly treated in NHS hospitals, though some private hospitals still provide treatment. If the child covered under the policy goes to an NHS hospital for treatment, the child is eligible for the NHS hospital cash benefit as described in the clause below NHS hospital cash benefit This benefit applies only to NHS day cases or stays in a general NHS ward, not an NHS PPU. The NHS hospital cash benefit is paid out only for conditions that PruHealth would have covered if treated privately under the policy. This benefit wouldn t be available for a visit to Accident and Emergency (A&E) as A&E treatment is not covered by PruHealth. Any standard or personal exclusions still apply (please refer to section 3). If the member is admitted to an NHS hospital for an acute event and is eligible for a transfer to a private hospital, they will be eligible for the cash benefit if they choose not to move to a private facility. If the member chooses to transfer to a private hospital for part of their treatment, then no benefit is payable for any of the nights they have spent as a non-paying NHS patient

10 The member, or their representative, must call PruHealth to request authorisation for the claim in accordance with the normal procedure (see section 4.9). They must submit the NHS discharge form to PruHealth as evidence of their treatment or hospital stay Assistance at home This benefit provides a member with help at home where required immediately following a period of eligible inpatient treatment authorised by us that lasts at least 72 hours. Inpatient treatment can be in either a hospital on the member s hospital list, or in a general NHS ward which qualifies for the NHS hospital cash benefit. Help at home can include personal care such as help with getting washed and dressed, and domestic duties such as general tidying and changing bed linen. Actual care will depend on the member s specific needs and circumstances and will be assessed by the third party providing this service. Cover is up to 14 hours care per week (maximum of 2 hours per day) for a maximum period of 2 weeks. Where more than one claim for this benefit is made in a policy year, cover is limited to 6 weeks in total. Assistance at home must be arranged direct with our third party provider, who will agree a care plan direct with the member. Full details of the third party provider, and the terms and conditions of this benefit, can be found in the member s secure inbox on the Member Zone. We do not pay for any assistance at home not arranged through our third party provider. We do not pay for any assistance at home that follows a period of inpatient treatment of less than 72 hours or which isn t eligible under this policy Cancer benefit Option 1: Full cancer benefit PruHealth will pay for treatment for all stages of cancer, for both cure and end of life care, subject to our general terms and conditions. Radiotherapy and chemotherapy are fully covered on all policies, subject to authorisation. The summary of benefits shows whether there are any limits on the policy. Treatments that follow all available National Institute for Health and Clinical Excellence (NICE) guidance, will be covered in full. NICE is responsible for providing national guidance on promoting good health and preventing and treating ill health. We will evaluate therapy not yet considered by NICE on a case by case basis using all currently available evidence from properly controlled mature phase III clinical trials. We may pay for the use of a new, licensed anti-cancer drug, or new use for a drug with a licensed indication where there is credible scientific evidence to support its use. Appropriate bone marrow or stem cell transplants are also covered. No time limits are placed on treatment and follow up care for cancer, provided cover is continuous and while a member is eligible for benefits. Rules covering chronic conditions do not apply to cancer. A donation is available for hospice care. PruHealth will not pay for complementary and alternative therapies as the primary treatment for cancer as part of the Cancer benefit. However, we will pay for complementary and alternative therapies from the Complementary and Alternative Therapies benefit. (Please see section 1.8). Option 2: NICE guidelines PruHealth will pay for treatment for all stages of cancer, for both cure and end of life care, subject to our general terms and conditions. Treatments that follow all available National Institute for Health and Clinical Excellence (NICE) guidance will be covered in full. NICE is responsible for providing national guidance on promoting good health and preventing and treating ill health. Drugs which fall outside of NICE guidelines on clinical effectiveness, or which NICE has not yet considered, will not be eligible for payment. No time limits are placed on treatment and follow up care for cancer, provided cover is continuous and while a member is eligible for benefits. Rules covering chronic conditions do not apply to cancer. A donation is available for hospice care. PruHealth will not pay for complementary and alternative therapies as the primary treatment for cancer from the Cancer benefit. However, we will pay for complementary and alternative therapies as part of the Complementary and Alternative Therapies benefit. (Please see section 1.8.) Option 3: No cancer benefit PruHealth will pay for consultations and investigations up to diagnosis, at eligible cancer treatment centres and by recognised consultants, but will not pay for any treatment related to cancer The Personal Health Fund (PHF) The PHF assists members in funding dayto-day health expenses which would not typically be covered by PMI benefits and are not included as standard on their policy. Members must complete a Health Review on the Member Zone during this policy year in order for PHF benefits to be available. Claims will only be paid if the PHF has been activated by completing the Health Review. The PHF has limits as agreed with the employer. The PHF covers expenses, up to the agreed limits from the list of benefits as chosen by the employer. These will be shown on the membership certificate. When a member uses funds from the PHF the amount available for future use will be reduced accordingly. To use funds from the PHF, a member will not need to call PruHealth for authorisation each time they need to see their practitioner. Usage of the PHF will not affect their Vitality rewards, their excess or their claims amount. In some cases the PHF will not be sufficient to pay for the treatment in full, but may pay in part. Where appropriate, PruHealth will use the PHF to pay for claims if they cannot be paid from the main benefits as detailed in section

11 PHF exclusions PruHealth will not pay funds used from the PHF if the member s doctor or therapist is not appropriately registered, or if the treatment needed is associated with an underwriting exclusion or general scheme exclusion. We will also not pay funds used from the PHF if they are for treatment unrelated to one of the benefits associated with the PHF as chosen by the employer. PHF renewal If the member does not exhaust their PHF by the end of this policy year, the unused amount (calculated as the limit less claims made from the PHF in the year) will not carry over to the following policy year. The Health Review must be completed during this policy year for the PHF funds to become available. Joiners and leavers The PHF is the amount of additional benefit the member is entitled to under this policy. It is not redeemable for cash to the member or to the employer at any point in time and it will cease without value when the contract is terminated by the employer or when the member s cover ceases. If the member has joined the company part way through their policy year they will not be eligible for the full year s allocation to the PHF. The allocation will be pro-rated based on remaining time until policy renewal Vitality This section explains a little more about our Vitality wellness programme. Our reason for creating the Vitality programme is simple. If our members stay healthy by exercising regularly, eating well and not smoking, they could add years to their life. And that s why we believe health insurance shouldn t only benefit people that need to claim. Under Vitality, everyone has access to our proven wellness programme which includes activities and partner discounts to help members get and stay healthy for less. There are discounts with our health partners and half price health screens, as well as useful tools to help members understand and monitor their health, and set goals to improve it. As they take part in the programme, they ll earn Vitality points which count towards their Vitality status, helping them to see their progress. Everyone starts at Bronze and can move up to Silver, then Gold and finally Platinum. We have also focused on two key areas that can help members improve their health exercising and eating well. So we give members a discount on monthly gym membership fees at Virgin Active or LA fitness and we will support their efforts to eat well by giving them bonus Nectar points with Sainsbury s. Vitality makes getting healthy more rewarding the more members participate and improve their Vitality status the higher their discounts will be with our range of reward partners. More about Vitality Here s some more information about Vitality but for full details on how it all works and the benefits, please visit our website and log onto the Member Zone. There are four statuses, Bronze, Silver, Gold and Platinum. Everyone starts at Bronze and a member s Vitality status is then determined by the points built up throughout the policy year, through activities ranging from exercise and healthy eating to health screens and regular check-ups. The Vitality status achieved by the end of a policy year will then remain for the whole of the next policy year, unless a member improves their status. A member can improve their Vitality status by achieving the required number of points to move from one status to the next; we call this the Vitality status threshold. For example, currently a member needs 800 Vitality points to reach Silver status and a member would need to increase this to 1,600 points to achieve Gold status. When there are two adults on a policy the thresholds are doubled, and so on. A member s Vitality status can go down at each renewal date if the number of Vitality points a member earns during that policy year isn t enough to maintain the status previously achieved. Vitality status can also change midway through the policy year as new adult dependants are added or removed. Insured members and insured dependants must be 18 or over to benefit from Vitality. How Vitality can change This section explains how and why our Vitality programme can change at any time. Our Vitality programme naturally changes over time as: 1. New opportunities and technologies arise. It is also dependent on our relationship with third party providers and the range of services they offer. 2. We may change the way we award points and/or the eligible activities in the Vitality programme and the Vitality status a member may achieve as a result. We may also change our Vitality partners from time to time and the incentives we offer. There may be instances where other aspects of the Vitality programme, such as particular benefits, may be significantly enhanced, changed or withdrawn. 3. These changes may occur if our Vitality partners offer additional services or become unable to maintain their levels of service to us, or where we add new Vitality partners to the programme. Vitality changes may also be required to prevent the fraudulent use of benefits. Revisions may be required as a result of other factors beyond our control. 4. Vitality benefits are expressed in one of two ways: as a straightforward price, or as a percentage discount off a provider s standard price. We reserve the right to increase the former during the policy year. If we do need to increase these prices, we will increase them for all our members at the same time, to avoid any confusion. Any price increases will only occur once during a policy year. No price increase shall exceed the amount equal to the change in the Consumer Price Index (since our last price increase for that benefit) as calculated against the Bronze price (or the price paid by all members if there is no difference in price according to Vitality status). For example, if the Bronze price (or standard price, if applicable) for a particular benefit is 100, and the CPI increases 3%, the maximum price increase for any Vitality status shall be 3. Therefore, 20 21

12 if the Platinum price for that particular benefit is 10, the most someone on Platinum status would pay is The cost of Vitality benefits expressed as a percentage discount off a provider s standard price may vary during the year if that provider changes its standard price. For example, the current discount on our health screens is 50%. If the current standard price is 40, the cost to a member would be 20. If the standard price was increased to 50, the cost to a member would be We will usually tell you about any changes to the Vitality programme, including any price increases, at least six weeks before the changes take effect, unless we re unable to do so due to factors outside our control. If your employer is not satisfied with the changes, they may cancel your policy in line with the cancellation provisions in section 4.8 (page 31). However, please note that a member may still be subject to the notice period of any relevant Vitality partner and to any other relevant terms and conditions of that Vitality partner. 7. Please note that the previous clause refers just to changes to the Vitality programme made within the policy year and does not prevent us from applying changes and price increases at each renewal date. 8. New adult dependants or partners who join during a policy year will alter the Vitality status thresholds but can immediately participate in Vitality activities and earn Vitality points up to the renewal of your policy. 9. Insured dependants or partners can be taken off the policy throughout the policy year but a member must give us 30 days advance notice. Anyone leaving the policy before the end of the policy year will not be entitled to any share of benefits they may have earned during that policy year. All of an insured member s Vitality benefits will cease when their cover ends subject to the notice period of any relevant Vitality partner. Also, all Vitality points they ve earned will be removed from the policy and Vitality status thresholds will be adjusted accordingly, and result in a change in Vitality status. 10. There will be no refund in respect of any Vitality activities or Vitality points earned once a policy has been cancelled. 2. Underwriting 2.1 Full Medical Underwriting Under full medical underwriting a member will have made a declaration regarding their medical history. Pre-existing conditions will be identified from that declaration and exclusions applied to the policy. PruHealth may request further information when a claim is being made to establish any relationship to a pre-existing condition and/or to check that all conditions were disclosed on the medical declaration. It is the responsibility of the member to disclose any pre-existing conditions to PruHealth upon joining the policy. Failure to do so may result in personal exclusions being applied and claims being declined, any sums already paid out on the member s behalf being recovered by PruHealth and/or even cancellation of the policy. If the member has any doubts about such disclosure they should call our Customer Services Team on PruHealth may request further information when a claim is being made to establish any relationship to the overall exclusions in section 3. Complications or increased treatment costs as a result of an excluded preexisting condition will not be covered. 2.2 Moratorium Underwriting If a member joins before 1 January 2013: Under moratorium underwriting, conditions which existed up to five years before the date of the start of cover will not be explicitly identified, but may be excluded from cover for two years from the date of commencement. We will exclude cover for treatment for any medical condition or related medical condition which the member or their covered dependants: Have had symptoms of, whether diagnosed or not Been aware of or sought advice on Received medical treatment for in the five years before the start of cover. PruHealth will in most cases request further information when a claim is being made to establish whether the condition is pre-existing and thereby excluded by the moratorium clause. PruHealth may also request further information when a claim is being made to establish any relationship to the overall exclusions in section 3. Complications or increased treatment costs as a result of an excluded pre-existing condition will not be covered. If a member joins on or after 1 January 2013: Under moratorium underwriting, we will not pay for treatment of any medical condition or related medical condition which the member or their covered dependants: have received medical treatment for, had symptoms of, have asked advice on, or to the best of their knowledge were aware existed in the five years before the start of cover. This is called a pre-existing condition. However, subject to the policy terms and conditions, a pre-existing condition can become eligible for cover providing when the member or their covered dependants first receive treatment they have not: consulted anyone (e.g. a GP, dental practitioner, optician or therapist, or anyone acting in such a capacity) for medical treatment or advice (including check-ups), or taken medication (including prescription or over-the-counter drugs, medicines, special diets or injections), for that pre-existing condition or any related medical condition for two continuous years after the start of their cover. PruHealth may also request further information when a claim is being 22 23

13 made to establish any relationship to the overall exclusions in section 3. Complications or increased treatment costs as a result of an excluded preexisting condition will not be covered. For more information, please read Appendix 1a and 1b at the back of this document. 2.3 Switch/CPME Underwriting Pre-existing conditions excluded by the previous provider s policy will be excluded from cover, where this option is selected. PruHealth may request further information when a claim is being made to establish any relationship to a pre-existing condition and/or to check eligibility of the transfer against the declaration signed. New members without previous medical insurance may be fully underwritten. PruHealth may also request further information when a claim is being made to establish any relationship to the overall exclusions in section 3. Complications or increased treatment costs as a result of an excluded preexisting condition will not be covered. Please note, we may ask for a switch application form to be completed, in which case, depending upon the answers given, we may apply personal medical exclusions. If this applies, then any exclusions will be listed in the member s membership certificate. 2.4 Medical History Disregarded Where medical history disregarded is selected, pre-existing conditions are covered subject to the overall exclusions in section 3. PruHealth may request further information when a claim is being made to establish any relationship to the overall exclusions in section 3. New members must join the policy at their earliest opportunity or at renewal. If the member joins more than 30 days after their earliest opportunity or renewal date, PruHealth will classify this as a material change in risk and reserves the right to underwrite the new member and their dependants. Complications or increased treatment costs as a result of an excluded pre-existing condition will not be covered. 2.5 Reviewing personal exclusions Personal exclusions can, in some cases, be reviewed in the future if the member asks us to do so within 30 days of their renewal date. But, if we need to obtain any medical evidence the member will have to pay for this. However, we will not remove any personal exclusion for a chronic condition. 3. Exclusions The following conditions and healthcare services are not covered by PruHealth under this policy, unless otherwise agreed and shown on the summary of benefits. In addition, any complications or subsequent treatment related to these exclusions are also not covered. Please also read section 1.17 in relation to the Personal Health Fund which may assist a member with paying for some of these exclusions. 3.1 Overseas treatment All treatment provided outside the UK is excluded. 3.2 Chronic conditions Any day-to-day monitoring and therapy of chronic conditions is excluded from cover. This includes consultations by any healthcare professionals, medication, investigations (blood tests, radiology) etc. Examples of chronic conditions include diabetes and asthma. However, acute conditions related to chronic conditions will be covered subject to the member s policy unless a specific exclusion relating to that condition has been applied. Consultations leading up to the diagnosis of a chronic condition will be covered. Many chronic illnesses are of a relapsing and remitting nature, requiring management of recurrent episodes where symptoms deteriorate e.g. multiple sclerosis, Crohn s disease, long-term depressive illness, psoriasis etc. The relapses are part of the normal illness course and therefore cannot be classed as acute complications of the disease and are not covered. 3.3 Frail care This refers to, for example, care received in convalescence and nursing homes, respite care, and domestic support that does not require a trained practitioner. 3.4 Routine check-ups Visits to a doctor where there is no specific medical complaint are excluded from cover, for example, visits to get prescriptions, blood pressure checks etc. 3.5 Preventative treatment (and regular checks) This includes sight tests, regular monitoring of, for example, cholesterol levels, and screening for early detection of diseases such as diabetes, cancer etc. The removal of healthy tissue for prevention of disease and genetic testing of any type are not covered. 3.6 Pregnancy and childbirth Treatment directly or indirectly arising from or required as a result of pregnancy, childbirth or infertility is not covered except for ectopic pregnancy, hydatidiform mole, post partum haemorrhage, miscarriage, retained placenta or stillbirth. 3.7 Retention of disposable and durable medical devices and equipment The cost of medical devices and equipment is not covered. Examples of exclusions are bandages and dressings, unless part of inpatient and day case treatment, wheelchairs, crutches, glasses and contact lenses, external prostheses, orthotics and hearing aids. 3.8 Cosmetic treatment Any treatment primarily for cosmetic reasons or resulting from previous cosmetic treatment is excluded, even if the request is psychologically motivated