Business healthcare PMI Cover Benefits and exclusions

Transcription

1 Business healthcare PMI Cover Benefits and exclusions This document contains the benefits and exclusions for business healthcare PMI Cover from PruHealth. Although we have included the benefit details relating to all of the available modules, for the purposes of the exclusion pages within this document, it has been assumed that the business healthcare plan will only include the Core Healthcare, Core Enhancement and Out-patient Treatment modules as standard. The What s not covered section on page 10 therefore contains the exclusions that would apply in this case. If other modules are selected, then the exclusions may vary. Also, this document has been based upon the business healthcare plan being underwritten on a medical history disregarded (MHD) basis only and therefore no underwriting exclusions have been included. We have tried to make sure this document is as clear and straightforward as possible by writing the terms in plain English. There are however certain words that have special meaning that we d like to draw to your attention: We/us/our means PruHealth You/your means the insured member and insured dependants. Where the words you or your refer specifically to the insured member, we ll say you (the insured member) We have printed the remaining defined words in bold to help you identify them as you read through this document. You ll find a full explanation of each word in the Definitions section. PruHealth 1

2 Your benefits explained PMI In this section we have set out the rules on paying benefits and the specific exclusions that apply to each benefit. Other exclusions applying to your plan are contained within the What s not covered section. All benefits are per insured person, unless stated otherwise. Important notes All treatment must take place in a hospital on the most recent hospital list we have issued to you. In the rare circumstances where eligible treatment is unavailable in a hospital on the hospital list we ve issued to you, we will make arrangements for it to take place at another convenient and appropriate hospital. All treatment must be arranged by your GP or dental practitioner. Also, all treatment must be: for a specific medical condition given by a specialist, physiotherapist, qualified nurse or other practitioner recognised by us, and given just to cure an acute condition or the acute flare-up of a chronic condition. We do not pay for treatment that takes place after your cover has ended, even if this is a continuation of treatment that started while you were still covered by this plan. We will pay benefit after taking off any excess that may apply under this plan. If the NHS wait option has been selected: What we mean by the NHS wait option This simply means that if treatment is available on the NHS within six weeks of the day your specialist tells you that you need in-patient or day-patient treatment, you agree to have your treatment as an NHS patient and cannot claim under your plan with us. However, if in-patient or day-patient treatment is not available on the NHS within six weeks, then you can immediately choose to be treated in a private hospital on your chosen list and can claim under your plan with us, subject to our normal benefits, terms and conditions. How we check if treatment is available on the NHS within six weeks The NHS has details of waiting times for both specialists and hospitals. If you know which specialist is treating you, then we ll check with the hospital to see if your specialist is able to treat you on the NHS within six weeks of telling you that you needed in-patient or day-patient treatment. If you don t know which specialist is going to treat you, then we ll check the hospital waiting times to see if you can be admitted to a public ward of an NHS hospital in your Regional Health Authority within six weeks of being told you needed in-patient or day-patient treatment. 2 PruHealth

3 If Core Healthcare selected: Core Healthcare Hospital charges Charges for in-patient treatment at a hospital on the most recent hospital list we ve sent you accommodation, nursing, drugs prescribed in a ward, intensive care operating theatre charges, surgical dressings and drugs surgical appliances needed as a vital part of an operation diagnostic tests, including pathology, radiology, CT, MRI and PET scans physiotherapy Charges for day-patient treatment at a hospital on the most recent hospital list we ve sent you accommodation, nursing, drugs prescribed in a ward, intensive care operating theatre charges, surgical dressings and drugs surgical appliances needed as a vital part of an operation diagnostic tests, including pathology, radiology, CT, MRI and PET scans for medical aids or appliances (e.g. neck collars, splints and foot supports) for mobility aids (e.g. deposit on use of a wheelchair and crutches) for any prosthesis when the prosthesis is not an integral part of the treatment for personal expenses Core Healthcare Consultants / specialists fees Specialist fees for in-patient and day-patient treatment that takes place at a hospital on the most recent hospital list we ve sent you surgeons and anaesthetists fees for operations and surgical procedures given as in-patient or day-patient treatment physicians fees and other specialist consultations Core Healthcare Treatment at a hospital not included on your list If you have in-patient treatment in a hospital that s not on your hospital list then we ll only pay a contribution towards all of the costs of your in-patient treatment, including your specialists fees. If you have day-patient treatment in a hospital that s not on your hospital list then we ll only pay a contribution towards all of the costs of your daypatient treatment, including your specialists fees. Important notice: the amounts we pay in the above circumstances may be much lower than the total cost of your treatment, so we strongly recommend that you always go to a hospital that s on your hospital list. 300 per night 150 per plan year PruHealth 3

4 Core Healthcare Out-patient scans CT, MRI and PET scans undertaken as an out-patient at a hospital on the most recent hospital list we ve sent you. Core Healthcare Cancer treatment The cover described within Core Healthcare also applies to the treatment of cancer. This section provides details of the other treatments covered that are specifically relevant to cancer. Specific treatment Reconstructive surgery Radiotherapy including internal and external radiotherapy Chemotherapy (the use of drugs to destroy cancer cells) cytotoxic drugs, antiemetics (anti-sickness drugs) and steroids as appropriate hormone therapy or bisphosphonates therapy combined with chemotherapy oral chemotherapy prescribed by an oncologist Biological therapy (the use of substances that occur naturally in the body to destroy cancer cells or prevent them from developing or spreading), including monoclonal antibodies (MABs) cancer growth blockers anti angiogenics Stem cell therapy Hormone therapy or bisphosphonates therapy (if prescribed on their own) *Important note: This means we will not pay for this type of treatment for more than the limit specified, whether treatment is received in consecutive months or spread out over a longer period. When the maximum limit has been reached, no further cover will be available for this type of treatment under this plan for the same or any related condition. Treatment at home for a maximum of 12 months* for a maximum of 3 months* for reconstructive surgery that takes place after three years have elapsed from the last date of any in-patient or day-patient treatment for personal expenses for any diagnostic tests or treatment not considered clinically appropriate within the UK Those treatments outlined under Specific treatment that can be safely delivered in your home setting or another clinically appropriate setting that otherwise would require hospital admission as an in-patient or day-patient. Specialists fees for supervising the treatment Out-patient treatment Treatment, including those outlined under Specific treatment, diagnostic tests and monitoring or follow-up consultations that are considered medically necessary. subject to the relevant limits shown under Specific treatment subject to the relevant limits shown under Specific treatment for any drugs that would normally be prescribed by your GP for personal expenses for any monitoring or follow-up consultations that take place after five years have passed since your last cancer treatment 4 PruHealth

5 Core Healthcare Private ambulance The use of a private ambulance to and from hospital if a specialist recommended it as medically necessary. Core Healthcare NHS cash benefits NHS hospital cash benefits for in-patient treatment received for a medical condition covered by the plan, as a non-paying NHS patient day-patient treatment received for a medical condition covered by the plan, as a non-paying NHS patient 250 a night, up to a total of 2,000 per plan year 125 per day, up to a total of 500 per plan year if treatment is not eligible under this plan If Out-patient Treatment selected: Out-patient Treatment Level 1 Specialist fees for out-patient treatment at a hospital on the most recent hospital list we ve sent you specialist consultations and diagnostic tests, including pathology and radiology physiotherapy but if you have out-patient treatment in a hospital that s not on your hospital list then we ll only pay up to 500 per plan year up to 150 per plan year please note this amount would then be deducted from your monetary limit for routine medical or dental checks for routine sight and hearing tests for medical aids or appliances (e.g. neck collars, splints and foot supports) for mobility aids (e.g. deposit on use of a wheelchair and crutches) for spectacles, contact lenses, hearing aids, cochlear implants or dentures for drugs or dressings that you take home Other levels of cover are available under the Out-patient Treatment module and these are shown below: Level 2 Level 3 Out-patient Treatment We will pay up to 1,000 per plan year but if you have out-patient treatment in a hospital that s not on your hospital list then we ll only pay up to 150 per plan year please note this amount would then be deducted from your monetary limit but if you have out-patient treatment in a hospital that s not on your hospital list then we ll only pay up to 150 per plan year PruHealth 5

6 If Psychiatric Treatment selected: Psychiatric Treatment In-patient and day-patient treatment in any psychiatric hospital on the most recent hospital list we ve sent you accommodation, nursing, drugs prescribed on a ward, diagnostic tests, physicians fees and specialist consultations Out-patient treatment in any psychiatric hospital on the most recent hospital list we ve sent you specialist consultations, ECT and diagnostic tests, for up to 28 days per plan year note: each session of day-patient treatment whether or not it is a half-day session will count as one full day towards the 28 day limit up to 1,500 per plan year for any treatment not under the control of a psychiatric specialist If Additional Therapies selected: Additional Therapies Level 1 The following therapies or consultations after referral by your GP or specialist chiropractic osteopathy chiropody/podiatry acupuncture homeopathy consultations with a dietician (maximum of 2 per plan year) up to 350 per plan year for drugs or dressings that you take home for medical aids or appliances (e.g. neck collars, splints and foot supports) for mobility aids (e.g. deposit on use of a wheelchair and crutches) for treatment following self-referral where you ve not visited your GP, unless this has been agreed by us in writing in advance of the treatment A further level of cover is available under the Additional Therapies module and this is shown below: Level 2 Additional Therapies We will pay 6 PruHealth

7 If Private GP selected: Private GP Private GP services including consultations, prescriptions, minor surgery and fees for the completion of claim forms at any private GP surgery. up to 300 per plan year If Maternity Cover selected: Maternity Cover Private ante-natal and post-natal care, including specialist consultations, diagnostic tests and investigations, and delivery for a normal pregnancy in any hospital on the most recent hospital list we ve sent you. up to 3,000 per pregnancy for any charges incurred before the mother-to-be has been covered under this plan for at least two continuous years for any treatment as a result of pregnancy complications PruHealth 7

8 If Core Enhancement selected: Core Enhancement Parent accommodation Accommodation for you or your insured husband, wife or partner to stay with your insured child under age 14 while they are receiving in-patient treatment in a hospital on the most recent hospital list we ve sent you. for personal expenses Core Enhancement Pregnancy complications Charges for in-patient and day-patient treatment at a hospital on the most recent hospital list we ve sent you for the following conditions and directly associated complications ectopic pregnancy miscarriage missed abortion still birth post partum haemorrhage retained placental membrane hydatidiform mole We will cover caesarean sections that are medically necessary but only in the following circumstances where the baby is breech at the end of the pregnancy (at 36 weeks) and where it has not been possible to move the baby round to head first if having twins and the first is in a breech position in an emergency (where there is an immediate threat to the life of the mother or baby) but we will not cover hospital charges and specialist fees where you choose to have your baby in a private facility except where these are directly related to the above complications for charges if the mother has not been insured under the plan for at least 10 months for ante-natal care for any complication of pregnancy and childbirth not listed under the What s covered section for any complications following infertility treatment, IVF or other assisted reproduction for investigations and treatment of recurrent miscarriages Core Enhancement Investigations into infertility The costs of investigations into the cause of infertility. The investigations must take place in a hospital on the most recent hospital list we ve sent you. for any form of infertility treatment, IVF or other assisted reproduction for any investigations unless you or your insured dependant have been on the plan for two years 8 PruHealth

9 Core Enhancement Oral surgery Charges for in-patient and day-patient treatment at a hospital on the most recent hospital list we ve sent you for the following oro-surgical procedures only removal of buried, impacted or unerupted teeth removal of roots from antrum removal of complicated buried roots covered by bone for any other dental treatment or oro-surgical procedure Core Enhancement Home nursing The services of a qualified nurse for skilled nursing care at home. For you to qualify for this benefit, all home nursing must immediately follow a period of in-patient treatment for a medical condition covered by the plan be certified by your specialist as necessary for medical (not domestic) reasons be skilled nursing care provided at your home, which would otherwise be provided in hospital as an in-patient be given by a qualified nurse and carried out under the direction of your specialist for up to 13 weeks per plan year for home nursing following in-patient treatment for psychiatric and mental conditions for any charges for domestic or social reasons Core Enhancement Help at home The services of a qualified nurse for secondary nursing care, or a care assistant to provide personal care services (or both) For you to qualify for this benefit, all secondary nursing care and personal care services must immediately follow a period of in-patient treatment for a medical condition covered by the plan and be certified by your specialist or GP as being medically necessary because of your domestic and medical circumstances be for those domestic duties which would normally be carried out by you or your insured dependant claiming this benefit, and not provided by your husband, wife or partner or a housekeeper regularly employed to do those duties be authorised in advance by our claims department. If you don t get our written approval before taking on costs for secondary nursing care and personal care services, we ll only pay 50% of any of those costs that you are covered for up to 3 hours per day for a maximum of 7 days per plan year for services provided by anyone other than a qualified nurse or care assistant under the direction of your specialist or GP PruHealth 9

10 What s not covered The following exclusions are based on Core Healthcare, Core Enhancement and Out-patient Treatment being the only modules selected. Final exclusions may vary depending on the choice of modules for each business healthcare plan. Below we ve set out the exclusions that apply to this section of your plan. For ease of reference, we have divided the exclusions into the following categories: Medical conditions Treatments General exclusions Medical conditions We will not pay for the following: treatment of alcoholism, drug abuse or any addiction and treatment of any related medical conditions resulting from these treatment of any self-inflicted illness or injury, or any treatment related to them, or treatment arising from attempted suicide treatment of any illness or injury which is medically considered to be linked directly or indirectly with Human Immunodeficiency Virus (HIV) and/or Acquired Immune Deficiency Syndrome (AIDS) and/or any form or variation of HIV or AIDS, however caused treatment of chronic conditions except treatment of an acute flare-up of a chronic condition treatment to maintain your state of health or to monitor your health on a regular basis treatment, including investigations and assessments, related to developmental problems and learning difficulties including but not limited to dyslexia, dyspraxia and behavioural problems such as attention deficit hyperactivity disorder (ADHD) treatment for myopia (short sightedness), hypermetropia (long sightedness), astigmatism or any other refractive error or treatment which results from, or is in any way related to, these conditions treatment of sleep apnoea, snoring, insomnia or other sleep disorders treatment for obesity, including surgery treatment of any psychiatric, mental or nervous conditions Treatments We will not pay for the following: the services of a GP or dental practitioner or any person acting as one treatment, including surgery, to remove healthy or non-diseased tissue whether or not for psychological or medical reasons, including but not limited to breast reduction and blepharoplasty (eyelid lift) cosmetic treatment, whether or not for psychological reasons, or any treatment that results from or relates to previous cosmetic treatment or reconstructive surgery. However, we will cover cosmetic treatment necessary as a direct result of an accidental injury that occurs after your cover start date sex change/gender reassignment or treatment which results from, or is in any way related to, sex change/gender reassignment hormone replacement therapy dental treatment regular or long-term dialysis in chronic or final kidney failure 10 PruHealth

11 treatment or drug therapy which, based on established medical practice in the UK, is considered to be experimental or unproven any treatment using unlicensed drugs or the use of drugs outside the terms of their licence in the UK rehabilitation following treatment out-patient drugs, medicines and dressings, surgical appliances (such as neck supports, shoe inserts and braces), dental appliances, hearing aids (such as cochlear implants), contact lenses, spectacles, and mobility aids such as wheelchairs and crutches treatment that s given solely to provide relief of symptoms including psychological support, terminal care or hospice care any treatment for, related to or arising from or as a consequence of male or female birth control including sterilisation and its reversal any type of contraception termination of pregnancy pregnancy, except the obstetric conditions listed in your benefit table childbirth, except the obstetric conditions listed in your benefit table treatment of infertility, but we will cover the cost of investigations into the cause of infertility providing you and, if applicable, your insured dependant have been covered under this plan for at least two continuous years before any investigations begin investigations into or treatment of impotence or other sexual dysfunction any form of human-assisted reproduction any treatment received within 91 days of birth by a dependant born as a consequence of any form of human-assisted reproduction oral surgery, except those procedures shown in your benefit table any kind of alternative or complementary therapy anything to do with routine, precautionary or preventive examinations, dental check-ups, routine hearing and sight tests, vaccinations, screenings (including screenings of familial conditions) or preventive treatment General exclusions In addition to the specific exclusions detailed, the following general exclusions apply: treatment arising from nuclear or chemical contamination, war, invasion, act of foreign enemy, hostilities (whether war is declared or not), civil war, riot, civil disturbance, rebellion, revolution, military force or coup, act of terrorism treatment received after the period covered by any premium or after the plan has been cancelled treatment in a hospital that s not on the hospital list we ve issued to you, unless specifically agreed by us extra accommodation costs for going into hospital early or leaving late because of your or your insured dependant s domestic circumstances or where there is no required treatment treatment received outside the UK (unless Travel Cover is included in your plan) PruHealth 11

12 12 PruHealth Definitions These definitions are shown in bold print throughout this benefits and exclusions document and have the same meaning wherever they appear. Accidental injury An injury directly caused by something accidental, outside the body, violent and visible. It does not include sickness, disease or any naturally occurring or deteriorating condition. Acupuncture A type of alternative medicine that must be carried out by a member of the British Acupuncture Council, or the Acupuncture Association of Chartered Physiotherapists, or by a medical practitioner who holds a Certificate of Basic Competence issued by the British Medical Acupuncture Society or a Diploma of Medical Acupuncture. Acute condition A disease, illness or injury that is likely to respond quickly to treatment which aims to return you to the state of health you were in immediately before suffering the disease, illness or injury, or which leads to your full recovery. Acute flare-up of a chronic condition A sudden and unexpected deterioration of a chronic condition that is likely to respond quickly to treatment. Annual renewal date The date, 12 months after the plan start date and each anniversary after that date. Cancer A malignant tumour, tissues or cells, characterised by the uncontrolled growth and spread of malignant cells and invasion of tissue. Care assistant A person attached to a registered nursing agency who is approved by that nursing agency as an approved carer or nursing auxiliary. Check-up A consultation with, or a visit to, any medical practitioner about any medical condition or any signs and symptoms of a medical condition. Chiropody/podiatry Disorders, diseases and deformities of the feet diagnosed and treated by a chiropodist/podiatrist. Treatment must be given by a practitioner who is registered with the Health Professions Council and recognised by us. Chiropractic A type of alternative medicine that must be carried out by a member of the General Chiropractic Council. Chronic condition 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

13 Company The employer who has agreed with us to operate a scheme for employees, paid for by the employer. Cover start date The date on which each insured person s cover starts. Day-patient A patient who is admitted to a hospital or day-patient unit because they need a period of medically supervised recovery but does not occupy a bed overnight. Dental practitioner A registered licensed dental practitioner in general practice. Diagnostic tests Investigations, such as x-rays or blood tests, to find or to help find the cause of your symptoms. Drug abuse The taking of any drug, substance or solvent unless it was as prescribed by a GP or specialist. Excess (per claim) The amount you will have to pay each time you or your insured dependants make a new claim for treatment covered by this plan. If treatment for the same condition has gone on for more than a year, we will treat it as a new claim for any further treatment after that date. Excess (per plan year) The first amount which must be paid by you before we make any payment under this plan for treatment covered by this plan. Only one excess is payable in each plan year for each insured person. General practitioner (GP) A registered licensed medical practitioner in general practice. Home nursing Skilled nursing care provided by a qualified nurse. Home nursing must be supervised by an insured person s specialist. Homeopathy A type of alternative medicine that must be carried out by a member of The Faculty of Homeopathy, Society of Homeopaths or Alliance of Registered Homeopaths. Hospital Any hospital that is on the most recent hospital list we have issued to you. In-patient A patient who is admitted to hospital and who occupies a bed overnight or longer, for medical reasons. Insured dependant Your insured husband, wife or partner, who live at the same address as you. Your insured children, who must be under the age of 25 at the cover start date and at each annual renewal date. Insured member Any qualifying employee or person in the company whom we accept for cover. PruHealth 13

14 Nurse A qualified nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number. Osteopathy A type of alternative medicine that must be carried out by a member of the General Osteopathic Council (GOsC). Out-patient A patient who attends a hospital, consulting room or out-patient clinic and is not admitted as a day-patient or an in-patient. Physiotherapy Treatment carried out by a person who is registered with the Health Professions Council (HPC) as a physiotherapist. Plan start date The date on which the plan began. Plan year A period of 12 months from the plan start date or from any annual renewal date. Planholder The company which has the contract with us. Private ambulance A road vehicle built just to use as an ambulance and run by a registered private ambulance service. Rehabilitation Medical services aimed at restoring a person s independence following treatment of a disease, illness or injury. Related condition Any symptom, disease, illness or injury which reasonable medical opinion considers to be associated with another symptom, disease, illness or injury. Specialist A medical practitioner who is fully registered with the General Medical Council, and who is recognised by us in writing. They must either: hold or have held a substantive consultant post with the NHS, or hold a Certificate of Completion of Training (CCT) and be registered on the Specialists Register, or fulfil the qualification criteria requirements set by the Postgraduate Medical and Educational Training Board (PMETB) and be registered on the Specialists Register. We reserve the right to withhold or remove recognition of any specialist, at our discretion, due to reasons such as fraud or unreasonable charges. Treatment Surgical or medical services (including diagnostic tests) that are needed to diagnose, relieve or cure a disease, illness or injury. UK Great Britain and Northern Ireland including the Channel Islands and the Isle of Man. PruHealth is a trading name of Prudential Health Insurance Limited (registered number ), and Prudential Health Services Limited (registered number ). Prudential Health Insurance Limited provides and manufactures benefits under the plan and Prudential Health Services Limited distributes and services the plan and issues the documentation. Companies are registered in England and Wales. Registered offices at Laurence Pountney Hill, London EC4R 0HH. Both companies authorised and regulated by the Financial Services Authority Calls may be recorded/monitored to help improve customer service. Call charges may vary PruHealth SLH/1786/1110