Health Essential policy wording International Healthcare for Jelf clients
Your policy These are your policy details, including full terms and conditions. Please read them carefully and then keep them in a safe, accessible place. Throughout this booklet certain words are shown in bold type. These are defined terms and have specific meanings when used in this booklet. The meanings are set out in the Definitions section. We will pay costs up to the amount specified in the benefit table in the event that you sustain accidental injury or contract an illness during the policy year. We will only pay costs that you incur whilst you are a member on the policy. All costs that you claim must be: reasonable, customarily, and necessarily incurred, for the medical services specified in the policy. If you have chosen region E, we will pay for treatment in any country. If you have chosen region A, region B, region C or region D, we will pay for treatment in any country except the USA. You may travel within your selected region or lower region to receive eligible elective treatment provided that you: are fit to travel without medical assistance; and make and pay for your own travel arrangements both to and from the place where you were injured or became ill. We cover treatment at any hospital within your chosen region, but we do not cover travel costs unless we organise an evacuation. Unless specifically stated otherwise, all benefit limits apply to each member each policy year. 2 Health Essential policy wording
Please note Benefit limits apply in the currency in which the policyholder pays the premium. For: each member of the policy each policy year we will cover: Benefits Amount payable Notes Overall annual limit 1,000,000, 1,100,000 or $1,500,000 = pounds sterling = euros $ = US dollars A. Treatment as an in-patient or a day-patient at a private hospital Hospital charges Specialists fees Diagnostic tests Treatment for cancer Psychiatric treatment Reconstructive surgery Organ transplant up to 30 days Consisting of accommodation and meals, nursing care, drugs and surgical dressings, operating theatre, intensive and high dependency care, prostheses, physiotherapy, and organ transplantation (excluding the cost of obtaining donor organs) Surgeons, anaesthetists and physicians fees For example endoscopy, removal of tissue for biopsy, blood tests, X-rays, scans and ECGs We will cover a surgical procedure to restore your appearance if the procedure immediately follows an accident or treatment for cancer. See cosmetic treatment exclusion We do not cover the costs involved in obtaining or harvesting organs for transplantation Health Essential policy wording 3
Benefits Amount payable Notes B. Treatment as an out-patient Surgical procedures Treatment for cancer CT, MRI and PET scans Consultations with a specialist or medical practitioner Diagnostic tests Physiotherapy Prescribed drugs, dressings, and vaccinations prescribed by a specialist or medical practitioner Complementary and Chinese medicine - cover for consultations, treatment, drugs and dressings with the following practitioners: Chinese medicine, chiropractic, osteopathy, acupuncture, homeopathy, chiropody and podiatry Purchase/hire of medical aids such as wheelchairs, crutches, stoma supplies and podiatry appliances Up to 1,000, 1,100 or $1,500 for each condition in combined total Up to 1,000, 1,100 or $1,500 for each condition For example blood tests, X-rays, scans, ECGs On specialist or medical practitioner referral Subject to appliances and prostheses exclusion 4 Health Essential policy wording
Benefits Amount payable Notes C. Additional benefits Nursing at home by a nurse Up to 30 days Immediately following eligible treatment as an in-patient or day-patient; see nursing at home benefit term Rehabilitation Up to 120 days for each condition See rehabilitation benefit term Local ambulance Emergency air ambulance Parent hospital accommodation when staying with a child covered by the policy Up to 5,000, 5,500 or $7,500 for each event Within the country in which the emergency medical situation occurs Children aged under 21 undergoing eligible treatment, one parent only Newborn hospital accommodation when staying with a parent covered by the policy Cash benefit for each night spent as an in-patient in a government or charitable hospital Up to age 112 days 100, 110 or $150 for each night Up to 20 nights when undergoing treatment which the policy covers; see cash benefit term Treatment for accidental dental injury Complications of pregnancy and childbirth See accidental dental injury benefit term See complications of pregnancy and childbirth benefit term Newborn cover Up to 6,250, 6,875 or $9,375 For acute conditions occurring during the first 30 days following birth; see newborn cover benefit term Treatment for acute phases of chronic conditions Up to 50,000, 55,000 or $75,000 We will cover unexpected acute flareups of a chronic condition until your condition is re-stabilised Treatment for HIV/AIDS Up to 10,000, 11,000 or $15,000 Investigations into infertility Local burial or transport of mortal remains Worldwide extension for emergency evacuation and treatment Up to 5,500, 6,050 or $8,250 up to 60 days Reasonable costs of investigation into the cause of infertility; see infertility benefit term See local burial benefit term See regions of cover benefit term Health Essential policy wording 5
Benefits Amount payable Notes C. Additional benefits Costs for your evacuation to a place where you can receive treatment that the policy covers Return flight for you and an accompanying close relative following evacuation Reasonable domestic travel costs (to and from medical consultations) following an evacuation Payment for hotel accommodation immediately before and immediately following hospital admission Reasonable domestic travel costs for a close relative visiting you in hospital following an evacuation Economy return flight (or equivalent) following the death of a close relative Medical Information Line (non-emergency) 24 hour medical information service Up to 100, 110 or $150 per night Up to 1,000, 1,100 or $1,500 Unlimited number of calls See evacuation benefit term Economy class. See evacuation benefit term See evacuation benefit term Up to 3,000, 3,300 or $4,500 per evacuation See evacuation benefit term See compassionate travel benefit term See medical information line benefit term Web service Unlimited use Access to online web services 6 Health Essential policy wording
Benefit Terms Accidental dental injury We cover costs for treatment as an in-patient which you need as a result of an accidental dental injury to sound, natural teeth. This includes the initial relief of pain, treatment necessary to preserve your natural dental structure, and any related permanent reconstruction work. Cash benefit We will pay cash benefit if: accommodation and all treatment is provided by a government or charitable hospital which does not ask you to pay, and you do not claim any other benefit under the policy. We only pay cash benefit for a condition that we would pay for if the hospital charged you for the treatment. Compassionate travel We cover the cost of one economy return flight (or equivalent), up to the benefit limit specified, for each member to travel to attend the funeral of a close relative. Complications of pregnancy and childbirth The conditions which we cover as complications for the purposes of this benefit are: ectopic pregnancy (development of foetus outside the womb) miscarriage (if you have miscarried, but not investigations into the cause of repeated miscarriages) still birth hydatidiform mole (cell growth abnormality in the womb) retained placenta (afterbirth retained in the womb) pre-eclampsia (a condition with a number of symptoms, including high blood pressure and fluid retention) eclampsia (a coma or seizure during pregnancy and following pre-eclampsia) diabetes (if diabetes begins in pregnancy, but not before) caesarean sections in specific clinical circumstances (we will need full clinical details from your specialist before we can make a decision about your cover). Health Essential policy wording 7
Evacuation If you are ill or injured, and the place where you are does not have either the facilities or equipment to treat you, we will discuss the situation with your medical practitioner or specialist and decide whether or not there is a medical need for an evacuation. If you do need to be evacuated, we will make all arrangements for that evacuation through our assistance service. An evacuation will take you to the nearest appropriate facility for treatment as an in-patient or day-patient which you need. We, together with our assistance service, will decide whether you need an air ambulance, or whether an economy class commercial flight is more appropriate. If we, or our assistance service, give specific written authorisation, this benefit will include the cost of one other member or close relative travelling with, staying with or escorting you. This benefit does not cover sea rescue or mountain rescue. We cover reasonable domestic travel costs (to and from medical consultations) following an evacuation, but we do not cover the costs of a hire car. We cover: travel costs to return home to recuperate following an evacuation we will cover economy class travel costs from: the place where you received treatment to your country of nationality, and back to your country of residence (or the place where you were evacuated to, or the place where you were before the evacuation if that is where you want to go) after your recuperation. We will cover these costs only when you are medically discharged and fit to travel on commercial transport. We do not cover the costs of treatment related to the recuperation. If we agree that evacuation is medically necessary for your circumstances, you can choose repatriation. This means that, instead of taking you to the nearest appropriate facility, we will pay to transport you from the country where you are to: your country of nationality, or your country of residence. We will only authorise and arrange repatriation if our assistance service and the doctors treating you agree that it is safe to do so. Infertility We cover consultations and diagnostic tests for infertility where both partners: are covered by the policy, and had been unaware of their infertility when they joined the policy. Local burial If a member dies, we will cover (up to the benefit limit specified) for either: burial or cremation at the place of death; or, the cost of transportation of body or ashes to the country of nationality. In either case, the policy does not cover the costs of a religious practitioner. Medical Information Line Each medical information line consultation is intended to deal with one call per member to a medical professional on our medical information line. The medical professional will provide information and advice which is reasonable to give a member over the telephone when medical concerns are presented by the member during a telephone call to the medical information line. Calls will last up to 15 minutes per consultation as required by the medical practitioner. Each such consultation may, at the discretion of the medical practitioner, involve a longer call or more than one call. The medical information line is designed to be available 24 hours per day but some reasonable delay may be experienced. It is not an emergency service. It may not provide a diagnosis or prescribe treatment and will only involve advice that it is reasonable and practical to give over the telephone. Call charges are the responsibility of the caller. 8 Health Essential policy wording
You may call on behalf of another member subject to any patient confidentiality requirements of the medical practitioner. In using the medical information line the member automatically authorises the use and disclosure of any medical or other information relating to them, on a fully confidential basis as between us, the medical practitioners and any service providers we use in making the service available, for the sole purpose of policy and service administration. We shall not be responsible for any failure in the provision of the medical information line to the extent that it is due to circumstances beyond the reasonable control of us or any of our service providers. The medical information line is designed to be compliant with English law and regulations only. Newborn cover This benefit covers treatment for: all acute conditions which occur during the first 30 days following birth, up to a combined maximum total of 10,000, 11,000 or $15,000 during the life of the policy. Conditions which occur after the 30th day following birth will not be subject to this benefit limit. Nursing at home We cover home nursing if: your specialist recommends and supervises it it takes place in your home, it immediately follows treatment as an in-patient or day-patient that is covered by the policy, it is carried out by a nurse and is the type of treatment that only a nurse can provide, and you need it for medical reasons. We do not cover nursing at home to help with your mobility, personal care or preparation of meals. Regions of cover We will cover you for treatment in any country, with the exception of the USA, unless you have chosen region E. If you have not chosen region E you will be covered in the USA for holidays and business trips to the USA for a maximum cumulative total of 60 days in any one policy year. We will only cover emergency evacuation benefit, emergency in-patient hospitalisation and emergency treatment, administered by a medical practitioner, and in-patient or day-patient treatment following an evacuation from the USA, if we pre-authorise that treatment. Rehabilitation We will pay for rehabilitation for up to 120 days per condition, per policy year, if: it takes place in a recognised rehabilitation unit of a hospital it follows treatment for a medical condition where you were an in-patient in hospital for at least three consecutive nights admission to the recognised rehabilitation unit takes place within 14 days of discharge from hospital treatment takes place under the supervision of a specialist your specialist has confirmed to us that rehabilitation is necessary. This benefit covers: use of special treatment rooms physiotherapy fees speech therapy fees other services usually given by a rehabilitation unit, including nursing care. Health Essential policy wording 9
Exclusions Benefits will not be available for: Addictions and substance abuse We do not cover treatment for addictions (for example alcohol addiction or drug addiction), or substance abuse (for example alcohol abuse or solvent abuse), or treatment of any illness or injury which you need as a direct or indirect result of any such abuse or addiction. Appliances and prostheses We do not cover hearing aids or neurostimulators. BUT: We do cover prostheses inserted into the body during surgery hand, back and knee braces required after surgery, and heart pacemakers and implantable cardioverter defibrillators. Birth control We do not cover birth control, for example contraceptive pills and devices, or sterilisation. Congenital conditions We do not cover congenital conditions, birth defects, genetic or hereditary conditions or any abnormality or disability arising during the ante-natal stages of pregnancy or as a result of childbirth. Cosmetic treatment We do not cover treatment, or any consequence of treatment, that is intended to change your appearance (for example a tummy tuck, facelift, tattoo, ear piercing), whether or not this is carried out for psychological or medical reasons. We do not cover treatment, or any consequence of treatment, to remove undiseased tissue. BUT: We will cover a surgical procedure to restore your appearance if: the surgical procedure immediately follows an accident, or treatment for cancer, and the accident or cancer treatment took place when you were covered under the policy and you have had no break in cover since then. We advise that you contact us before treatment begins so that we can confirm if you are covered. Dental treatment We do not cover: treatment carried out by a dentist or dental surgeon, treatment of gum disease or treatment carried out to help you wear dentures, bridges or implants, or orthodontic treatment unless it is treatment as an in-patient as a result of an accidental dental injury. Developmental delay We do not cover treatment in relation to the developmental delay of children, for example delayed speech, mobility, learning, continence and social and behavioural disorders, for example attention deficit hyperactivity disorder (ADHD). Dialysis We do not cover kidney dialysis as part of long-term treatment of a chronic condition. BUT: We cover short-term kidney dialysis: if you are admitted to hospital for eligible treatment as an in-patient for another condition and you need your regular kidney dialysis during this admission, or if required as a result of secondary kidney failure during eligible treatment as an in-patient, or immediately before or after a surgical procedure to transplant a kidney as part of treatment as an in-patient. Experimental treatment We do not cover experimental treatment, unless it meets the criteria set out below. We only pay for treatment that is: proven or established within common UK practice, for example, a drug used within the terms of its licence or approved by NICE for use in the NHS, and supported by peer reviewed and published clinical evidence which proves that the treatment has positive clinical outcomes, and is acceptable clinical practice, practised widely by specialists in your country of residence. If your treatment meets all these requirements, we will not exclude treatment on the basis that it is experimental. Before we can decide if your proposed treatment is eligible, we must receive all the clinical details we need from your specialist. We must confirm your cover in writing before any treatment begins. BUT: Even if we consider your treatment to be experimental because it does not satisfy all the requirements listed above, we will still pay for the lowest cost of either: the experimental treatment or the equivalent established treatment usually provided for your condition, if this is available. Please note: No payment will be made if there is no established treatment available for your condition (for which the experimental treatment is being proposed). If you undergo experimental treatment that is not successful, we will not pay towards further treatment of your condition or for any other condition that you develop as a result of undergoing experimental treatment. 10 Health Essential policy wording
Eyesight We do not cover treatment for: short-sight or long-sight, such as glasses, contact lenses or laser eyesight correction surgery, or macular degeneration. Infertility We do not cover treatment directly or indirectly arising from or required in connection with: infertility (although we do cover investigations into the causes of infertility), or any form of assisted reproduction. Nursing home care We do not cover treatment received in private beds registered as nursing homes or a hospital where the hospital has effectively become your home or place where you live permanently. Pregnancy and childbirth We do not cover pregnancy and childbirth or treatment required as a result of pregnancy or childbirth. We do not cover termination of pregnancy. BUT: We do cover the specific complications listed under the complications of pregnancy and childbirth benefit. Preventative treatment, routine medical examinations and screening We do not cover routine physical examinations by a medical practitioner, for example gynaecological investigations and tests, hearing tests or other treatment, for example drugs or surgery, which aims to prevent a disease or illness (this does not affect cover under the consultations with a medical practitioner ; Chinese medicine and prescribed drugs, dressings and vaccinations benefits). Psychiatric We do not cover treatment of psycho-geriatric conditions of any kind eating disorders psychological conditions such as anxiety bereavement or any related conditions. Region of cover We do not cover treatment received outside the terms of the regions of cover benefit term. Self-inflicted injury We do not cover treatment directly or indirectly arising from or required as a result of self inflicted injury. Sexual dysfunction We do not cover treatment of sexual dysfunction, such as impotence. BUT: We do cover investigations, including diagnostic tests, to find the cause of sexual dysfunction. Sexually transmitted disease We do not cover venereal disease or any other sexually transmitted diseases. This exclusion does not apply to treatment for HIV/AIDS. Sleep disorders and sleep problems We do not cover treatment directly or indirectly related to sleep disorders and sleep problems, such as snoring, insomnia or sleep apnoea (when breathing stops temporarily during sleep). Sport professional sports We do not cover treatment of an injury sustained whilst you are: training for, or taking part in sport for which you are paid or funded by sponsorship or grant (unless you receive travel costs only). This exclusion does not apply if you are coaching the sport. War and hazardous substances We do not cover treatment directly or indirectly arising from or required as a consequence of: war, invasion, acts of foreign enemy hostilities (whether or not war is declared), civil war, rebellion, revolution, insurrection or military or usurped power, mutiny, riot, strike, martial law or state of siege, attempted overthrow of Government or any acts of terrorism, unless you sustain bodily injury covered by the policy whilst an innocent bystander. chemical contamination or contamination by radioactivity from any nuclear material whatsoever or from the combustion of nuclear fuel. Weight loss surgery We do not cover treatment that is directly or indirectly related to: bariatric surgery (weight loss surgery), such as gastric banding or a gastric bypass, or the removal of surplus or fat tissue. Health Essential policy wording 11
Conditions Policy duration and premiums The policy lasts for one year and (if we still offer International Healthcare for Jelf clients) we will automatically renew it unless the policyholder notifies us that they do not wish to renew it. We also have the option not to renew the policy, for example if trade sanctions were imposed or legislation passed which meant that we could no longer offer cover. If we do not renew the policy, we will tell the policyholder. We reserve the right to close the International Healthcare for Jelf clients product at the renewal date. If this happens, we will contact the policyholder to discuss the options. The financial statement shows how much to pay, when and by which payment method. We will: advise the policyholder if the premium changes collect premiums in advance of the date they are due, and collect any premiums due unless the policyholder tells us to cancel the policy in time for us to stop collecting the payment. If the policyholder wishes to change the way they pay the premium (for example from monthly to annually) they can do this at the renewal date. The policyholder must pay the premium for all members and must not recover the premium relating to any group members from those group members. We do not pay any claims if premiums are not paid to date at the time a member s treatment takes place. If the policyholder pays the premium: monthly, each premium payment is for one month s cover; quarterly, each premium payment is for one quarter s cover; annually, each premium payment is for one year s cover. We only pay claims for treatment that takes place while the member is included on the policy. Policy information for members It is the policyholder s responsibility to ensure that the group members have a copy of: the group member booklet (and any inserts) their policy certificate (if applicable), and any other literature that we send. Break in cover Where there is a break in cover, we reserve the right to underwrite members again and exclude any pre-existing conditions. This has the same effect as starting the policy again, and means that we may exclude a condition or course of treatment which we previously covered. Compliance with policy terms We shall not be liable under this policy if you fail to comply with its terms and conditions, except where the circumstances of any claim are unconnected with that failure and no fraud is involved. Change of risk The policyholder must tell us as soon as possible about: any changes relating to members, for example a change of name, address, marital status, if somebody works for the diplomatic service or a foreign embassy, or of any other material changes that affect information given to us relating to the application for cover under this policy, such as a change of a member s country of residence or region, or for example the policyholder s liquidation, insolvency or bankruptcy. We reserve the right to alter the premiums or policy terms or cancel cover for a member of the policy following a change of risk. We will not backdate changes to before the date we were told of them. We reserve the right to alter the premiums or policy terms or cancel cover for a member of the policy following a change of risk, to the extent permissible by the laws of a member s country of residence. We will always write to the policyholder s last known address with details of any changes to your cover. Changes to cover We may change the terms and conditions of the policy at the renewal date. If there are changes to the policy, we will let you know before the next renewal date. If the policyholder decides to cancel the policy as a result of those changes, they must let us know in writing. Only Aviva can make changes to the terms and conditions of the policy. Cancellation When we may cancel the policy If any premium is not paid, we will automatically cancel the policy. If the policyholder pays the premium within 45 days of the date on which it was due, we may, subject to our reasonable requirements, reinstate cover although we will not pay any claims until outstanding premiums have been paid in full. If we cancel the policy we may, subject to our reasonable requirements, offer cover on an alternative product. If we continue cover on this policy, we can continue to charge the premium for a minimum of two group members (and their family members). 12 Health Essential policy wording
If the policyholder or a member has at any time: misled us, for example dishonestly telling us incorrect information or not telling us something that we have asked for, or defrauded or attempted to defraud us, or agreed to any attempt by someone else to defraud us, or not acted openly and honestly in their dealings with us we may at any time (and backdate this action where appropriate): cancel the policy, or terminate a member s cover, or apply different terms (in line with reasonable underwriting practice) to a member s cover. If we cancel the policy for these reasons: we may backdate the cancellation (this means that we may not pay claims), we will notify the policyholder in writing to their last known address, and this will end the cover of all members who were covered by the policy. If a group member is no longer included on the policy (for example the group member no longer works for the policyholder, or the policy has been cancelled), his / her family members will also no longer be included. The policyholder must advise the group member that their membership has ended. We reserve the right to close the International Healthcare for Jelf clients product at the renewal date. If this happens, we will contact the policyholder to advise them of their options. We will not cancel the policy simply because of the number of eligible claims that a member has made. Our right to cancel is subject to any relevant law of the group member s country of residence. We will not return any premiums if the policyholder cancels the policy. Territorial limits Territorial limits under this policy are arranged into five geographical regions. The policyholder selects the region that they need at the start date and can change this: at any renewal date, or at any time if they can show us that a member will live in a different region for 6 months or more. Benefit under this policy is limited to that described in the regions of cover benefit term. Law This policy is governed by English law and shall be subject to the exclusive jurisdiction of the courts of England and Wales unless we have agreed that this is not the case. If we agree to the policy being governed by any other law, we will show this on the policy certificate. This will not affect statutory rights you may have under the laws of your country of residence. If we decide to waive any term or condition of this policy, we may still rely on that term or condition at a later time. Changes in legislation Where the laws of your country of residence make or are changed to make the sale and purchase of medical insurance by an international insurer illegal, we may have to cancel or not renew this policy. If this happens we will, wherever possible, try to ensure that we cover any ongoing claim (if applicable). Legal rights This policy is a contract between the policyholder and us. Members have no right under the Contracts (Rights of Third Parties) Act 1999 to enforce this policy or any part of it. This will not affect other legal rights or remedies (if any) which someone else (a third party) may have, that is to say rights which do not exist solely by virtue of that Act. Ex-gratia payments If we agree to pay for treatment that is not normally eligible on the policy, this does not mean that we will make another payment for treatment in the same or similar circumstances. Any ex-gratia payments we do make towards the cost of ineligible treatment will count towards any benefit limit listed in the policy terms and conditions. We may call these payments ex-gratia payments or without prejudice payments. Health Essential policy wording 13
Third party claims You must let us know if you needed treatment because someone else was at fault - for example, if you were injured as a result of a road traffic accident. If the laws of your country of residence allow, we may be able to recover the cost of any treatment that we have paid for. We call this a third party claim. You must keep us informed of any claim that you are making against the person at fault and take whatever steps we reasonably require. If we have paid any costs for treatment then you must not settle your personal injury claim unless we have given our agreement to you or your lawyers. If you recover costs we have paid for your treatment, including any interest on any payments we have made, you must forward these sums to us immediately. We will be entitled to prosecute the third party in your name for any claim relating to any costs we have incurred. We will not pay for any costs or prosecute any third party for costs that are not covered by the policy. We cannot offer legal advice. Other private medical insurance If you have any other insurance covering any of the benefits covered by this policy such as other private medical insurance or travel insurance, you must let us know and we may recover these costs from that other insurer. Fraudulent / unfounded claims If any claim under this policy is in any way fraudulent or unfounded: we will be entitled to recover any benefits that we have paid, and we will not pay any further benefit for that claim. Second opinions We will only pay for a second (or subsequent) opinion from a medical practitioner or specialist in respect of the same condition if we authorise it. If we ask for a second opinion, we will make and pay for the arrangements. Benefit limits apply in the currency in which the policyholder pays the premium. We will pay claims by cheque, currency draft or bank transfer the policyholder can choose the method. Data protection and disclosure of information Data protection and disclosure of information On behalf of itself and all members, the policyholder agrees and consents to the processing (including electronic or computer processing) and the use of all personal and medical details received by us, by the data controllers and by relevant third parties (which may include the policyholder, medical and service providers and relevant intermediaries). Processing will be for the purposes of policy administration, service provision, reinsurance, claims validation and fraud prevention. Processing may be in any part of the world and will be carried out according to standards of data protection within the meaning of English law. The data controllers are Aviva UK Health Limited, Aviva Insurance Limited and Aviva Life & Pensions UK Limited. As a client of Jelf, you acknowledge that they have full authority to act on your behalf. This means we may treat any instruction from them as being an instruction from you (including an instruction to set up or alter a policy). We are entitled to inspect the policyholder records relating to the policy at any time if we give reasonable notice. If we ask for it, the policyholder must provide (or arrange for third parties to provide) evidence, at its cost, to confirm that: one or more members are eligible for cover on the policy, and/or the definition of policyholder is satisfied. This may include (but is not limited to): management accounts PAYE, NI, Inland Revenue records and returns employee records employee contracts VAT records and returns. Insurance premium tax The premium includes all relevant premium taxes. Currency conversion If we receive a bill in a different currency from the currency in which we calculate the benefit limits, we will convert the amount of the bill into that currency using the published exchange rate which applied at the beginning of the month in which the treatment took place. 14 Health Essential policy wording
Definitions 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. Advice Any consultation, advice or prescription from a medical practitioner or specialist. Birth defect Any deformity, anomaly, abnormality or disability arising during the ante-natal stages of pregnancy or as a result of childbirth. Cancer A malignant tumour, tissues or cells, characterised by the uncontrolled growth and spread of malignant cells and invasion of tissue. Chronic conditions A disease, illness or injury which 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. Close relative A member s: husband or wife partner or civil partner child or step-child brother sister parent parent-in-law brother-in-law or sister-in-law. Country of nationality For the purposes of the policy, this will be the country for which you hold a passport. If you hold more than one passport, the country of nationality will be the country you were born in. Country of residence The country in which you normally live at the time the policy is first taken out, or at each subsequent renewal date. Day-patient A patient who is admitted to a hospital or day-patient unit because they need a period of medically supervised recovery but does not occupy a bed overnight. Diagnostic tests Investigations, such as X-rays or blood tests, to find or to help to find the cause of your symptoms. Drugs and dressings Drugs, medicines, dressings, supports and appliances (including prostheses) prescribed by a specialist or medical practitioner. Emergency air ambulance Air ambulance transport needed for an emergency out of medical necessity to the next available and appropriate hospital or licensed medical facility within the country in which the emergency medical situation occurs. We will only pay for an emergency air ambulance if a local ambulance is not suitable. Evacuation The transportation of a member from the country of residence, or country of incident (if different), to the nearest appropriate facility, as determined by a member s medical practitioner or specialist in conjunction with our medical advisers and the prescribed assistance service for the sole purpose of receiving treatment as an in-patient or day-patient. Family member A group member s: husband wife partner, or children under 21 years of age (24 if they are in full time education) who are covered by the policy. Financial statement A statement addressed to the policyholder giving details of (amongst others) members and premiums Health Essential policy wording 15
Group member(s) An employee of the policyholder who is covered on the policy in accordance with the terms of the financial statement. Hospital An establishment which is legally licensed as a medical or surgical hospital under the laws of the country in which it is situated. In-patient A patient who is admitted to hospital and who occupies a bed overnight or longer, for medical reasons. Local ambulance Road ambulance transport needed for an emergency out of medical necessity to the next available and appropriate hospital or licensed medical facility. Member / you / your A group member or family member (to be eligible for cover under this policy, a member must normally live or work outside his or her country of nationality). Newborn Any child from birth up to 112 days old. Nurse A qualified resident or daily nurse whose name is currently on any register of nurses maintained by any statutory nursing registration body within the country in which he/she is resident. Out-patient A patient who attends a hospital, consulting room, or out-patient clinic and is not admitted as a day-patient or an in-patient. Palliative treatment Treatment which temporarily relieves symptoms but does not cure the actual medical condition causing the symptoms. Policy Our contract of insurance with the policyholder providing cover as detailed in the policy document. The application and policy certificate form part of the contract and you should read these together with the policy document (as amended from time to time). Policyholder The company or other business entity which is named as the policyholder on the financial statement. Policy year The period of time from the date the policy began or renewed until the day before the next renewal date. Region The area of the world (as shown on the Region Guide) for which the policyholder has selected cover. These are identified as: Region A - Indian subcontinent, Middle East & Africa (excluding Nigeria) Region B - South & Central America, Nigeria and Far East Asia & Pacific Rim (excluding Australia, New Zealand, Singapore, Japan and China) Region C - EU, Central and Eastern European countries (excluding Russia), Andorra, Cyprus, Gibraltar, Iceland, Liechtenstein, Malta, Monaco, Norway and San Marino Region D - China, Singapore, Japan, Australia, New Zealand, the Caribbean and Russia Region E - worldwide including the USA. Related Illnesses or injuries are related if, in our reasonable medical opinion, one is a result of the other or if each is a result of the same illness or injury. Renewal date Annually, on 1 September. Specialist A registered medical or dental practitioner who: a) has at any time held, and is not precluded from holding, a substantive consultant appointment in that specialty in the United Kingdom in a National Health Service hospital; or b) has at any time held and is not precluded from holding a substantive consultant appointment which we on professional advice accept as being of equivalent professional status; or c) is recognised as a specialist by the statutory bodies of the country in which he/she practises. Start date The start date shown on the policy certificate. Cover starts at 00.01am UK time on that date. 16 Health Essential policy wording
Treatment Surgical or medical services (including diagnostic tests) that are needed to diagnose, relieve or cure a disease, illness or injury. You / your See member. We / our / us Aviva Health UK Limited, who administers the policy on behalf of Aviva Insurance Limited, who underwrites and provides the contract of insurance. Health Essential policy wording 17
If you have any cause for complaint Our aim is to provide a first class standard of service to our customers, and to do everything we can to ensure you are satisfied. However, if you ever feel we have fallen short of this standard and you have cause to make a complaint, please let us know. Our contact details are: Aviva Health UK Ltd Complaints Department PO Box 540 Eastleigh SO50 0ET Telephone: 0800 015 1024 E-mail: hccomp@aviva.co.uk We have every reason to believe that you will be totally satisfied with your Aviva policy, and with our service. It is very rare that matters cannot be resolved amicably. However, if you are still unhappy with the outcome after we have investigated it for you and you feel that there is additional information that should be considered, you should let us have that information as soon as possible so that we can review it. If you disagree with our response or if we have not replied within eight weeks, you may be able to take your case to the Financial Ombudsman Service to investigate. Their contact details are: The Financial Ombudsman Service South Quay Plaza 183 Marsh Wall London E14 9SR Telephone: 0300 123 9123 Email: complaint.info@financialombudsman.org.uk Website: www.financial-ombudsman.org.uk Please note that 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 your legal rights. Language All our communications with you in connection with this policy will be in English. The Financial Services Compensation Scheme (FSCS) We are covered by the FSCS. You may be entitled to compensation from the scheme if we cannot meet our obligations. This depends on the type of business and the circumstances of the claim. Where you are entitled to claim, insurance advising and arranging is covered for 90% of the claim with no upper limit. Further information about compensation scheme arrangements is available from: Financial Services Compensation Scheme, 7th floor, Lloyds Chambers Portsoken Street London E1 8BN. Website: www.fscs.org.uk. About us The Financial Services Authority (FSA) is the independent watchdog that regulates financial services. It requires us to give you this information. Use this information to decide if our services are right for you. Aviva Health UK Limited, Chilworth House, Hampshire Corporate Park, Templars Way, Eastleigh, Hampshire, S053 3RY is authorised and regulated by the Financial Services Authority. Our FSA registration number is 308139. Our permitted business is advising on, arranging and administering general insurance and pure protection contracts. You may check this on the FSA s website www.fsa.gov.uk/register or by contacting the FSA on 0845 606 1234. Aviva Health UK is a wholly owned subsidiary of Aviva Plc, which includes within its group a number of insurers. Aviva Health UK offers a range of products from Aviva. Jelf will provide you with information about their permitted business and the range of products they offer. You only need pay the premium; you do not otherwise have to pay us for our services to you. 18 Health Essential policy wording
Health Essential policy wording 19
Aviva Health UK Limited. Registered in England Number 2464270. Registered Office 8 Surrey Street Norwich NR1 3NG. This insurance is underwritten by Aviva Insurance Limited. Registered in Scotland Number 2116, Registered Office Pitheavlis, Perth PH2 0NH. Authorised and regulated by the Financial Services Authority. Aviva Health UK Limited, Head Office: Chilworth House Hampshire Corporate Park Templars Way Eastleigh Hampshire SO53 3RY. www.aviva.co.uk/health 20 Health Essential policy wording GEN4218 11/2011 Aviva plc