Welcome to the Simplyhealth Employee Plan

Transcription

1 Welcome to the Simplyhealth Employee Plan

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

22 Beverley Beverley is married to a Simplyhealth employee who pays for her membership of the Employee Plan. She has been covered on the plan for five years under Module 2 (In-patient, day-patient and out-patient) and Module 4 (heart and cancer cover) when she is diagnosed with breast cancer. Following discussion with her specialists she decides: to have the tumour removed by surgery. As well as removing the tumour, Beverley s treatment will include a reconstruction operation to undergo a course of radiotherapy and chemotherapy to take hormone therapy tablets for several years after the chemotherapy has finished Will her policy cover this treatment plan, and are there any limits to the cover? The Helpline will arrange the surgery to remove the tumour and also one operation to reconstruct Beverley s breast, and pay the bills for these. If she needed it, we would also arrange and pay for one further operation to improve the symmetry of Beverley s breasts following her reconstruction operation. Provided that Beverley has sufficient funds available from the 50,000 policy lifetime limit for cancer treatment, the Helpline will arrange and pay for Beverley s radiotherapy and chemotherapy treatment. The Employee Plan does not cover the hormone therapy tablets because we consider these to be preventative treatment. However, Beverley will be able to get these tablets directly from her GP. The Helpline will arrange for Beverley to receive follow up consultations and monitoring for a period of five years once she has finished treatment, provided that there are sufficient funds available from the 50,000 policy lifetime limit. If the total costs look like exceeding 50,000 and Beverley decides not to pay for private treatment herself, a Simplyhealth nurse adviser will work with her specialist and the NHS to make sure that treatment continues smoothly as an NHS patient. During the course of chemotherapy Beverley suffers from anaemia. Her resistance to infection is also greatly reduced. Her specialist admits her to hospital for a blood transfusion to treat her anaemia and prescribes a course of injections to boost her immune system Will her policy cover this treatment plan and are there any limits to the cover? Whilst Beverley is receiving chemotherapy (or radiotherapy) that we pay for, we will also pay for treatment prescribed by her specialist that she needs to deal with its side effects. This includes the drugs to boost her immune system and blood transfusions, provided that there are sufficient funds available from the 50,000 policy lifetime limit. We would also pay for, for example, antibiotics, anti sickness drugs, steroids and pain killers. Despite the injections to boost her immune system, Beverley develops an infection and is admitted to hospital for a course of antibiotics. Will her policy cover this treatment and are there any limits to the cover? As the infection is as a direct result of Beverley s cancer treatment we will pay for the admission and antibiotic treatment provided that there are sufficient funds available from the 50,000 policy lifetime limit. Five years after Beverley s treatment finishes the cancer returns. Unfortunately it has spread to other parts of her body. Her specialist has recommended a treatment plan: a course of six cycles of chemotherapy aimed at destroying cancer cells to be given over the next six months monthly infusions of a drug to help protect the bones against pain and fracture. This infusion is to be given for as long as it is working (hopefully years) weekly infusions of a drug to suppress the growth of the cancer. These infusions are to be given for as long as they are working (hopefully years) 22

23 Will her policy cover this treatment plan, and are there any limits to the cover? The Helpline will arrange and pay for the chemotherapy as this is aimed at curing Beverley s cancer, or at least achieving a remission. Whilst Beverley is having the chemotherapy we will also pay for the monthly bone strengthening infusions and the weekly infusions to suppress the growth of the cancer, provided that there are sufficient funds available from the 50,000 policy lifetime limit. However, we will stop paying for these infusions once the cancer has been cured, gone into remission or if it fails to respond to treatment. If Beverley decides not to pay for the infusions herself, a Simplyhealth nurse adviser will work with her specialist and the NHS to make sure that treatment continues smoothly as an NHS patient. David David has worked for Simplyhealth for seven years when he is diagnosed with cancer. Following discussion with his specialist he decides to undergo a course of high dose chemotherapy, followed by a stem cell (sometimes called a bone marrow ) transplant. Will his policy cover this treatment plan, and are there any limits to the cover? The Employee Plan does not pay for a stem cell transplant, or the special course of high dose chemotherapy which leads to the transplant. If David decides not to pay for private treatment himself, a Simplyhealth nurse adviser will work with his specialist and the NHS to make sure that treatment continues smoothly as an NHS patient. When his treatment is finished, David s specialist tells him that his cancer is in remission. He would like him to have regular check-ups for the next five years to see whether the cancer has returned. Will his policy cover this treatment plan, and are there any limits to the cover? The Helpline will arrange for David to receive follow up consultations and monitoring for a period of five years from the time that he last had treatment that we paid for. If the only treatment that David had was the stem cell transplant, then the five year time period will start from the date of David s diagnosis. We will only pay for monitoring provided that there are sufficient funds available from the 50,000 policy lifetime limit. Eve Eve has been with Simplyhealth for five years when she develops breathing difficulties. She is a staff member and so has private medical insurance cover under modules 2 (in-patient, day-patient and out-patient), 3 (psychiatric treatment), and 4 (heart and cancer cover). Her GP refers her to a specialist who arranges a number of tests. These reveal that Eve has asthma. Her specialist puts her on medication and recommends a follow up consultation in three months to see if her condition has improved. At that consultation Eve states that her breathing has been much better, so the Specialist suggests she has check-ups every four months. The Helpline will arrange the consultation with a specialist and diagnostic tests to diagnose Eve s condition, and then pay the bills for these. The Employee Plan does not cover follow up consultations for long term monitoring of Eve s condition, drugs taken as an out-patient or drugs taken home from hospital, so Simplyhealth will not pay for: the drugs that Eve takes to control her symptoms, or any further consultations to monitor her condition Eighteen months later, Eve has a bad asthma attack. Simplyhealth would pay for treatment (or NHS cash benefit) if: Eve needed to be admitted to hospital as an in-patient for that treatment and the treatment aimed to quickly stabilise her condition and the flare-up was unexpected (for example we would not pay for recurring in-patient admissions which may be a natural consequence of Eve s condition, and which happen on a regular or predictable basis) However, we would not continue to pay benefit for Eve s asthma indefinitely. 23

24 Bob Bob has worked for Simplyhealth for three years when he develops hip pain. His GP refers him to an osteopath who treats him every other day for two weeks and then recommends that he return once a month for additional treatment to prevent a recurrence of the original symptoms. Bob s private medical insurance cover will not pay for treatment by an osteopath. However, as a member of Simplyhealth staff he can claim up to 300 each claiming year for osteopathy under module 1 (The Essentials) or up to 450 if he has chosen the Module 1 upgrade. Eric Eric would like to be admitted to a hospice for care aimed solely at relieving symptoms. Will his policy cover this, and are there any limits to the cover? Hospices do not charge for their services, but we will make a donation to the hospice of 100 for each night that Eric is admitted, up to a maximum total of 91 nights each claiming year provided that there is benefit remaining in the 50,000 policy lifetime limit for cancer. Jenny Jenny has been diagnosed with cancer. Her policy has a limit and she decides to commence private treatment. What help will be available if the policy limit is reached and she needs to transfer into the NHS? If Jenny decides not to pay for private treatment herself once she has reached the policy limit, a Simplyhealth nurse adviser will work with her specialist and the NHS to make sure that treatment continues smoothly as an NHS patient. 24

25 Making a claim under Modules 2, 3 and 4 Directed Private Medical Care We know that, at times of ill health, a friendly and efficient claims service is very important to you. For your peace of mind, we aim to simplify the paperwork and make claiming on your plan as easy as possible. You must call our helpline on to authorise and arrange treatment. Remember, you can only claim benefit under the choices detailed on your membership certificate. We will only pay benefit for treatment that we have arranged. We will arrange diagnostic tests, medical treatment and select hospital accommodation and other treatment providers on your behalf. Our Helpline is the simple way to sort out your healthcare and can be a valuable plus whenever you need treatment. If you need hospital treatment we will pay for a private room, wherever possible in a hospital within 35 miles of your home. We look after the small details that can make such a big difference, authorising and arranging your treatment at a time to suit you (where possible) and then settling bills directly with your specialist and hospital. Making a claim When your GP needs to refer you to a specialist, claiming under the policy is straightforward. In order to claim you need to follow the following claims procedure: 1. Call our Helpline on Our helpful staff will then authorise and arrange eligible treatment over the phone. In most cases it s as simple as that no claim forms and no paperwork to complete. We may ask you to give us a copy of your GP s letter of referral (which should include the start date of your symptoms and the recommended specialty) and sometimes we may need more medical information. Any charges for the supplying of a referral letter will be your responsibility. We will confirm your treatment plan by phone or letter. Your appointment will normally be within three weeks of authorisation. 2. If this is your first claim in your claiming year under Directed Private Medical Care, you will need to pay your excess now (your membership certificate shows your excess). You can pay over the phone by debit card or credit card. 3. Once you ve had your consultation, please call the helpline and let us know if your treatment has been completed, or if you need us to arrange any further treatment. We pay invoices directly and promptly to the treatment providers and we ll send you details of any payments we make. If you are given an invoice but are not asked for immediate payment, just send it to us, along with your membership details, and we ll settle the account. If you are asked to pay for your treatment immediately, please send us the receipted invoice, along with your membership details, and we ll refund you directly. Second opinions If you feel you need a second opinion then we will arrange this for you, provided your GP supports this request on medical grounds. Claiming for further treatment If you need further treatment, simply call the helpline again and we will tell you if it is covered by the policy. If you need a series of medical treatments, we ll provide you with a personal contact who can help you every step of the way. As we select your treatment provider and all treatment that will be paid for is arranged by us, you must call the Helpline. We will only pay for treatment arranged through the Helpline. 25

26 Making a claim for NHS cash benefit Call our Helpline on Our helpful staff will then confirm if your claim is covered by the policy and what you need to do next. If you have already been in hospital and have a discharge letter, please have it to hand when you call as we will ask some questions about it. If you haven t been to hospital yet, simply ask the hospital for a discharge letter when you leave. There is no need to send us a claim form and the policy excess doesn t apply to an NHS cash benefit claim either. Claims under Directed Private Medical Care important notes 1. We do not cover fees charged for providing supporting information to assess your claim, for example GP fees for completing a claim form or producing a medical report. These fees are your responsibility. 2. Benefit is only payable for treatment received, by an enrolled member, during a period for which premiums have been paid. Treatments are limited to those shown in the benefit table for the modules included in the policy. You can see these on the membership certificate. 3. For the assessment of all in-patient claims the days of admission and discharge shall count as one day. 4. Only Simplyhealth can confirm the acceptance on any claim. No one else has any power or authority to confirm acceptance or change any of the policy rules on our behalf. You must call the Helpline on to confirm eligibility of cover. We will arrange treatment for you. 5. Authorisation is valid for three months from the date given to you for your first appointment. If your original appointment is cancelled for any reason and is not rearranged within three months of your original authorisation date, the authorisation will lapse. You must call us for new authorisation to proceed further. 6. We will not be responsible for any charges made for an appointment that you fail to attend unless you notify us, the hospital, clinic and/or specialist at least 48 hours in advance of the appointment. These charges may include costs that would have been incurred for diagnostic procedures. 7. Premiums are payable in advance. We will only pay for treatment received during a period for which premiums have been paid. If a staged treatment plan has been authorised it is your responsibility to check with us that we will still pay for the treatment. 8. Treatment expenses must, in our opinion, be reasonable and exclusively for the treatment of an eligible acute condition. 9. Maximum limits of benefit apply to each person included in the policy. 10. We will only pay for treatment if your GP, or a specialist your GP has referred you to, knows about it and approves it. 11. We may refuse to pay any expenses in excess of those normally charged for similar treatment in the UK. We may require full itemisation of any charges giving rise to a claim. We will not pay more than the actual expenses incurred (except for payment of NHS cash benefit). We select your treatment provider and specialist, and will only pay for treatment authorised and arranged through the Helpline. Your obligations under Directed Private Medical Care 1. You need to follow the steps set out under Making a Claim on page 25 as we arrange all your treatment. If we do not authorise your claim you will be responsible for paying any expenses for treatment that you receive. 2. Authorisation is only valid for three months. If you do not start treatment within three months of authorisation you must call us for new authorisation before proceeding with treatment, otherwise you may be responsible for the cost of treatment. 3. You will be responsible for any charges made for an appointment that you do not attend. This will include the costs that would have been incurred for diagnostic procedures where you do not give us, the hospital or specialist at least 48 hours advance notice of cancellation if you are unable to attend an appointment. 4. You are responsible for ensuring that we receive any voluntary premiums. If we do not receive these premiums, you will not be covered for treatment under these voluntary parts of cover. 26

27 5. You must pay any excess on the policy before receiving any treatment. Your excess will be collected when you call us to authorise your claim. 6. If you receive invoices for treatment that you wish to claim for, you should send them to us as soon as you receive them. 8. You should follow specific medical advice - for example taking prescribed medication or resting after surgery. If you do not follow specific medical advice and suffer ill health as a direct result, we will not pay for any treatment which you need because you didn t follow that advice. 7. You must tell Simplyhealth if you have a personal injury claim against another party as a result of an accident, or if you have insurance with another insurance company or provident association that covers you for any of the same benefits under this policy. Senior Manager Private Medical Insurance You can see on your membership certificate if you are covered for this benefit. Senior Manager Private Medical Insurance includes an extensive range of benefits to provide peace of mind. Your Senior Manager Private Medical Insurance gives you access to some of the finest medical facilities. If your GP refers you to a specialist, you can have the reassurance that you will be able to see a consultant quickly, have treatment at a private hospital and if necessary, be covered for physiotherapy to help you recover. Our dedicated team of advisers are here to guide you through every step of your treatment. What is Senior Manager Private Medical Insurance? The policy is designed to provide cover to diagnose and treat acute medical conditions. These are medical conditions that are likely to respond quickly to treatment, leading to your full recovery and returning you to your previous state of health. Your health cover benefits explained The following table shows you the wide range of benefits included under your Senior Manager Private Medical Insurance cover. For details of how to make a claim under the policy please refer to page 37. Where we have stated full cover this is subject to the terms of the policy. Treatment expenses must, in our opinion, be reasonable and exclusively for the treatment of an eligible acute condition. We will not pay for treatment of a chronic condition. We may need full itemisation of any charges giving rise to a claim. We will not pay more than the actual expenses incurred (except for payment of NHS cash benefit and hospice benefit). We may refuse to pay any expenses in excess of those normally charged for similar treatment in the UK. We pay specialists fees based on a fixed fee schedule for the treatment that is being provided. To find out more about the Simplyhealth fee schedule call us on We will not pay for fees that are greater than those listed within our fee schedule. Except in an emergency, all treatment for which you wish to claim must be arranged with the knowledge and approval of your GP or of a specialist that your GP has referred you to. For details of the limited cover available for emergency in-patient treatment overseas, and the claiming process that needs to be followed, please refer to page 39. For the assessment of all in-patient claims the days of admission and discharge shall count as one day. For all benefits we will only pay for treatment that is normally provided under the NHS or approved by the National Institute of Health and Care Excellence (NICE). 27

28 Senior Manager Private Medical Insurance what is covered 1 Out-patient specialist consultations Full cover 2 CT, MRI and PET scans Full cover 3 Out-patient services diagnostic tests physiotherapy acupuncture Full cover for specialist referrals Out-patient consultations with a specialist to diagnose a condition or to assess progress of treatment of an acute condition covered by the policy. Routine monitoring of a chronic condition is not covered. There is a combined limit of 500 each claiming year for X-rays, ultrasounds, acupuncture, podiatry or chiropody, osteopathy and chiropractic where referral is made by a GP. podiatry/chiropody chiropractic osteopathy 4 Hospital charges for in-patient and day-patient treatment accommodation and nursing (including intensive care) operating theatre charges drugs and dressings prescribed for use while an in-patient or day-patient physiotherapy and diagnostic tests prostheses, when implanted as an integral part of a surgical procedure Full cover We will pay hospital charges for in-patient and day-patient treatment that you receive in a hospital which is listed in our Hospital Directory within your scale of cover or a lower scale of cover If you receive in-patient or day-patient treatment in a hospital which is: not listed in our Hospital Directory or in a hospital which is in a higher scale of cover we will only pay the equivalent cost to what we would have paid if you had received that treatment at a hospital within your scale of cover. This could leave you with a large shortfall that you will have to pay to the hospital. We will not pay hospital charges for drugs and dressings related to in-patient or day-patient treatment: that you receive later as an out-patient or that you take home from the hospital 28

29 Senior Manager Private Medical Insurance what is covered 5 Surgeons and anaesthetists fees Full cover We pay surgeons and anaesthetists fees up to the maximum amounts set out in our fee schedule. The Simplyhealth fee schedule can be seen on or call us on Treatment for cancer Full cover Please refer to Cancer treatment what is covered? on page Specialist physicians fees for in-patient and day-patient treatment Full cover 8 Dental surgery Full cover for specific treatment only in accordance with hospital charges and surgeons and anaesthetists fees 9 Psychiatric benefits Out-patient consultations and treatment In-patient and day-patient treatment Full cover You must be under the regular care of a specialist and, for in-patient treatment, we would not normally pay unless the specialist attends you on at least five days each week. Paid for up to 91 days in any one claiming year. We pay physicians fees up to the maximum in amounts set out in our fee schedule. Dental surgery carried out in a hospital by an oral and maxillofacial surgeon. We will only pay for: surgical removal of impacted/buried or unerupted teeth surgical removal of complicated buried roots removal of the tip of a tooth s root (apicectomy) surgical removal of a cyst from the jaw bone (enucleation of cyst) Paid provided the treatment is carried out under the care of a recognised specialist and treatment has been agreed in advance by us. In-patient treatment must be in a hospital which is listed in the Hospital Directory, either within your scale or a lower scale of cover. Maximum of 28 days cover each claiming year for in-patient and day-patient treatment. 29

30 Senior Manager Private Medical Insurance what is covered 10 NHS cash benefit 100 each day or night If you are admitted free of charge on the NHS for treatment or diagnostic tests that we would have paid for as a private patient, we will give you 100 for: each admission you have as a day-patient or each night when you are an in-patient up to a maximum of 91 days or nights in combined total each claiming year (the 91 day limit includes a maximum of 28 days for psychiatric treatment). We will not pay NHS cash benefit for out-patient treatment (for example radiotherapy), or for treatment that we would not pay for as a private patient (for example rehabilitation / convalescence, or an admission for treatment of a chronic condition). 11 Parent accommodation charges Full cover For one parent staying overnight in hospital while their child receives in-patient treatment. The child must be under the age of 12 and enrolled in their parents membership. 12 Private ambulance Full cover Paid when an ambulance is required out of medical necessity and in connection with in-patient or day-patient treatment covered by the policy. 13 Home nursing Full cover Paid for the full time services of registered nurses, on a resident or daily basis, following an in-patient stay, when prescribed by a specialist solely for medical reasons. 14 Hospice benefit 100 each night 15 Emergency in-patient treatment overseas 100,000 policy lifetime limit for each person A donation to the hospice, up to 91 nights in any one claiming year. Limited overseas medical cover for emergency inpatient treatment available to members resident in the UK while travelling outside the UK. All treatment must be authorised in advance by our Overseas Assistance Helpline and we will only pay up to a 100,000 policy lifetime limit for any treatment. This limited cover does not replace the medical section of a travel insurance policy. Please refer to page 39 for more information. What is NOT covered by your Senior Manager Private Medical Insurance? Any exclusions specific to your cover as shown on your membership certificate Treatment not normally provided under the NHS or approved by the National Institute of Health and Care Excellence (NICE) 30

31 Surgeons, anaesthetists and physicians fees which exceed those listed within the Simplyhealth fee schedule Repatriation or transfer from a ship, an oil rig, or similar offshore location. Repatriation to the UK from a hospital abroad Dental treatment which has not been carried out in a hospital by an oral and maxillofacial surgeon and is not specifically listed in the benefit table. You may be able to claim for dental treatment under Module 1 - The Essentials, please check your membership certificate to see whether you are covered Chronic conditions see page 33 for further details Drugs and dressings you take home from hospital or medical, surgical or dental appliances, for example hearing aids, glasses and contact lenses, braces or walking aids such as crutches or frames. This exclusion does not apply to a prosthesis, for example a knee or hip replacement, or an electronic device such as a pacemaker. However, even if we pay for an electronic device, we will not pay for the replacement of: consumables, for example batteries or leads the device itself Cosmetic treatment or surgery Treatment you need as a result of alcoholism, alcohol abuse, solvent abuse, drug abuse or addictive conditions, or any associated condition (for example hepatitis, cirrhosis, oesophageal varices or psychiatric conditions) Treatment related to developmental problems, learning difficulties or delayed speech disorders, for example, dyslexia or attention deficit hyperactivity disorder HIV infection, AIDS or any associated condition Preventative treatment or diagnostic tests for example sight testing, vaccination/inoculation, routine medical or dental examinations and monitoring of a condition Genetic testing Treatment of low fertility or infertility, or pregnancy, or childbirth resulting from such treatment Pregnancy or childbirth, or any medical conditions relating to childbirth Termination of pregnancy Dialysis regular or long term renal dialysis Transplantation operations or procedures. For example autologous plasmapharesis, transplant of bone marrow or stem cells, organ transplant, autologous blood transfusion or similar procedures Removal of non diseased tissue, for example breast reduction Self inflicted non accidental conditions Treatment you need as a result of dangerous sports Accommodation without treatment. For example a stay in hospital wholly or partly for domestic reasons; when the patient is not undergoing regular treatment by a specialist or where treatment could be reasonably provided elsewhere. Or where the hospital has effectively become your permanent home. We also exclude stays in a convalescent home, convalescent hospital, health hydro or nature cure clinic GP or dentists fees. You may be able to claim for dental treatment under cash plan cover, please check your membership certificate to see whether you are covered Unlicensed drugs, or the use of drugs outside the scope of the licence issued by the European Medicines Agency (EMEA) or the National Institute of Health and Care Excellence (NICE) Treatment for injuries or illness arising out of war, invasion, act of foreign enemy, nuclear or chemical contamination, hostilities (whether war be declared or not), civil war, riot, civil commotion, rebellion, revolution, insurrection or military or usurped power 31

32 Treatment received outside the UK, where the purpose of being abroad is wholly or in part to obtain such treatment. See page 39 for details of emergency inpatient treatment overseas Cancer treatment under your Senior Manager Private Medical Insurance what is covered? Cancer as a condition does not fit easily into the acute and chronic definitions used to categorise other illnesses. We want you to have a clear understanding of what is covered and what is not covered for cancer treatment under your policy. If you ever need treatment for cancer, you will have the personal support of your own Simplyhealth nurse adviser. We will authorise your claims, guide you through your treatment programme and explain what treatment is covered under the policy. Your nurse adviser will be there to support your care whether this is given privately or through the NHS. Remember, we are always here to help. What we will pay for: Surgery One operation to reconstruct a breast that has been removed (either by mastectomy or lumpectomy), and we will pay for one further operation to improve symmetry of your breasts. We will not pay for further cosmetic operations to a reconstructed breast. Radiotherapy Chemotherapy which aims to cure your cancer or induce a remission. We will not pay for chemotherapy whilst you are in remission or to keep your cancer stable (this is sometimes called maintenance, or palliative, treatment) Whilst you are receiving chemotherapy or radiotherapy that we pay for, we will also pay for treatment prescribed by your specialist that you need to deal with their side effects, for example: antibiotics anti sickness drugs steroids pain killers Treatment for cancer can mean that you need a variety of services. If your specialist recommends it, we will pay for treatment or advice from: a dietician, to stabilise your diet following surgery, chemotherapy or radiotherapy a stoma nurse, to show you how to care for your stoma a specialist nurse to show you how to manage lymphoedema NHS cash benefit If you are admitted free of charge on the NHS for treatment or diagnostic tests that we would have paid for as a private patient, we will give you 100 for: each admission you have as a day-patient or each night when you are an in-patient up to a maximum of 91 days or nights in combined total each claiming year. We will not pay NHS cash benefit for out-patient treatment (for example radiotherapy), or for treatment that we would not pay for as a private patient (for example rehabilitation / convalescence, or an admission for chemotherapy whilst you are in remission). We will make a donation to a registered hospice for each night that you are admitted, up to 91 nights each claiming year We will pay for consultations and diagnostic tests to monitor your condition for five years after the last treatment for cancer that we paid for on this policy We will not pay for: drugs that are still under trial or not licensed by the European Medicines Agency (EMEA), trials of combination drug treatment or combination drug treatment that is not widely recognised within the NHS maintenance or long term treatments where the condition is stable, remains in remission, or remission cannot be achieved. At this time your nurse adviser can help with the smooth transition of care into the NHS. We will continue to support you during this transition period drugs to boost your immune system, and blood transfusions 32

33 What is a chronic condition? A chronic condition is a disease, illness, or injury that has one or more of the following characteristics: it needs ongoing or long term monitoring through consultations, examinations, check-ups, and/or tests it needs ongoing or long term control or relief of symptoms it requires your rehabilitation or for you to be specially trained to cope with it it continues indefinitely it has no known cure it comes back or is likely to come back It is not always clear that you have a chronic condition when you visit your GP. This is why we will pay for referral to a specialist and any diagnostic tests and consultations to make a diagnosis. The aim of any treatment must be to return you to the state of health you were in immediately before suffering the disease, illness or injury, or lead to your full recovery. What does this mean in practice? If your condition has or acquires one or more of the characteristics of a chronic condition, we will not pay any benefit for this condition under Senior Manager Private Medical Insurance cover, unless agreed by us in advance of the treatment. Even if we have paid for previous treatment, it does not mean that we will continue to cover that condition, if we think it has become chronic. If your diagnosis is for a chronic condition, we will confirm to you that we will not pay for further consultations, diagnostic tests or treatments. What if your condition gets worse? We do not pay for on-going treatment, consultations or diagnostic tests to maintain a chronic condition in a stable state. However, we will pay for treatment (or NHS cash benefit) for an acute flare-up of a chronic condition if: you need to be admitted to hospital as an in-patient for that treatment and the treatment aims to quickly stabilise your chronic condition and the flare-up was unexpected (for example we will not pay for recurring in-patient admissions which may be a natural consequence of your chronic condition, and which happen on a regular or predictable basis) If you have an acute flare-up of a chronic condition, please call us on for pre-authorisation of treatment. We would not pay benefit for an acute flare-up of a chronic condition unless the cost of treatment has been pre-authorised by us. Examples of chronic conditions Whilst these case studies are fictitious they are intended to illustrate how this section of the policy works in practice to support the health and wellbeing of individual members. Alan Alan has worked for Simplyhealth for many years. He develops chest pain and is referred by his GP to a specialist. He has a number of investigations and is diagnosed as suffering from a heart condition called angina. Alan is placed on medication to control his symptoms. We will pay for the consultations with a specialist and diagnostic tests to diagnose Alan s condition. 33

34 The Employee Plan does not cover follow up consultations for long term monitoring of Alan s condition, drugs taken as an out-patient or drugs taken home from hospital, so Simplyhealth will not pay for: the drugs that Alan takes to control his symptoms, or any further consultations to monitor his condition Two years later, Alan s chest pain recurs more severely and his specialist recommends that he have a heart bypass operation. We will pay for Alan s consultation with the specialist and for his heart bypass operation. Following his operation Alan will need to have further consultations to check that the operation was a success, which we will pay for. Bob Bob has worked for Simplyhealth for three years when he develops hip pain. His GP refers him to an osteopath who treats him every other day for two weeks and then recommends that he return once a month for additional treatment to prevent a recurrence of the original symptoms. Bob has up to 300 of benefit under Module 1 The Essentials which he can use to claim the costs of the osteopathy (or up to 450 if he has chosen the Module 1 upgrade). However, if he has used up his annual entitlement he can still make a claim under Module 5 Senior Manager Private Medical Insurance. Under Module 5 we will pay for Bob s initial two week course of treatment. However, this course of osteopathy is subject to the 100 excess, and falls within the 500 limit for treatment on GP referral. If Bob had seen a specialist who had recommended osteopathy, this 500 limit would not apply. We will not pay for Bob s additional treatment as this is purely being recommended as a preventative measure, not to cure his hip pain. Deirdre Deirdre has worked for Simplyhealth for two years when she develops symptoms that indicate she may have diabetes. Her GP refers her to a specialist who organises a series of investigations to confirm the diagnosis, and she then starts on oral medication to control the diabetes. After several months of regular consultations and some adjustments made to her medication regime, the specialist confirms the condition is now well controlled and explains he would like to see her every four months to review the condition. We will pay for the consultations with a specialist and diagnostic tests to diagnose Deirdre s condition. We will also pay for the consultations and diagnostic tests that Deirdre s specialist needs to ensure that the condition is stabilised. Once Deirdre s diabetes has been stabilised, we will not pay for any further consultations to monitor the condition on a long term basis. One year later, Deirdre s diabetes becomes unstable and her GP arranges for her to go into hospital for treatment. Simplyhealth would pay for treatment if: Deirdre needed to be admitted to hospital as an in-patient for that treatment and the treatment aimed to quickly stabilise her condition and the flare-up was unexpected (for example we would not pay for recurring in-patient admissions which may be a natural consequence of Deirdre s condition, and which happen on a regular or predictable basis) However, we would not continue to pay benefit for Deirdre s diabetes indefinitely. We would strongly recommend that Deirdre calls us before going into hospital as a private patient so that we can advise her whether or not we will pay for the admission. 34

35 Eve Eve has been with Simplyhealth for five years when she develops breathing difficulties. Her GP refers her to a specialist who arranges a number of tests. These reveal that Eve has asthma. Her specialist puts her on medication and recommends a follow up consultation in three months to see if her condition has improved. At that consultation Eve states that her breathing has been much better, so the specialist suggests she has check-ups every four months. We will pay for the consultation with the specialist and diagnostic tests to diagnose Eve s condition. The Employee Plan does not cover follow up consultations for long term monitoring of Eve s condition, drugs taken as an out-patient or drugs taken home from hospital, so Simplyhealth will not pay for: the drugs that Eve takes to control her symptoms, or any further consultations to monitor her condition Eighteen months later, Eve has a bad asthma attack. Simplyhealth would pay for treatment (or NHS cash benefit) if: Eve needed to be admitted to hospital as an in-patient for that treatment and the treatment aimed to quickly stabilise her condition and the flare-up was unexpected (for example we would not pay for recurring in-patient admissions which may be a natural consequence of Eve s condition, and which happen on a regular or predictable basis) However, we would not continue to pay benefit for Eve s asthma indefinitely. Beverley Beverley is married to a senior manager and has been covered on the plan for five years when she is diagnosed with breast cancer. Following discussion with her specialists she decides to: have the tumour removed by surgery. As well as removing the tumour, Beverley s treatment will include a reconstruction operation undergo a course of radiotherapy and chemotherapy take hormone therapy tablets for several years after the chemotherapy has finished Will her policy cover this treatment plan, and are there any limits to the cover? We will pay for the surgery to remove the tumour and also one operation to reconstruct Beverley s breast. If she needed it, we would also arrange and pay for one further operation to improve the symmetry of Beverley s breasts following her reconstruction operation. We will also pay for Beverley s radiotherapy and chemotherapy treatment. The Employee Plan does not cover the hormone therapy tablets because we consider these to be preventative treatment. However, Beverley will be able to get these tablets directly from her GP. We will pay for Beverley to receive follow-up consultations and monitoring for a period of five years once she has finished treatment. During the course of chemotherapy Beverley suffers from anaemia. Her resistance to infection is also greatly reduced. Her specialist: admits her to hospital for a blood transfusion to treat her anaemia prescribes a course of injections to boost her immune system Will her policy cover this treatment plan, and are there any limits to the cover? Whilst Beverley is receiving chemotherapy (or radiotherapy) that we pay for, we will also pay for treatment prescribed by her specialist that she needs to deal with their side effects. This includes the drugs to boost her immune system and blood transfusions. We would also pay for, for example, antibiotics, anti sickness drugs, steroids and pain killers. 35

36 Despite the injections to boost her immune system, Beverley develops an infection and is admitted to hospital for a course of antibiotics. Will her policy cover this treatment and are there any limits to the cover? As the infection is as a direct result of Beverley s cancer treatment we will pay for the admission and antibiotic treatment. Five years after Beverley s treatment finishes the cancer returns. Unfortunately it has spread to other parts of her body. Her specialist has recommended a treatment plan: a course of six cycles of chemotherapy aimed at destroying cancer cells to be given over the next six months monthly infusions of a drug to help protect the bones against pain and fracture. This infusion is to be given for as long as it is working (hopefully years) weekly infusions of a drug to suppress the growth of the cancer. These infusions are to be given for as long as they are working (hopefully years) Will her policy cover this treatment plan, and are there any limits to the cover? We will pay for the chemotherapy as this is aimed at curing Beverley s cancer, or at least achieving a remission. Whilst Beverley is having the chemotherapy we will also pay for the monthly bone strengthening infusions and the weekly infusions to suppress the growth of the cancer. However, we will stop paying for these infusions once the cancer has been cured, gone into remission or if it fails to respond to treatment. If Beverley decides not to pay for the infusions herself, a Simplyhealth nurse adviser will work with her specialist and the NHS to make sure that treatment continues smoothly as an NHS patient. David David has worked for Simplyhealth for seven years when he is diagnosed with cancer. Following discussion with his specialist he decides to undergo a course of high dose chemotherapy, followed by a stem cell (sometimes called a bone marrow ) transplant. Will his policy cover this treatment plan, and are there any limits to the cover? The Employee Plan does not pay for a stem cell transplant, or the special course of high dose chemotherapy which leads to the transplant. If David decides not to pay for private treatment himself, a Simplyhealth nurse adviser will work with his specialist and the NHS to make sure that treatment continues smoothly as an NHS patient. When his treatment is finished, David s specialist tells him that his cancer is in remission. He would like him to have regular check-ups for the next five years to see whether the cancer has returned. Will his policy cover this treatment plan, and are there any limits to the cover? We will pay for David s follow up consultations and monitoring for a period of five years from the time that he last had treatment that we paid for. If the only treatment that David had was the stem cell transplant, then the five year time period will start from the date of David s diagnosis. Eric Eric would like to be admitted to a hospice for care aimed solely at relieving symptoms. Will his policy cover this, and are there any limits to the cover? Hospices do not charge for their services, but we will make a donation to the hospice of 100 for each night that Eric is admitted, up to a maximum total of 91 nights each claiming year. 36

37 Making a claim under Module 5 Senior Manager Private Medical Insurance Simplyhealth is here to help. We know that, at times of ill health, a friendly and efficient claims service is very important to you. We want to simplify the paperwork and make claiming as easy as possible. If you want to make a claim please call us on before arranging any private treatment. We can give you guidance on exactly what you are covered for, checking whether the costs of your treatment are within our fee schedule and that the hospital you plan to use is within your scale of cover - offering you peace of mind at a worrying time. We can also highlight any costs you may be liable for, helping you make an informed decision about your treatment. If you prefer, for no extra charge, we can also arrange diagnostic tests, medical treatment and hospital accommodation on your behalf. We look after the small details that can make such a big difference, authorising and arranging your treatment at a time to suit you (subject to availability) and then settling accounts directly with your specialist and hospital. Making a claim Where your GP has informed you that you need to be referred to a specialist, claiming under the Senior Manager Private Medical Insurance is straightforward. In order to claim you need to follow the following claims procedure: Step 1: You must call our helpline on Step 2: Our helpful staff will discuss your requirements and authorise eligible treatment. They can even arrange your treatment over the phone if you want them to. In most cases it s as simple as that, no claim forms and no paperwork to complete. Although on some occasions we may need more medical information. We will confirm the extent of the treatment we have authorised by phone or letter. If this is your first claim in your claiming year under Senior Manager Private Medical Insurance we will now ask you to pay the excess over the phone by credit card or debit card. Your membership certificate will show the amount of excess you have to pay (where applicable). Step 3: Once you ve had your consultation, please call the helpline to either discuss further treatment or to let us know if your treatment has been completed. Step 4: We pay invoices directly and promptly to the treatment providers and we ll send you details of any payments we make. If you are given an invoice but are not asked for immediate payment, just send it to us, along with your membership details, and we ll settle the account. If you are asked to pay for your treatment immediately, please send us the receipted invoice, along with your membership details, and we ll refund you directly. We will confirm to you in writing the payments that we have made and that the excess has been paid. What do I do in an emergency? If you need emergency treatment, please go to your nearest NHS emergency department. If you have received emergency treatment in an NHS hospital and then require further non urgent treatment, you may be eligible to be transferred to a private hospital. Please call us on to check whether your transfer and treatment is covered. For details of what is and is not covered for emergency in-patient treatment while travelling overseas and the claims process that needs to be followed before your treatment starts please refer to page

38 Second opinions If you have had a consultation and you and your GP are unhappy with the outcome, you can request a second opinion where there are medical grounds to support this. Just call us and follow the steps for making a claim. Claiming for further treatment You must call us if you require further treatment. We will confirm whether this treatment is eligible for cover, ensuring that you know exactly what is covered under the policy. If you need to undertake a prolonged series of medical treatments, we ll provide you with a personal contact who can help you every step of the way. Making a claim for NHS cash benefit Call our Helpline on Our helpful staff will then confirm if your claim is covered by the policy and what you need to do next. If you have already been in hospital and have a discharge letter, please have it to hand when you call as we will ask some questions about it. If you haven t been to hospital yet, simply ask the hospital for a discharge letter when you leave. There is no need to send us a claim form and the policy excess doesn t apply to an NHS cash benefit claim either. Claims under Senior Manager Private Medical Insurance important notes 1. We do not cover fees charged for providing supporting information to assess your claim, such as fees charged for completing a claim form or producing a medical report. These fees are your responsibility. 2. Only Simplyhealth can confirm the acceptance of any claim. No one else has any power or authority to confirm acceptance or change any of the policy rules on our behalf. Please call our helpline on to confirm cover is available. 4. We will not be responsible for any charges made for an appointment that you fail to attend. You must provide us, the hospital or specialist at least 48 hours advanced notice if you are unable to attend an appointment. Any charges, including the costs that would have been incurred for diagnostic procedures, must be met by you where you fail to provide the appropriate notice. 5. We will only pay for treatment received during a period for which premiums have been paid. If a staged treatment plan has been authorised it is your responsibility to check with us that we will still pay for the treatment. Scales of cover Private hospitals are classified according to how much they charge for treatment. The hospital scales are from A to D, where scale A covers the most expensive hospitals (such as those in the central London), and scale D covers the least expensive. The scale does not reflect the quality of the treatment received in these hospitals, merely the associated expenses like the cost of a room. Your scale of cover is scale B. Our Hospital Directory confirms the scale that applies to each hospital. Out of scale limits what is and isn t covered If you choose to go to a hospital that is in a higher scale than you are covered for, we will only pay the equivalent cost to what we would have paid if you had received that treatment at a hospital within your scale of cover. This could leave you with a large shortfall that you will have to pay to the hospital. We strongly recommend that you have treatment in a hospital which falls within your scale of cover so you avoid additional costs. If you are in any doubt, or would like to discuss your options, call our helpline on Authorisation is valid for three months from the date given to you for your first appointment. If your original appointment is cancelled for any reason and is not rearranged within three months of your original authorisation date, the authorisation will lapse. You must call us for new authorisation to proceed further. 38

39 Emergency in-patient treatment overseas Your Senior Manager Private Medical Insurance policy is designed to provide you with health cover here in the UK. Its range of health benefits are designed to work within the UK healthcare system and the costs of cover reflect claims for treatment within the UK system. Should you unexpectedly find yourself in a medical emergency whilst overseas, it will provide cover for emergency in-patient treatment, emergency evacuation and emergency repatriation up to a combined lifetime policy limit of 100,000 each person for eligible acute conditions. Please read the sections What we will pay for and What we will not pay for below for full details. This overseas assistance does not replace the need for travel insurance to ensure you are fully covered for medical emergencies. The costs of treatment overseas can significantly exceed the costs of treatment within the UK, we would therefore encourage you to make other provisions prior to travelling abroad, as you will be liable for any costs where you have exceeded the lifetime 100,000 policy limit. What we will pay for: Emergency overseas in-patient treatment for unexpected acute conditions when travelling overseas, where you require immediate hospitalisation out of medical necessity in order to treat an eligible acute condition and where treatment could not, in our opinion, have been reasonably anticipated or delayed. All admissions for in-patient treatment must be authorised in advance by our Overseas Assistance Helpline Medical evacuation of the patient (but not accompanying parties) to an alternative hospital abroad if, in our opinion, the facilities at the original hospital are not able to provide suitable treatment of your acute condition. The evacuation must be approved and organised in advance by our Overseas Assistance Helpline Repatriation of the patient (but not any accompanying party) to the UK if, in our opinion, the original travel arrangements are unsuitable, when authorised in advance by our Overseas Assistance Helpline We will not pay for: Costs associated with a medical condition that, in our opinion, does not require emergency in-patient treatment and immediate hospitalisation out of medical necessity, as set out above Claims not normally covered by the policy as set out on page 31. For example, any treatment of a medical condition related to a personal exclusion as detailed on your membership certificate and repatriation or transfer from an oil rig or cruise ship Any claim for repatriation to a country other than the UK Any treatment or repatriation that is not authorised in advance by our Overseas Assistance Helpline Treatment, evacuation, or repatriation where the total costs claimed for Overseas Assistance for the lifetime of the policy have reached 100,000 Any treatment which is not provided as an in-patient in the UK, including day-patient admissions, consultations with the overseas equivalent of a GP and out-patient treatment including drugs, medicines and dressings prescribed as an out-patient or on discharge from hospital following an in-patient stay Treatment received abroad where the purpose of the overseas trip is wholly or in part to obtain such treatment Treatment of any condition overseas where you are fit enough to travel to the UK for treatment. In these circumstances you must return to the UK The costs of hotel accommodation or travel (for you or other people who are travelling with you) and other related costs Treatment in or repatriation from a country where the Foreign & Commonwealth Office have advised against all travel or essential travel only at the time of your departure from the UK Repatriation of your body if you die outside the UK 39

40 Making a claim whilst overseas In the event that you need to use your Senior Manager Private Medical Insurance for emergency in-patient treatment while travelling overseas, you must call the Overseas Assistance Helpline immediately for authorisation before any treatment or repatriation commences. This service is available 24 hours a day, 7 days a week. Overseas Assistance will confirm whether or not you have any cover for your emergency in-patient treatment, evacuation or for your repatriation to the UK. It also provides a range of practical services to help deliver emergency healthcare when you are travelling abroad. One call puts you in touch with an experienced multilingual medical co-ordinator. Payment of authorised claims for treatment received outside the UK is made in Sterling. Eligible claims for treatment submitted in other currencies will be converted to Sterling at the exchange rate prevailing as at the date of treatment. Emergency Telephone and Fax Number for Overseas Assistance From the UK Tel: Fax: From the USA Tel: Fax: From the rest of the world Tel: Fax: Your obligations under Senior Manager Private Medical Insurance 1. You are required to follow the steps set out under Making a Claim on page 37 and seek authorisation of your claim from Simplyhealth before arranging any private treatment. Failure to obtain authorisation may mean that your claim may not be paid. You will then be responsible for paying any expenses for treatment that you receive. 2. Authorisation is only valid for three months. If you do not start treatment within three months of authorisation you should call us for new authorisation before proceeding with treatment, otherwise you may be responsible for the cost of treatment. 3. You are responsible for any charges made for an appointment that you fail to attend. This will include the costs that would have been incurred for diagnostic tests where you do not give us, the hospital or specialist at least 48 hours advance notice of cancellation if you are unable to attend an appointment. 4. We strongly recommend that you use a hospital which is classified in our Hospital Directory within your scale or a lower scale of cover. Your scale of cover is shown on your membership certificate. If you choose to go to a hospital that is in a higher scale than you are covered for, we will only pay the equivalent cost to what we would have paid if you had received that treatment at a hospital within your scale of cover. This could leave you with a large shortfall that you will have to pay to the hospital. 5. We strongly recommend that you contact our Overseas Assistance Helpline to check that your emergency in-patient treatment is covered by the policy and the eligible treatment is within the policy limits before any treatment commences. You will be responsible for paying any additional amount above the lifetime 100,000 policy limit (refer to page 39 for further details). 6. You are required to pay any excess on the policy before receiving any treatment. Your excess will be collected when you call us to authorise your claim. 7. You are responsible for ensuring any voluntary premiums are received by us. If we do not receive these premiums you will not be covered for treatment under these voluntary parts of cover. 8. If you receive invoices for treatment that you wish 40

41 to claim for, you should send them to us as soon as you receive them. 9. You must tell Simplyhealth if you have a personal injury claim against another party as a result of an accident, or if you have insurance with another insurance company or provident association that covers you for any of the same benefits under the policy. 10. You should follow specific medical advice - for example taking prescribed medication or resting after surgery. If you do not follow specific medical advice and suffer ill health as a direct result, we will not pay for any treatment which you need because you didn t follow that advice. General terms and conditions for the Policy How any excess on the policy is applied to Modules 2, 3, 4 and 5 If an excess applies to the policy then this is shown on your membership certificate. The excess applies once each claiming year for each person included on the policy. The full excess is not applied for every claim made. You will need to pay the excess when you call us to authorise the first claim for treatment in your claiming year. We apply the excess to the first claim. If the cost of treatment is less than the excess, the remainder will be carried over to subsequent claims, until it is paid in full. The excess starts again at the renewal date each year. If you are continuing treatment when the policy renews, the excess will apply again. The same out-patient limits apply whether you have an excess or not. Excesses do not apply to any NHS cash benefit or hospice benefit. Year 1 Claiming year starts with 100 excess September November Member joins January Member receives consultation, cost 90 Full excess 100 Member pays 90 We pay 0 March Member has consultation with specialist, cost 150 Year 2 September Remaining excess 10 Member pays 10 Member has diagnostic tests, cost 500 Remaining excess 0 Member pays 0 Group renewal date with 100 excess Member receives surgery, cost 8,000 Full excess 100 Member pays 100 We pay 140 We pay 500 We pay 7,900 Remaining excess 10 Remaining excess 0 Remaining excess 0 41

42 Membership Fraud The contract between you and us is based on mutual trust. To protect our members, we have rigorous anti fraud measures. These include: investigating claims through the use of private investigators passing details of suspected fraudulent claims to the police or the Crown Prosecution Service for them to investigate and prosecute through the criminal court. working with the NHS Counter-Fraud team, Health Professionals Trade Associations, other insurance companies and other agencies with an interest in controlling fraud of this nature Fraud is a criminal offence that can result in a large fine or even a prison sentence. When we find examples of fraud, we will always seek to prosecute offenders. If a member acts fraudulently, we will always seek to recover the costs of all fraudulent claims plus interest and our own legal costs. If we reasonably suspect that you have submitted a fraudulent claim, we are unlikely to pay any claims and we may suspend your membership. We may cancel all your insurance policies with us and with any other company within the Simplyhealth Group. To avoid doubt, the following list contains examples of practices we would class as fraudulent: Cancellation rights Can I cancel my policy? You are free to cancel the policy for any reason up to 14 days from either the day you receive your new policy documents, including employee membership certificate, or the day on which payment of premiums is received for the new policy, whichever is the later. The right to cancel is subject to no claims having been made since the cover commencement date, which is stated on the membership certificate. In this event we will cancel the policy from the cover commencement date and no premiums will be charged. If you do not tell us that you wish to cancel the policy within 14 days, the policy will start on the cover commencement date specified in the membership certificate, subject to the terms and conditions of the policy. How do I cancel my policy? If you wish to cancel the policy, call us on You can us at: [email protected] Deliberately giving us false information about you, a person on the policy or a claim on the policy Making any claim under the policy where you know the claim is false, or is exaggerated in any respect Making a statement in support of a claim where you know the statement is false in any respect Sending us a document in support of a claim where you know the document is forged, false or otherwise misleading in any respect Making claims under more than one insurance policy in order to receive a sum greater than the cost of treatment (this is called betterment ) 42

43 Our right to cancel the policy We can cancel the policy or amend the terms for the following reasons: the premium (or any part of it) due is more than 30 days in arrears the Group Secretary cancels the group policy we discontinue the product or any part of it, in which case we will offer alternative arrangements for cover a resolution is passed or an order made for the winding up of Simplyhealth you knowingly claimed benefits which are not covered you, or the Group Secretary, misled us by misstatement or concealment you, or the Group Secretary, attempted to obtain an unreasonable financial advantage to our detriment you, or the Group Secretary, failed to act in good faith if Simplyhealth goes out of business, or into administration or liquidation the policy cover will end immediately To protect our staff, we ask that you treat us in the way you wish to be treated. If you are abusive during our contact with you, we will terminate the contact. If you continue to be abusive, we reserve the right to cancel all policies you hold with Simplyhealth. If you have an accident If you use this policy to make a claim for treatment because someone else was at fault (for example you have been involved in a car accident), we have a legal right to recover any medical expenses that we have paid (the other person is described as a third party ). You must: tell your legal representative immediately that you are insured by Simplyhealth for medical expenses. include all the medical expenses which you have claimed, or will claim, from us under this policy in your personal injury claim. ask your legal representative to help us. You must ensure we can contact your legal representative and obtain copies of any correspondence, reports or documents concerning your claim. We will pay reasonable photocopying charges for anything we request not do anything which prejudices the recovery of medical costs that we have paid. not agree any final settlement of your claim or waive our right to recover expenses paid out for medical treatment unless you or your legal representative have discussed this with us first and obtained our approval ask your legal representative to repay your medical expenses directly to us from any settlement of your claim Important: Simplyhealth cannot fund your personal injury claim. You must pay the costs of making a personal injury claim yourself. If you decide not to bring a claim against the third party then you must give us reasonable cooperation and assistance to enable us to bring a claim in your name. We will be responsible for the legal costs arising out of any claim we bring in your name. When you make a claim under this policy you have an obligation to tell us if you could have a claim against a third party. If you decide to instruct a legal representative, we will need their details because we will need to discuss the claim with them. Once you have told us about your claim, you, or your legal representative, must keep us informed of the claim s progress. 43

44 If you have other insurance policies If you: have other insurance that covers you for any of the same benefits under this policy (for example travel insurance, or medical insurance from your partner s employer) and you make a claim on this policy we will have the right to seek a proportion of any costs from the other insurer. When you make a claim you must tell us if you have other insurance which could cover your treatment costs and give us the other insurer s contact and policy details. How information we hold about you will be used Simplyhealth will hold and use information relating to you and any other persons entitled to receive benefits under this policy. This information may include medical information. We call this information personal data. The main purpose which we use personal data for is to enable us to provide insurance services to you in relation to your policy. Other purposes which we use personal data for are to identify, analyse and calculate insurance risks, to improve our services to you and our other customers, to comply with legal obligations which we are subject to, to protect our interests and for fraud detection and prevention. If you have a complaint We aim to provide you with the very highest levels of customer service and care at all times. To maintain this service standard, we have a procedure you can use to raise any concern, complaint or recommendation you have by contacting Customer Services on or writing to Simplyhealth Customer Services, at our registered office address of Hambleden House, Waterloo Court, Andover, Hampshire SP10 1LQ. We will investigate any complaint and issue a final response. If you are not satisfied with our response, or we have not replied within eight weeks, you have the right to refer your complaint to: Financial Ombudsman Service Exchange Tower London E14 9SR Telephone: The Financial Ombudsman Service will only consider your complaint if you have given us the opportunity to resolve the matter first. Making a complaint to the Ombudsman will not affect any legal rights that you may have. We will send you full details of our complaints procedure if you ask us for them. We may receive and share personal data with persons appointed by you or who provide a service to you, for example your GP and other healthcare providers. We may also provide personal data to persons who provide services to us, including companies operating outside the United Kingdom, and to persons engaged in fraud prevention. We operate strict procedures to ensure that personal data is kept secure. If you have any questions or concerns about the personal data we hold and how we use it please write to: The Data Protection Officer Simplyhealth Hambleden House Waterloo Court Andover Hampshire SP10 1LQ 44

45 You are protected by the Financial Services Compensation Scheme You are protected by the Financial Services Compensation Scheme (FSCS) in the unlikely event that we go out of business or into liquidation the FSCS protects you. Should this happen, the scheme will pay any valid outstanding claims you have at the appropriate level applicable to the scheme at the time of the claim. For more details on the scheme please visit or contact the FSCS direct on Important notes Any correspondence will be sent to the address given in your Application Form unless you have informed us of a change of address. The terms and conditions of this policy: (i) shall not confer rights upon any third party and any third party rights are specifically excluded (ii) may be changed without reference to and without the consent of any third party No verbal communication can override or vary the written terms and conditions of this policy unless confirmed by us in writing. This policy is governed by the laws of England and Wales. Any disputes arising in connection with the policy which are not resolved through our complaints process can only be dealt with by the courts of England and Wales unless you and we agree to a different method to resolve the dispute. Definitions Certain words and phrases sometimes occur with special meanings. The special meanings of those words and phrases are defined below. Acupuncture: treatment given by a practitioner who is qualified and registered with an approved professional organisation recognised by us in the appropriate field. 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. Cancer: a malignant tumour, tissues or cells, characterised by the uncontrolled growth and spread of malignant cells and invasion of tissue. Chemotherapy: drugs that are used to treat cancer. These include: drugs used to destroy cancer cells or prevent tumours from growing (these could be cytotoxic drugs, targeted or biological therapy drugs) drugs used to strengthen bones (these are called bisphosphonates) hormones 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 Claiming year: your claiming year running from your renewal date. Day-patient: a patient who is admitted to hospital or day-patient unit because they need a period of medically supervised recovery but does not occupy a bed overnight. 45

46 Dependant: (i) your wife, husband or civil partner (ii) a person who lives with you on a permanent basis as if your legal spouse (iii) unmarried children up to the annual renewal date following their 21st birthday or 24th birthday if in full time education Diagnostic tests: investigations, such as X-rays or blood tests, to find or to help to find the cause of your symptoms Dangerous sports: for the purposes of this policy, dangerous sports are: ballooning, hang gliding, parachuting or bungee jumping, flying (except where a fee paying passenger) motor racing scuba diving or free diving potholing, rock climbing mountaineering where ropes or guides should be used any form of martial arts off piste skiing or snowboarding Full Medical Underwriting: you are asked to give details of your medical history. You must give all the information that you are asked for. If you have a medical condition that is likely to come back (and any related to it) we will issue a policy but that condition might not be covered. Details of exclusions or restrictions will be found on your membership certificate. General Practitioner (GP): a doctor who is on the GP register (a register of doctors who are able to work in general practice in the health service in the UK) of the General Medical Council and who has a current licence to practise. Group Secretary: the person responsible for your group policy with Simplyhealth. Home nursing: the full time services of qualified nurses, on a resident or daily basis, following an in-patient stay, when prescribed by a specialist solely for medical reasons. Hospital: any hospital in the current Hospital Directory. In-patient: a patient who is admitted to hospital and who occupies a bed overnight or longer, for medical reasons. Member: the individual nominated by the Group Secretary and accepted by Simplyhealth as a member including each nominated eligible dependant. Membership certificate: provides details of your chosen form of medical underwriting and any personal restrictions that apply to your policy. Nurse: a qualified nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number. Out-patient: a patient who attends hospital, consulting room or out-patient clinic and is not admitted as a day-patient or in-patient. Policy: your cover within the contract of insurance from Simplyhealth. Policy document: the full terms and conditions that relate to the policy including your membership certificate and personal underwriting exclusions. Pre-existing condition: any disease, illness or injury for which: you have received medication, advice or treatment; or you have experienced symptoms; whether the condition has been diagnosed or not in the five years before the start of your cover Renewal date: the date the group contract is renewed by your employer. Simplyhealth: a trading name of Simplyhealth Access. Specialist or consultant or surgeon: a doctor who holds or has held an NHS consultant post, is on the Specialist Register held by the General Medical Council and has a current Licence to Practise. Treatment: surgical or medical services (including diagnostic tests) that are needed to diagnose, relieve or cure a disease, illness or injury. We or our or us: Simplyhealth You or your: you, and where applicable, any dependant who are members of the policy as nominated by your Group Secretary. 46

47 Appendix - understanding the underwriting options How we deal with conditions that you have before you join the policy (called pre-existing conditions) The Simplyhealth Employee Plan provides cover for unexpected illnesses and injuries which happen after the start of the policy. Underwriting is the process by which we decide whether or not to accept cover for illnesses and injuries which you had before buying the policy. This section explains the two most common methods of underwriting the type that the policyholder chooses will be shown on your membership certificate. Your membership is based on the information that you give us on the application form. You should take care to give us full and accurate answers to all the questions that we ask. We will then write and confirm your policy details. Any personal exclusions that we apply to your cover will be on your membership certificate. Option 1 - moratorium With this option you do not need to complete a health questionnaire. Instead, we automatically exclude any preexisting conditions which you have: received treatment or medication for received advice about, or had symptoms of (whether or not those symptoms have led to a diagnosis) during the five years immediately before you join the policy. However, if you do not have any: symptoms of advice about, or treatment or medication for those pre-existing conditions, or any directly related conditions, for two continuous years after you join the policy, the automatic exclusion will not apply for those conditions. For children who are under five when their cover starts, we will take into account all the conditions that they have had from the day they were born until the date their cover starts. Important: long term medical conditions, which are likely to continue to need regular or periodic treatment, medication or medical advice will always remain excluded from cover on this policy. You should not delay seeking medical advice or treatment for a pre-existing condition simply to obtain cover for that condition under the policy. Why some customers choose moratorium underwriting You will only be asked to provide basic information about yourself. We will not ask for details of your medical history when you join the policy, but we may need to ask for medical information if you make a claim. If you do not have any symptoms of, advice about, or treatment or medication for a pre-existing condition for a continuous two year period after you join the policy, we will not apply the automatic exclusion. Option 2 - full medical underwriting Each person has to complete a health questionnaire before joining the policy. This will enable us to understand their medical history. It is important that you consider the questions carefully for each person that you want the policy to cover, and answer them fully. We will assess the information and decide the basis on which we can accept you for cover. If necessary, we may ask your doctor for any more information we need to help us do this (you will have to pay if the doctor charges for this information). If you have a pre-existing condition that may need treatment in the future, we will probably exclude it from cover, and also exclude any conditions related to it. For example, if you suffer from diabetes we would not pay for treatment of eye disorders which occur as a result of having diabetes, for example diabetic retinopathy. If the policyholder chooses full medical underwriting, we will show any exclusions on your membership certificate. If we exclude a pre-existing condition from the time the policy starts we can, in some cases, review the exclusion at a later date if you ask us to do so. It is very important that you give full and accurate information in answer to the questions that we ask. If you do not, it may mean that we cannot cover a claim or even that your policy is void. Why some customers choose full medical underwriting Although this option involves more of your time when completing your application, it does mean that when you receive your policy documentation you will know which conditions are excluded from cover. An example of how both options work: Lisa s story Lisa had an operation on her right knee recently. Will she be covered for any further treatment to the knee after her policy starts? Moratorium Not immediately. As Lisa had her operation before the policy started, we would apply an automatic exclusion to that knee if Lisa makes a claim for further treatment for, or diagnostic tests and consultations about, the knee. However, we would not apply the automatic exclusion if there was a continuous two year period after Lisa s policy started when she did not have: treatment to the knee advice about the knee from a medical professional, or symptoms in the knee. Full medical assessment No. When Lisa completed her full medical assessment she told us about her knee operation, we placed an exclusion on her membership for any condition directly related to her knee operation. We will show this exclusion on her membership certificate. 47

48 About us and our insurance services Simplyhealth is a trading name of Simplyhealth Access which is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Our Financial Services Register number is You can check this on the Financial Services Register by visiting the Financial Conduct Authority s website gov.uk/register/home.do or by contacting the Financial Conduct Authority on We can only provide you with information on our own products and you will not receive any advice or a personal recommendation from us for our health plans. We may ask you some questions to narrow down the product option on which we provide you with information, but you will then need to make your own choice about how to proceed. How to contact us If you need to discuss any aspect of your cover call our freephone number, where one of our friendly and dedicated team will be pleased to help you [email protected] Visit: Lines open 8am to 6pm Monday to Friday Your calls may be recorded and monitored for training and quality assurance purposes PRO-cSEP-PD-0614 Simplyhealth is a trading name of Simplyhealth Access, which is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Simplyhealth Access is registered and incorporated in England and Wales, registered no Registered office, Hambleden House, Waterloo Court, Andover, Hampshire, SP10 1LQ. Your calls may be recorded and monitored for training and quality assurance purposes.