Bupa by you training pack

Transcription

1 Bupa by you training pack For Intermediary Use Only Bupa Health Funding December 2013 bupa.co.uk

2 2 BUPA BY YOU PRODUCT (BBY)

3 BUPA BY YOU OPTIONS Comprehensive cover Treatment and Care Treatment and Care with Scan and Test Cover Out-patient Consultations Paid in full following treatment of condition/operation and within six months of being discharged Paid in full* Paid in full following 1,000 Combined 750 Combined 500 Combined treatment of condition/operation and within six months of being discharged Minor Diagnostic Tests Paid in full* Paid in full* Out-patient Therapies Paid in full* Paid in full* Paid in full* MRI, CT and PET Scans Paid in full* Paid in full* Paid in full* Paid in full* Paid in full following treatment of condition/operation and within six months of being discharged Paid in full* Cancer Treatment/ Cancer Cover Plus Paid in full*/nhs Cancer Cover Plus (see details on page 15) Paid in full*/nhs Cancer Cover Plus (see details on page 15) Paid in full*/nhs Cancer Cover Plus (see details on page 15) Paid in full*/nhs Cancer Cover Plus (see details on page 15) Paid in full*/nhs Cancer Cover Plus (see details on page 15) Paid in full*/nhs Cancer Cover Plus (see details on page 15) * For eligible treatment on your core health insurance when you use a facility from your chosen Bupa network and a Bupa recognised consultant who agrees to charge within Bupa limits (a fee assured consultant) 3

4 Scheme Wide Benefits Mental Health and Wellbeing Paid in full* or up to your combined allowance if you have chosen an out-patient limit. In-patient and Day-patient care is limited up to 28 days per year. In-patient Treatment Hospital charges and Surgeon and Anaesthetist fees paid in full*. Anytime HealthLine Members can speak with a private GP or nurse 24/7 365 days a year. Parental Accommodation Up to 16 years old. One Parent or Guardian to accompany child into hospital. Treatment at home Bupa discretionary and clinically appropriate. Paid in full*. Home Nursing Bupa Discretionary and clinically appropriate. Paid in full*. Private Ambulance Up to 60 per journey. Medically necessary. NHS Cash Benefit o o 50 per night up to 35 nights per policy year. NHS Cancer Cash Benefit o o 100 per day or night. * For eligible treatment on your core health insurance when you use a facility from your chosen Bupa network and a Bupa recognised consultant who agrees to charge within Bupa limits (a fee assured consultant). 4

5 Excess and Hospital list 5

6 Excess Excess Options Available 0, 100, 150, 200, 250, 500, 1,000 and 2,000 Chosen excess only applies once per person, per policy year and is applicable against first claims received. If treatment spans a policy renewal the excess will apply for that policy year so your excess could apply twice to a single course of treatment. Excess will not erode out-patient limit (if out-patient limit chosen and first eligible claim is for an out-patient claim). 6

7 Hospital Lists and NHS Cancer Plus 3 Choices of Hospital Lists Essential Access Lowest cost network. Access to a limited national hospital network. Extended Access Most comprehensive hospital access outside Central London. Excludes Central London. Extended Choice With Central London Most extensive hospital list. Includes Central London hospitals such as the Bupa Cromwell. NHS Cancer Cover Plus Your client would be treated by the NHS if they are diagnosed with cancer. However if the radiotherapy, chemotherapy (including cancer drugs) or surgical operation they need to treat their cancer is not available to them from the NHS, Bupa will then step in to cover the cost of their eligible treatment. This is providing they use a Bupa recognised consultant we have already agreed our fees with, within their chosen Bupa hospital network. 7

8 8 Discounts and No claims discount (ncd)

9 No Claims Discount (NCD) Facts about the NCD 14 levels more levels means it would take four years if claiming more than 500 per year to get to the bottom. Levels will not reduce by any more than three in one policy year. Claims for NHS cashback or claims that fall entirely within the excess will not affect the NCD. NCD applies at member level. Bupa differentiates between claim amounts. 9

10 No Claims Discount (NCD) The No Claims Discount Table below shows how Claims can affect the discount Claim free year Up 1 Entry NCD Level Discount 0% 10% 20% 27.5% 35% 40% 45% 50% 55% 59% 62% 65% 68% 70% Down dependent on claim value Unlike some of our competitors, we believe it s unfair to penalise all claiming members the same and that s why our new No Claims Discount Scale is based on the actual claimed amount. In addition to being fairer for our members, we have introduced this hybrid scale because evidence suggests that claimed amount is a strong estimator of future claims experience. Claim amount table CLAIM VALUE NCD LEVEL 0 Move up the scale by 1 level move down the scale by 1 level move down the scale by 2 levels > 500 paid move down the scale by 3 levels 10

11 DISCOUNTS 10 percent FOR DOCTORS AND DENTISTS Main member must be eligible for discount. Discount applies to everyone on the policy. Full list of discount eligibility can be found on the portal. Discount applied to base rate before NCD is added. Discounts cannot be used in conjunction with each other. Discounts are not available on Ex-Bupa Group Scheme leaver policies. Bupa may ask for prf from your client confirming discount eligibility. Discount applies to core Bupa by You product and does not relate to any add ons such as travel or dental cover. 11

12 12 ELIGIBILITY AND GENERIC FactorS

13 Eligibility and Generic FACTOrs Must be living in the UK and registered with a GP for at least six months. Priced around age, postcode and smoking status. Sports Injuries covered however not eligible for cover if professional or semi-professional sports person. Annually renewed and reviewed with your client through you. Mid-term changes are administered by our retention team your client would call us directly. Monthly payment. Your clients have 21 days from receiving their paperwork to make changes to the policy or cancel to receive a full refund providing a claim hasn t been made. Direct debit details from a UK bank account. NOTE: Treatment and Care options not available on Ex-Bupa Group Scheme leaver policies. 13

14 14 Add On Options

15 Bupa By You Add On Matrix Bupa By You Core Product Travel Options (One of the below) Cancer Assist COMPLEMENTARY Therapies Dental and Health Expenses Options (One of the below) Worldwide or Europe (Single Level) Health Expenses 10 or 20 Worldwide or Europe (Family Level) Dental 10 or 20 No claims discount not affected by claiming on any of the add ons, in addition to this no claims discount also not affected by NHS Cash Benefit. If selling add ons it must be made clear that they are optional enhancements to the policy. 15

16 Dental 10 NHS Cover All NHS dental treatments are covered by standard charges that fall into three separate bandings; Band 1, Band 2 and Band 3. Bupa will pay up to each banding limit detailed in the table below If your client is charged more than once in any two month period we will reimburse you for the highest banded treatment only. DENTAL COVER 10: aimed at customers with an NHS dentist TYPE OF COVER BENEFIT LIMITS WAITING PERIOD FROM POLICY INCEPTION NHS Band 1 NHS Band 2 NHS Band 3 Band 1 course of treatment: Examination Diagnosis (e.g. X-rays) Advice on how to prevent future problems Scale and polish Application of fluoride varnish or fissure sealants Band 2 course of treatment: Covers everything listed in Band 1 above, plus: Fillings Rt canal work Extraction of one or more teeth Band 3 course of treatment: Covers everything listed in Bands 1 and 2, plus: Crowns Dentures Bridges None 4 months 4 months Oral cancer treatment Full refund* 6 months NHS Charging Bands What we pay back Current band prices paid back (as of April 2013) Band 1 Band 2 Band 3 Price *All your eligible oral cancer treatment costs are paid in full (following a six month waiting period) when you use a facility from your chosen Bupa network and a Bupa recognised consultant who agrees to charge within Bupa limits (a fee assured consultant). 16

17 Dental 10 NHS Cover The band amounts that we pay back will cover treatment under the NHS in England and Wales. However this is not guaranteed in Scotland and Northern Ireland. Instant cover on Band 1 treatment (no waiting periods). Emergency Dental and Dental Injury in the UK to alleviate pain or acute dental conditions; covered in full within relevant band (four month waiting periods apply to any treatment from Band 2 or 3). Your client needs to call Bupa to confirm benefits before receiving any treatment; as exclusions apply such as injury sustained whilst participating in a physical contact sport. We will then send out a claim form for the dentist to complete. Priced on single age bandings (price will change on renewal). Pre-existing conditions are not covered. Waiting period means that your client will not be able to claim benefit until shown time has exhausted. 17

18 Dental 20 PrivATe Dental Bupa Dental Cover 20 is dental insurance for privately registered patients. DENTAL COVER 20: aimed at privately registered patients TYPE OF COVER BENEFIT LIMITS PERIOD FROM POLICY INCEPTION Routine treatment (examinations, X-rays and scale and polish) Dental treatment (non-routine treatment) fillings, rt canal, extractions, crowns, bridgework and dentures Emergency dental treatment in the UK to alleviate pain or acute dental conditions Up to 150 per year Up to 700 per year - Bupa pays 75% of eligible claims Up to 600 per year None 4 months 14 days Dental injury treatment Up to 5,000 per year 4 months Oral cancer treatment Full refund* 6 months Instant cover on routine treatment (no waiting periods). Dental 20 can also be used to pay for NHS dental charges. 100 percent reimbursement on routine treatment and oral cancer*. Your client needs to call Bupa to confirm benefits before receiving any treatment; as exclusions apply such as injury sustained whilst participating in a physical contact sport. We will then send out a claim form for the dentist to complete. No pre-enrolment checks. No age bandings, priced on single age increments (price will change on renewal). Pre-existing conditions are not covered. Waiting period means that your client will not be able to claim benefit until shown time has exhausted. * All your eligible oral cancer treatment costs are paid in full (following a six month waiting period) when you use a facility from your chosen Bupa network and a Bupa recognised consultant who agrees to charge within Bupa limits (a fee assured consultant). 18

19 Health Expenses 10 and 20 HEALTH EXPENSES percent reimbursement up to benefit limits. TYPE OF COVER Dental services BENEFIT LIMITS Up to 125 per year Your client needs to send original copy of receipt back to Bupa within 90 days of treatment with claim forms provided. Your client will be reimbursed via BACS into their bank account. Optical services Prescription costs Up to 125 per year Up to 25 per year Optical includes prescription glasses, prescription sunglasses, appointments and contact lenses. Dental includes check-ups, hygienist and treatment any dental related medications are excluded. Can claim prescriptions from a private GP or your dentist. HEALTH EXPENSES 20 TYPE OF COVER BENEFIT LIMITS Dental services Up to 250 per year Optical services Up to 250 per year Prescription costs Up to 50 per year 19

20 Complementary Medicines and Cancer ASSIST Complementary Medicines TYPE OF COVER BENEFIT LIMITS NOTES Acupuncture services Pre-existing conditions excluded underwriting applied as per health insurance underwriting. Health insurance excess does not apply. Chiropractic services 350 per year combined limit Includes treatment for cancer, regardless of the rest of the health insurance product Do not need a GP referral, go straight to our Musculoskeletal referral team. Osteopathy services Cancer Assist TYPE OF COVER BENEFIT LIMITS NOTES Pre-existing conditions excluded underwriting applied as per health insurance underwriting. Financial support benefit 2,000 per year, on diagnosis of primary/ secondary cancer Paid upon diagnosis of a new primary or secondary cancer, up to a maximum of one claim per person per year Upper age limit of 59 (at point of sale your client can then keep cover as long as they wish). 20

21 Travel Cover TYPE OF COVER BENEFIT LIMITS Available either for Europe or Worldwide on a single or family cover basis. Maximum trip duration 31 days in a row and 183 in each annual insurance period. No hospital network; your client uses the most appropriate hospital dependent on country and condition. General Exclusions apply (see policy summary). Even covers trips inside the UK if your client has pre-bked two or more consecutive nights (see policy summary for more detail). Maximum age for dependants on a family policy is 18. Pre-existing conditions excluded underwritten at the point of claim. Does not cover business trips. Medical emergency and other related expenses Cancellation or cutting short the trip Personal baggage Bupa Health Screen Unlimited ( 50 excess per claim) (maximum of 1,000 for emergency dental treatment) Medical expenses only, claims must be pre-authorised please refer to documentation Up to 3,000 ( 50 excess per claim) Up to 1,500 ( 50 excess per claim) One upon return to the UK in the event of a 5 night stay in a facility abroad Hospital daily benefit Up to 15 per night, up to a maximum of 1,000 Personal liability Up to 2,000,000 Personal accident Up to 30,000 Legal protection Up to 25,000 Money and passport Missed departure Baggage delay Up to 150 Travel delay Up to 150 Mugging benefit Up to 500 Hijack Up to 500 Kennel and cattery Up to 250 Up to 500 ( 50 excess per claim) (Cash losses are limited to 250 and 50 if under 18) Up to 500 ( 50 excess per claim) Ski equipment Hire ski equipment Ski pack Piste closure Avalanche Up to 500 ( 50 excess per claim) Up to 500 ( 50 excess per claim) Pro rata refund up to 150 ( 50 excess per claim) Up to 200 ( 25 per day) Up to 150 ( 30 per day) ( 50 excess) 21

22 SOME EXAMPLES OF GENERAL EXCLUSIONS Below are some examples of what Bupa will not cover for each product. Bupa By You Core product Aging, menopause or puberty. Chronic conditions. Cosmetic surgery. Dialysis. Please see membership guide for full list of exclusions. Dental Cosmetic dental treatment. Contamination, wars or riots. Surgical implants. Please see membership guide for full list of exclusions. Health Expenses Tth cleaning and tth whitening materials purchased for use at home. Any dental related medications. Please see membership guide for full list of exclusions. Cancer Assist Any claim not relating to a new diagnosis of cancer. Please see membership guide for full list of exclusions. Complementary Therapies Homeopathy, aromatherapy and reflexology. Please see membership guide for full list of exclusions. Travel Pre-existing conditions excluded underwritten at the point of claim. Does not cover business trips. Please see membership guide for full list of exclusions. 22

23 Underwriting 23

24 Underwriting Options Full Medical Underwriting Medical History filled out via editable PDF containing all the questions. Guidance notes to help with underwriting (see next page). Support from our Medical Assessment Team if needed. Customers go through our early claims process. Moratorium Two year Rolling Moratorium. Lking back at the five years prior to joining date. Medical report requested upon claiming. To clarify any specific exclusions or review timeframes, please call our Medical Assessment Team on Opening Hours Monday to Friday 8am to 6pm. Calls may be recorded and may be monitored. 24

25 Medical Underwriting Guidelines FMU Conditions are likely to be excluded if - The customer is currently: seeing a medical professional (including physiotherapist, chiropractor, consultant, GP) for advice. receiving treatment (including medication whether prescribed or not). has symptoms (whether or not they have been to the GP and had anything diagnosed). is undergoing tests (including bld tests). has any planned or pending treatment or follow up consultations. Conditions are often reviewed within a seven year timeframe once they have been symptom, treatment and advice free. Exclusions can only be reviewed at renewal, upon the request of the customer. Each review timeframe is specific to the condition, however those that require surgery often have longer timeframes eg two years+ (such as Musculoskeletal, bowel and cancerous conditions). Some conditions may never be reviewed. These are chronic conditions such as blindness, deafness, arthritis, joint replacements, some psychiatric conditions, as well as others. Once a condition has been treated and resolved, each one will have a timeframe that follows in which they will still be excluded for that condition (based on risk of recurrence and / or complications). To clarify any specific exclusions or review timeframes, please call our Medical Assessment Team on Opening Hours Monday to Friday 8am to 6pm. Calls may be recorded and may be monitored. 25

26 Medical Underwriting and Enrolment Process FMU Complete editable PDF application form including full medical history section Send to our Support team when enrolling via either the portal or post If there is any medical information that needs clarifying, our medical assessment team will call the member directly to discuss Your client will receive documentation within five to seven working days of enrolment. Editable PDF application form for each underwriting option. Please ensure you use the correct form for the relevant underwriting term. Missing, incorrect or crossed out information on application forms cannot be accepted. All applications must be signed by the customer. Bupa will contact you to resubmit new application form. Moratorium Complete editable PDF application form, no medical history required Send to our Support team when enrolling via either the portal or post When the member comes to claim we will request medical history as required To clarify any specific exclusions or review timeframes, please call our Medical Assessment Team on Opening Hours Monday to Friday 8am to 6pm. Calls may be recorded and may be monitored. 26

27 GUIDED REFERRAL and FEE ASSURED consultants 27

28 Guided Referral and Fee ASSUred ConsulTANTS Customer visits their GP and asks their GP for an Open Referral letter As sn as customer has an Open Referral letter, customer calls Bupa Bupa can then advise of two or three fee assured consultants Customer can have peace of mind that Bupa will pay for everything within benefit limits Pre-authorisation completed over the telephone. Customers using this process and using our fee assured consultants are guaranteed no shortfalls. The GP will not specify the name of the consultant but just the specialty of the consultant they would need to see for their condition. GP s can call our member services team to find a suitable consultant for their patient. Guided Referral means that members can see well over 20,000 highly qualified, experienced consultants, more than 11,000 of whom are fee assured. Bupa recognised consultants have at least seven years experience in their medical speciality and the average age (50 years) and experience of our fee assured consultants is the same as that of our non-fee assured consultants. This process is not mandatory however it needs to be clear to the member that only if they use this process can we guarantee there will be no shortfalls with our consultants. If they chse not to follow the guided referral process they can speak with our advisers when preauthorising a claim. You and your clients can use our free consultant finder to help you and your client find their nearest Fee Assured Consultants and hospitals finder.bupa.co.uk 28

29 EX-BUPA GROUP SCHEME (XGS) 29

30 Ex-Bupa Group Scheme (XGS) Leaver Eligibility Ex-Bupa Group Scheme (XGS) is a customer insured by Bupa UK as a member of their employers health insurance scheme. The main applicant and all dependants to be covered must have two years continuous cover or were fully medically underwritten. The main applicant must be an eligible leaver i.e they are retiring, being made redundant or leaving the company and application date must be within three months from departure of company. You can quote up to 60 days in advance and quotes are valid for 14 days. XGS policies can only be backdated up to 100 days in the past from the cancellation date. Many companies allow child dependants to remain on the company cover until they are 21, or 24 if in full time education. Once they reach this cut off age they may be offered continuation providing they meet all other standard eligibility rules. XGS policies must start from the date of previous policy cancellation (no break in cover) a back payment will be taken if this is the case. Payment cannot come from a business bank account, payment must be from a personal account. Disclaimer to be read out before taking any details from the member to inform the member that all details given need to be accurate. Treatment and Care options not available on XGS policies. 30

31 Bupa Group Leavers Triage Questions Q1. In the last five years has the person to be covered had ANY form of cancer that is not already excluded on their existing scheme? If a member has experienced cancer of any form within the last five years then this question should be answered as Yes. When lking at claims history be wary of anything using the words malignant, neoplasm and leukaemia. Q2. In the last five years has the person to be covered had a heart or circulatory condition that is not already excluded on their existing scheme? For example Coronary Artery Disease (angina and heart attacks), stroke, abnormal heart rhythms, bld clots or aneurysms, heart valve disorders, uncontrolled high cholesterol/bld pressure etc. Q3. In the last five years has the person to be covered had any arthritic conditions and/or back, neck and spinal conditions (including sciatica) or joint replacements that is not already excluded on their existing scheme? Q4. Does the person to be covered have ANY planned or pending investigations, treatment, surgery, follow ups or therapies for any condition or symptom? (This applies whether the treatment is planned privately or under the NHS.) Once questions have been answered you will be able to obtain an indicative price for your client this is subject to validation checks. If your client wishes to go ahead you will need to fill out the relevant forms and send to Bupa. Once received, Bupa will check claims history etc to make sure all details given are accurate. If details are inaccurate then the price is subject to change as we will re-answer the questions correctly. There will be a link on the portal which has helpful hints and tips for answering the triage questions. To clarify any specific exclusions or review timeframes, please call our Medical Assessment Team on Opening Hours Monday to Friday 8am to 6pm. Calls may be recorded and may be monitored. 31

32 Enrolment Process Bupa Group Leavers Quotes are indicative and could change due to inaccurate answers to triage questions. Your client will receive documentation within five to seven working days of enrolment. Scan signed application form and send via the portal Your clients policy will need to start the date the company policy ended or is due to end. Missing, incorrect or crossed out information on application forms cannot be accepted. All applications must be signed by the customer. Bupa will contact you to resubmit a new application form. XGS Complete the indicative quote on the portal answering all eligibility and triage questions When customer is happy with the indicative quote, complete application form and ask customer to sign OR Send application in the post 32

33 SWITCH Switch is currently in development and will be available as an option for your clients sn. We will keep you updated as and when we have more details. 33

34 Your Consumer Intermediary Support Team What if I cannot find the information I m lking for? Our support team are on hand to answer questions regarding products, services and general queries. Please note the team will be unable to answer questions surrounding medical history, please use telephone number at the bottom of page 31. Intermediary Support Team Option 2 or personalintermedquotes@bupa.com Open Monday to Friday from 8AM TO 5PM Calls may be recorded and may be monitored 34

35 NOTES 35

36 Bupa Health Insurance, Dental Insurance and Travel Insurance are provided by Bupa Insurance Limited. Registered in England and Wales No Bupa Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Registered office: Bupa House, Blmsbury Way, London WC1A 2BA. Bupa 2014 Care homes Cash plans Dental insurance Dental services Health assessments Health at work services Health coaching Health information Health insurance Home healthcare International health insurance Travel insurance BBY/8017/JAN _4032 bupa.co.uk