My Health Plan. Policy document

Transcription

1 My Health Plan Policy document 2016

2 Your table of cover Base Level 1 Level 2 Monthly premium for you Monthly premium for you and your partner Monthly premium for up to four of your children under the age of 18 (all premiums include insurance premium tax where applicable) My lifestyle FREE Annual limit for each person All cash back benefi ts are 100% payback Executive level Fitness Lifestyle and diet Travel advice and vaccinations Counselling services Tips and exercise suggestions to improve your fi tness as well as discounts at health clubs and gyms* Use our Health and Fitness Information Service* Cash back towards the cost of a consultation with a dietitian Access to travel advice and information* Cash back towards the cost of vaccinations and inoculations Speak to a qualifi ed counsellor over the phone 24 hours a day as well as face to face counselling sessions following an assessment referral from the helpline Discounts and special offers at over 2,000 leading health clubs and gyms face to face sessions for each issue that you present within a 12 month period (beginning with your fi rst session for each issue) My check-ups and treatment Speak to or see a GP Speak to a GP over the phone when you need to. Unlimited access 24 hours a day, 365 days a year or web chat with a GP during business hours 1 Cash back towards the cost of seeing a GP privately Visits to a dentist or hygienist Find a dentist near you, access a range of dental tips and advice* Cash back towards the cost of check-ups and treatment, for example fi llings, hygienist s fees, dentures, crowns and bridges Visits to an optician Cash back towards the cost of sight tests, prescription glasses and contact lenses Visits to complementary therapists and Rapid Access to Physiotherapy Cash back towards the cost of physiotherapy, osteopathy, chiropractic, acupuncture, homeopathy and refl exology Access the Rapid Access Physiotherapy service booked through our provider which guarantees you a prompt appointment with an accredited practitioner and get cash back towards the cost Visits to a chiropodist Cash back towards the cost of seeing a chiropodist or podiatrist Prescriptions Hospital stay Private prescription delivery service when prescribed by our GP helpline* Cash back towards the cost of private or NHS prescriptions issued by a GP or dentist Cash amount for each day or night when you are admitted to hospital Up to 20 days/nights each claiming year My health checks

3 Health assessment (adult only) Diagnostic consultations and allergy tests X-rays and scans Assess your risk of certain health conditions and get a discount on Health assessments booked through our provider* Cash back towards the cost of a detailed assessment of your health with a nurse, doctor or pharmacist Cash back towards consultant s fees for a diagnostic consultation that is to fi nd or help to fi nd the cause of your symptoms. Includes allergy testing Cash back towards the cost of X-rays and scans when referred by a consultant (this does not include CT, MRI or PET scans) My family s health New child payment Hospital stay with a child Care for older family members Speak to a childcare advisor over the phone 24 hours a day* Cash amount to help with the cost if you or your partner has a baby or adopts a child (6 month qualifying period) Cash amount for each night you stay in hospital with your child. Up to 10 nights each claiming year Speak to an elder care advisor over the phone 24 hours a day*, receive a discount on our full product range such as daily living aids at one of our stores or online 10% discount at Simplyhealth stores My unexpected healthcare Dental accident Recuperation Personal accident cover - burns, fractures and cuts 2 Cash back towards the cost of dental treatment to return your oral heath to its pre-accident state if you see a dentist or doctor within 30 days of the accident Cash amount following seven consecutive nights stay in hospital, payable once each claiming year Cash amount following an accident that results in a third degree burn, fracture or cut (6 month qualifying period applies to cuts). Please refer to your policy documentation for more information about Personal accident cover including full details about the annual limits for each person - Up to 15,000 Up to 20,000 Up to 25,000 Employer choice Base Level 1 Level 2 Executive level If your employer has chosen to include this choice, the monthly premium for you will be If your employer has chosen to include this choice, the monthly premium for you and your partner will be PMI excess Helps you pay any excess on your Private Medical Insurance policy. If your employer has chosen to include this choice, details will be on your membership certifi cate European cover: Unless otherwise stated you will receive these benefi ts for stays up to and including 28 days wherever you are in the European Economic Area (EEA) and Switzerland. * These services can be accessed on all levels of cover through mywellbeing when you register for Online Self Service at 1 Web chat with a GP during business hours can be accessed Monday to Friday 8.30am to 6.30pm, available on all levels of cover. 2 Personal accident cover is administered by FirstAssist Insurance Services and underwritten by Cigna Europe Insurance Company S.A.-N.V. FirstAssist Insurance Services is a trading style of Cigna Insurance Services (Europe) Limited. The joining age for this policy is from 18 years old up to 79. If anyone on the policy is aged 80 or over, you will not be able to increase the level of cover. You can fi nd full policy details in the policy documents. AONVOL / AONFLEX 0516

4 Introduction These terms and conditions set out the way we provide you with cover under the policy. As a member, they bind you, whether or not you have signed the application form or other documents. Please read them carefully and keep them in a safe place for future reference. If you have any questions about these terms and conditions, please contact Customer Services on Calls to 03 numbers are no more expensive than calling numbers starting with 01 or 02 and are included in free call packages from landlines and mobiles. We recommend that you review your cover on a regular basis to ensure that it continues to meet your needs. Making information about us accessible We aim to make information about us accessible to you, whatever your needs, and information is available in large print or audio. Section 1: Definitions To avoid repetition, the following words or expressions, wherever used in this policy, have the specific meanings given below. To identify the defined words or expressions, these are shown in bold print throughout this policy. Child/children Natural or legally adopted dependent children of the policyholder or their partner. Children must be under the age of 18. Claiming year The period of time during which you can claim the benefit for your chosen level of cover. Your summary of cover shows the dates for your claiming year. Date of treatment The date that the treatment or service was supplied. For new child payment this will be the date of adoption or birth of the child. Member Anyone who we have accepted for cover under this policy. Partner Anyone in a relationship with, and who lives with, the policyholder. This could be their husband, wife, civil partner or unmarried partner. Policy The insurance contract between Simplyhealth and the policyholder. Policyholder The first person named on the summary of cover. Qualifying period A set period of time in which we will not pay claims: for any treatment or service that you receive if you have a baby or adopt a child during that time. The qualifying period starts from the date that you join the policy or the date of any increase in cover. The table of cover shows any qualifying periods that apply to the policy. Table of cover The table (current at the date of treatment) that we give you. This will show: the levels of cover available for each level the benefit entitlements available under each level of cover any age rules for joining and changing your level of cover whether or not partners or children can be covered by the policy. We/our/us Simplyhealth Access trading as Simplyhealth, a company incorporated in England and Wales. You/your Anyone who is a member on the policy. Section 2: Details of what is covered and not covered This section explains what is and is not covered for each of the benefits on the policy. You decide the treatments and services that you receive, and the people who provide them. We make no claims about the effectiveness or safety of treatments, or the people who provide the treatment and services which the policy covers. We will pay you up to the maximum amount of your chosen level shown in the table of cover for each benefit, every claiming year. You will need to pay the cost of the treatment and claim this back from us.

5 To make a claim online, you will need to log in to Online Self Service. If you haven t already registered for Online Self Service, please visit co.uk/register and follow the simple registration process. mywellbeing We have a wealth of services and health-related information available to you. You can access this information through Online Self Service. If you haven t already registered for Online Self Service, please visit and follow our simple registration process. The information and services available on the mywellbeing website can change without notice from time to time. Some of these services are only available in the UK. The mywellbeing website will tell you which of the services this applies to. Fitness My lifestyle You can use mywellbeing for fitness tips and exercise suggestions as well as accessing the discounted gym membership. Lifestyle and diet You can access fitness and health information using mywellbeing. Dietitian fees Annual limit Important: In order to be able to practise in the UK dietitians must be registered with the Health and Care Professions Council (HCPC). We will not pay for treatment by someone who is not registered with the HCPC. What dietitian consultation fees benefit covers fees for a private consultation with a dietitian. What dietitian consultation fees benefit does not cover any tests, treatment or services provided by a dietitian Travel advice and vaccinations You can access travel advice and information using mywellbeing. Vaccinations Annual limit What vaccinations / inoculations benefit covers fees for vaccinations and inoculations from a GP or nurse. What vaccinations / inoculations benefit does not cover Counselling services The myadvice and Counselling service allows you to call for advice on a range of basic medical, legal, health and wellbeing matters, as well as telephone counselling. This service is available 24 hours a day, seven days a week - just call free on You also have access to six face to face counselling sessions for each issue that you present within a 12 month period (beginning with your first session for each issue). If you need face to face counselling please call You can find more information about these benefits on mywellbeing. My check-ups and treatment Speak to or see a GP The mygp Surgery service is also available 24 hours a day, 365 days a year by calling You can also book a webcam appointment with a GP by calling You can find more information about the webcam appointment times and these benefits on mywellbeing. Private GP fees This benefit is to help towards the costs of seeing a private GP in person. Annual limit

6 What GP fees benefit covers fees for a private consultation with a GP. What GP fees benefit does not cover any tests, treatment or services provided by a GP Visits to a dentist or hygienist You can use mywellbeing to find a dentist near you, as well as accessing dental tips and advice. Dental This benefit is to help towards the costs when you see a qualified dental professional (for example a dentist or hygienist) in a dental surgery. Annual limit What the dental benefit covers dental check-ups treatment provided by a dentist, periodontist or orthodontist endodontic (root canal) treatment hygienists fees local anaesthetic fees and intravenous sedation dental brace or gum-shield provided by a dentist or orthodontist dental crowns, bridges and 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 the dental benefit does not cover dental prescription charges dental consumables, for example toothbrushes, mouthwash and dental floss dental implants and bone augmentation procedures, for example sinus lift, bone graft cosmetic procedures, for example dental veneers, tooth whitening and the replacement of silver coloured fillings with white fillings laboratory fees not connected to dental treatment or performed by a dentist dental treatment provided at a hospital as a daypatient or in-patient Visit an optician The optical benefit is to help towards the costs when you see a qualified optical professional (for example an optometrist or optician). Annual limit What the optical benefit covers sight-test fees, scans or photos for an eye test fitting fees prescribed lenses and accompanying frames for: - glasses - sunglasses - safety glasses - swimming goggles adding new prescribed lenses to existing frames fitting fees glasses frames contact lenses (including contact lenses paid for by instalment) consumables supplied as part of an optical prescription, for example solutions and tints repairs to glasses. What the optical benefit does not cover eye surgery (for example laser eye surgery, lens replacement surgery or cataract surgery) optical consumables, for example contact lens cases, glasses cases and glasses chains/cords, cleaning materials solutions that are not part of a prescription magnifying glasses eyewear that does not have prescription lenses ophthalmic consultant charges or tests related to an ophthalmic consultation

7 Visits to complementary therapists and Rapid Access Physiotherapy This benefit is to help towards the costs of physiotherapy, osteopathy, chiropractic, acupuncture, homeopathy and reflexology (POCAHR). Annual limit 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 (GOsC) chiropractors must be registered with the General Chiropractic Council (GCC). We will not pay for treatment by someone who is not registered with the HCPC, GOsC or GCC (as appropriate). What the POCAHR benefit covers physiotherapy. If you would like to see a physiotherapist but you are not sure where to go, you can call our Rapid Access Physiotherapy service on The service can arrange a prompt appointment with a physiotherapist near where you live or work. osteopathy chiropractic acupuncture homeopathy and homeopathic medicines prescribed by and bought directly from a homeopath reflexology. What the POCAHR benefit does not cover any other treatments, for example aromatherapy, herbalism, sports/remedial massage, Indian head massage, reiki, Alexander technique X-rays and scans appliances, for example lumbar roll, back support, TENS machine homeopathic medicines bought from a professional who is not a homeopath or bought from a chemist health food shop, by mail order or over the internet Visit a chiropodist This benefit is to help towards the costs of seeing a chiropodist / podiatrist. Annual limit Important: In order to be able to practise in the UK chiropodists / podiatrists must be registered with the Health and Care Professions Council (HCPC). We will not pay for treatment by someone who is not registered with the HCPC. What the chiropody/podiatry benefit covers treatment supplied by a chiropodist or podiatrist assessments, for example gait analysis, performed by a chiropodist or podiatrist consumables prescribed by and bought from the chiropodist or podiatrist at the time of treatment, for example orthoses, dressings consultations with a podiatric surgeon. What the chiropody/podiatry benefit doesn t cover cosmetic pedicures X-rays consumables not bought from the chiropodist or podiatrist at the time of treatment, for example corn plasters bought from a pharmacy surgical footwear, for example corrective footwear Prescriptions You can have a private prescription delivered to your home or place of work when prescribed by the mygp surgery service. You can find more information on mywellbeing. Prescription charges This benefit is to help towards the costs of your prescription charges. Annual limit What the prescription charges benefit covers charges for NHS or private prescriptions from a GP or a dentist. What the prescription charges benefit doesn t cover NHS Prescription Prepayment Certificates (C) prescriptions issued outside the UK pharmacy items bought without using a prescription, for example medicines (sometimes called over the counter medicines) 7

8 Hospital This benefit can help pay for costs such as meals for visitors, telephone calls, travel costs or even hospital parking fees, if you are admitted to hospital. Maximum number of days or nights each claiming year: 20 Cash amount each day or night To make an online claim for hospital cover you can use a copy of your discharge letter as evidence of your admission. If you do not have your discharge letter you can get the hospital cover section on the back of the claim form stamped and signed by a doctor, nurse, or the medical record department from the hospital where you were a patient. What the hospital benefit covers an admission to hospital as a day-patient for tests or treatment. A day-patient is 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. If you are admitted as a day-patient and then stay overnight, we will pay one night s hospital cover (not one day and one night) an overnight stay in a hospital as an in-patient for tests or treatment. An in-patient is a patient who is admitted to hospital and who occupies a bed overnight or longer for medical reasons out-patient cancer treatment, for example chemotherapy or radiotherapy. What the hospital benefit doesn t cover the first 14 nights of any stay in hospital during which you give birth out-patient visits, for example consultations, tests, scans out-patient treatment (although treatment for cancer is covered) day care, for example psychiatric, respite care (short term temporary relief for a carer of a family member), care for the elderly and maternity care permanent residence in a nursing home kidney dialysis attendance at an accident and emergency department, or treatment not in a hospital, for example operations carried out in a GP s surgery or clinic pregnancy termination laser eye surgery cosmetic surgery hotel ward admission ante or post-natal admission for a child registered on the policy My health checks You can use mywellbeing to access a range of online tools to assess your health or get a discount on a health assessment that is booked through a chosen provider. You can use the health assessment benefit to help towards the costs if you have booked one through the chosen provider. Health assessment This benefit is to help towards the costs of a detailed assessment of your health. This benefit is not available to children. Annual limit What is covered under health assessment tests which you have in order to assess your general health. The tests must be carried out within one appointment: - by a doctor registered with the General Medical Council (GMC) or - by a nurse registered with the Nursing and Midwifery Council (NMC) or - by a pharmacist registered with the General Pharmaceutical Council (GPhC) - at an establishment registered with the General Pharmaceutical Council (GPhC) or Care Quality Commission (CQC). For example, these could include a hospital, GP practice, pharmacy or health screening clinic. The doctor, nurse or pharmacist must hold a current licence to practise. The health assessment must include at a minimum (although it can include additional tests): body composition measurement including height, weight (BMI) and body fat percentage blood pressure measurement cholesterol or diabetes check, and kidney or liver function test. When you make a claim, you should give us a list of

9 the tests included in your health assessment, along with your receipt. If you do not give us a list of the tests that you have had, we may not be able to pay your claim. What health assessment does not cover any test that you have which is: - not carried out at a CQC or GPhC registered establishment - not carried out by a registered person - not part of a health assessment, or - has been carried out at a separate appointment (for example, having a blood test, or a magnetic resonance, CT or other high tech scan on its own) For help with GMC, NMC, GPhC and CQC registration checks please visit: Diagnostic consultation A diagnostic consultation is to find or to help to find the cause of your symptoms. Annual limit What the diagnostic consultation benefit covers the fees for a diagnostic consultation that you have as a private patient. The consultation must be with a medical professional who is (or has been) a consultant in an NHS hospital or the Armed Services. The consultant post must be a substantive appointment (that is to say not as a locum). In addition, the consultant must hold a current licence to practise and also be included on the: - General Medical Council s specialist register (please see or - General Dental Council s dentist s register (please see If you have any questions as to whether your consultant meets these criteria then please contact Customer Services on blood tests or visual field tests directly connected to a diagnostic consultation allergy tests performed by a GP or consultant (not tests or advice about nutrition or food intolerance) What the diagnostic consultation benefit does not cover follow-up consultations and check-ups after you have been diagnosed, for example cancer remission checks or management of a condition treatment charges, for example private hospital charges, operation fees, anaesthetic fees consultations with a podiatric surgeon diagnostic tests and procedures, for example X-rays and high-tech scans, endoscopy, tests on body tissue samples, ECGs, health screening counselling, for example psychological counselling, speech therapy and dyslexia services assisted conception, fertility treatment or termination, pregnancy care consultations on a cruise ship where the cruise itinerary is outside the waters of the European Economic Area X-rays and scans Annual limit What the X-rays and scans benefit covers X-rays and scans when you have been referred by a consultant who must be (or have been) a consultant in an NHS hospital or the Armed Services. The consultant post must be a substantive appointment (that is to say not as a locum). In addition, the consultant must hold a current licence to practise and also be included on the: - General Medical Council s specialist register (please see or - General Dental Council s dentist s register (please see If you have any questions as to whether your consultant meets these criteria then please contact Customer Services on

10 What the X-rays and scans benefit does not cover dental X-rays any form of imaging using computerised tomography (CT), magnetic resonance (MR) or positron emission tomography (PET) My family s health You can use mywellbeing to speak to a childcare advisor. This service is available 24 hours a day, seven days a week - just call free on New child payment This benefit has a qualifying period of 6 months. Payment for each child If, after the qualifying period, you have a baby or adopt a child, we will pay new child payment for that baby or child. We only make one payment for each baby or child no matter how many policies you or your partner are covered on. If you have more than one policy you will have to choose which one to claim the new child payment under. We will also make a payment at the appropriate rate for your level of cover following a stillbirth of your child after 24 weeks of pregnancy. To claim under this benefit we may ask you for supporting documents, for example a birth or stillbirth certificate, or adoption papers. We will make a new child payment after: the birth of your child the legal adoption of a child by you or your partner. However, we will not pay new child payment if that child is already related to either you or your partner (for example if you adopt your partner s child) the stillbirth of your child after 24 weeks of pregnancy. We will not make a new child payment for: a miscarriage of up to 24 weeks gestation foster children a baby born to a child who is covered under the policy pregnancy termination a child born or adopted before or during the qualifying period. Hospital stay with a child This benefit can help pay for costs such as meals for visitors, telephone calls, travel costs or even hospital parking fees, if you stay with your child in hospital. Maximum number of nights each claiming year: 10 Cash amount each night To make an online claim for hospital cover you can use a copy of your child s discharge letter as evidence of their admission. If you do not have their discharge letter you can get the hospital cover section on the back of the claim form stamped and signed by a doctor, nurse, or the medical record department from the hospital where your child was a patient. What the hospital stay with a child benefit covers an overnight stay in a hospital for one parent who has accompanied their child where the child is an in-patient for tests or treatment. Both the parent and child must be covered by the policy. An in-patient is a patient who is admitted to hospital and who occupies a bed overnight or longer for medical reasons. What the hospital stay with a child benefit does not cover the first 14 nights of any stay in hospital during which you give birth day care, for example psychiatric or respite care (short term temporary relief for a carer of a family member) attendance at an accident and emergency department, or treatment not in a hospital, for example operations carried out in a GP s surgery or clinic hotel ward admission ante or post-natal admission for a child registered on the policy

11 Care for older family members You can use the mywellbeing service to speak to an elder care advisor. This service is available 24 hours a day, seven days a week - just call free on You can also use mywellbeing to access a discount that can be used at a Simplyhealth store or online. My unexpected healthcare Dental accident Annual limit This benefit is to help towards the costs of returning your oral heath to its pre-accident state following an accident. An accident is an incident that happens by chance, which could not have been expected, causes a significant dental injury and requires medical or dental attention. To make a claim for a dental accident, please call You must provide reasonable evidence of the accident having taken place and of the treatment being clinically necessary as a direct result of the accident. The evidence that we ask for may include the date of the accident, witness statements, photographs, X-rays, medical and dental reports and police incident numbers. What the accident benefit covers restorative treatment to return your oral health to its pre-accident state if you receive medical or dental attention within 30 days of the accident the standard NHS rate for one prescription (whether the prescription is an NHS or private prescription). The prescription must be written by a dentist or doctor. This does not cover Prescription Prepayment Certificates (C). What the dental accident benefit does not cover dental treatment that you need as a direct result of an accident that occurred before you joined the policy dental treatment where you did not receive medical or dental attention within 30 days of the accident further dental treatment that you need after the immediate restoration of the accident damaged area, for example remedial improvements to, or the modification of, work carried out as a result of the accident dental treatment that you need as a result of participating in a sport that has a higher than average likelihood of dental injury and where it is reasonable to expect you to wear face or mouth protection, for example hockey or rugby, and where you were not wearing the appropriate face or mouth protection dental treatment that you need as a result of injury caused by foodstuffs or foreign bodies while eating, chewing or drinking any dental treatment undertaken in a hospital following a referral from a dentist any preparation for and treatment connected with having implants or veneers fitted. This exclusion does not apply to an existing veneer which is damaged in an accident covered by the policy, or for an existing implant abutment, crown or bridge which is damaged in an accident covered by the policy claims relating to treatment arising directly or indirectly from: - you participating in a criminal act - an accident while you were under the influence of alcohol or drugs - deliberate self-inflicted injury dental treatment that you need as a result of war or terrorist activity Recuperation If you have a minimum stay of seven consecutive nights stay in hospital as an in-patient and we have paid hospital cover for those seven nights, we will make a single payment of: Single payment We will only make one recuperation payment each claiming year. Personal Accident burns, fractures and cuts The benefits and terms and conditions that apply to your Personal Accident cover are set out in the separate Personal Accident Policy Document burns, fractures, cuts. If you suffer a loss covered under the terms of the policy please contact Customer Services on

12 Employer Choice If your employer has chosen to include this choice, your membership certificate will show whether the Employer Choice benefits applies to your cover. Employer choice - PMI excess Please read your membership certificate to see whether your cover includes this benefit. Annual limit What the PMI excess benefit covers private medical insurance (PMI) excess cover if you have a PMI policy which has a claims excess, we will pay towards that excess. In order to claim, you must send us: - evidence from your PMI insurer that the excess has been deducted from a claims payment and - a receipt from the provider showing that you have paid the excess amount. What the PMI excess benefit does not cover General exclusions This policy will not pay for: - any benefit if your date of treatment is before the date that your cover under the policy started - any treatment or service that you receive from a: member of your immediate family a parent, child, brother or sister, or your partner business that you own. - any consultation with, or treatment by, a trainee (even if they are supervised by a qualified professional) - any consultation which is not face to face, for example telephone, video or internet consultations (this exclusion does not apply to the services available through mywellbeing) - insurance premiums for any goods or services, or payment for any type of extended warranty or guarantee for goods or services - regular payment plans for treatment, for example dental practice plan payments - postage and packing costs - administration or referral costs, joining fees or registration fees - claims where you have paid costs with: discount vouchers or coupons any type of retail points scheme or loyalty scheme - fees or charges for: missing an appointment completing a claim form or providing a medical report providing further information in support of a claim. Section 3: Who can join the policy, and being covered on the policy 3.1 To join this policy a person must be aged between the lower and upper joining age limits shown on the table of cover. Members must live permanently at an address in the UK (if we send any correspondence by mail, this is the address that we will use). If a member no longer lives in the UK, we can cancel their membership of the policy. Who can join the policy 3.2 The policyholder decides who can become a member on this policy and the level of cover that they have. 3.3 If the table of cover shows cover for partners or children, the policyholder can apply to include them on the policy. 3.4 We do not have to accept an application to include anyone on the policy or provide an explanation for our refusal. Rules for partners included on the policy 3.5 The policyholder s partner can join if: they are aged between the upper and lower joining age limits shown on the table of cover they live permanently with the policyholder and we receive the increased premium.

13 A policyholder s partner must have the same level of cover as the policyholder. Rules for children included on the policy 3.6 We will cover a maximum of four children, who must be under the age of 18. We may ask to see proof that a child is eligible to join the policy (for example a birth or adoption certificate). On a child s 18th birthday we will cancel their membership of the policy. 3.7 A policyholder s children must have the same level of cover as the policyholder. 3.8 Children can only be covered under one Simplyhealth cash plan. We will not add a child to this policy if that child is already covered under another Simplyhealth cash plan. 3.9 If there are currently more than four children on the policy or children registered on more than one policy, those children can remain covered. However, we will not allow other children to join the policy until there are fewer than four children covered. Removing a child 3.10 Once a child has been added to the policy, they must stay on the policy for 12 months. If a child is removed from cover, we will not add that child back on to the policy during the following 36 months. How long your cover lasts 3.11 Your cover starts from the date that we and the policyholder agree to include you on the policy and continues from one month to the next until either we or the policyholder cancel it. Section 4: Premiums and cover Premiums 4.1 We accept premiums by direct debit. We may ask for your first payment by debit or credit card. 4.2 We must receive the full premium before we will provide cover under the policy and we must continue to receive the premium in order for you to be able to claim. If we do not receive the premium, we may suspend the policy. Your cover under the policy 4.3 Your level of cover has been chosen by the policyholder and sets the benefits that are available to you. The table of cover shows the levels of cover and the benefits available under each level. The membership certificate / summary of cover will show which level applies to you. Changing cover 4.4 If the policyholder increases the level of cover or adds a partner or child to the policy, we must receive any additional premiums: before the change can take effect, and in order for them to be entitled to claim. If we do not receive the full premium for an increased level of cover, or for a partner or child added to the cover, we may suspend the policy. If the policyholder changes the level of cover, you must stay on the new level for a minimum of 12 months before the policyholder can change the level of cover again. We will not allow an increase to your level of cover if either the policyholder or their partner (if they are also covered by this policy) are aged above the upper joining age limit for this policy. You can find this on the table of cover. Changing cover: your claiming year 4.5 Any changes to your level of cover will not change your claiming year. 4.6 If your level of cover changes for any reason, any claims paid in the claiming year under the previous level of cover will count towards the entitlement available under the new level of cover. Changing cover: qualifying periods 4.7 If you change to an increased level of cover and your cover includes benefits that have qualifying periods, those qualifying periods will start again. However, if you make a claim for a benefit during the new qualifying period, we will assess your claim as if you hadn t increased your level of cover. This means that if: you have completed the qualifying period for the previous level of cover, any claim that we pay will be up to the maximum benefit limit for that level you have claimed the maximum benefit on the previous level of cover, we will not pay your claim because there is no more benefit available to you for that level. 13

14 For benefits that do not have a qualifying period, you can claim the increased benefits as soon as your increased level of cover comes into effect. Insurance Premium Tax (IPT) 4.8 Where it applies, IPT is included in the premium. If the Government changes IPT, we may amend the premium from the date that the IPT change is implemented. Section 5: Claims rules 5.1 We will not pay any claim while we have not received the premium for your cover, or you are in breach of these policy conditions. Making a claim 5.2 To make a claim online, you will need to log in to Online Self Service. If you haven t already registered for Online Self Service, please visit and follow the simple registration process. 5.3 If you are unable to make a claim online you can call Customer Services on What we need to know 5.4 In order for us to be able to pay a claim, we need to be satisfied that what you are claiming for is covered by the policy for example, that any service or treatment is given to a person covered by the policy, or by a person who is qualified to provide it, or that what you are claiming for is not subject to a policy exclusion. If we are not satisfied that what you are claiming for is covered by the policy, we may not pay your claim. 5.5 When you make a claim, you need to send us documentation that should leave us in no doubt about: the name of the patient the details of the practitioner or establishment and the service or treatment that they have provided the date of the service or treatment and the amount paid for that service or treatment. 5.6 We do not accept receipts that have been altered, or invoices, credit or debit card receipts or photocopies of any accounts. We do not return any documentation. If we need more information 5.7 If the information that you have given us is not enough for us to validate your claim, we may need to ask the person who provided the service or treatment for more information (although we will not pay if there is a charge for this). We will not be able to process your claim if we do not have the information that we need. 5.8 If we incur any costs in obtaining extra information, we can deduct these from your claim; if we do this, we will explain how we have calculated these costs. 5.9 We may ask for a second opinion from a Simplyhealth medical practitioner or specialist in their field of expertise (for example a dentist), chosen by us. We will pay the cost for this. We will ask for your consent before we give your information to anybody outside Simplyhealth. Paying claims rules 5.10 We will only pay for treatment that you have already received, been charged for and have paid for. If you have a course of treatment over a period of time (for example in stages), you can only claim for the stages of treatment you have already received and paid for We will pay claims from the entitlement available at the date of treatment in the claiming year in which you: receive the treatment or service that you are claiming for have a baby or adopt a child are admitted to and/or discharged from hospital We pay claims into a bank account. It is the policyholder s responsibility to give us the bank account details where they want us to pay claims If we pay a claim which is more than you are entitled to under the policy, we can recover the overpayment. We will ask you to repay the overpayment or deduct that amount from any other claim that you make. Paying claims timescales 5.14 We try to pay valid claims as quickly as possible but we are not obliged to pay them within a specific timescale. The longer the time between the date of treatment and submitting your claim the more difficult it may be for us to validate it. If we are not able to validate your claim for any reason, for example your health professional no longer has access to your records, we may not be able to pay your claim. For this reason we recommend that you send your claim to us within six months of your date of treatment.

15 Claims outside the UK 5.15 We will only accept claims for treatment and services that you receive in the United Kingdom (UK) and for treatment and services that you receive during a trip of up to and including 28 days duration in the countries of the European Economic Area (EEA) and Switzerland. We will not pay a claim if the purpose of the trip is to receive treatment or services outside the UK. We will only pay claims where you have provided suitable evidence, including that your visit did not exceed 28 days in total. We will need a translation of the receipt in English, giving details of the claim If you send us receipts in a foreign currency, we will calculate the rate of exchange to sterling using the rate published by Oanda ( which applied on the date of treatment. Other claims rules 5.17 You can only claim under one benefit for each treatment that you receive If you submit a claim under the wrong benefit (for example trying to claim for a pair of glasses under a dental benefit) we will allocate the claim to the appropriate benefit and settle the claim accordingly If we have asked for further information from you or a health professional in order to validate a claim, we may not pay any claims on this policy until we have received that information and been able to fully assess the claim. Other insurance policies 5.20 Other insurance held by you with us if you are covered under another insurance policy with us, then you can claim on both policies up to your maximum benefit limits (subject to specific policy restrictions). It is your responsibility to tell us if you wish to claim from other policies you should contact customer services or complete the appropriate claim forms. The total that we pay under all policies cannot be more than the costs that you have paid Other insurance held by you with a different company you may have other insurance (for example a cash plan, or medical insurance from your partner s employer) that gives you the same cover as this policy. If you do have duplicate cover and you make a claim on this Simplyhealth policy: you must tell us and give us the other insurer s name, contact details and policy number we may contact the other insurer with details of your claim to ensure that we do not pay costs that have already been covered by the other insurer we will have the right to seek a proportion of costs from the other insurer Claims you may have against third parties if you are bringing or are entitled to bring a legal compensation claim against a third party which would cover claims met under the policy, you must tell us about this as we may have the right to recover these sums from that third party. To enable us to do this, you must tell us about the claim, keep us informed of its progress, and act in accordance with our instructions. If we consider that you have a legal right to compensation from another party for costs which you have claimed for under the policy, we are entitled to take legal action against that third party (including legal action in your name) to recover the amount that you have claimed. Section 6: Fraud 6.1 Fraud is a criminal offence that can result in a fine or even a prison sentence. To protect Simplyhealth and our customers we have rigorous anti-fraud measures. These include: conducting internal reviews of all activity on the policy conducting external investigations through the use of private investigators passing details of suspected fraudulent claims to the relevant authorities for them to investigate and prosecute through the criminal courts sharing information with NHS counterfraud teams, health professionals trade associations, other insurance companies and other agencies with an interest in preventing fraud. 6.2 If we suspect fraud, or that the policyholder or any member is not being completely open and honest with us, we can: temporarily stop taking premiums and paying claims while we review the information. We will tell the policyholder if we stop taking the premiums and when we will start to take them again. We will start paying claims when we have received the premiums that were not collected while the policy was suspended ask the member (or, if more appropriate, the policyholder) for an appointment to discuss the matter. The member (or policyholder) agrees to co-operate with our reasonable requests for an appointment and with our requests for additional information regarding their policy 15

16 recover from any member the full amount that we have paid to them for a claim (including any element of the claim that is not fraudulent) irrespective of who made the claim cancel the cover for that member cancel the whole policy (this includes cancelling cover for every person on the policy) cancel all a member s insurance policies with us and with any other company within the Simplyhealth Group take legal action to recover any costs that we reasonably incur in connection with the fraud, plus interest. 6.3 Examples of practices that we consider to be not open and honest include: deliberately giving us false information about anyone covered by the policy or about a claim on the policy making a claim, a statement in support of a claim or sending us a document in support of a claim knowing that it is false, misleading or exaggerated in any way making a claim under more than one insurance policy in order to receive more money than the cost of treatment. Section 7: Limitations and cancellations of cover 7.1 We are an organisation run purely for the benefit of our customers, with no shareholders and therefore no need to pay dividends. We adopt a community pricing approach for the majority of our products; this means that customers with the same product pay the same premium regardless of their personal circumstances or stage in life. By taking this approach, cover is there for you at a reasonable cost when you most need it, with the help of contributions from other customers covered by the same product as you. In order to protect our ability to continue to offer community pricing, and maintain premium and benefit levels for as many customers as possible, we may transfer a group of customers to a new product by cancelling their existing policies and providing them with a new policy in its place. Where we do this, the new policy will have premiums, benefits and terms and conditions that more fairly reflect the level of claims made by that group of customers whose policies have been transferred. A group includes all customers who: live within a postcode area (for example XY1), or are part of an employee scheme, or regularly use a particular healthcare establishment. 7.2 We will only take action under section 7.1 where the group has an adjusted claims loss ratio which is at least 150% of the average adjusted claims loss ratio of all members covered by these terms for each of the last 3 full calendar years or for at least 4 of the last 5 full calendar years. The adjusted claims loss ratio is the amount claimed in a given calendar year divided by the premiums received in the same calendar year, excluding claims for new child payment and hospital cover (where these benefits are available). 7.3 If you are affected we will: explain why we have taken such action, and why it has impacted you give you details of the new product you are being transferred to, including premiums, table of cover and terms and conditions give you at least 3 months notice of such a change offer you the right to cancel with immediate effect, in which case the earliest date on which the policy will terminate will be the end of the month for which you have paid premium. You will not need to re-serve any qualifying periods, but claims made under this policy or the new product will count towards the maximum benefit entitlement of the new product for the claiming year in which the transfer takes effect. 7.4 You agree to us providing you with the new product unless you tell us that you wish to cancel. This clause does not affect your right to cancel under section 7.3.

17 Section 8: How does cover end? When we can cancel the policy 8.1 The circumstances when we can cancel the policy are: if we have not received the premium for three consecutive months. We will always attempt to contact the policyholder to tell them that we have not received the payment. We do this before we cancel the policy in order to give the policyholder the opportunity to pay the unpaid premium and keep the cover active if the policyholder dies. Their partner and children will be able to continue cover with Simplyhealth, although the premiums, benefits and exclusions may not be the same as this product if the policyholder has: - deliberately misled us in any way, for example given us false information, or not given us information that we have asked for about a person on the policy or a claim on the policy. We can backdate the cancellation in these circumstances - not acted honestly in their dealings with us if we make a commercial decision to no longer offer this product. If this happens, we will give the policyholder at least three months written notice of our decision and offer an alternative product, if we have one, in order for cover to continue. When we can cancel a member from the policy 8.2 The circumstances when we will cancel a member from the policy are: if the policyholder asks us to. However, we will not backdate the cancellation of membership to before the date that the policyholder notifies us that the member has left the policy. This means that we will not refund premium to the policyholder if there is a delay in telling us that a member has left the policy a partner - if they no longer live with the policyholder a child - when they reach the age of 18 if they deliberately mislead us in any way, for example give us false information, or do not give us information that we have asked for about a person on the policy or a claim on the policy. We can backdate the cancellation in these circumstances if they have not acted honestly in any of their dealings with us if they are abusive to our staff. If they continue to be abusive, we may cancel all policies that they hold with Simplyhealth. When the policyholder can cancel the policy 8.3 The policyholder can cancel the policy for any reason during the cooling off period. This is up to 14 days from the day that the policy starts or the day that they receive the policy documentation, whichever comes later. Provided that we have not paid any claims, we will refund in full any premium that we have received. If we have paid claims, we will deduct the cost of those claims from any refund we give. If the cost of the claims is greater than the premium, we do not have to refund the premium. 8.4 After the cooling off period the policyholder can cancel the policy by giving us one month s notice. We will not backdate the cancellation to before the date that the policyholder tells us and we will not refund any premiums that we have received. To cancel the policy, please call us on or write to us at Hambleden House, Waterloo Court, Andover, Hampshire SP10 1LQ. What happens when cover is cancelled? 8.5 If Simplyhealth or the policyholder cancels the policy, cover will end for all members on the policy. The policyholder should tell all members that the policy has been cancelled. Cancellation of the policy, or your membership of the policy, means that we will not pay for any treatment or services that you receive after the cancellation date. Section 9: Customer care 9.1 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 which you can use to raise any concern, complaint or recommendation that you have. In the first instance you should contact Customer Services on or write 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. 17