JLL Private medical benefit summary

Transcription

1 JLL Private medical benefit summary Effective from 1 April 2019

2 Welcome to your private medical scheme This guide has been designed to provide you with the key information about your scheme, and it s important that you read this and keep for your records. The guide doesn t, however, contain the full terms, conditions, benefits and exclusions that apply to your scheme. These are contained in the full benefit wording, a copy of which is available on request from your company or by contacting Aviva. Your healthcare scheme is designed to provide you with benefit for treatment of acute symptoms and conditions. An acute condition is a disease, illness or injury that s 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. About Aviva Aviva is the largest insurer in the UK and provides 33 million customers with insurance, savings and investment products worldwide as well as expertise in administering private medical insurance and trust schemes. Your private medical benefit with Aviva provides you with the peace of mind that you ll receive prompt access to diagnostic tests and eligible medical treatment, should you need it. Along with comprehensive healthcare, we also provide you with additional benefits to help you look after your health and wellbeing. 2

3 How to make a claim How to make a claim Your scheme includes the BacktoBetter service and mental health pathway This means that if you need to claim for pain in the back, neck, muscles or joints (musculoskeletal conditions) or, if you need support with your mental health, you don t need to see your GP, just call the customer service helpline. If your claim is eligible, we ll put you through to our independent clinical case management providers who will assess your symptoms and arrange the most appropriate treatment. Making a claim for any other symptoms or conditions For other symptoms or conditions, either visit your GP in the usual way, or access Aviva Digital GP. If the GP refers you to a specialist for diagnostic tests or treatment, you can start a claim by calling the customer service helpline, or online through MyAviva. If you have any questions or want to make a claim, call the customer service helpline: :00am - 8:00pm Monday to Friday 8:00am - 1:00pm Saturday Quoting scheme number: 961BDP Calls to and from Aviva may be monitored and/or recorded. Get the most out of your private medical benefit with MyAviva MyAviva brings together the products and services that help our customers protect their life, health, loved ones, future and possessions in one secure and simple-to-use online place. view details of your Aviva policies online, including scheme and benefit information and your hospital list monitor a wealth of details about your claim such as all invoices paid and the name of the treatment provider track any excess or out-patient limit spend start a claim online or update an existing claim online, at a time that suits you enjoy discounts when you buy a new product from a selected range. You should read the terms and conditions that apply to each product. These can be found on MyAviva. 3

4 Your benefit Your benefit summary Benefit limits shown below apply each member every scheme year and all treatment must be on referral by, and under the care of, a specialist unless otherwise stated. As a member of the scheme you have your medical history disregarded which means that any pre-existing conditions you have will be eligible for benefit providing they fall within the terms and conditions of the scheme. In-patient or day-patient treatment of acute conditions at a facility recognised by us, a hospital on your list or an NHS hospital recognised by us for your treatment or condition Hospital accommodation charges Prescribed medicines, drugs and dressings Operating theatre fees Nursing care including intensive/high dependency care Specialists fees including surgeons, anaesthetists and physicians fees (subject to Aviva s fee guidelines for specialists) Radiotherapy and chemotherapy Diagnostic tests including blood tests, X-rays, scans and ECG s. Out-patient treatment of acute conditions at a facility recognised by us, at a hospital recognised by us CT, MRI and PET scans at a diagnostic centre recognised by us Radiotherapy/chemotherapy Treatment for cancer Invasive surgical procedures (subject to Aviva s fee guidelines for specialists) Physiotherapy for pain in your back, neck, muscles or joints (musculoskeletal pain) Pre-admission tests required within 14 days of an admission to check that you are fit to undergo surgery and anaesthesia. The following benefits are subject to an overall combined maximum of 1,500: Consultations with a fee approved specialist Charges for diagnostic tests, for example X-rays, blood tests and ECGs Treatment (other than physiotherapy) for pain in your back, neck, muscles or joints. Osteopathy and chiropractics (if agreed) is limited to 10 sessions per condition each member every scheme year Physiotherapy, chiropractics, osteopathy, acupuncture and homeopathy for conditions other than pain in your back, neck, muscles or joints (if directly referred by your GP) is limited to 10 sessions in combined total per condition, each member every scheme year GP referred X-rays and ultrasounds for conditions other than pain in your back, neck, muscles or joints. The out-patient limit doesn t apply to treatment for gender dysphoria Mental health benefits at a hospital or clinic within the clinical provider's network consisting of: In-patient and day-patient treatment up to 28 days each member every scheme year Out-patient treatment by a psychiatric specialist or psychiatric therapist Cover for chronic psychiatric conditions, if clinically appropriate One addictive conditions programme during the lifetime of the scheme, if clinically appropriate The excess and out-patient limit don t apply to treatment received through the mental health pathway Psychiatric treatment is not available under any other benefit on this scheme, except for gender identity benefit. BacktoBetter In-patient, day-patient or out-patient treatment of acute musculoskeletal conditions, at a hospital or clinic within the clinical providers networks There s no need to see your GP to claim for these conditions. All you need to do is call us and we'll refer you through the BacktoBetter service to access the most appropriate treatment for your condition. 4

5 Your benefit Additional benefits Nursing at home immediately following eligible in-patient or day-patient treatment Private ambulance where medically necessary for transportation to the nearest available hospital for the purpose of eligible treatment Parent accommodation costs when staying with a child of 15 or under receiving eligible treatment; one parent only Minor surgery by a GP up to 100 per procedure; payable to the GP. To see what procedures are eligible visit: aviva.co.uk/gp-minor-surgery Hospice donation of 70 per day up to 10 days maximum NHS cash benefit of 100 per night where eligible in-patient treatment takes place as an NHS patient without charge. Benefit is limited to 5,000. NHS cash benefit is not available: where you have been admitted to the NHS hospital as a fee-paying patient of any kind, if you claim for the cost of an NHS amenity bed for the same treatment, or for cancer treatment Baby bonus of 100 per baby born or adopted within a year of birth; payable once per baby Treatment for complications of pregnancy and childbirth. Click here for the list of conditions that are eligible for benefit Gender identity benefit. Click here for more information Surgical procedures on the teeth performed in a hospital. Hospitals You can access any hospital on Aviva's Extended hospital list. You can see which hospitals are in your area by downloading the hospital list from: aviva. co.uk/hospital-list or by accessing MyAviva. Excess An excess of 125 per each member every scheme year applies to all members. Benefits will only be paid once the excess amount has been exceeded and this should be settled directly with the relevant provider (for example the hospital or specialist). The excess does not apply to physiotherapy for pain in the back, neck, muscles or joints (musculoskeletal conditions) managed by one of our independent providers, to treatment received through the mental health pathway or to treatment for gender dysphoria received through the mental health provider. If you claim for a benefit that has a limit, the excess will count towards the benefit limit. 24 hour stress counselling helpline If you re stressed and just want someone to talk to, whatever the reason, just call the stress counselling helpline on It doesn t matter what s on your mind work issues, relationships, social strains, bereavement, money worries, anything at all. Experienced counsellors are there for you 24 hours a day, 7 days a week. The stress counselling helpline is available for members aged 16 and over. This is a summary of the scheme benefits. Full details are given in the full benefit wording, a copy of which is available upon request. Eligible dependants An employee s spouse, partner or civil partner. Unmarried children and step children under 21 years of age or under 25 years of age, whilst in full time education in the UK and who are included on the scheme. Private Healthcare Information Network You can find independent information about the quality and cost of private treatment available from doctors and hospitals from the Private Healthcare Information Network: phin.org.uk 5

6 Benefit for cancer treatment Benefit for cancer treatment Extensive benefit Our cancer pledge and support We understand the importance of providing extensive benefit and support at every stage of your cancer treatment. Our cancer pledge means we ll provide benefit for the cancer treatment and palliative care you need, as recommended by your specialist. We also want to make things as comfortable as possible for you following your cancer treatment, so we ll provide extensive benefit for your aftercare, including consultations with a dietician, as well as money towards prostheses and a wig. What s eligible for benefit Hospital charges for surgery and medical admissions at a hospital recognised by Aviva. Specialists fees (subject to Aviva's fee guidelines for specialists') NHS cancer cash benefit. This is payable where eligible treatment as an NHS patient takes place for cancer without charge We ll pay 100 for each day you receive treatment: - as an in-patient - as a day-patient. We ll pay 100 for each day you: - receive out-patient radiotherapy, chemotherapy or blood transfusions - undergo out-patient surgical procedures. We ll also pay 100 for: - each day you receive intravenous (IV) chemotherapy at home - each week whilst you're taking oral chemotherapy drugs at home. You won t be able to claim more than 100 in any one day, but there s no limit on the amount of days you can claim. NHS cancer cash benefit isn t available if you claim for the cost of an NHS amenity bed for the same treatment. We may need to contact your GP or specialist for details of your treatment before we can pay your claim. We may also ask for the discharge summary from the hospital Post surgery services - includes specialist services immediately following surgery such as consultations with a dietician or stoma nurse, and insertion and replacement of a tube for artificial feeding Radiotherapy and chemotherapy, including targeted drug therapies for cancer. Hormone therapy is only eligible if you need it to shrink a tumour before surgery or radiotherapy Bone strengthening drugs (such as bisphosphonates) that are being used to treat metastatic bone disease Treatment prescribed by your specialist for side effects while you're receiving chemotherapy or radiotherapy Stem cell and bone marrow transplants. This includes collection, storage and implantation Monitoring for up to ten years after your treatment for cancer has finished. We don t pay for monitoring after treatment for non-melanoma skin cancer Up to 100 towards a wig if you suffer hair loss caused by cancer treatment. We ll pay 100 in total whilst you're a member of the scheme, not per scheme year Up to 5,000 towards the cost of the first external prosthesis following an amputation for cancer Ongoing needs, such as regular replacement of tubes or drains, for up to five years after your treatment for cancer has finished Preventative surgery, only if you ve already had treatment for cancer that we ve paid for. For example, we ll pay for a mastectomy to a healthy breast in the event that you've been diagnosed with cancer in the other breast. (We won t pay for surgery where you have no symptoms of cancer, for example where you have a strong family history of cancer) End of life care: - we ll pay for end of life care in a hospital if this is medically necessary - hospice donation of 100 per night, up to 10,000 if you re admitted to a hospice - donation of 50 per day to a registered charity if you re visited at home by one of their nurses, up to 10,000. 6

7 What s not eligible What s not eligible summary There are some things which aren t eligible for benefit so it s important you speak to the customer service helpline before receiving any treatment. Some examples of what isn t eligible include: Long term or chronic conditions, except as provided under the mental health benefit and the psychiatric treatment under the gender identity benefit. This exclusion doesn't apply to treatment for cancer Treatment undertaken by a specialist without GP referral (except through BacktoBetter or the mental health pathway) Any musculoskeletal,mental health or gender identity treatment that has not been pre-authorised by us Seeing a GP privately Prescription charges Charges by a GP, medical practitioner or specialist for completion of a claim form unless the claim is confirmed by us Take home drugs and dressings HIV/AIDS and related conditions Treatment received in a health hydro or similar establishment Cosmetic treatment (except following an accident or surgery for cancer) Routine medical examinations including eye tests and health screens etc. (If we ve paid for you to have treatment for cancer, this exclusion won t apply with regard to cancer) Sports injuries where you're paid or personally sponsored Convalescence Experimental treatment (limited benefit may be available - please contact us) Incidental hospital expenses such as newspapers and telephone calls Kidney dialysis Routine dental treatment Investigations into the causes of infertility, or infertility treatment Treatment for pregnancy or childbirth other than the complications specified by clicking here Overseas treatment other than as provided for in the limited emergency overseas benefit specified by clicking here Surgical or medical appliances such as neurostimulators (e.g cochlear implants) and crutches Alcoholism, alcohol abuse, solvent abuse, drug abuse and other addictive conditions; except as provided for under the mental health benefit psychiatric conditions requiring a longterm, coordinated, multidisciplinary approach to treatment, for example anorexia nervosa and personality disorders Treatment required as a result of war, terrorism, contamination by radioactivity, biological or chemical agents Varicose veins of the leg, unless they meet the criteria detailed in the full benefit wording Sleep disorders and sleep problems, such as snoring and sleep apnoea Treatment for warts, verrucas and skin tags Treatment by a practitioner, specialist or other healthcare professional who isn't recognised by us Treatment at a hospital, facility or any other treatment centre that isn't recognised by us Weight loss surgery Treatment for lipoedema This is a summary of the scheme benefits. Full details are given in the full benefit wording, a copy of which is available upon request. Chronic conditions explained A chronic condition is 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. Psychiatric benefit explained For psychiatric treatment, we provide benefit for treatment that aims to lead to your full recovery. We don t provide benefit for: treatment that's given solely to alleviate symptoms, or We don t provide benefit for treatment, including diagnostic tests to treat or assess learning difficulties or developmental or behavioural problems such as Attention Deficit Hyperactivity Disorder (ADHD) and Autistic Spectrum disorders. 7

8 Points to remember Points to remember If you leave your company You ll only be entitled to leave the scheme during the annual benefits window or following an appropriate lifestyle event. For more information please contact your company HR team. If you leave your company, your membership of the scheme will cease immediately, even if treatment was pre-authorised by Aviva. However you re entitled to benefit from continued medical benefit on an individual policy. Benefits, exclusions, terms and conditions on an individual policy may be different to those on this scheme. If you d like to discuss this further, please contact our sales advice line on: (calls to and from Aviva may be monitored and/or recorded). To qualify for continued benefit without affecting your underwriting you need to apply within 45 days from the date your membership under the scheme ceases. Claims for children Children aged 12 and older can use our BacktoBetter service and our mental health pathway without seeing their GP. For any other symptoms or conditions, consult their GP in the usual way and contact the customer service helpline to let us know what they have recommended. Income tax liability Under current UK tax rules, the contribution that s paid to us for your inclusion on the scheme arises from your employment and is therefore a taxable benefit. Please contact your company HR team if you require further information. Change of personal details Please advise your company immediately should any of your personal details change, e.g. address, name, etc. If you wish to add new dependants, for example, a newborn baby, please notify your HR team as soon as possible. The Financial Services Compensation Scheme (FSCS) We re covered by the FSCS. You may be entitled to compensation from the FSCS if we become insolvent and can't meet our obligations. This depends on the type of business and the circumstances of the claim. Where you re 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: Website: fscs.org.uk Telephone: or 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 re satisfied. However, if you ever feel we ve fallen short of this standard and you ve 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: hcqs@aviva.com We ve every reason to believe that you ll be totally satisfied with your Aviva scheme, and with our service. It s very rare that matters can't be resolved amicably. However, if you re still unhappy with the outcome after we ve investigated it for you and you feel that there s 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 haven't 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 Exchange Tower London E14 9SR Telephone: or complaint.info@financial-ombudsman.org.uk Website: financial-ombudsman.org.uk The Financial Ombudsman Service will only consider your complaint if you ve given us the opportunity to resolve the matter first. Making a complaint to the Ombudsman won t affect your legal rights. Clinical complaints Clinical complaints are not subject to our complaints process. Any clinical complaints about the conduct or competency of your specialist or facility should be directed to the specialist or hospital/clinic directly. Please see the full benefit wording for details. Benefit outside the UK Your healthcare scheme provides benefit for treatment in the United Kingdom with only limited benefit for emergency treatment overseas (more detail is available in the full benefit wording). If you need to travel outside of the United Kingdom, you should consider taking out a travel insurance policy. 8

9 Use of personal information Use of personal information Personal Information We collect and use personal information about you so that we can provide benefit for your company private medical scheme. This notice explains the most important aspects of how we use your information but you can get more information about the terms we use and view our full privacy policy at aviva.co.uk/privacypolicy or request a copy by writing to us at Aviva, Freepost, Mailing Exclusion Team, Unit 5, Wanlip Road Ind Est, Syston, Leicester, LE7 1PD The data controller(s) responsible for this personal information is Aviva Insurance Limited as the provider of your company s private medical scheme. Additional controllers are Aviva Health UK Limited who administers the scheme and your company s intermediary (if applicable), who are responsible for the sale and distribution of the scheme and any applicable reinsurers. Personal information we collect and how we use it We will use your personal information: to provide you with the benefit of your company s private medical benefit: we need this to decide if we can offer private medical benefit and if so on what terms and also to administer the scheme, handle any claims and manage any renewal; to support legitimate interests that we have as a business: we need this to manage arrangements we have with reinsurers, for the detection and prevention of fraud and to help us better understand our customers and improve our customer engagement (this includes marketing, customer analytics and profiling), to meet any applicable legal or regulatory obligations: we need this to meet compliance requirements with our regulators (e.g. Financial Conduct Authority), to comply with law enforcement and to manage legal claims; and to carry out other activities that are in the public interest: for example we may need to use personal information to carry out anti-money laundering checks. As well as collecting personal information about you, we may also use personal information about other people, for example your eligible dependants who you wish to benefit from your company s private medical scheme. If you are providing information about another person we expect you to ensure that they know you are doing so and are happy to have their information shared with us. You might find it helpful to show them this privacy notice and if they have any concerns please contact us in one of the ways described below. The personal information we collect and use will include name, address, date of birth, current state of health and any existing conditions of each person included in the application. If a claim is made we will also collect personal information about the claim from you and any relevant third parties. We recognise that information about health is particularly sensitive information. Where appropriate, we will ask for consent to collect and use this information. If we need your consent to use personal information, we will make this clear to you when you complete an application or submit a claim. If you give us consent to using personal information, you are free to withdraw this at any time by contacting us. Please note that if consent to use information is withdrawn we may not be able to continue to process your claims and we may need to cancel your benefit under the scheme. Of course, you don t have to provide us with any personal information, but if you don t provide the information we need we may not be able to proceed with your application or any claim you make. Some of the information we collect may be provided to us by a third party. This may include information already held about you within the Aviva group, including details from previous quotes and claims, information we obtain from publicly available records, our trusted third parties and from industry databases, including fraud prevention agencies and databases. How we share your personal information with others We may share your personal information: with the Aviva group, our agents and third parties who provide services to us, your company s intermediary (if applicable) and other insurers (either directly or via those acting for the insurer such as loss adjusters or investigators) to help us administer our products and services; with clinicians, including hospitals, and third party case managers from whom you and others under the scheme receive eligible treatment or who manage your care or treatment pathway; 9

10 Use of personal information With regulatory bodies and law enforcement bodies, including the police, e.g. if we are required to do so to comply with a relevant legal or regulatory obligation; With other organisations including insurers, public bodies and the police (either directly or using shared databases) for fraud prevention and detection purposes; Some of the organisations we share information with may be located outside of the European Economic Area ( EEA ). We ll always take steps to ensure that any transfer of information outside of Europe is carefully managed to protect your privacy rights. For more information on this please see our Privacy Policy or contact us. How long we keep your personal information for We maintain a retention policy to ensure we only keep personal information for as long as we reasonably need it for the purposes explained in this notice. We need to keep information for the period necessary to administer your benefit and deal with claims and queries on the scheme. We may also need to keep information after our relationship with you has ended, for example to ensure we have an accurate record in the event of any complaints or challenges, carry out relevant fraud checks, or where we are required to do so for legal, regulatory or tax purposes. Your rights You have various rights in relation to your personal information, including the right to request access your personal information, correct any mistakes on our records, erase or restrict records where they are no longer required, object to use of personal information based on legitimate business interests, and data portability. For more details in relation to your rights, including how to exercise them, please see our full privacy policy or contact us. Contacting us If you have any questions about how we use personal information, or if you want to exercise your rights stated above, please contact our Data Protection Team by either ing them at dataprt@aviva.com or writing to the Data Protection Officer, Level 4, Pitheavlis, Perth PH2 9NH. If you have a complaint or concern about how we use your personal information, please contact us in the first instance and we will attempt to resolve the issue as soon as possible. You also have the right to lodge a complaint with the Information Commissioners Office at any time. 10

11 Notes Claims authorisation number: Diagnosis/condition: Type of speciality and sub-speciality required: Date of appointment: Treatment (CCSD) code if known: 11

12 This brochure is also available in braille, large print and audio format. If required, please contact the customer service helpline to request a version in a format more suitable for you. Useful contacts Customer service helpline :00am - 8:00pm Monday to Friday 8:00am - 1:00pm Saturday Calls to and from Aviva may be monitored and/or recorded. Scheme number: 961BDP 24 hour stress counselling helpline To talk to an experienced counsellor, phone This benefit is available for members aged 16 and over. Aviva Health UK Limited. Registered in England, Number Registered Office: 8 Surrey Street, Norwich, NR1 3NG. Authorised and regulated by the Financial Conduct Authority. Firm Reference Number A wholly owned subsidiary of Aviva Insurance Limited. This insurance is underwritten by Aviva Insurance Limited. Registered in Scotland, Number Registered Office: Pitheavlis, Perth, PH2 0NH. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Firm Reference Number Aviva Health UK Limited Head Office: Chilworth House, Hampshire Corporate Park, Templars Way, Eastleigh, Hampshire, SO53 3RY. aviva.co.uk/health 12 GEN /2019 REG001 Aviva plc