Welcome to Simplyhealth

Transcription

1 Welcome to Simplyhealth HEALTH CASH PLANS

2 We wish you the very best of health and by choosing a cash plan from Simplyhealth it s clear that you do too. This booklet sets out the benefits available to you and what you can claim. You will also find the terms and conditions on page 18 which outline exactly what is and isn t covered. At Simplyhealth, we re committed to helping you feel better every day. So if you have any queries or questions please call us. Customer Services

3 Contents Introduction 4 Your table of cover 6 Your benefits in more detail 7 Claiming couldn t be simpler 12 How to fill out your claim form 14 Your questions answered 16 Terms and conditions 18 3

4 Simply covered You can now claim up to 100% immediately on consultation, dentist and optician bills as well as up to 75% towards the cost of physiotherapy, osteopathy, chiropractic treatment, acupuncture and homeopathy all up to an annual limit. For example, if you are on the level 3 option, you can claim up to 130 money back towards your dental bills every year. So if a dental bill comes to 40 we ll refund you the total bill, leaving you 90 to use towards other dental fees. If you have hospital cover and you are an in-patient or a day case on the NHS or being treated privately, we can help cover the cost of everyday bills too. We can be bothered Your membership benefits include access to health and wellbeing advice as well as telephone counselling. If you re feeling stressed or would like advice on health or lifestyle issues, call the 24 hour free advice helpline at any time on and talk to one of our trained professionals. Simply claim We take the bother out of claiming so you can start right away (with the exception of pre-existing conditions under hospital benefit). Ask for a receipt when you pay for your treatment Send us your completed claim form (enclosing your receipt) within six months of treatment Receive money back from Simplyhealth To make life easier for you, we even pay the funds directly into your bank. 4

5 Our commitment to you Simplyhealth is here to make life easier for you. It s why we pay claims directly to you usually within a few days. It s why all Simplyhealth customer documents will be sent within five days and it s why we have real people on the other end of the line no answer phones or automated calls. We provide all services from within the UK. Simply flexible The following table shows your annual entitlement for each benefit under each level of cover. Please refer to the column which represents your level of cover to see how much you can claim. If you d like to increase your cover, just call us on and we ll send you an upgrade form. There are a few things you should be aware of before you increase your payment option. Please see section 2 of the terms and conditions for more information. 5

6 Your table of cover Your table of cover Dental Payback level Level 1 Level 2 Level 3 Annual limit for each person 100% Includes check-ups, hygienist s fees, fi llings, dentures, crowns and bridges Optical Includes sight tests and fi tting fees, prescription glasses, sunglasses and contact lenses Physiotherapy, osteopathy, chiropractic, acupuncture and homeopathy Treatment carried out by a qualifi ed practitioner that we recognise Consultation fees Diagnostic consultations with a specialist 100% % % Please refer to your Summary of Cover to find out whether you are covered for any of these additional benefits: Hospital benefit Cash amount for each day or night to help towards everyday expenses if you need to stay in hospital. This includes day-case, in-patient and parental stay. Pre-existing conditions are excluded Employee Assistance Programme (employees only) Gives you face to face support if needed, with a qualifi ed counsellor. This service is provided by FirstAssist Occupational health (employees only) Access to an occupational health service. This service is provided by FirstAssist 20 days or nights max per year Six face to face counselling sessions following assessment from the helpline. Your Human Resources department will be in contact with you to arrange an appointment, should this benefi t apply to you. Free helpline Your plan gives you access to a free confi dential helpline to advise you on health and lifestyle issues, as well as an over the phone counselling service. This service is available 24 hours a day, 7 days a week and can be accessed by calling European cover You ll receive these benefi ts (excluding Employee Assistance Programme) for stays up to and including 28 days, on business or pleasure, wherever you are in the EEA and Switzerland. The joining age for this policy is from 16 years old up to 65. You can increase your level once a year but you must stay on that level for a minimum of 12 months before you can decrease your level again. Premiums include Insurance Premium Tax. For full details of the plan please refer to the Policy Document. C_WB 6

7 Your benefits in more detail Here is an easy guide to all the benefits your Simply Cash Plan offers. Please remember that Simplyhealth will only pay for treatment by registered health care professionals that we recognise, where applicable. For more information about exactly what is and isn t covered, please refer to the terms and conditions. Acupuncture Acupuncture can be particularly helpful in treating arthritic and rheumatoid pain in joints, chronic muscle strains and sports injuries. It can also help relieve headaches, period pains, allergic symptoms and insomnia. Simplyhealth will pay up to 75% of your acupuncture bills up to your annual entitlement. There is currently no government legislation in the UK covering acupuncture. This means that anyone can provide acupuncture treatment without any professional acupuncture training. Until the introduction of compulsory registration for this profession, Simplyhealth will continue to pay claims for treatment from professionals who provide acupuncture treatment. For more information or to find your nearest acupuncturist contact the following: The British Acupuncture Council Tel: , The Acupuncture Association of Chartered Physiotherapists Tel: , The British Medical Acupuncture Society Tel: , 7

8 Chiropractic By manipulating and adjusting the vertebrae of the backbone a therapist can correct malfunctioning nerves and muscles throughout the body. You can claim up to 75% money back for chiropractic treatment with a chiropractor who is registered with The General Chiropractic Council, up to your annual limit. For more information or to find your nearest registered chiropractor contact the following: The General Chiropractic Council Tel: , Dental We all know how hard it is to find a dentist on the NHS these days, so there s no need to suffer with toothache or put off going to the dentist because of the cost. Simplyhealth pays up to 100% of your dental bills up to your yearly entitlement, whether you are treated privately or on the NHS. This includes regular check-ups as well as treatment such as fillings. To find your nearest dentist visit NHS Direct Tel: (England & Wales), Tel: (Scotland) British Dental Health Foundation Tel: / British Dental Association 8

9 Consultation fees If you are unwell and need to find out what s wrong, this benefit helps you to see a private consultant fast, without the long, uncomfortable wait. Simplyhealth enables you to claim up to 100% towards a diagnostic consultation up to an annual limit. If you think something s wrong, your GP will be able to refer you to the appropriate consultant. To find your nearest GP visit NHS Direct Tel: (England & Wales), Tel: (Scotland) Hospital benefit This section applies only if your cover includes the additional hospital benefit. If you need to go into hospital either as an in-patient or a day case, whether you are treated privately or by the NHS, Simplyhealth will pay you money for a maximum of 20 days/nights in a claiming year. This could help cover the cost of everyday bills. Please note pre-existing conditions are not covered. Simply refer to the benefit table to see how much you can claim. 9

10 Optical Whether working with computers or driving a car, everyone should still get their eyes tested regularly. Simplyhealth will give up to 100% money back towards your optician bills, including sight tests, new glasses or contact lenses, up to your annual entitlement. To find your nearest optician visit NHS Direct Tel: (England & Wales), Tel: (Scotland) Osteopathy This treatment provides relief for many disorders of the bones and joints, especially back pain. Treatment includes palpation, manipulation and massage. With Simplyhealth you can claim up to 75% towards osteopathy with an osteopath who is registered with The General Osteopathic Council up to an annual limit. For more information or to find your nearest registered osteopath contact the following: The General Osteopathic Council Tel: , 10

11 Physiotherapy If you have a strenuous job, suffer from backache or are a sports enthusiast, you ll appreciate this benefit. Physiotherapy uses physical methods to promote healing. The therapist may use a combination of light, infrared and ultraviolet rays, heat, electric current and manipulation. You can claim up to 75% of your physiotherapy bills up to your yearly entitlement. The physiotherapist must be qualified and registered with the Health and Care Professions Council. For more information or to find your nearest physiotherapist contact the following: The Health and Care Professions Council Tel: , 11

12 Claiming couldn t be simpler There are three types of claim: Claims with receipts Pay your bill to the physiotherapist, dentist etc. as normal. Simplyhealth will only pay claims for treatment provided by registered healthcare professionals Keep your receipt see the receipt requirements below Fill in the Claims with receipts section of the claim form, following the guide on the following pages. Don t forget to sign and date the Declaration section You can make four claims per form, if you need more claim forms or need assistance, please call Simplyhealth Customer Services on Send your claim form and receipt back to Simplyhealth in the reply envelope provided within six months of treatment Receipt requirements A completed claim form is required together with a receipt confirming payment. The receipt must show: The full name, address and telephone number of the practice The patient s full name and address A description of the treatment given, including dates and amounts settled by the patient Simplyhealth does not accept receipts which have been altered, nor do we accept invoices, credit card receipts or photocopies of any accounts, please note receipts cannot be returned. 12

13 Hospital claims Turn to the Hospital claims section on the back of the claim form Fill in the Patient s details yourself Ask a hospital representative to complete the Admission details section or send us your discharge letter from the hospital Sign and date the Declaration on the front of the form Send your claim form back to Simplyhealth in the reply envelope provided within six months of discharge Pre-existing conditions are not covered. 13

14 How to fill out your claim form The front for healthcare claims with a receipt We ve already included a claim form in this welcome pack. When making a claim, please complete your form in blue or black ink, and remember to enclose the original receipt for your treatment. If we ve got your details wrong, please correct them in this box Each person covered under your plan has their own personal code Each benefit has its own benefit code For all claims, except hospital or new child payment, please enter the personal code and the treatment code Enter the treatment date and the full amount paid For all claims, the policy holder must sign and date here Please provide your current contact details below E mail: Tel No: Mr & Mrs Sample Sample address Sample Road Sample Town Postcode Your personal details Claim Form The codes shown below are for use when completing your claim form. If you need any help with your claim or any of your personal information shown is incorrect, just call us free on the number above. PERSONAL CODE Claiming details (See overleaf for claims not listed above) Please complete a separate line below for each treatment, selecting the PERSONAL CODE and the TREATMENT CODE from the above lists. Then enter the treatment date and if applicable the amount paid from your receipt. Please use black or blue ink and complete the form in BLOCK CAPITALS and always submit your claim within 6 months of treatment. EXAMPLE 704 A / 0 Policy no PERSON COVERED DATE OF BIRTH TREATMENT TREATMENT DESCRIPTION TREATMENT CODE CODE PERSONAL CODE TREATMENT CODE TREATMENT DATE FULL AMOUNT PAID Customer Services Hambleden House Waterloo Court Andover Hampshire SP10 1LQ Minicom service: (For hearing or speech impaired members only) Opening hours: 8am to 9pm weekdays9am to 5pm weekends (The example above shows a claim for physiotherapy for the person coded 100 who received treatment on 9th January 2008 and paid 50.95). D D M M Y Y D D M M Y Y. D D M M Y Y. D D M M Y Y. TREATMENT DESCRIPTION 100 Mrs Sample 03/10/ Optical 085 Chiropody/Podiatry 201 Mr Sample 05/06/ Dental 302 Charlie Sample 11/10/ Physiotherapy 081 Chiropractic 082 Osteopathy 083 Acupuncture. EXAMPLE Please enclose your original receipts in the envelope provided (do not staple them to the claim form). Please note that receipts will not be returned, only scanned images are retained on our records. Declaration I consent to Simplyhealth seeking medical information in respect of this application and any subsequent claim under this membership, from any relevant doctor, professional or hospital representative. I consent to Simplyhealth processing sensitive information about me (and anyone covered under my policy) including health information. I understand that any charges levied for completing this form are my responsibility and are not refundable by Simplyhealth. I declare that the information given is to the best of my knowledge and belief, true and complete. I understand that any false statements may disqualify me from membership and/or reimbursement of any claim. Your details All claims (except hospital or new child payment) Your signature Customer s signature: Date: 14

15 The back for hospital claims The reverse of the form is for hospital and new child payment claims only. Please remember to sign and date the declaration on the front of the form. Please note that you may only claim for cover that is specified in the Policy Document of your Plan New-child payment For New-child payment just complete below and enclose each child s birth certificate/adoption papers, then simply sign the declaration overleaf. If a hospital stay of more than 14 nights was needed, also ask a hospital representative to complete the Hospital claims section below. For all hospital claims, fill in your details, then sign and date the declaration I wish to claim for New-child payment (4) Hospital claims To assist the hospital in completing this form, please complete the Patient s details yourself, then ask the hospital representative to complete the Admission details where appropriate. Patient s details First name Surname Number of birth certificates/adoption papers enclosed Personal code (see front of form) Date of birth D D M M Y Y Admission details I certify that the above patient was admitted to this establishment for the period and reason shown below: Your establishment (4) Hospital Establishment stamp and details of representative Convalescent Home Nursing Home Duration of admission As a day case: admitted on D D M M Y Y As an in-patient: admitted on D D M M Y Y discharged on number of nights D D M M Y Y Hospital claims The relevant hospital authorities must complete this section (Excluding home visits) Reason for admission (4) Care for the elderly Mental/Psychiatric Ante/Post natal Other Please always confirm nature of condition/procedure below Signature: Position: Date: If a parent stayed with a child Parent s first name Personal code (see front of form) Parent s surname D D M M Y Y D D M M Y Y Stayed from to Number of nights 15

16 Your questions answered What is a Simply Cash Plan? The Simply Cash Plan provides insurance cover towards the costs of dental and optical healthcare, consultation costs and more. When can I claim? You can claim immediately. Simply use the claim form provided or request another form by calling us on Please refer to the terms and conditions. When do my annual benefits start and end? Your annual benefits commence from your policy start date and begin again on the same day every year. Please refer to your enclosed Summary of Cover to find your claiming year details. What is the duration of my cover? The cover under your plan is monthly and runs from month to month subject to the continued payment of premiums by your employer. In order that your cover remains appropriate for your needs, you should review it regularly and inform us of any significant changes to your healthcare requirements. Refer to section 1 of our Terms and Conditions for more details. Are existing conditions covered? The great thing about Simplyhealth is that you can start claiming straight away, even if you already have a problem that needs treatment when you join. Please note that under hospital benefit, pre-existing conditions are not covered Does cover continue when I reach 65? Yes, cover doesn t cease when you reach a certain age. You can keep your policy for as long as you wish, however, you cannot increase your cover after your 66th birthday. There are some circumstances where cover will end. Please refer to section 5 of your terms and conditions for full details. How are my claims paid? To make life easier for you, Simplyhealth provides a service which pays your money directly into your bank account, sending you confirmation in the post. You will need to provide us with your bank account details if you haven t done so already. 16

17 When will I receive money back from my claim? We normally settle claims within a few days. What if you ve printed my details incorrectly on my claim form? If any of your pre-printed details on the form are incorrect, please update them clearly in blue or black pen before sending the form back to us. What happens if my personal details change? So that your cover remains appropriate for your needs, it is important that you review it regularly and let us know about any significant changes to your healthcare requirements. Where can I get more information or additional help when making a claim? If you have any queries, please call Simplyhealth Customer Services on who will be pleased to help you. What do I do if I have changed my mind? You have 14 days from receipt of your welcome pack in which to change your mind and receive a full refund from Simplyhealth, provided no claims have been made. Simply call Customer Services on After this period our standard cancellation rights apply please refer to section 5 of the terms and conditions for full details. How do I make a complaint? At Simplyhealth we aim to provide you with the very highest levels of customer service and care at all times. In order to maintain this service standard, we encourage feedback from our customers and have put in place a procedure that you can use to raise any concern or complaint that you may have. In the first instance you should write to: Customer Services, Simplyhealth, Hambleden House, Andover, Hampshire SP10 1LQ or contact customer services direct on If you are not satisfied with our response, or we have not replied within eight weeks, you have the right to refer your complaint to: Financial Ombudsman Service. Please refer to section 6 of the terms and conditions for full details. 17

18 Terms and Conditions of your Simplyhealth Cash Plan Please check your summary of cover to see what level of cover you are entitled to. Pre-existing medical conditions are covered by these benefits. General enquiries Dental We will pay you the full cost of dental treatment fees that are paid by you directly to the Dental Professional, up to the appropriate maximum entitlement of your plan. What is covered Treatment provided by a Dental Professional registered with the General Dental Council (GDC) Dental check-up Treatment provided by a dental surgeon Hygienist fees Fees paid to dentists for private treatment including dental crowns, dentures, bridges and white fillings, braces etc X-rays What is not covered Dental prescription charges Sundry items including toothbrushes, mouthwash, dental floss etc Dental insurance premiums or dental care schemes Dental veneers Missed appointment fees or administration fees There is no qualifying period. Time limit for claiming - 13 weeks from the date of treatment. Optical We will pay you the full cost of optical treatment fees that are paid by you directly to the Optician, up to the appropriate maximum entitlement of your plan. What is covered Treatment by a qualified optician Sight tests Prescribed glasses including frames and prescribed lenses Addition of new prescribed lenses to existing frames Fitting fees Eye laser surgery (excludes consultation) New spectacle frames/repairs to frames Contact lenses including those paid by instalment (please submit your claim when the total fees are equal to the maximum entitlement offered) Sunglasses, safety spectacles and swimming goggles with prescription lenses What is not covered Optical sundry items i.e. solutions, tints, spectacle cases, spectacle chains/cords etc Non-prescription glasses Lenses supplied under an optical insurance plan Contact lens replacement insurance premiums Optician s insurance premiums Visual field tests, retinal scans and glaucoma tests Dyslexia and colour blindness tests Frames which have not been purchased from an optician There is no qualifying period. Time limit for claiming - 13 weeks from the date of treatment. Physiotherapy, acupuncture, osteopathy, chiropractic and homeopathy treatment We will pay you up to the appropriate maximum entitlement of your plan for treatment you receive directly from a physiotherapist, acupuncturist, osteopath, chiropractor or homeopath. What is covered Physiotherapy, acupuncture, osteopathic, chiropractic or homeopathy treatment supplied by a professional registered with an organisation recognised by Simplyhealth, which includes those as detailed below: Physiotherapy Registered with the Health and Care Professionals Council (HCPC) Osteopathy Registered with the General Osteopathic Council (GOsC) Chiropractic Registered with the General Chiropractic Council (GCC) Acupuncture Registered with the British Acupuncture Council (MBAcC) or The British Medical Acupuncture Society (BMAS) or The Modern Acupuncture Association 18

19 What is not covered Any treatment supplied by a professional who is not registered with the appropriate professional body to provide Physiotherapy, Acupuncture, Osteopathic, or Chiropractic treatment All other treatments i.e. aromatherapy, herbalism, sports massage, Indian Head Massage, Reiki, Alexander Technique, Cranial-Sacro Therapy etc MRI scan, CT scan etc Appliances such as lumber roll, spinal pillows/ cushions, self-help books, flexiband, tape etc There is no qualifying period. Time limit for claiming - 13 weeks from the date of treatment Consultation fees We will pay you up to the appropriate maximum entitlement of your plan in respect of the fee for a diagnostic consultation, which you have paid directly to a medically qualified specialist, consultant or surgeon. What is covered A diagnostic consultation undertaken by a Physician or surgeon with consultancy status at a hospital, including follow-up tests by a medically qualified specialist that has been recommended at the consultation IVF consultation What is not covered Tests and treatment charges in isolation Operation fees and fixed price medical procedures Medical examinations and reports Private hospital charges including room fees etc Laser eye consultations Visits to clinics X-rays including mammograms, CT scans, ultrasounds and MRI scans etc Fees for investigative procedures i.e. colonoscopy, laparoscopy, colposcopy, sigmoidoscopy etc Pathology and biopsy Haematology and biochemistry directly connected to a diagnostic consultation Medical tests for example ECG, EEG, lung function test etc Anaesthetic fees Dietician/nutritional services Speech therapy and dyslexia services There is no qualifying period. Time limit for claiming - 13 weeks from the date of consultation. Hospital day case We will pay you at the appropriate rate under your chosen premium level for the period you are admitted as a day case patient for treatment in a recognised hospital up to a maximum of 20 days in a claiming year. Hospital day case, parental stay and hospital in-patient cover share the same maximum entitlement of up to 20 days/nights in total. Please refer to 4.17 for full details. What is covered An admission to a day case ward or unit for treatment or investigation as classified on the claim form by the hospital authorities Out-patient treatment for chemotherapy Out-patient treatment for radiotherapy Out-patient treatment for oncology What is not covered The period immediately prior to, or following an overnight in-patient stay for which payment has been made under hospital in-patient Out-patient appointments Out-patient treatment for kidney dialysis Day care, including but not limited to psychiatric, respite care, care for the elderly and maternity Cancelled operations prior to admission Minor operations carried out in a GP s surgery or clinic Attendance at an accident and emergency department Pre-admission appointments Treatment at home Hospital in-patient We will pay you at the appropriate nightly rate under your chosen premium level for the period you are admitted for in-patient treatment in a recognised hospital up to a maximum of 20 nights in a claiming year. Hospital day case, parental stay and hospital in-patient cover share the same maximum entitlement of 20 days/nights in total. Please refer to 4.17 for full details. What is covered Any period of overnight stay in an NHS or private hospital from 1 to 20 nights fortreatment or investigation of an acute or chronic medical condition which developed while you were a member of Simplyhealth Separate ante or post natal hospital in-patient admissions 19

20 What is not covered The first five nights of any stay in hospital during which childbirth takes place Any period of overnight stay in an NHS or private hospital for treatment of a pre-existing condition Respite care Out-patient treatment Attendance at an accident and emergency department Hospital day case Hotel ward admission Parental stay We will pay for one parent only at the appropriate nightly rate under your chosen premium level, when you have accompanied your child (who is covered under your policy) who has been admitted as an in-patient overnight and for which payment has been made at the appropriate child rate under hospital in-patient cover. Up to a maximum of 20 nights in a claiming year, can be paid provided that the claim is supported by written confirmation from the hospital that one parent accompanied their child overnight. Hospital day case, parental stay and hospital in-patient cover share the same maximum entitlement of up to 20 days/ nights in total. Please refer to 4.17 for full details. What is covered Any period of overnight stay in a NHS or private hospital from 1 to 20 nights where one parent has accompanied their child Legally adoptive/foster parent accompanying their child (when the child is registered under the policy) What is not covered More than one parent accompanying their child A grandparent or other relative accompanying the child The post natal period following the birth of a child Your claim form must be completed by the hospital with details of your child s admission and authorised by a hospital officer. Comprehensive Employee Assistance Programme Specially for our members we provide access to helpline and counselling services as set out in the summary of cover up to your annual entitlement. FirstAssist provides these services on behalf of Simplyhealth. What is covered Unlimited access to a free confidential helpline, 24 hours a day 7 days a week, that can provide help and guidance in relation to a number of areas including legal, tax and medical issues What is not covered Counselling services other than those arranged through the helpline Self-help or guidance products or services There is no qualifying period. Additional Benefits Confidential Helpline The Simplyhealth well-being plan Helpline is available 24 hours a day, 7 days a week, 365 days a year just phone Counselling Just pick up the phone and speak directly to a fully trained counsellor. Typical problems we can help with include stress, relationships, bereavement and family issues. We can also provide planned (weekly) telephone counselling sessions and onward referral to self-help groups in your area. UK tax advice Discuss personal taxation problems with tax experts. Typical issues we cover are advice on self-assessment forms, PAYE, National Insurance and company benefits. Travel advice You can get advice on inoculations, current medications, currency, local health issues, visa requirements and even equipping a first aid kit. Legal advice Discuss personal legal problems with solicitors and legal experts. We can advise on consumer problems, wills, motoring, employment problems, probate, property buying or selling and accident or injury claims. Health and fitness information Just call for help with nutritional assessments, complementary health, giving up smoking and sports injuries. Medical advice line The medical team can provide advice and information on a wide range of issues including all medical and surgical conditions, pre and post treatment advice, hospital procedures and details of local and national help and support groups. 20

21 Parental advice Call the Helpline for guidance on childminders, nursery places in your local area and advice on changing schools. We can also help with general paediatric issues, details of paediatric experts in your local area and with the sorts of communication issues that arise from time to time, especially with teenagers.the Helpline is provided by FirstAssist. There are stringent service level agreements in place and a number of calls are recorded to ensure quality standards are met so that complaints can be rectified accordingly. First Assist is IS09001:2000 compliant and provides us with management information on a monthly basis. This service is provided as an initial source of advice. Any costs incurred following advice must be borne by the member. Section 1: How to join 1.1 You can become a member if you are employed by a participating employer that has agreed to provide you with cover under a policy and you permanently reside in the United Kingdom. 1.2 All the information you give to us in relation to your membership, any claim under a policy and your state of health must be accurate, true and complete to the best of your knowledge and belief. If you fail to provide information to us in accordance with this obligation, we reserve the right to cancel your membership. 1.3 Cover under your membership is provided on a monthly basis and will commence from the date that we receive payment of premium in relation to your membership and are notified of your details by a participating employer. Under these Terms and Conditions, you consent to the renewal of cover for further monthly periods and on a monthly continuous basis subject to the continued payment of premiums by a participating employer. Section 2: Upgrades, dependent children and partners 2.1 If you have chosen to upgrade your level beyond that provided by your participating employer, all cover except Employee Assistance cover (face-to-face sessions) and Occupational Health, increase to the upgraded level. 2.2 You can increase your level once a year but you must stay on that level for a minimum of twelve months before you can decrease your level again. 2.3 Dependent children under the age of 17, residing at the same address as the member, are covered for all benefits with the exception of the 24 hour helpline, Employee Assistance Programme and Occupational Health. 2.4 Dependent children must be listed on a member s policy in order to be entitled for cover. 2.5 We may refuse to allow a child to be added to the policy until you have provided information satisfactory to us about them including sight of birth certificate (or certified copy). 2.6 You can apply to include your partner (or another adult residing at the same address) on the well-being Family plan (thereby agreeing to pay the appropriate increased premium to cover him/her) if your partner is over the age of 17 but under 65 years of age. Section 3: Premiums 3.1 The premium level that a participating employer has chosen to pay determines the cover available to you. The cover applicable to the policy is shown in the summary of cover, which accompanies this document. 3.2 The payment of premiums on your behalf by a participating employer may mean that you incur income tax liabilities. You should consult with your employer s Human Resources or Payroll department to confirm what these liabilities are. 3.3 Premiums must continue to be paid in order for you to be provided with cover and to be entitled to claim. We reserve the right to cancel the policy should the premiums fail to be kept up to date. 3.4 If a participating employer or Employee increases the premium level, any claims paid in the claiming year under the previous premium level will count towards the maximum entitlement available under the new premium level. 3.5 Your claiming year will not change if a participating employer or Employee increases or decreases your premium level during a claiming year. 3.6 Included as part of the premium paid by a participating employer is Insurance premium Tax (IPT) a tax levied by the Government. Should the Government announce an increase in IPT, it may be necessary for us to amend the premium to reflect this. 21

22 Section 4: How to claim We continually review our claims procedures to make them as simple as possible and may introduce improvements in the future. Should this happen, we will notify you in advance. When you join you can claim straight away. Employee assistance elements of cover 4.1 The Confidential 24 hour helpline can be accessed by calling In order to access counselling services, you should call the helpline who will arrange counselling sessions. 4.3 The advice line provides general medical advice only and should not be used as a substitute for your normal personal medical care. It is not an emergency service and will not prescribe treatments or provide diagnostic services. Advice from this service is free but calls are charged at national rate. Other elements of cover 4.4 You have to have received and paid for treatment before we will pay your claims. Claims will be offset against the claiming year in which treatment was received. You must use the claim form we provide for making claims. If you do not have a claim form, please call Customer Services on , or log on to to request one. 4.5 When making a claim you should send a fully completed claim form and original receipt for any bill that you are seeking reimbursement for. The original receipt and/or bill must be on official headed paper and must show the name of the patient, the name, address and qualifications of the person providing the treatment, a description of the treatment and the amount paid for the treatment. You should submit claims as soon as you can but no later than 13 weeks from the date treatment was supplied. We reserve the right to reject any claim which is not sent to us within 13 weeks. 4.6 You must provide us with any information or proof to support your claim if we make a reasonable request for you to do so. We may seek written consent for medical information relating to a claim to be disclosed to an Simplyhealth medical practitioner. 4.7 We do not accept original receipts that have been altered, nor do we accept invoices, credit card receipts or photocopies of any accounts. We do not return any receipts or invoices. 4.8 We will not pay any claim while you are in breach of these Terms and Conditions. 4.9 We do not pay any amounts you may be charged by a hospital or doctor or other person for completing your claim and/or for medical information requested by us in support of your claim. These charges will be your responsibility You can only claim for treatment you have received under one area of cover We will cover you for business or holiday visits within the European Economic Area (EEA) of up to and including 28 days duration. Claims must be supported where necessary with a translation of the endorsement or relevant receipt, providing the details of the claim Cover will not be provided in respect of any treatment provided by a member of your family to you All outstanding claims must be submitted within one month if a participating employer increases or decreases the premium level We reserve the right to recover any overpayment of claims from any sums payable to you and/or to recover any such overpayments directly from you If you or anyone included on your policy holds, or is covered under another insurance policy with us, you can claim on either or both policies up to your maximum entitlement as long as you have individual receipts to support your claim. The total reimbursement cannot exceed the value of the costs you have incurred If you are making a claim and you have insurance with another insurance company that covers you for any of the same benefits under your plan you must tell us. We may need to contact this other company as we will not be liable to pay more than our proportionate share when split between the insurance companies The maximum period for which any combination of daily or nightly rates are payable under cover for hospital in-patient, hospital day case and parental stay is up to 20 days/nights in total for each entitled person in any one claiming year. 22

23 Section 5: How does cover end 5.1 All cover under this policy will end automatically and you will not be covered for claims not yet submitted in respect of you and all other persons included on your policy when: a) You decide to cancel your policy, by giving us 30 days notice in writing (which will take effect immediately on receipt by us). We will not refund any of your monthly premiums that have already been paid. Where your premiums are paid through your employer via payroll deduction, you must notify your payroll department to avoid further premiums being deducted. b) You become more than 30 days behind with the payment of your premiums. At our discretion, we may reinstate that cover once outstanding premiums have been paid. c) You mislead us by providing incomplete or untruthful information to us or knowingly claim cover for any purpose other than is provided for under this policy. d) You breach the Terms and Conditions of this policy, for which we will give you not less than 30 days cover. e) In the event of your death. Section 6: Customer care 6.1 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 you can use to raise any concern, complaint or recommendation you have by contacting Customer Services on or writing to Simplyhealth Customer Services, at our registered office address of Hambleden House, Waterloo Court, Andover, Hampshire SP10 1LQ. We will investigate any complaint and issue a final response. If you are not satisfied with our response, or we have not replied within eight weeks, you have the right to refer your complaint to: Financial Ombudsman Service South Quay Plaza 183 Marsh Wall London E14 9SR Telephone: The Financial Ombudsman Service will only consider your complaint if you have given us the opportunity to resolve the matter first. Making a complaint to the Ombudsman will not affect any legal rights that you may have. We will send you full details of our complaints procedure if you ask us for them. 6.2 Changing your mind - you have 14 days from receipt of your welcome letter in which to change your mind and cancel your membership, provided no claims have been made. If you do change your mind, please call or write to Customer Services, Simplyhealth, Hambleden House, Andover, Hampshire SP10 1LQ and we will cancel your membership for you. 6.3 Changes to your details - you must inform us as soon as is reasonably possible of any changes to the information that you have given to us, including any change of address, marital status or any other material change. Failure to do so may result in cover being refused or cancelled or your membership being cancelled. 6.4 Making information about us accessible - we aim to make information about us accessible to you, whatever your needs. Information is available in large print or audio. Please call us if we can help in any other way. 6.5 You are protected by the Financial Services Compensation Scheme (FSCS) in the unlikely event that we go out of business or into liquidation the FSCS protects you. Should this happen, any valid outstanding claims you have at that point would be paid by the scheme. For more details on the scheme please visit or contact the FSCS direct on Section 7: What happens if we change the terms and conditions of your plan 7.1 Before making such changes to the Terms and Conditions, we will give a participating employer the following periods of notice: a) In respect of any changes to the levels of cover, premiums or Terms and Conditions, at least one month s prior notice in writing. 7.2 Where a participating employer has been notified of a change to the Terms and Conditions, claims will be paid in accordance with the Terms and Conditions in operation at the time treatment was supplied. 23

24 Section 8: Additional information 8.1 Waiver - waiver by us of any Term or Condition of a policy or these Terms and Conditions will not prevent us from relying on such Term or Condition thereafter. 8.2 Choice of law - the parties to insurance contracts in the United Kingdom may choose which law will apply. Unless we agree otherwise, English law will be applied to a policy. We will communicate with you in English. 8.3 How we use information about you - as the Data Controller, we will store and process your personal data in accordance with the Data Protection Act 1998 (DPA). Simplyhealth and other companies within the Simplyhealth Group will use your information to provide our services, for assessment and analysis, for underwriting and claims handling, to improve our services and to protect our interests. We may use your information to keep you informed by post, telephone, or other means about products and services, which may be of interest to you. If you do not wish your information to be used for these purposes please write to: The Data Controller, Simplyhealth, Hambleden House, Waterloo Court, Andover, Hampshire SP10 1LQ. We will keep information about you confidential. However, we may give information about you and how you use our products to the following: (a) Fraud prevention agencies and other organisations who may record, use and give out information to other insurers; (b) People who provide a service to us or acting as agents on the understanding that they will keep the information confidential; (c) Anyone to whom we may transfer our rights and duties under this agreement; (d) We may also give out information about you if we have a duty to do so (such as to regulatory bodies), if the law allows us to do so or if the person requesting the information has in our opinion, a legitimate interest in the disclosure. 8.4 Sensitive Data - in order to assess the terms of the insurance contract or administer claims we may collect data, which the DPA defines as sensitive. By agreeing to these Terms and Conditions you consent to this data being processed by us. 8.5 You have the right to see personal information, which is held by us. There may be a charge if you want to do this. For more details write to: The Data Controller, Simplyhealth, Hambleden House, Waterloo Court, Andover, Hampshire SP10 1LQ. 8.6 To make sure we maintain a high quality service, we may monitor or record phone calls. 8.7 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 your Simplyhealth 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 notify us of the claim, keep us informed of its progress and act in accordance with our instructions. Alternatively, we may take over or bring a claim in your name in relation to the part of your claim that has been covered by us. 8.8 You may be covered under this policy and a separate Simplyhealth policy in relation to a particular element of cover. However, you may only make one claim in relation to a single treatment under one policy. Once you have reached the limit of cover under this policy, you may then make a further claim for other treatments under the other policy that you hold. 8.9 We do not cover any element of a claim that is insured under another Section 9: Definitions Certain words in the policy have a special meaning. Whenever the following words and phrases appear in this policy, they will always have these meanings: Claiming year - your claiming year runs annually from the date of commencement of cover for the employees of a participating employer. Cover - The range of cover under your plan as detailed in the summary of cover. EEA - The countries of the European Union at the date of treatment or cost incurred, together with Iceland, Norway and Liechtenstein. Member - An employee of a participating employer who is covered under a policy. Membership - The provision of cover and other benefits to a member by us. Participating employer - An employer of a member that has purchased cover under a plan on the member s behalf. Partner - A spouse or a person who resides with you on a permanent basis as if your legal spouse, regardless of gender. Plan - The Simplyhealth product to which these Terms and Conditions apply. 24

25 Policy - Our contract of insurance with a participating employer. Premium - The amount a participating employer has selected to pay, which determines the level of cover available to you. Specialist, consultant or surgeon - A medically qualified person who specialises in a specific field of medicine who may or may not hold a consultant position in an NHS Hospital but who is a member, Fellow or Licentiate of one of the Royal Colleges. Summary of cover - Details what level you are covered for. Table of cover - Shows the individual treatments you are entitled to claim for. We/Simplyhealth Simplyhealth is a trading division of Simplyhealth Access. You - The member. 25

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28 About us and our insurance services Simplyhealth is a trading name of Simplyhealth Access which is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Our Financial Services Register number is You can check this on the Financial Services Register by visiting the Financial Conduct Authority s website or by contacting the Financial Conduct Authority on We can only provide you with information on our own products and you will not receive any advice or a personal recommendation from us for our health plans. We may ask you some questions to narrow down the product option on which we provide you with information, but you will then need to make your own choice about how to proceed. If you have any questions please call us on from landlines from mobiles 1 8am to 8pm weekdays, 9am to 5pm Saturdays ¹Some mobile networks charge for calls to 0800 numbers. Our 0370 number is free if you have mobile inclusive minutes available. If not it s still no more expensive than calling numbers starting 01 or LRM-C_WB-WB-1012 Simplyhealth is a trading name of Simplyhealth Access, which is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Simplyhealth Access is registered and incorporated in England and Wales, registered no Registered office, Hambleden House, Waterloo Court Andover, Hampshire, SP10 1LQ. 28 Your calls may be recorded and monitored for training and quality assurance purposes.