LPF TRUSTS MEDICAL SCHEME TERMS AND CONDITIONS

Transcription

1 LPF TRUSTS MEDICAL SCHEME TERMS AND CONDITIONS

2 CONTENTS Opening hours and contact details 2 Introduction 3 Scheme rates 4 What is covered by the Scheme? 5 NHS claims 5 What is not covered by the Scheme? 6-7 How to make a private medical claim 8 Making a civil claim 9 Scheme Limits Definitions Terms Complaints and Appeals 16 Direct Debit 17 LPF Trusts Privacy Statement 18 Please read this guidance carefully so you fully understand the terms and conditions. Opening hours and contact details: Monday to Friday from 9.00am to 4.00pm Tel: Fax: Medical@lpf-trusts.co.uk Kerry Meuldyk Medical Scheme Manager Tel: Kerry.Meuldyk@lpf-trusts.co.uk Hannah Williams Medical Scheme Nurse Tel: Hannah.Williams@lpf-trusts.co.uk Rebecca Simons Medical Scheme Account Manager Tel: Rebecca.simons@lpf-trusts.co.uk 2

3 INTRODUCTION This document details the guidelines and current subscription costs for the LPF Trusts Medical Scheme. Authorisation for any claim, test or procedure can be obtained by telephone, or with your claim. Under the terms of membership, you are obliged to recover the Scheme costs as special damages. Please note that there is an administration fee of 30 per medical claim. Please note that all changes to your membership must be made in writing to the Medical Scheme. We will acknowledge any changes to membership in writing. s can be accepted as written authority providing that the address has been registered with the Scheme on our website. Please ensure that you keep up-to date with the current rules of the Scheme. Further information can be found at the LPF Trusts website You will be notified of any changes to the Scheme via and/or post. 3

4 MEDICAL SCHEME RATES STUDENT OFFICERS 1st year FREE 2nd year at 50% of age banded rate CHILDREN First child Additional children 5.00 SINGLE MARRIED** These rates apply as of 1 February ** Married refers to any co-habiting partnership Married st child nd child 5.00 Total 57.20

5 WHAT IS COVERED BY THE SCHEME? The Medical Scheme will consider authorising claims up to the limits shown on the Discretionary Benefit Schedule, for the following: Consultations when referred by a General Practitioner (GP). Imaging - such as MRI and CT scans. Pathology, x-rays, ECGs and other diagnostic procedures. Post treatment/surgery in-patient stay at approved hospital if clinically necessary. Fixed cost surgery. Drugs, dressings and medicines prescribed for in-patient treatment. Orthotics and splints are limited to one fitting and one set per member. Physiotherapy at approved location. Consultant approved alternative therapy. NHS cash benefit. Spinal surgery subject to Scheme approval. Benevolence payments for members with a cancer diagnosis. treatment or authorisation. NHS claims Unplanned admission The NHS benefit for unplanned admission is per night with a maximum of per claim. Pre-planned admission The NHS benefit for pre-planned admission is per night with a maximum of per claim. Pre-planned claims are subject to the following criteria: You must see a consultant. You are put on a NHS waiting list. You must obtain authorisation from the Medical Scheme prior to treatment. The condition requiring treatment must usually be covered by the Medical Scheme. Treatment taking place in the NHS must not be due to exceeded limits for an ongoing claim with the Medical Scheme. All claims are subject to receipt of hospital discharge papers. 5

6 WHAT IS NOT COVERED BY THE SCHEME? The following will not be considered under the Medical Scheme rules: Treatment, management and/or monitoring for any chronic or long term condition. Any emergency treatment. Joint replacements are limited to one full OR one partial (including tibial osteotomy). Any care provisions at a nursing home or rehabilitation centre or any other similar location. Any treatment arising from pregnancy or childbirth. Infertility (including investigations) and sexual disfunction, contraceptive devices, sterilisation, Contraceptive devices, sterilisation, reversal of sterilisation and termination of pregnancy. Neurological disorders undertaken as an in-patient. Alcoholism, drug abuse, self-harm and eating disorders or conditions arising therefrom or associated therewith. Continuing treatment for any condition involving heart disease, cancer or any other malignant condition other than the original consultations and investigations up to diagnosis (including chemotherapy and radiotherapy). Injury or disablement directly or indirectly caused or contributed to by war, invasion or while engaged or taking part on active service in military, naval or air services or operations arising from any reserve military duty. Supportive treatment of renal failure including dialysis. Treatment directly or indirectly related to Acquired Immune Deficiency Syndrome (AIDS) or any syndrome or condition of a similar kind howsoever it may be named including any STD. Pain management. Psychiatric assessment or treatment as an in-patient. Membership for non EU residents. Treatment outside the UK. Spinal surgery is limited to one surgical intervention per member. 6

7 Cosmetic treatment including for psychological purposes. Drugs, dressings and aids as an outpatient. Private ambulance. Private GP appointments. Routine health checks, annual consultations and screening. Transfer from the NHS to a private in-patient facility once treatment has commenced as an NHS in-patient. of drugs. In-patient treatment for medical investigations or monitoring. Any treatment that has been refused by the NHS or is a direct result of medical advice not being followed. Any treatment for pre-existing symptoms or conditions regardless of whether they were treated that existed prior to the start of membership that you failed to inform us about. A second opinion from another consultant, specialist or healthcare provider. Any specialist costs above BUPA rates. Injuries relating to, or derived from, semi-professional, or professional sporting activity. Reverse moratoriums. Repeated investigations for on-going symptoms. Revision surgery. Multi-stage surgery after initial procedure (subject to Scheme consideration). The Scheme does not provide an enhanced treatment or recovery package. Learning and development disorders including speech therapy. Natural aging including menopause and puberty. General dental and optical checks and prescriptions. Organ or tissue donation. Varicose veins unless causing other health problems. Allergy testing unless presenting with a medical problem that is being contra-indicated by the possibility of an allergy. Gender reassignment or gender confirmation. Genetic testing, preventative treatment and screening tests. Weight loss surgery. 7

8 HOW TO MAKE A PRIVATE MEDICAL CLAIM 1. Contact the Medical Scheme for advice or guidance if needed. 2. Consult your GP who will carry out all relevant preliminary tests prior to referral. 3. This will generate a claim number and a claim form which will be sent to you for completion. 4. administration fee within 14 days. Failure to return the completed claim form and administration fee may result in the cancellation of your claim, making you liable for any costs incurred. 5. Contact the authorised hospital to arrange an appointment. 6. authorisation and treatment is within Scheme Limits (see pg 10-11). 7. The Scheme does not provide an enhanced treatment or recovery package. appointments are made. If you have any queries or concerns over the eligibility of your claim, please contact 8

9 MAKING A CIVIL CLAIM You are required under the terms of the Scheme to apply for reimbursement of medical costs under special damages as part of any civil claim. We recommend that you use the LPF Trusts appointed solicitor, as they are familiar with this requirement. Should you choose to, or are required to use another solicitor, you should inform the Scheme of their contact details and ensure the solicitor is aware of your medical claim and the requirement to apply for special damages. Failure to make a claim for special damages will mean that you may be required to reimburse the Scheme. As we are a not-for-profit organisation, failure to collect special damages incurs extra costs to the Scheme which may increase future subscriptions. 9

10 SCHEME I LIMITS Leicestershire only As of 1 February 2017 Specialist fees (a) Consultations - 1 new and 4 follow-ups (b) Pathology (outpatient) 500 (c) Physiotherapy - up to 8 appointments (d) Physiotherapy can only be utilised to reach an acceptable level of fitness. We will not cover enhanced rehabilitation. (e) Specialist Diagnostic Tests (Outpatient) e.g Nerve conduction tests, scopes, visual fields, ECG, speculum, vestibular testing, micro suction. (1 test per claim) - up to Any more please contact the Scheme. (f) Imaging MRI and/or CT up to 3 scans Radiology (ultrasound-x-ray) up to 3 scans Injections with imaging - 2 in a 3 month period For multiple area imaging, each area is classed as 1 scan (g) Psychiatric and psychological treatment 1 new and 4 follow-ups (h) Splints and orthotics if part of treatment and approved - 3 appointments and 1 set Counselling - up to 10 sessions Please note the Scheme does not cover outpatient dressings or take home drugs, boots or braces. There is a maximum individual claim limit of 20,000, with a maximum limit of 30,000 over all claims in any Scheme year. 10

11 SCHEME I LIMITS Outside Leicestershire As of 1 February 2017 Specialist fees (a) Consultations (including psychiatric or psychological treatment) (b) Pathology (outpatient) (c) Physiotherapy - up to 8 appointments or 500 (whichever comes sooner) (d) (e) (f) (g) Physiotherapy can only be utilised to reach an acceptable level of fitness. We will not cover enhanced rehabilitation. Specialist Diagnostic Tests (Outpatient) e.g. Nerve conduction tests, scopes, visual fields, ECG, speculum examination, vestibular testing, micro suction. (1 test per claim) - up to Any more please contact the Scheme. Outpatient diagnostics (1 test per claim) - up to 1,000. Any more please contact the Scheme Counselling - up to 10 sessions or 500 whichever comes first (h) Splints and orthotics if part of treatment and approved - 3 appointments and 1 set (i) All members receiving treatment outside of Leicestershire will only be covered for treatment costs up to the Leicestershire pricing for any and all such treatments that the Scheme covers. Members outside Leicestershire can elect to travel to Leicester and the Scheme will reimburse reasonable receipted travelling costs for fuel used travelling to and from Leicester for treatment. (j) Any costs for post-operative complications that are not included as part of a fixed cost package. Please note the Scheme does not cover outpatient dressings, take home drugs, boots or braces. There is a maximum individual claim limit of 20,000, with a maximum limit of 30,000 over all claims in any Scheme year. 11

12 DEFINITIONS ACUTE: Describing an illness that is of short duration, rapidly progressive, and in need of urgent care. 2. CHRONIC ILLNESS: A health condition or disease that is persistent or otherwise long-lasting in term chronic is usually applied when the course of the condition lasts for more than three months. 3. DAY PATIENT: A patient who attends a hospital for treatment without staying overnight. 4. ELIGIBILITY: of a pension under the Police Pension Regulations, may make application to join and may include their dependants. The LPF Trusts Medical Scheme trustees reserve the right to refuse any application and to terminate membership without giving any reason. 5. ELIGIBLE DEPENDANTS: A spouse and dependant children until the renewal date following their 18th birthday. Over 18 dependants may remain in the Scheme subject to standard charges. Members may make application to join other dependents e.g. grandchildren at the standard child rates. 6. GENERAL PRACTITIONER: A physician whose practice consists of providing ongoing care covering a variety of medical problems in patients of all ages, often including referral to appropriate specialists. 7. HOSPITAL (NHS): A National Health Service hospital in the United Kingdom. 8. HOSPITAL (PRIVATE): An independent hospital operated for profit. 9. IN-PATIENT: A patient who occupies a bed overnight in a hospital. 10. NHS CASH BENEFIT: Benefit payable for each pre-authorised night spent in an NHS hospital without charge for conditions covered by the Scheme. 11. OUTPATIENT: A term referring to a patient who receives care at a medical facility but is not admitted to the facility overnight, or for 24 hours or less. The term may also refer to the healthcare services that such a patient receives. 12. PHYSIOTHERAPIST: A healthcare professional that assesses, diagnoses, treats, and works to prevent disease and disability through physical means. 13. REGISTERED NURSE: A qualified nurse whose name is currently on any register or roll of nurses maintained by the recognised registration bodies in the United Kingdom. 14. SCHEME: LPF Trusts Medical Scheme. 15. SCHEME RENEWAL DATE: Triennially.

13 16. SCHEME YEAR: Financial year. 17. SECOND OPINION: Obtaining an alternative view of a medical condition from a second specialist. 18. SPECIALIST: Healthcare professional who has completed advanced education and clinical training in a specific area of medicine. 19. TREATMENT: The management and care of a patient with the purpose of curing or substantially relieving a medical condition under the direction of a specialist. approaches to prevent, reduce or stop pain sensation. Pain can be categorised into two domains: ACUTE: associated with injury, headaches, disease and other conditions. CHRONIC: endures beyond a normal healing time; identifiable as unremitting pain that lacks physical cause; pain that lasts longer than 12 weeks. Any treatment provided by a pain consultant is deemed as pain management. This includes all of the below and any other injections administered by such specialists: Epidural Root block Denervation Facet joint injections Steroid injections Trigger point injections Image guided injections. When a pain management procedure has been authorised, LPF Trusts will cover an initial diagnosis and injection and then one subsequent follow-up injection after three months as there is no guarantee of immediate relief from pain. The follow-up injection cannot be used after this point. Following treatment, if pain is not resolved, the LPF Trusts Scheme nurse will provide you with a letter for your GP advising that an onward referral to the pain clinic within the NHS should be considered if symptoms continue. 13

14 TERMS 1. BENEFITS Benefit shall only be payable for treatment that has been following direct referral from the member s GP. All treatment must be given or supervised by a specialist. There is a maximum individual claim limit of 20,000, with a maximum limit of 30,000 over all claims in any Scheme year. Children enrolled within three months of birth will be accepted without evidence of health. Claims where a period of six months has elapsed since the last treatment undertaken will normally be deemed to be closed. Further treatment undertaken after this period will be regarded as a new claim. All benefits payable are as per the approved benefit schedule. The benefit schedule should be read in conjunction with the rules of the Scheme. Benefits are payable subject to all subscriptions, administration fees and other charges set by the LPF Trusts Medical Scheme trustees being paid. No cash benefit can be claimed until a full 12 months continuous subscription has been paid. 2. CLAIMS All claims must be pre-authorised prior to treatment. No claims will be settled retrospectively unless authorised by the Medical Scheme. Clarity of any pre-exisiting conditions or symptoms will be confirmed by a report from a GP or specialist. 3. CONTRIBUTIONS Subscription fees to the LPF Trusts Medical Scheme shall be paid by instalments on a monthly basis via the agreed payment method. Failure to pay any subscriptions or administration fees to the LPF Trusts Medical Scheme shall void your membership. Contributions will be held in trust by the LPF Trusts Medical Scheme for the benefit of the members. You must give one month s notice to withdraw from the Scheme to allow the Scheme time to inform payroll of the changes. The request must be in writing or an . 14

15 TERMS CONTINUED 4. GENERAL To enable the LPF Trusts Medical Scheme to keep its records up to date members shall notify the Scheme immediately of any changes in circumstances. The LPF Trusts Medical Scheme will be allowed to use this information to advise members of any changes or benefit. The member is not automatically entitled to private medical provision and all benefits provided by the Medical Scheme trust are at the absolute discretion of the trustees. No third party shall be entitled to enforce any provision of the Scheme rules to obtain any medical provision detailed in the rules. No provision of these rules is enforceable by any third person other than the member or the trust and trustees. The rules and provisions may be revoked, supplemented or varied from time to time or new rules introduced in their place by resolution of the Trustees. immediately or as soon as is practical under the circumstances. In the event of such claims the member must provide all relevant information that is required of the Scheme to recover the costs of any medical provision provided to the member resultant from the accident or injury. The Scheme does not cover approved expenses which at the time the treatment was incurred would, but for the existence of this Scheme, be insured by any existing policy or policies except in respect of any excess beyond the amount which would have been payable under such policy or policies had this Any fraud, misstatement or concealment made on the member s claim or application to join the Scheme made by or on behalf of a Scheme member shall render the membership void and all claims thereunder shall be forfeited. from any date specified by the trustees but not less than 28 days notice will be given to the member; save in the case of minor alterations or alterations that the trustees consider in their absolute discretion to be necessary or desirable so as to comply with law and they may In the event that a member s claim arises out of an accident or injury where a third party may be involved and may be legally liable to compensate, the member MUST notify the Scheme 15

16 COMPLAINTS AND APPEALS Any appeal or complaint should in the first instance be brought to the attention of the Trust Manager, LPF Trusts, Unit B, Grange Business Park, Enderby Road, Whetstone, Leicestershire LE8 6EP. Telephone No Should the matter not be adequately resolved for either party then the trust manager will prepare such documents to be given to the trustees for them to form a decision in regard to any appeal or complaint. The person appealing or making a complaint will be invited to supply the trustees with any documentation that they feel would assist their appeal or complaint. Complaint received and logged - medical@lpf-trusts.co.uk Stage 1 - Acknowledgement of complaint Complaint will be sent to LPF Trust Manager - Malcolm Mills Full response sent within 20 working days Are you happy with our response? Yes Complaint closed and any lessons drawn - thank you No Ask for a review of our response Stage 2 - Acknowledgement of complaint Complaint sent to trustees for review Full response to be provided to member within 20 days Are you happy with our response? 16 Yes Complaint closed and any lessons drawn - thank you No Consider sending an appeal to LPF Trusts

17 DIRECT DEBIT Please note that any member or dependant who has had continuing membership of the Scheme whose circumstances alter e.g. change of employment, may make application to pay premiums by Direct Debit and continue as a Scheme member. All such applications must be approved by the Scheme. Any failed Direct Debit payments and returned cheques are liable for an extra administration charge. The Direct Debit Guarantee to pay Direct Debits. If there are any changes to the amount, date or frequency of your Direct Debit, LPF Medical Scheme will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request LPF Medical Scheme to collect a payment, confirmation of the amount and date will be given to you at the time of the request. If an error is made in the payment of your Direct Debit, by LPF Medical Scheme or your bank or building society you are entitled to a full and immediate refund of the amount paid from your bank or building society. If you receive a refund you are not entitled to, you must pay it back when LPF Medical Scheme asks you to. You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us. 17

18 LPF TRUSTS PRIVACY STATEMENT Here at LPF Trusts we take your privacy seriously and will only use your personal information to administer your membership and to provide the services that you have requested from us. How do we collect information from you? We will collect personal information about you when you join the Scheme and register a claim. We also obtain personal information from the contracted providers of your services such as the Medical Facility at which you are treated and the underwriter of your insurance policy. What type of information is collected? We collect personal information such as your name, address, contact information and personal medical information pertaining to your claims. How will we use this information? We use the information provided to administer your membership and to provide the services you have requested from us. We will never pass on your information to any other external organisation for the purpose of marketing. Scheme Marketing and Updates We will never pass on your personal information to any other organisation for the purpose of marketing; however, from time to time we would like to contact you with details of internal promotions special offcers and upcoming events. If you consent to us contacting you for this purpose, please tick the relevant boxes to say how you would like to be contacted: Post Telephone SMS/Text Message We will contact you with any updates or changes to the service provided as part of your membership. How to contact us Please contact us if you have any questions about our privacy policy or information we hold about you. LPF Trusts, Lancaster House, Grange Business Park, Enderby Road, Whetstone, Leicester LE8 6EP Our full Privacy Policy can be found on our website lpf-trusts.co.uk 18

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20 LPF Trusts Suite B, Lancaster House Grange Business Park Enderby Road Whetstone Leicestershire LE8 6EP T: E: W: lpf-trusts.co.uk Published January 2018.