How Solutions works. Solutions. Flexible private medical insurance for small and medium sized companies, covering employees

Transcription

1 How Solutions works Solutions Flexible private medical insurance for small and medium sized companies, covering employees

2 Welcome to Solutions At Aviva, we understand that when running a small or medium sized company, any level of employee absence can have a significant impact on your business. Having Solutions, our private medical insurance for SMEs, in place means that if an employee injures themselves or falls unwell, you can get them back to work as quickly as possible, limiting the effect on your business. Solutions is one of the most versatile company healthcare products on the market, offering you and your employees real choice in both the cover you need and the premium you ll pay. The way we have designed Solutions enables us to offer you the levels of flexibility, which are usually only associated with large group schemes. In a nutshell, this approach has some obvious advantages for your company: l Simple One product satisfies a wide range of healthcare needs l Extensive A wide range of core cover, including the proven BacktoBetter service for back, neck, muscle or joint pain (musculoskeletal conditions), as standard l Flexible Select from a wide range of healthcare options to suit your needs l Cost-effective You choose the cover required for you and your employees, at a budget that s right for your business. 2

3 How Solutions works Contents Solutions at a glance 6 Will employee absence hurt your profits? 7 How Solutions works - Core cover - Options to increase or reduce cover - BacktoBetter - Cancer cover - Added value benefits 21 Our approach to claims 24 Underwriting 27 How we manage costs 28 Policy summary - What s covered - Options to increase your cover - What is not covered 35 Your questions answered 36 Legal 39 Choose Solutions today l Specifically designed to meet the needs of SMEs and their employees l A flexible policy that can be shaped to meet your business need and budget l No limit to the amount of eligible claims that can be made by your employees each year l Extensive benefits within core cover l Includes BacktoBetter, our independent clinical case management service for musculoskeletal (MSK) conditions l We use our clinical expertise to develop and shape our products, giving you and your employees a first class service l Simple claims process l Cover from the UK s largest insurance group. 3

4 Why choose Aviva? At Aviva UK Health, we combine financial strength and corporate efficiency with in-depth clinical expertise. The result is a flexible approach to healthcare that our customers can trust. You have added peace of mind when choosing Solutions, because Aviva UK Health is part of the wider Aviva group so you benefit from our extensive network and financial security. Aviva is the largest insurer in the UK and operates across the globe. We have over 300 years of financial services experience meaning we re here to stay and are committed to providing the best possible service to you and your employees. Our experience of working in financial services shouldn t be the only reason why you would choose us; we re committed to providing you with the best claims service, which not only benefits your employees, but also your business. We aim to manage costs in order to keep your premiums sustainable for future years. Manage Aviva polices at the touch of a button MyAviva helps members manage their Aviva policies, allows existing customers to access a 20% discount on selected new Aviva products, and enjoy Aviva Advantages offers and competitions, all in one place. Here are a few key advantages of our claims service: l BacktoBetter we include our independent clinical case management service for back, neck, muscle or joint pain (musculoskeletal conditions) as standard with Solutions. This approach allows quick and easy access to a clinical case manager to help your employees get better as soon as possible they don t even need to take time off work to see their GP. l Specialist claims management teams we understand that certain conditions, such as cancer, heart conditions, or mental health problems have complex clinical needs. So for these conditions we take a case-managed approach for every claim. Your employees will speak with one named case manager at Aviva who will help them throughout the duration of their claim. This gives extra reassurance through a very worrying time and can support in getting them back to work as soon as possible. l Many claims are approved over the phone your employees don t need to worry about having to fill out long claim forms with their GP. In the vast majority of cases our experienced claims consultants will be able to approve the claim over the phone with no need for further information. l Our cancer pledge Solutions offers extensive, clear and easy to understand cancer cover as standard. Networks To help manage costs and drive consistent quality of care, we re developing a number of networks of facilities, specialists and other practitioners. If we have a network for your employees conditions or suspected conditions, we ll tell your employees where they can have treatment. 4

5 How Solutions works Awards and ratings You shouldn t just take our word for it though, over the years we ve won multiple awards for our products and services. These awards have been won as a result of support from industry experts and intermediaries alike. We are grateful to our customers and the industry for recognising our commitment and the hard work that goes into developing and improving our products and services. We are always looking for ways to improve our products and the way we work, so you can be sure that you will always receive the service that you re satisfied with. Health Insurance Awards Health Insurance Company of the Year 2010, 2011, 2012, 2013, 2014 & 2015 Best Group PMI Provider 2010, 2011, 2012, 2013, 2014 & 2015 Defaqto 5 star rating Rated 5 stars for quality of cover by independent financial researcher Defaqto. Defaqto have given Solutions their highest rating, 5 stars, meaning that it is one of the most comprehensive products in its class within the private health insurance market. Clinical excellence is in our DNA We have a team of clinicians working for Aviva whose clinical expertise helps to inform every aspect of our work. We use our clinical knowledge to develop and shape our products and services. From innovating and creating our propositions, to pricing a product or analysing its benefits, our clinicians have an input every step of the way. Not only that, but they monitor our claims process and manage our relationships with hospitals and specialists. We believe it s our clinical excellence, combined with everything else you d expect from a major insurance company, that means our healthcare offering is the right product for your business. Cover Excellence Awards Best Group PMI Provider 2014 &

6 Will employee absence hurt your profits? Will employee absence hurt your profits? How much does absence cost your business? If you re a small business, having just one of your employees off work can seriously impact your company and your profits. Especially if that employee is a key member of staff or they re off for a prolonged period of time and have to wait for the medical treatment they need. Private health cover is designed to cover the costs of private medical treatment for curable, short-term illnesses or injuries, generally covering in-patient and day-patient treatment as well as eligible out-patient treatment. Enabling your employees to return to work quickly. Solutions from Aviva provides flexible, affordable private health cover for companies just like yours, helping to protect your employees and keep your profits healthy. On average, across all major business sectors, employees are absent for 7 working days per year, at a cost of 554 for each employee and this doesn t include time off to see their GP. So this means if you have a workforce of 50 employees, absence will cost you around 27,700 a year (Absence statistics are taken from the CIPD Absence Management Report 2015). This shows just how important it is to manage absence within your business. Covering your employees with Solutions means that they ll get back to work quicker after injury or illness, saving you money and making your business more productive. It s also why we include the BacktoBetter service as standard on Solutions policies, as this can lead to an even quicker recovery time for your employees, getting them back to work even faster. To see how much absence costs for your specific industry type have a look at our absence calculator at: aviva.co.uk/health-products-for-smes/absence-calculator 6

7 How Solutions works How do we structure Solutions? Solutions is a flexible product that offers you extensive benefits through its core cover, you then have the option to upgrade or downgrade your cover so that it meets the needs of your business and your budget. The following pages take you through what s covered within core cover and shows the options available to you. Option 1 Mental health treatment Options to enhance your cover Option 2 Routine & GP referred services Out-patient treatment of acute conditions Radiotherapy/ chemotherapy Physiotherapy, osteopathy and chiropractic Consultations or treatment with a fee-approved specialist Option 3 Hospital lists Diagnostic tests Psychiatric treatment Treatment for musculoskeletal (MSK) conditions Radiotherapy/ chemotherapy Option 4 Dental and optical BacktoBetter Option 5 Six week option Hospital charges Specialists fees Option 8 Reduced out-patient cover Diagnostic tests In-patient/day-patient treatment of acute conditions Option 6 Member excess Option 7 Selected benefit reduction Options to reduce your cover 7

8 How Solutions works Core cover Cover for different employees With Solutions you can mix-and-match cover to suit up to three different categories of employees. All we ask is that all employees within a defined category have the same benefits and there must be at least two group members within each category. For example, managers could have core cover plus additional benefits, and all other employees could have core cover only. Single member categories can be considered where there is a clear distinction between the levels of employees. Out-patient treatment of acute conditions Radiotherapy/ chemotherapy Physiotherapy, osteopathy and chiropractic On specialist referral for non-musculoskeletal (MSK) conditions Consultations or treatment with a fee-approved specialist Out-patient treatment is subject to Aviva s fee guidelines for specialists Diagnostic tests Such as pathology, X-rays, CT scans and physiological tests such as ECGs Psychiatric treatment as an out-patient, up to 2,000 per member per policy year, on GP referral to a psychiatric therapist or psychiatric specialist Musculoskeletal (MSK) Out-patient, day-patient or in-patient treatment and diagnostics for back, neck, muscle or joint pain Radiotherapy/ chemotherapy BacktoBetter Hospital charges Including accommodation, meals, nursing care and drugs and dressings Diagnostic tests Such as pathology, X-rays, CT and MRI scans Specialists fees Subject to Aviva s fee guidelines for specialists In-patient/day-patient treatment of acute conditions 8

9 How Solutions works Core cover explained These benefits are shown in more detail within the policy summary section on page 28 of this brochure. Networks These are specified groups of facilities, specialists or other practitioners that we recognise to provide treatment for particular conditions or suspected conditions. If we have an appropriate network for your employees conditions or suspected conditions, we ll tell them where they can have their treatment which may not be at a hospital on your chosen list. We will only pay for that treatment if it is carried out within our network. A list of the conditions or suspected conditions for which we have networks in place can be found at Out-patient treatment of acute conditions Consultations or treatment with a specialist Core cover provides for payment in full for out-patient consultations with a fee approved specialist. And we don t put a limit on the number of eligible consultations that your employees can claim for - so they can focus on getting better. If your employees have an eligible consultation with a specialist or other practitioner who isn t fee approved we ll only pay up to the amount we pay our fee approved providers. Treatment by a specialist as an out-patient is subject to our fee guidelines. If we have a network of facilities, specialists or other practitioners for the treatment your employee needs, we ll only pay for that treatment if it is carried out within our network. This is why we strongly recommend that your employees get in contact with us before attending consultations or undertaking any treatment so that we can tell them whether we have a network, and check that their chosen specialist or practitioner is fee approved and has agreed to work within our guidelines. If we don t have a network and your employees don t know which specialist they want to see then we can find a specialist and hospital for them, this will make sure that there won t be any shortfalls on the amount we ll pay their chosen specialist. Diagnostic tests Costs for diagnostic tests, such as pathology, X-rays, scans and physiological tests such as ECGs are all covered in full, at a diagnostic centre, as part of Solutions core cover. Psychiatric treatment Core cover offers your employees psychiatric treatment as an out-patient with a psychiatric therapist or psychiatric specialist, up to 2,000 per member, per policy year. This is on referral from either their GP or a specialist. Cancer treatment Core cover provides full out-patient cover for treatment of cancer on referral from a specialist. We still cover cancer in full for your employees even if you select the reduced out-patient cover (option 8, see page 17), because we believe that cancer cover isn t something that should be limited. 9

10 How Solutions works Physiotherapy, osteopathy, chiropractic treatment Solutions covers these therapies, in full, if they are referred by a specialist for conditions other than back, neck, muscle or joint pain (musculoskeletal conditions). Please read the next section that covers our independent clinical case management service for musculoskeletal conditions BacktoBetter. BacktoBetter Treatment and diagnostics for back, neck, muscle or joint pain (musculoskeletal conditions) Solutions includes BacktoBetter, our independent musculoskeletal case management service, as standard for everyone covered on the policy helping your employees get better and back to work quicker. BacktoBetter offers rapid access to a clinical case manager who can help employees deal with the pain and disruption of a musculoskeletal injury. There is no need for your employees to see their GP before accessing BacktoBetter. Clinical case managers will make sure they get the very best advice and quickly organise any necessary treatment. For more information on our BacktoBetter service, please turn to page 18. In-patient/day-patient treatment of acute conditions Hospital charges The Key hospital list is provided as standard with core cover giving you and your employees access to around 300 hospitals across the UK, and also access to use any NHS hospital recognised by us. If we don t have a network for the treatment they need, your employees can have treatment at any of the hospitals on this list and will have all hospital charges covered in full, including costs for accommodation, meals, nursing care, drugs and dressings. Diagnostic tests Solutions gives you and your employees cover for in-patient and day-patient diagnostic tests on referral from a specialist. This includes tests such as pathology, X-rays or CT and MRI scans. Specialists fees We will pay specialist fees for in-patient or day-patient treatment, up to the amount specified within Aviva s fee guidelines for specialists. Treatment for cancer Solutions provides cover in full for in-patient or day-patient treatment of cancer, on referral from a specialist. With every Solutions policy we offer extensive benefits for cancer and its treatment, through our cancer pledge for more information on this please turn to page

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12 How Solutions works Options to enhance your cover Options to enhance your cover Option 2 Routine & GP referred services Consultations or treatment with a fee-approved specialist Option 3 Hospital lists Out-patient treatment of acute conditions Diagnostic tests Psychiatric treatment Option 4 Dental and optical Option 1 Mental health treatment Radiotherapy/ chemotherapy Physiotherapy, osteopathy and chiropractic for nonmusculoskeletal conditions Treatment for musculoskeletal (MSK) conditions Radiotherapy/ chemotherapy BacktoBetter Hospital charges Specialists fees Diagnostic tests In-patient/day-patient treatment of acute conditions 12

13 How Solutions works You can add any of the following options to your core cover and enhance the benefits available from your Solutions policy. Remember, if you choose any of these options your premium will increase. Option 1: Mental health treatment To complement the out-patient psychiatric benefit available under core cover, you can choose to add in-patient and day-patient psychiatric treatment to your scheme. Your plan can provide a maximum of either 28 or 45 days combined in-patient and day-patient psychiatric treatment each member every policy year. This also includes benefit for specialists fees for in-patient treatment of up to 210 per week. We cover treatment that aims to lead to your full recovery. We do not cover chronic psychiatric conditions. Option 2: Routine & GP referred services This option has an overall benefit limit of 1,000 per member per policy year. As with most health insurance policies, our core cover excludes long-term treatment for chronic conditions. However, with Solutions you can add cover for out-patient monitoring of chronic conditions by adding option 2. This means that for extra peace of mind, your employees can undertake routine monitoring of these conditions, as long as they are not excluded under the policy, when they would usually have to use the NHS. In addition, we recognise that more and more people want to use complementary and alternative treatments and want to be able to access diagnostic services following a visit to their GP. This option includes the following benefits up to a combined total of 1,000 each member every policy year: l consultations with a fee approved specialist and tests for chronic conditions and follow up consultations with a fee approved specialist to monitor a member when they have finished treatment for an acute condition l GP referred radiology/pathology for non-musculoskeletal conditions l GP referred physiotherapy, chiropractic, osteopathy and acupuncture treatment for non-musculoskeletal conditions up to 10 sessions in combined total per condition per member per policy year l GP referred chiropody, podiatry and homeopathy for non-musculoskeletal conditions l GP minor surgery up to 100 per procedure (payable to the GP). What are chronic conditions? Chronic conditions are those illnesses, diseases or injuries that either continue indefinitely, have no known cure, come back (or are likely to come back), need long term monitoring or need ongoing control or relief of symptoms. Examples of chronic conditions are Diabetes or Crohn s Disease. Like most insurers we do not cover chronic conditions. However, if you choose Option 2: Routine and GP referred services, we will cover consultations with a fee approved specialist and tests for chronic conditions and follow up consultations with a fee approved specialist to monitor a member when they have finished treatment for an acute condition, up to the overall benefit limit. For a full explanation of chronic conditions turn to page

14 How Solutions works Option 3: Hospital lists As part of your core cover you and your employees have access to the Key hospital list, this list gives you and them access to around 300 private hospitals across the UK. There are additional options that you can select to either add more, or to remove hospitals from your cover. You can add more hospitals by selecting: l The Extended hospital list an upgrade which gives access to more hospitals, predominantly in the Greater London area. However, you can also reduce your costs by choosing one of the reduced hospital lists below: l The Signature hospital list a great option for companies whose employees are solely based in Scotland or Northern Ireland, as this list excludes all hospitals in England and Wales from your cover. l The Trust hospital list a cost saving option that uses the excellent private patient units of NHS Trust and partnership hospitals. Option 4: Dental & optical Our core cover provides benefit for surgical procedures on the teeth performed in a hospital and ophthalmic procedures, however as with most health insurance policies, cover for routine dental treatment and optical expenses is excluded. With Solutions this needn t be the case our dental & optical option can provide the following benefits: l 500 routine dental benefit (excess applies) l 600 accidental dental injury benefit l 300 optical benefit (excess applies) A 50 excess applies separately to both the routine dental benefit and optical benefit. This means that there will be a 50 excess applied to any dental claims and another 50 excess applied to any optical claims meaning that employees will need to pay the first 50 of any claim and we will pay up to a further 450 for dental expenses or up to a further 250 for optical expenses. Please note that the Trust hospital list is only available on Solutions policies covering 2-99 employees. Remember if we have a network for your employees conditions or suspected conditions, they will need to use our network facility for their treatment. Our networks may include hospitals or other facilities that aren t on your chosen list. 14

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16 How Solutions works Options to reduce your cover Consultations or treatment with a fee-approved specialist Out-patient treatment of acute conditions Diagnostic tests Psychiatric treatment Radiotherapy/ chemotherapy Physiotherapy, osteopathy and chiropractic for nonmusculoskeletal conditions Treatment for musculoskeletal (MSK) conditions Radiotherapy/ chemotherapy BacktoBetter Option 5 Six week option Hospital charges Specialists fees Option 8 Reduced out-patient cover Diagnostic tests In-patient/day-patient treatment of acute conditions Option 6 Member excess Option 7 Selected benefit reduction Options to reduce your cover 16

17 How Solutions works Perhaps you feel that while your company would benefit from the advantages of Solutions you may prefer a lower cost option. If you want to reduce your premium to help meet your budget, you can do this by choosing from the following cost containment options. Option 5: Six week option If you choose the six week option, your employees will still have the benefit of prompt cover should a GP refer them to a specialist for a consultation. And, if subsequent eligible treatment as an out-patient is required, that is covered too, including out-patient treatment from BacktoBetter and certain out-patient treatments covered under the NHS cancer cash benefit. The difference is that your employees will only be covered for in-patient or day-patient treatment if the wait for that treatment is longer than six weeks on the NHS. If the NHS waiting time for any in-patient or day-patient treatment is less than six weeks they will need to use NHS facilities as a non-paying patient or self-fund any private treatment; members won t be able to claim for NHS cash benefit, NHS cancer cash benefit or the cost of an NHS amenity bed if their treatment is available on the NHS within six weeks from the date their specialist recommends it. This option can be taken so that your employees avoid long NHS waiting lists as it means that the maximum amount of time they ll have to wait for a procedure is six weeks. Option 6: Member excess Another way you can reduce your premium is by choosing a 50, 100, 150, 200, 250 or 500 member excess. We apply our excess once each member every policy year, irrespective of the number of claims made during that policy year. The excess does not apply to NHS cash benefit, the baby bonus, donations we make to a hospice, any benefit claimed under the dental and optical option, NHS cancer cash benefit or to the wigs benefit for cancer treatment. Option 7: Selected benefit reduction You may feel that you require cover for only in-patient, day-patient and out-patient costs and not the less essential extras. That s why Solutions includes the selected benefit reduction option, which lets you remove cover and costs associated with infertility, complications of pregnancy, surgical procedures on the teeth and limited emergency overseas cover. Option 8: Reduced out-patient cover Another cost saving option is to reduce your out-patient cover. This option limits out-patient cover to 0, 1,000 or 1,500 each member every policy year. As some out-patient diagnostics and treatment can be more expensive, it does however provide cover in full for CT, MRI and PET scans at a diagnostic centre that we recognise, radiotherapy and chemotherapy and physiotherapy for pain in the back, neck, muscles or joints (musculoskeletal conditions) through BacktoBetter. The monetary limit does not apply to out-patient cancer treatment received after you have been diagnosed with cancer. In addition we will also cover any costs for pre-admission tests required within 14 days of admission to check that you are fit to undergo surgery and anaesthesia. This is a summary of benefits. If you d like a copy of the full terms and conditions, just ask and we ll send them to you. If you d like to take out a policy, you ll need to complete an application. If we accept your application, the details you give us and the options you select will determine the final terms of your policy. 17

18 How Solutions works BacktoBetter Musculoskeletal (MSK) injuries are a leading cost in health claims they re also one of the leading causes and costs of absence. Health and safety statistics 2014/15 from HSE, claim that 9.5 million working days are lost to work-related musculoskeletal disorders. We believe they re one of the biggest health challenges employers are facing today. It s not always easy for employees to work out exactly what s wrong or what to do about it. The challenge is to make high quality clinical services easily available as quickly as possible, when they re needed. Tackling the problem head on BacktoBetter is a musculoskeletal case management service delivered by our carefully selected independent clinical case management providers. It introduces high quality clinical decision-making throughout your employees claims. One great advantage of BacktoBetter is that your employees don t need to see their GP; they just need to call us and we will arrange an assessment with a clinical case manager. This ensures that only appropriate and effective interventions are approved, which means a better outcome for your employees, a well-managed claims spend, and a positive impact on absence levels. We ve proved that BacktoBetter works. For a number of our corporate customers, the average cost per MSK claim has reduced by 15% when managed through BacktoBetter, and can be as much as 30% (compared to MSK claims that were not managed). One way BacktoBetter reduces claims costs is that only 20% of MSK claims require further investigations by a specialist through BacktoBetter, compared with 60% of MSK claims that were not managed. What are musculoskeletal (MSK) conditions? MSK conditions are any conditions relating to back, neck muscle or joint pain, also commonly referred to as orthopaedic conditions. BacktoBetter can help BacktoBetter can help your employees recover faster. That means you can keep your productivity levels up and your claims spend down because BacktoBetter intervenes quickly and effectively. l BacktoBetter provides rapid access to a clinical case manager who can help employees deal with musculoskeletal pain. (Please note, only valid claims can be referred to our BacktoBetter service certain underwriting types may require your employees supplying more information before they can begin their claim). l There s no need to see a GP. l Your employees get the right treatment at the right time, whether this is advice and self management, referral to a physiotherapist, or referral to a specialist. This can lead to a faster recovery. l It s an end-to-end service that delivers clinical best practice no matter how complicated the problem is or what route your employee s treatment requires. l We will support members to access an experienced physiotherapist, if appropriate, that is local and convenient to them through our independent clinical provider s quality assured physiotherapy networks. l Plus, any physiotherapy treatment your employees receive through BacktoBetter won t come out of any chosen out-patient limits. Where your employees have already seen their GP about their musculoskeletal (MSK) pain, they can move to the standard claim process if: l the employee s GP has recommended osteopathy or chiropractic treatment, or l the employee s condition does not relate to their back or neck, and l the employee s GP has recommended radiology, pathology, or referral to a specialist. Otherwise the employee can continue to follow the BacktoBetter claims process. 18

19 How Solutions works Cancer cover According to Cancer Research UK, 1 in 2 people born after 1960 in the UK will be diagnosed with some form of cancer during their lifetime. We have an experienced cancer claims management team that can give your employees the personal support they may need if they face this challenge. A dedicated case manager is on hand from the point of diagnosis so your employees will have a named contact all the way through their claim, to make the process as easy as possible through a very stressful time. We re committed to making sure your employees get not only the right treatment but also a high level of aftercare. Our clinicians are also there as a point of reference for extra support and guidance. In-patient and day-patient treatment is covered at any hospital on your hospital list unless we have a network in place for the treatment required, in which case we ll tell your employees where they can have their treatment. If you choose to take out the six week option (option 5), it means that we will not pay for treatment as an in-patient if it is available on the NHS within six weeks from the date a specialist recommends it. If an employee is diagnosed with cancer, this may mean that their treatment will be available on the NHS and we will not pay for most of the treatment they need. If you choose to reduce your out-patient cover (within option 8 0, 1,000 or 1,500), the monetary limit does not apply to out-patient cancer treatment received after an employee has been diagnosed with cancer. Out-patient treatment for cancer is covered at a network facility or other hospital that we recognise. Our cancer pledge We understand the importance of providing extensive cover and support at every stage of cancer treatment. Our cancer pledge means we ll cover the treatment and palliative care your employees need as recommended by their specialists. We also want to make things as comfortable as possible following treatment, so we ll provide cover for aftercare, including dietary consultations and money towards prostheses and wigs. 19

20 How Solutions works Added value benefits with Solutions It s widely accepted that, if employees lead healthier lives and feel more appreciated by employers, then a business could see a boost in workforce performance, morale and positivity. We include a range of helpful extra features at no extra charge with every Solutions policy. Access to a 24-hour GP helpline For over-the-phone consultations with a fully qualified GP when employees need reassurance about medical issues, day or night. A 24-hour stress counselling helpline When employees want to talk about a personal or professional issue that s causing them distress. This benefit is available to members aged 16 and over. Aviva News & Guides An online portal of tips and tools that can help your employees improve their health and fitness. MyAviva - Manage Aviva policies at the touch of a button Because everything we do is full of good thinking for our customers, we created MyAviva. Our online platform will help your members manage their Aviva policies in one secure, easy-to-use place at a time that suits them. There s a whole host of other benefits at their fingertips. Members can: l Check their policy information l Change their personal details l Get access to useful online tools l 20% discount for existing customers off selected new Aviva products l Enjoy Aviva Advantages offers and competitions l Download our smartphone app to view their policies on the go Up to 25% off gym membership Solutions PMI also offers up to 25% off membership fees at some of the UK s leading health and fitness clubs. Access to Aviva Advantages All customers on our Solutions policies get given access to Aviva Advantages this gives your employees lots of rewards and money saving offers not just on personal Aviva insurance products (such as car or home insurance) but with 100s of other businesses too. 20

21 Our approach to claims Our approach to claims Understanding clinical needs Our in-house clinicians work closely with our claims teams to understand your employees clinical needs. Together, they use a proven telephone clinical assessment process that identifies routine pathways (treatment for things like hernias and cataracts), separating them from the more complex conditions such as heart and mental health conditions, and cancer. And if it s a more complex case, then one of our specialist claims teams will provide dedicated case management to employees so they have one point of contact throughout their claim. Sensitivity combined with expertise and efficiency Consistency of service is all the more important for sensitive conditions such as cancer, heart conditions and mental health problems. We have a team of expert clinicians who help us provide dedicated management of these cases. Everyone involved understands the complexities of the condition, so employees get reassurance and seamless support from one treatment stage to the next. Our clinical case management service for musculoskeletal (MSK) conditions BacktoBetter offers rapid access to clinical case managers who assess MSK conditions and recommend the most appropriate course of treatment, whether this is self-managed advice or exercises, a course of physiotherapy or onward referral to a specialist. With BacktoBetter, there s no need to see a GP and members will be assessed and provided with advice quickly, along with a speedy referral for treatment if appropriate. Open referral With Solutions we don t mind which type of referral your employees receive, they ll get great service either way. If a GP recommends that your employee needs to see a specialist for further assessment or treatment, they will give them a referral. This may either be in the form of an open referral or a named referral. l An open referral is where the GP just states which type of specialist they need to see or the type of treatment they need, without giving them a specific named specialist. If an employee receives an open referral, our claims team will help them to find a specialist and hospital. In most cases, we ll connect them directly with the hospital to book their appointment over the phone. l A named referral is where the GP recommends a particular specialist. If they receive a named referral, they will need to ring to check whether we have a network for their condition or suspected condition. If we do, we ll tell them where they can have their treatment. If we don t have a network in place we ll check to make sure the specialist is recognised by us. However, even if their GP provides a named referral, we can still offer to find other suitable specialists when they call us, as this may provide more choice and convenience for their particular circumstance. Musculoskeletal (MSK) conditions MSK conditions are any conditions relating to back, neck, muscle or joint pain, also commonly referred to as orthopaedic conditions. 21

22 Our approach to claims How to claim three simple steps When employees feel unwell, the last thing they want to face is a difficult claims journey. So we ve made ours as easy and as hassle free as possible. BacktoBetter claims: For back, neck, muscle or joint pain (musculoskeletal (MSK) conditions), the claims journey is even easier than the standard processfor your employees they don t even need to see their GP. 1. For musculoskeletal pain There s no need to wait to see a GP. The employee just needs to contact the customer service helpline and describe their symptoms. If an employee has already seen their GP, they can move to step 2 of the standard claim process if: the employee s GP has recommended osteopathy or chiropractic treatment, or the employee s condition does not relate to their back or neck (spine), and the employee s GP has recommended radiology, pathology, or referral to a specialist. Otherwise the employee can continue to follow the BacktoBetter pathway. 2. Telephone clinical assessment Our advisers arrange for a clinical case manager from one of our independent clinical case management providers to contact the employee to assess their symptoms. We always aim to provide this assessment at a time that is convenient for your employee. 3. Treatment The clinical case manager will determine whether treatment is necessary. If treatment is not necessary, the member will be taught how to self manage their condition. If clinically appropriate, this will include being referred to a physiotherapist from our clinical case management providers networks for treatment within two working days and/or onward referral to a specialist. For all other claims For non-musculoskeletal claims your employees will need to follow the standard claims process 1. Consult your GP If an employee is unwell they will need to see a GP, where they may be referred for further assessment or treatment. This could be an open referral or a named referral (as detailed on the previous page). It s really important that your employees get in touch with us before attending any appointments so we can make sure their claim is covered under the terms and conditions of the policy before they incur any costs. 2. Contact Aviva After your employee has been referred by their GP they ll need to call us to set up their claim. If we have a network for the treatment your employee needs, we ll let them know where they can have their treatment. Our network facilities may be different to the hospitals on your chosen hospital list. If we do not have a network for your employee s condition or suspected condition: - if the employee has been given a named referral, we ll check to make sure the specialist is recognised by us. - if it s an open referral, we ll use our specialist finder database to select an appropriate specialist and/or hospital. 3. Diagnosis, treatment or surgery After the employee attends an appointment, their specialist may recommend hospital treatment this is where they need to ask for a procedure code. Once they ve called us with these details, we can confirm whether or not their treatment is covered and provide information about where your employee can receive treatment whether this is through our networks, at a hospital on your list or at other facilities recognised by us. 22

23 Our How approach Solutions to claims works Payment of bills At the end of a claim all bills will be settled by us directly with the treatment provider. If your employees do receive a bill for their treatment, they will need to forward it onto us (taking a photocopy for their records), so we can arrange for payment directly with the provider. 23

24 Underwriting Underwriting Private medical insurance is designed to cover new and unexpected medical conditions. Solutions offers a wide choice of underwriting options. The standard underwriting offered is dependent on the number of employees covered under your group policy. Full details are set out below. Full medical underwriting means that we ask your employees questions about their past health and any pre-existing medical conditions. This means that related conditions will be excluded unless we agree to accept them. Full medical underwriting is offered as standard to all previously uninsured businesses with between 2-99 employees. Companies with between employees wishing to contain costs can also opt to be fully medically underwritten. Continued medical exclusions can be chosen if your company is transferring from an existing fully medically underwritten medical insurance plan. With this option we will accept the existing health of your employees, and apply the same personal medical exclusions to Solutions that were used on your previous plan. We require all certificates and previous medical insurance documents for each employee for the underwriting to be completed. Moratorium underwriting replaces filling out a health questionnaire. An automatic exclusion applies to any disease, illness or injury (whether or not diagnosed) or any related condition if: l your employee had symptoms of, medication for, diagnostic tests for, treatment for, or advice about such a disease, illness or injury within five years before joining Solutions and l there has not been a clear two-year period after joining during which your employees have been free of medication for, diagnostic tests for, treatment for, and advice about such a disease, illness or related condition. The full moratorium process is explained in more detail on the diagram on page 26. Continued medical exclusions underwriting is available to all group sizes (2-249). 24

25 Underwriting Continued moratorium means your company can apply to transfer from an existing medical insurance plan which is underwritten on a moratorium basis. We apply our moratorium wording with effect from each employee s original moratorium start date. Continued moratorium underwriting is available to all group sizes (2-249 employees). The full moratorium process is explained on the diagram opposite. For both continued underwriting options proof of previous terms will be required. Medical history disregarded means that any pre-existing medical conditions your employees have had will be covered, providing they fall within the terms and conditions of the policy. Medical history disregarded is offered as standard for all companies with employees. However, these companies may opt for Full Medical Underwriting if preferred. Companies with employees may also opt for medical history disregarded, however a premium loading will apply. Part medical history disregarded schemes may be considered, please contact your insurance adviser if you want to go down this route, or alternatively, contact your usual Aviva healthcare sales consultant. Declaration for companies with 2-99 group members We are committed to customer growth and retention through offering competitive, value for money premiums. In order to help us achieve our aim, we have reviewed our new business selection criteria and brought them in line with many other major providers in the market. This means that we require any company with between 2-99 employees transferring from another PMI provider or selecting medical history disregard (MHD) underwriting to notify us of any past, present and future claims for certain medical conditions that they are aware of at the out-set of the policy. Failure to notify us may result in a change in the policy terms, the level of premium charged or we may cancel the policy. If you are transferring with continued medical exclusions, we may exclude additional symptoms or conditions according to the information provided. The declaration (on the company application form) will apply to all business for schemes with 2-99 members transferring from another PMI provider. Company policies with employees covered will not have to complete the health declaration for each member when switching from another provider. 25

26 Underwriting The below diagram explains how moratorium underwriting works If your employees have any pre-existing conditions in the 5 years prior to their start date on the policy......then... they need to go 2 years advice, medication, diagnostic test or treatment free for that condition from their start date. If they do this then the condition will be covered under the policy, provided it falls within the terms and conditions. 5 Years Start Date 2 Years If they have advice, medication, diagnostic tests or treatment for that condition within the first 2 years of their start date then the moratorium is not satisfied and they will only be covered after there has been a continuous period of 2 years where they have been advice, medication, diagnostic test and treatment free for that condition. 26

27 Why buy PMI How for Solutions your business? works How we manage costs How we manage costs We proactively manage costs throughout the life of your policy without compromising the quality of private care. Our clinical expertise informs every aspect of our work from monitoring our claims process to managing our relationships with hospitals and specialists. Greater efficiency with our claims management system Our claims management system helps us identify and manage high costs, complex cases and treatment programmes, such as cardiac, musculoskeletal, psychiatric and cancer cases. By working closely with hospital providers we can negotiate the costs of long stay and complex cases, but still make sure your employees get the best possible case. Keeping your healthcare scheme sustainable Advances in medicine are happening all the time. That s why we re always evaluating fees and challenging our supply chain partners doctors, hospitals, and specialists to make sure we re offering the right treatments at the right costs. We believe this approach helps us secure the best possible outcome for your employees, helps you contain costs and contributes to keeping your premiums down, year on year. Networks To help manage costs and drive consistent quality of care, we re developing a number of networks of facilities, specialists and other practitioners for specific conditions or suspected conditions. If we have a network for an employee s condition or suspected condition, we ll tell them where they can have treatment which may not be at a hospital on your chosen list. 27

28 Policy summary Policy summary Solutions from Aviva This policy summary has been designed to provide you with the key information about the product, and it is important that you read this section. The policy summary does not, however, contain the full standard terms and conditions that apply to the product. These can be found in the Solutions policy wording, if you d like a copy, just ask and we we ll send them to you. Non-standard terms may apply. For more information visit aviva.co.uk/business. What does Solutions offer? Solutions offers you and your employees an extensive range of cover as standard. If your employees need to claim for back, neck, muscle or joint pain (musculoskeletal conditions) then they ll be covered through our BacktoBetter service. Should a GP recommend a visit to a specialist for non-musculoskeletal conditions, Solutions provides access to consultations, diagnostics, and eligible treatment as an out-patient. Furthermore, should a specialist advise it, Solutions will also provide cover for prompt access as a day-patient or in-patient for eligible treatment through our treatment networks or at one of the hospitals on your chosen hospital list. There is also cover for eligible treatment as an in-patient or day-patient using pay-beds at NHS hospitals recognised by us, although we cannot guarantee immediate access to NHS hospitals. Some insurance companies offer set limits on private hospital accommodation costs. With Solutions, there are no such limits on accommodation costs at any facilities on our networks or hospitals from your chosen hospital list and no overall restriction on how often a person can claim for eligible treatment. We pay all specialists fees in accordance with Aviva s specialist fee guidelines. To view our fee guidelines visit aviva.co.uk/pmifees 28

29 Policy summary What is covered summary of core cover It is important to note that this benefit table is intended to provide you with only a summary of the core cover benefits offered by Solutions. Full details can be found in your Solutions policy wording. Benefits Amount payable Notes A. Hospital treatment as an in-patient or day-patient Key hospital list, facility recognised by us as part of a network, or an NHS hospital recognised by us If you have the six week option, your employees cannot claim for these benefits if their treatment is available on the NHS within six weeks from the date their specialist recommends it. Including accommodation and meals, nursing care, drugs and surgical Hospital charges In full dressings, theatre fees Specialists fees Up to the limits in our specialist fee schedule Diagnostic tests In full Including blood tests, X-rays, scans, and ECGs CT, MRI and PET scans Radiotherapy/chemotherapy In full In full NHS cash benefit 100 each night, up to 25 nights Treatment for pain in the back, neck, muscles or joints musculoskeletal conditions B. Treatment as an out-patient Consultations with a fee approved specialist In full In full Managed through our BacktoBetter service At a network facility if we have a network for your symptoms or condition If your employees have a consultation with a specialist who is not fee approved we will only pay up to the limits we pay our fee approved providers. Treatment by a specialist as an out-patient In full Specialists fees are covered up to the limits in our fee schedule Diagnostic tests Pre-admission tests (tests carried out at hospital before a member s admission to check that they are fit to undergo surgery and anesthesia. These can include ECG s and blood tests) Radiotherapy/chemotherapy In full In full In full CT, MRI and PET scans as an out-patient are only covered at a diagnostic centre. Specialists fees for surgical procedures are covered up to the limits in our fee schedule 29