Terms and conditions of your health insurance by fxw33739

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									Terms and conditions of
your health insurance.

POLICY SUMMARY AND
POLICY DOCUMENT
Contents.

                                                        page

Your policy summary                                       3

Your policy document                                      7

  1. Cover and benefits in detail                        14

  2. Underwriting                                        21

  3. Exclusions                                          22

  4. Policy terms and conditions, general conditions,
     policy administration                               26

  5. Complaints                                          35

  6. Law and interpretation                              37

  7. Currency                                            37

  8. Glossary of definitions                             37

How to contact us                                        44
Your policy summary.


  This policy summary highlights the benefits of your
  PruHealth private health insurance.
  Please read your policy document for full terms and
  conditions.


What is PruHealth private                          made by any member(s) on the policy
health insurance?                                  will be taken into account.
n It is an insurance plan underwritten          n The no claims discount will be increased
  by PruHealth that aims to cover the             by 5% for each year the member does
  cost of private medical treatment for           not claim to a maximum of 35%. It will
  acute conditions for UK residents.              decrease by 10% if a claim is made in
  You must be aged 18 or over to have             the policy year.
  a PruHealth policy.
                                                n A Vitality renewal reward will also be
n Your policy with us is for a 12 month
                                                  calculated based on a member’s attained
  period.                                         Vitality status in the policy year. The
                                                  Vitality renewal reward will be based on
What benefits does this plan                      a combination of the member’s Vitality
offer me?                                         status and the monthly premium paid in
n With our Vitality programme everyone            the policy period.
  can benefit from a healthy lifestyle. If      n Prices with our Vitality partners may
  you eat well, take a bit of exercise and        increase during the year. For our fixed
  maintain an all round healthy lifestyle you     price Vitality benefits no price shall
  could receive a reward when you renew.          exceed the amount equal to the change
n At policy renewal, PruHealth will               in the Consumer Price Index (since
  allocate a no claims discount per policy        our last price increase) against the
  based on claims made during the policy          Bronze price. For our percentage
  year. The full twelve months of the             discount Vitality benefits, the amount
  policy year will be reviewed. Where late        may vary during the year if that retailer
  claims are received and not taken into          changes its standard price (please see
  account these will be added into the            section 1.16ii of your policy document
  following renewal calculation. Claims           for full details).

                                                                                          3
What does each plan cover?                      What our plans do not cover:
We have four different types of cover.          As with many private health insurance
You’ll be able to check which one you chose     plans, there are some standard treatments
by reading your membership certificate.         and conditions that we don’t cover.
                                                These are as follows:
The Comprehensive plan covers:                  n Any regular monitoring or treatment of
n All eligible hospital fees, including           chronic conditions. Examples of chronic
   specialist fees, plus greater levels of        conditions include diabetes, HIV/AIDS
   outpatient care and higher cover limits        and allergies
n All eligible outpatient costs                 n Any treatment received outside the UK
n A wider range of additional benefits          n Emergency treatment or visits to
  such as complementary and alternative           your GP
  therapies.                                    n Preventative treatment (and regular
                                                  checks)
The Select plan covers:                         n Pregnancy and childbirth
n All eligible hospital fees, including         n Self-inflicted injuries
   specialist fees, plus greater levels of      n Cosmetic treatment
   outpatient care
                                                n Organ transplants
n Option of £0 or £250 excess.
                                                n Medication and dressings (except when
                                                  administered during hospital
The Core plan covers:
                                                  admissions)
n All eligible hospital fees, including
                                                n Fertility, infertility and menopause-
   specialist fees
                                                  related treatment
n Limited outpatient costs following and        n Experimental, unproven or unregistered
  directly related to a hospital stay             treatment or practices
n Option of £0 or £250 excess.                  n Treatment related to developmental
                                                  problems, learning difficulties, or
The Value plan covers:                            delayed speech disorders
n All eligible hospital fees and limited        n Dentistry
   outpatient costs. The member will need       n Refractive eye surgery and optometry
   to contribute a pre-set amount per benefit
                                                n Treatment for obesity
   in the form of a fixed co-payment.
                                                n Deafness
Please read the ‘Summary of PruHealth
plans and benefits’ section in your policy
document for full details on what your plan
covers. This includes details on our full
cancer cover.


4
If you selected ‘moratorium underwriting’,         – Full details of your condition/injury,
any conditions that you have been affected           diagnosis and intended treatment
by in the five years before the start of your
                                                   – Full name and address of the
cover will not be covered in the first two
                                                     specialist and the hospital/clinic
years of your policy. Please read the
                                                     you've been referred to.
'Underwriting' section in your policy
document for full details.                      n Step 2: Give us a call on
                                                  0800 092 7333.
Depending on the plan you have selected
there may be times when you are required           Once you've got all the details, call
to contribute towards the treatment you            our dedicated Claims Team for your
receive through an excess or co-payment,           authorisation number – jot this down
or where your treatment cost exceeds the           and keep it safe for your trip to the
PruHealth fee maximum. Please see your             specialist. If you have treatment without
membership certificate for details of any          it, it could mean you won't be covered.
excess or co-payments that may apply.
                                                   It's worth remembering that you might
                                                   be asked to give details of your condition
Out of hospital list co-payment
                                                   over the phone, so you may want to
An out of hospital list co-payment applies         make the call in private. To double
for services outside of a member’s selected        check any of the details of your
hospital list. For an inpatient admission          cover, log on the Member Zone at
outside of the member’s selected hospital          pruhealth.co.uk/member and click
list a 40% co-payment will apply to the            on `My cover'.
hospital charges. For a diagnostic scan
outside of the member’s selected hospital          You may be able to receive an
list a 40% co-payment will apply to the            authorisation number online.
hospital tariff. Under the Value plan there        Please log onto the Member Zone at
will be no cover for the outpatient                pruhealth.co.uk/member to find out.
diagnostic scans outside of the member’s        n Step 3: Book your appointment.
selected hospital list.
                                                  You can now book your appointment
                                                  with the specialist and start your
How do I claim?                                   treatment. When you go, make sure you
                                                  take the authorisation number we gave
We hope you don’t need to claim but if you
                                                  you. If you need further visits, ask for a
do we’ve made the process as simple as
                                                  procedure code and description of the
possible.
                                                  treatment or investigation. Always speak
n Step 1: Visit your GP. If you need              to our Claims Team to make sure you're
  medical treatment, the first thing to do is     covered for further treatment.
  to visit your GP. If they refer you for
  treatment, tell them you have cover with
  PruHealth and ask for the following:
                                                                                              5
n Step 4: Settling the bill. In most             www.fsa.gov.uk/register or by contacting
  cases, bills will be sent direct to us.        the FSA directly on 0845 606 1234.
  If you do get a bill, simply forward it on
                                                 This is a free service. Using it will not
  to us at PruHealth Customer Services,
  Stirling FK9 4UE. If you make a payment        affect your legal rights.
  yourself, send us the bill with proof of
  payment and we'll pay you back.                Compensation
                                                 You may have a right to compensation if we
Can I change my mind?                            or another authority decide that you’ve
You have 30 days from the start date of your     bought a plan in which the information
cover, or from when you received your            provided by PruHealth was incorrect or
policy documentation, whichever is later, to     misleading and resulted in financial loss.
cancel your policy and receive a full refund.    Please contact our Customer Services office
If you have any claims larger than your          for more information.
premium we will collect the difference and       If PruHealth is unable to meet its financial
any outstanding claims will be cancelled.        obligations in full you may be entitled
You will not receive a refund for any Vitality   to help from the Financial Services
activities used or points earned. Cool off       Compensation Scheme. Further information
provisions for any gym membership will           is available from the Financial Services
depend on the terms and conditions of the        Compensation Scheme. Telephone
relevant gym.                                    020 7892 7300 or visit the website at
                                                 www.fscs.org.uk
What if I need to complain?
We hope that you never need to complain,         How to contact us
but if you do, you can write to us at:           Online
PruHealth Customer Services,                     Via our Member Zone at
Stirling FK9 4UE.                                pruhealth.co.uk/member and send
                                                 us a secure message.
Copies of our Complaint Handling
Procedures are also available at this            By post
address. Or you can call us on                   PruHealth Customer Services
0800 096 6322.                                   Stirling
                                                 FK9 4UE
If you are not satisfied with our reply
you can take your complaint to:                  By phone
                                                 0800 092 7333
The Financial Ombudsman Service,
South Quay Plaza,                                Please note that PruHealth can only give
183 Marsh Wall,                                  information on PruHealth products.
London E14 9SR.

6
Your policy document.
    About this document
    This document reflects the Terms and Conditions of the policy as agreed between
    PruHealth and the policyholder.

    Please refer to this document in conjunction with your membership certificate for full
    details of cover and exclusions that may apply.

    Words in italics in this document are defined terms which have a specific meaning.
    You should check their meaning in the glossary at the back of this document.


    About PruHealth
    PruHealth was launched in October 2004 and is a joint venture between Prudential
    and Discovery Holdings, the South African health insurance leader. PruHealth’s
    model for private medical insurance is based on a successful concept in South Africa.


    About Prudential UK and Discovery Holdings
    Established in 1848, today Prudential plc is a leading international financial services
    company with some 21 million customers, policyholders and unit holders and some
    23,000 employees worldwide. Discovery Holdings was founded in 1992 as a
    specialist health insurance company in South Africa. It is now one of the market
    leaders in healthcare and life insurance in South Africa.

    For more information visit www.prudential.co.uk and www.discovery.co.za




        Best Individual       Best Individual PMI         Best PMI         Overall winner of
    PMI Provider 2006, 2007     Provider 2006,      Provider 2007 & 2008   the best Customer
                                                                           Experience league
            & 2008               2007 & 2008                                 table for 2008
      Health Insurance         Best Group PMI
     Company of the Year        Provider 2007
        2006 & 2007




8
Important regulatory information

PruHealth is the trading name of both Prudential Health Limited and Prudential
Health Services Limited. Prudential Health Limited, registration number 5051253,
is an insurer that underwrites the insurance products. Prudential Health Services
Limited, registration number 5933141, is an insurance intermediary with FSA
authorisation to mediate insurance business. Our registered offices are at Laurence
Pountney Hill, London EC4R 0HH. Both Prudential Health Limited and Prudential
Health Services Limited are authorised and regulated by the Financial Services
Authority (FSA). You can check our authorisation on the FSA’s Register by visiting
the FSA’s website:

www.fsa.gov.uk/register or by contacting the FSA directly on 0845 606 1234.

The products we offer

Prudential Health Services Limited only offers products underwritten by Prudential
Health Limited. Prudential Health Services Limited can offer other insurance
products from a specific range of insurers. If you wish to see this list of insurers and
insurance products, it is available on request.

Statement of demands and needs

This policy is designed to meet the demands of people who wish to ensure their
health needs are met quickly.

We aim to offer increased choice and access to high quality facilities. Our products
will also reward you if you make an effort to lead a healthy lifestyle. To ensure you
are completely confident that our products will meet your personal demands and
needs, we would advise that you read the information we give you both before and
immediately after we have completed a sale with you.




                                                                                           9
     Data Protection

     PruHealth, our group of companies and our business associates, service providers
     and agents will use your information, together with other information, for
     administration, customer services, marketing and profiling your purchasing
     preferences and fraud prevention. We will only pass your information to them for
     these purposes.

     We will also pass your information to any legal or regulatory body such as the
     Financial Ombudsman or the Financial Services Authority if we are required to do so.

     If you have appointed a broker in relation to this policy, we may also need to pass
     certain information of yours to that broker.

     Please rest assured that we will always maintain the greatest care in the transfer of
     this information to the parties noted and act in accordance with the most up-to-date
     data protection legislation to ensure your confidentiality is not breached in any way.

     For the above purposes it will be necessary to transfer your information to countries
     that provide a different level of data protection from the UK. We have contracts in
     place to ensure your information is protected in accordance with UK law.

     You have a right to obtain a copy of your personal information (for which we may
     charge a fee) and to have any inaccuracies corrected by writing to:

     PruHealth
     c/o The Privacy Manager
     Information Risk and Privacy Team
     Prudential Assurance Company Ltd
     3 Sheldon Square
     London, W2 6PR.




10
Your PruHealth policy terms and conditions.

Overview                                    Contacting us
This is the policy wording and benefit      For more information or further
description for the PruHealth private       clarification on the benefits, cover,
health insurance (PMI) taken out by the     exclusions and the rules included in this
policyholder.                               policy you can contact us as follows:

PruHealth expects that this policy will     Online
enable the member to protect and
                                            Via our Member Zone at
enhance their wellbeing and that of their
                                            pruhealth.co.uk/member and
dependant members in times of both
                                            send us a secure message.
illness and health. It is intended to
complement rather than replace NHS          By post
services provided in the UK.                PruHealth Customer Services
Any examples contained in this policy       Stirling FK9 4UE
wording are for illustrative purposes
                                            By phone
only and do not reflect the totality of
the circumstances covered by the            0800 092 7333
relevant clause.                            Or contact your adviser.


                                            How we will communicate
                                            with you
                                            We will use a member’s email address as
                                            the primary form of contact regarding
                                            this policy and our Vitality programme.
                                            Please note we generally do not send
                                            paper copies of our policy documentation
                                            or Vitality information to you unless
                                            explicitly requested. All policy
                                            documentation can be found by logging
                                            in to our secure online Member Zone at
                                            pruhealth.co.uk/member.

                                                                                        11
     Summary of PruHealth plans and benefits
     'Covered' in the summary of benefits means we will pay for treatment at
     hospitals on your selected hospital list, where charges are within the
     PruHealth fee maxima for the services provided.

                         Comprehensive       Select              Core                Value
     INPATIENT CARE
     Hospital charges    Covered             Covered             Covered             Covered3

     Specialist          Covered             Covered             Covered             Covered3
     consultant fees

     Diagnostic tests    Covered             Covered             Covered             Covered3
     Radio- and
                         Covered             Covered             Covered             Covered
     chemotherapy
     Psychiatric         Combined            Combined            None                None
     treatment           psychiatric limit   psychiatric limit
                         of £20,000 per      of £7,000 per
                         policy year         policy year

     OUTPATIENT CARE

     Specialist          Covered             Combined limit of   Combined limit of   Combined limit of
     consultations                           £750 per policy     £600 per policy     £600 per policy
                                             year1               year1,2             year1,4

     Diagnostic scans:   Covered             Covered             Covered             Covered4
     MRI, CT, and PET
     scans

     Diagnostic tests:   Covered             Covered             Combined limit      Combined limit
     other                                                       of £600 per         of £600 per
                                                                 policy year1        policy year1,5

     Physiotherapy       Covered             Combined limit      Combined limit      Combined limit
                                             of £750 per         of £600 per         of £600 per
                                             policy year1        policy year1,2      policy year1,5

     Chiropractic and    Limit of £800 per   Combined limit      Combined limit      Combined limit
     osteopathy          policy year         of £750 per         of £600 per         of £600 per
                                             policy year1        policy year1,2      policy year1,5

     Radio- and
                         Covered             Covered             Covered             Covered
     chemotherapy
     Psychiatric         Combined            Sub limit of        None                None
     treatment           psychiatric limit   £750 to an
                         of £20,000 per      overall combined
                         policy year         psychiatric limit
                                             of £7000 per
                                             policy year

12
                         Comprehensive                Select                 Core                 Value

    OTHER BENEFITS

    Complementary        Limit of £600 per     None                  None                  None
    and alternative      policy year
    therapies

    Childbirth cash
                         £100 per child        £100 per child        £100 per child        £100 per child
    benefit
    Home nursing         Covered               £3,000 limit per      £3,000 limit per      £3,000 limit per
                                               policy year           policy year           policy year
    Private ambulance    Covered               £60 per trip          £60 per trip          £60 per trip

    Parental             Yes (for children     Yes (for children     Yes (for children     Yes (for children
    accommodation        of 12 or under,       of 12 or under,       of 12 or under,       of 12 or under,
                         1 parent)             1 parent)             1 parent)             1 parent)

    NHS hospital cash    £100 per day          £50 per day           £50 per day           £50 per day
    benefit              (overall annual       (overall annual       (overall annual       (overall annual
                         limit of £2000)       limit of £2000)       limit of £2000)       limit of £2000)

    EXCESS
                         Option of £0,         Option of £0 or       Option of £0 or       No excess
                         £100, £250, £500      £250                  £250                  available
                         or £1000
    VITALITY
    BENEFITS

                         Full Vitality         Full Vitality         Full Vitality         Full Vitality
                         benefits              benefits              benefits              benefits

1    The combined limit means that claims for specialist consultations, diagnostic tests, physiotherapy,
     chiropractic and osteopathy all aggregate to one limit for each member on the policy.
2    Cover is restricted to treatment following and directly related to an eligible hospital admission.
     We consider treatment which falls within a maximum of six months of the eligible hospital admission to
     be directly related to the original admission. Generally any treatment after six months would not be
     considered to be directly related to the original hospital admission.
3    A co-payment of £100 applies per inpatient admission within selected hospital list.
4    A co-payment of £50 applies per interaction.
5    A co-payment of £20 applies per interaction.

Notes:

n      Specialist/consultant fees: includes surgeons’, anaesthetists' and physicians' fees whilst as an
       inpatient or day case patient
n      Diagnostic scans include CT, MRI and PET scans. These must be following consultant referral only
       and also within the member’s selected hospital list. A co-payment of 40% of the tariff will apply for
       scans undertaken outside of member’s selected hospital list.
n      Other diagnostic tests include pathology, X-rays and physiological tests such as an ECG.
n      Physiotherapy, chiropractic and osteopathy. Cover will only apply up to the number of
       authorised sessions.
                                                                                                               13
     1. Cover and benefits in detail            1.0 Hospital lists and co-payments
     We will only pay for the treatments and    The selected hospital list where the
     services as expressly laid out in the      member can be treated is specified in
     schedule on page 12, subject to the        the membership certificate and is
     conditions of cover, definitions and       available on our website. PruHealth
     exclusions detailed later in this          hospital lists may change from time to
     policy document and laid out in the        time and we recommend that the
     membership certificate. We will not pay    member check the most up-to-date
     for any other treatments or services       version on our Member Zone before
     unless we expressly agree to do so in      their treatment commences.
     writing. Please read the summary of        Our hospital lists are made up of some
     benefits in conjunction with ‘Conditions   of UK’s leading private hospital groups.
     of cover’ and ‘Exclusions’ set out over    The member's selected hospital list will
     the page. Cover is available only to       be able to provide most services which
     permanent residents of the UK and is       are available within their purchased
     for treatment in the UK, Channel Islands   benefits. If the member has any
     and the Isle of Man.                       problems finding a service they need in
     PruHealth will cover fees charged by       the selected hospital list, they should
     consultants who hold or have held an       contact us and we will help to locate a
     NHS post or equivalent and are             facility and/or consultants who provide
     registered as a specialist with the        that service. In certain circumstances
     General Medical Council. Other             this may mean they will need to travel to
     therapists must be registered with         obtain the service within the selected
     appropriate regulatory bodies. If the      hospital list and avoid a co-payment.
     proposed provider charges outside the      If the member goes to a hospital not
     PruHealth fee maximum the member           on their selected hospital list they will
     may be expected to pay the difference.     be liable to contribute up to 40% of
     This will be specified at the claim        the hospital charges relating to
     authorisation stage.                       their treatment.




14
1.1 Benefit limits                          The co-payment will be deducted
Any benefit limits stated apply for each    from the PruHealth fee maximum
person covered under the policy. These      or the tariff that we will pay in relation
limits also apply to the total of claims    to the treatment in question.
over the policy year.
                                            1.4 Out of hospital list co-payment
Where a combined limit applies it means
                                            An out of hospital list co-payment
that the cost of any treatment paid for
                                            applies for services outside of a
out of those benefits accumulates
                                            member’s selected hospital list. For an
towards the overall limit. There may be
                                            inpatient admission outside of the
sub-limits within the overall combined
                                            member’s selected hospital list a 40%
limit and the member should check the
                                            co-payment will apply to the hospital
summary of benefits in this document
                                            charges. For a diagnostic scan outside
for further detail.
                                            of the member’s selected hospital list
                                            a 40% co-payment will apply to the
1.2 Excesses
                                            hospital tariff. Under the value plan
Excesses apply per person covered           there will be no cover for the outpatient
under the policy. Excesses relate to the    diagnostic scans outside of the
total amount of claims over a policy year   member’s selected hospital list.
for an individual, not to each claim
event. Please note that after every
                                            1.5 PruHealth fee maximum
renewal a new excess will apply to
                                            If the proposed treatment cost is
each person covered.
                                            above the PruHealth fee maximum for
                                            that treatment, the member will have
1.3 Value plan co-payments
                                            to contribute the difference between
A co-payment is a set value a member        this amount and the claimed amount.
must contribute towards treatment           Alternatively, the member can choose
specified in the summary on page 12,        to have treatment with a different
for services provided within the            practitioner who charges within
member’s chosen hospital list.              the PruHealth fee maximum for
Co-payments apply per member per            that treatment.
claim event covered under the policy
and applies each time they see or
receive treatment from their medical
provider. The co-payment amount
will vary for different treatment types.

                                                                                         15
     1.6 Intensive and high                         1.7 Psychiatric care
     dependency care                                PruHealth will actively manage
                                                    psychiatric treatment in order to achieve
     Critical care
                                                    the best outcome for the member on a
     We will pay for critical care where it is
                                                    case by case basis. Please note that due
     part of the expected post-operative
                                                    to the nature of psychiatric illness it may
     management of the member and where
                                                    be that over the course of treatment, the
     the intention is to treat a disease, illness
                                                    condition will be deemed to be chronic
     or injury which is likely to respond
                                                    (see Exclusions: chronic conditions).
     quickly to treatment.
                                                    The overall psychiatric treatment limit
     We will pay for unexpected care in a
                                                    applies for both inpatient and outpatient
     private hospital providing the following
                                                    treatment or services and includes both
     conditions are met:
                                                    accommodation and treatment costs.
     n It follows an elective, non-                 The outpatient sub-limit is for outpatient
       emergency admission;                         treatment or services and accumulates
                                                    to the overall psychiatric limit.
     n It is provided in a dedicated critical
       care area; and
                                                    1.8 Rehabilitation
     n It is the most appropriate setting for
                                                    Cover is available for rehabilitation,
       such treatment
                                                    which is treatment intended to restore
     We do not pay for unexpected critical          health or mobility or return the member
     care in an NHS hospital under any              to independent living, following a stroke
     circumstances. We do not pay for any           or injury. The rehabilitation must be
     level of critical care which is not            integral to eligible inpatient treatment,
     medically necessary for the condition          should start no more than 2 months
     being treated.                                 after initial diagnosis or date of injury
                                                    and will normally be covered for 30 days
                                                    only and will be managed within our
                                                    guidelines for chronic conditions. To be
                                                    eligible a specialist should make the
                                                    referral to a rehabilitation unit.




16
1.9 Complementary and                        1.11 Nursing at home
alternative therapies                        In order to claim the nursing at home
Where covered, this category includes        benefit, such treatment must:
medical and healthcare systems and
                                             n immediately follow a period of
practices that are not presently
                                               inpatient treatment for a medical
considered to be part of conventional
                                               condition covered by the policy;
medicine. To be eligible for cover, these
therapies must be used for treatment of      n be for treatment that would
an acute condition following referral by       otherwise be provided in hospital
a GP or specialist. All practitioners must     as an inpatient;
have adequate experience and                 n be undertaken by a trained nurse;
indemnity insurance and must be                and
registered with the appropriate
authority and be a member of a               n be recommended by and carried
speciality organisation. Our list of           out under the supervision of the
criteria for entry for all providers is        member’s specialist.
available on request and on the Member
Zone. Treatment for pre-existing             1.12 Private ambulance
conditions or chronic conditions is not      Use of an ambulance is covered for
covered, nor are associated medicines        private transfers between hospitals,
and products.                                whether NHS or private. This use is
                                             limited to paid services provided by
1.10 Childbirth cash benefit                 independent companies or the NHS.
This is payable on the birth of a child to   It is limited to medically necessary
a member who has been covered by a           transfers where there is a reasonable
policy for at least nine months prior to     medical need for the action to be taken.
the birth. In order to claim the benefit     Transfers for non-medical reasons will
the member must provide PruHealth            not be covered.
with a copy of the birth certificate and
request the payment of benefit within
six months of the birth.




                                                                                        17
     1.13 Parental                                   If the member does choose to claim the
     accommodation benefit                           cash benefit, this will be recorded as a
     This benefit is paid to enable one parent       claim in the normal way and will affect the
     to stay in the same hospital as their child     calculation of the reward payable to the
     (up to and including 12 year olds) when         member on renewal (see Section 4.10b).
     the child is admitted as an inpatient to a      The member, or their representative,
     private hospital or an NHS private ward         must call PruHealth to request
     within an NHS Private Patient Unit (PPU).       authorisation for the claim in accordance
                                                     with the normal procedure (see Section
     Paediatric conditions are mainly treated        4.9b) and submit to PruHealth the NHS
     in NHS hospitals, though some private           discharge form as evidence of their
     hospitals still provide treatment. If the       treatment or hospital stay.
     child covered under the policy goes to
     an NHS hospital for treatment, the child
                                                     1.15 Cancer benefit
     is eligible for the NHS hospital cash
                                                     PruHealth will pay for treatment for all
     benefit as described in the clause below.
                                                     stages of cancer, for both cure and
                                                     palliative care, subject to our general
     1.14 NHS hospital cash benefit
                                                     terms and conditions. Radiotherapy and
     This benefit applies only to NHS day            chemotherapy are fully covered on all
     cases or stays in a general NHS ward,           plans, subject to authorisation. There
     not an NHS PPU. The NHS hospital cash           are no financial limits on inpatient and
     benefit is paid out only for conditions         outpatient cancer treatment on any plan
     that PruHealth would have covered if            and a donation is available for hospice
     treated privately under the policy.             care. Where an annual outpatient
     Consequently, this benefit wouldn’t be          benefit limit applies, consultations and
     available for a visit to Accident and           diagnostic tests directly related to
     Emergency (A&E) as A&E treatment is             cancer treatment will be fully funded.
     not covered by PruHealth. Any standard
     or personal exclusions still apply (refer       We will evaluate therapy not yet
     to Section 3).                                  considered by NICE on a case by case
                                                     basis using all currently available
     If the member is admitted to an NHS             evidence from properly controlled
     hospital for an acute event and is eligible     mature phase III clinical trials and may
     for transfer to a private hospital, they will   pay for the use of a new, licensed anti-
     be eligible for the cash benefit if they        cancer drug, or new use for a drug with
     chose not to move to a private facility.        a licensed indication where there is
                                                     credible scientific evidence to support

18
its use. Chemotherapy, radiotherapy          an evolving range of offers. The
and surgery for the treatment of cancer      programme promotes members’ health
will be covered provided it follows          and reduces the likelihood of their need
guidance issued by the National              to make a claim on the policy.
Institute for Health and Clinical
                                             i) Vitality status
Excellence (NICE).
                                             There are 4 statuses, Bronze, Silver,
Appropriate bone marrow or stem cell
                                             Gold and Platinum. A member's Vitality
transplants are also covered.
                                             status is determined by the recorded
No time limits are placed on treatment       efforts that the member makes with
and follow up care for cancer provided       Vitality during a policy year. On renewal
cover is continuous and while you are        of the policy, a member maintains their
eligible for benefits. Rules covering        Vitality status based on the points
chronic conditions do not apply to cancer.   earned during the year until the next
                                             policy renewal or until the member
A donation is available for hospice care.
                                             improves it.
PruHealth will not pay for complementary
                                             Every member starts at Bronze level
and alternative therapies as the primary
                                             when the policy commences.
treatment for cancer as part of the cancer
benefit. However, we will pay for            Vitality status can go down following
complementary and alternative therapy        renewal if the number of Vitality points
as part of the Complementary and             required to maintain the status is not
Alternative Therapies benefit. (See          achieved.
section 1.9).
                                             Vitality status can change midway
                                             through the policy year as new adult
1.16 Vitality
                                             dependants are added or removed.
This is our dynamic programme in which
members can engage in a wide selection       ii) Vitality commitment
of health-promoting activities and be        The Vitality programme evolves to give
awarded points which move them               our members the advantage of new
through different statuses, each of          opportunities and technologies as they
which has a published threshold based        arise. It grows from our relationship with
on the number of adults on the policy.       third party providers and depends on
While higher statuses entitle members        the range of services they offer. We
to higher value rewards, all members         actively revise the ways in which points
have the opportunity to participate in       can be earned and rewarded.

                                                                                          19
     Specifically, we may change the               equal to the change in the Consumer
     methodology for awarding points               Price Index (since our last price increase
     or eligible activities in the Vitality        for that benefit) as calculated against the
     programme and the Vitality status             Bronze price (or the price paid by all
     the member may achieve as a result.           members if there is no difference in
     We may also change our Vitality               price according to Vitality status).
     partners from time to time and the            For example, if the Bronze price (or
     incentives we offer. There may be             standard price, if applicable) for a
     instances where other aspects of the          particular benefit is £100, and CPI
     Vitality programme, such as particular        increases 3%, the maximum price
     benefits, may be significantly enhanced,      increase for any vitality status shall be
     changed or withdrawn.                         £3. Therefore, if the Platinum price for
     The revisions may occur if our Vitality       that particular benefit is £10, the most
     partners offer additional services or         the Platinum member would pay is £13.
     become unable to maintain their levels        The cost of Vitality benefits calculated as
     of service to us, or where we add new         a percentage discount to a retailer’s
     Vitality partners to the programme.           standard price may vary during the year
     Vitality revisions may also be required to    if that retailer changes its standard price.
     prevent the fraudulent use of benefits.       For example, the discount on a Boots
     Revisions may be required as a result of      health screen is 50%. The current
     other factors beyond our control.             standard price is £40, so the cost to
     Vitality benefits are calculated in one       members is currently £20. If Boots were
     of two ways: as a fixed price, or as a        to reduce the standard price to £30, the
     percentage discount by reference to           cost to members would be £15. If the
     the standard retail rate.                     standard price was increased to £50, the
                                                   cost to members would be £25.
     We reserve the right to increase the cost
     of fixed price Vitality benefits during the   Any changes to the Vitality programme,
     policy year. If we do need to increase        including the prices of fixed price Vitality
     these prices, we will increase them           benefits, will be communicated to you at
     for all our members at the same time,         least 42 days before the changes take
     to avoid any confusion. Such price            effect, unless this is made impossible by
     increases, if made, will only occur once      factors outside our control. If the
     during a policy year and take effect          policyholder is unsatisfied with the
     either on 1 January or 1 July. No such        changes they may cancel the policy in
     price increase shall exceed the amount        accordance with the cancellation

20
provisions in section 4.8 below. Members        being applied and claims being declined
will still be subject to the notice period of   or any sums already paid out on the
any relevant Vitality partner, and to any       member’s behalf being recovered by
applicable terms and conditions relevant        PruHealth. If the member has any
to that Vitality partner.                       doubts about such disclosure they
                                                should call our Customer Services Team
For the avoidance of doubt, please note
                                                on 0800 092 7333.
that this clause refers to changes to the
Vitality programme made within the
                                                2.2 Moratorium Underwriting
policy year and does not prevent
PruHealth from applying changes and             Under “moratorium underwriting”,
price increases at renewal following the        conditions which existed up to five
expiry of a policy year.                        years before the date of the start of
                                                cover will not be explicitly identified
                                                but may be excluded from cover
2. Underwriting                                 for two years from the date
                                                of commencement.
2.1 Full Medical Underwriting
Under “full medical underwriting” a             We will exclude cover for treatment
member will have made a declaration             for any medical condition or related
regarding their medical history. Pre-           condition which the member or their
existing conditions will be identified          covered dependants have had
from that declaration and exclusions            symptoms of, whether diagnosed
applied to the policy. The member can           or not, been aware of or sought advice
request that these exclusions are               on or received medical treatment for in
reviewed at renewal. These may be               the five years before the start of cover.
removed at the underwriters' discretion.        PruHealth will in most cases request
PruHealth may request further                   further information when a claim is
information when a claim is being made          being made to establish whether the
to establish any relationship to a pre-         condition is pre-existing and thereby
existing condition and/or to check that         excluded by the moratorium clause.
the condition was disclosed on the
medical declaration. It is the
responsibility of the member to disclose
any pre-existing conditions to PruHealth
upon joining the policy and failure to do
so may result in personal exclusions

                                                                                            21
     2.3 Switch/CPME Underwriting                  However, acute complications related to
     Where this option is selected, only pre-      chronic conditions will be covered
     existing conditions excluded by the           subject to the member’s policy unless
     previous provider’s policy will be            a specific exclusion relating to that
     excluded from cover. PruHealth may            condition has been applied.
     request further information when a            Consultations leading up to the
     claim is being made to establish any          diagnosis of a chronic condition will be
     relationship to a pre-existing condition      covered. Many chronic illnesses are of a
     and/or to check eligibility of the transfer   relapsing and remitting nature e.g.
     against the declaration signed.               multiple sclerosis. The relapses are part
     Complications or increased treatment          of the normal illness course and
     costs as a result of an excluded pre-         therefore cannot be classed as acute
     existing condition will not be covered.       complications of the disease.

                                                   3.3 Complications of any treatment
     3. Exclusions
                                                   not approved by PruHealth
     The following conditions and healthcare
                                                   This relates to unproven or
     services are not covered by PruHealth
                                                   unregistered treatment or treatment
     under this policy. In addition, any
                                                   received whilst overseas. This also
     consultations, complications or
                                                   refers to increased treatment costs
     subsequent treatment related to these
                                                   incurred for a disease, illness or injury
     exclusions are also not covered.
                                                   which is ineligible for cover or for
                                                   which cover has been excluded.
     3.1 Accident and Emergency care
     This includes all immediate care until        3.4 Cosmetic treatment
     stabilisation has been achieved.              Any treatment primarily for cosmetic
                                                   reasons or resulting from previous
     3.2 Chronic conditions                        cosmetic treatment is excluded,
     Any day-to-day monitoring and therapy         even if the request is psychologically
     of chronic conditions is excluded from        motivated. Breast reduction or
     cover. This includes consultations            augmentation operations are excluded,
     by any healthcare professionals,              whether or not for back pain. Treatment
     medication, investigations (blood tests,      which involves the removal of healthy
     radiology) etc. Examples of chronic           tissue or the removal of surplus or fat
     conditions include diabetes and asthma.       tissue is also excluded.

22
Exceptions to this exclusion:                Surgical procedures performed by a
Post-traumatic or post-surgical              consultant oral or maxillofacial surgeon
reconstruction to restore function or        will be assessed for eligibility when
appearance is included if performed          treating an acute medical condition
within 12 months of major injury or          for example:
primary surgery.                             n re-implantation of the member’s
We will pay for the initial reconstructive     own teeth following trauma;
surgery to restore function and              n elective reduction of facial and
appearance following cancer treatment.         mandibular fractures following
Any subsequent related treatment will          recent trauma;
only be covered if it is intended to cure
                                             n surgical removal of impacted teeth,
an acute medical condition.
                                               buried teeth and complicated buried
                                               roots;
3.5 Deafness
We will not cover any treatment for          n surgical drainage of a fascial space
deafness that arises as a result of any        (tracking) abscess;
congenital abnormality, maturity or          n removal of cysts of the jaw; and
ageing. We will only pay for treatment
                                             n apicectomy.
for deafness that arises as a result of an
acute medical condition.
                                             We do not cover:
3.6 Dentistry                                n orthognathic surgery for functional
                                               (eating and speech) or aesthetic
This includes any general conservative
                                               reasons; or
dental procedures, e.g. simple
extractions, restorations, root canal        n procedures to prepare for
treatment, implants, crowns, veneers,          orthodontics or prosthetic surgery.
bridges and dentures including
periodontal or orthodontic treatment are
excluded. Minor enamel, dentine and
incisal edge fractures restored through
conservative means are also not covered.




                                                                                        23
     3.7 Experimental, unproven or                3.10 Gender re-assignment
     unregistered treatment or practices          operations or any related medical
     This includes those that are not             or surgical treatment
     considered to be established UK
                                                  3.11 General practitioner
     medical practice or for which there is
                                                  consultations or visits
     insufficient evidence of safety or
     effectiveness e.g. not having been
                                                  3.12 Healthcare services related to:
     reviewed and approved for general use
                                                  n Alcohol, drug or solvent abuse
     in the NHS by the National Institute for
     Health and Clinical Excellence (NICE).       n Wilfully self-inflicted illness or injury;
     Experimental treatment may be                  including treatment related to
     considered for cover if it is conducted in     attempted suicide
     a properly controlled clinical trial.
                                                  n Injuries sustained during
                                                    participation in professional or
     3.8 Fertility and hormone-related              semi-professional sports
     treatment
                                                  n Injuries sustained in a road traffic
     Assisted reproductive therapy and other
                                                    accident where a seat belt has not
     treatments related to infertility and
                                                    been worn
     sterilisation are excluded.
                                                  n Injuries sustained during
     Treatment of physiological or natural
                                                    participation in a wilful violation
     changes as a result of ageing e.g.
                                                    of the law
     menopause or puberty and hormone
     replacement therapy is also excluded.        n Injuries sustained during war,
                                                    terrorist activity, riot, civil
     3.9 Frail care                                 commotion, rebellion or insurrection

     This refers to, for example, care            n Any exclusion. This includes any
     received in convalescence and nursing          consultations and other services
     homes, respite care, and domestic              related to these exclusions.
     support that does not require a
     trained practitioner.




24
3.13 Medication and dressings                 3.18 Refractive eye surgery
Except when administered for use              and optometry
during hospital admissions, medicines         This is surgical treatment to correct long
or outpatient dressings provided or           or short sightedness, astigmatism, or
prescribed to take home are not covered.      any other refractive error, including
                                              accommodating lenses following
3.14 Organ transplants                        cataract surgery.

3.15 Overseas treatment                       3.19 Retention of disposable and
All treatment provided outside the            durable medical devices and
UK is excluded.                               equipment
                                              The cost of medical devices and
3.16 Pregnancy and childbirth                 equipment is not covered. Examples of
Treatment directly or indirectly arising      exclusions are bandages and dressings,
from or required as a result of               unless part of inpatient and day case
pregnancy, childbirth or infertility is not   treatment, wheelchairs, crutches,
covered except for ectopic pregnancy,         glasses and contact lenses, external
hydatidiform mole, post partum                prostheses, orthotics and hearing aids.
haemorrhage, miscarriage, retained
                                              Consultations related to these are not
placenta or stillbirth.
                                              covered.

3.17 Preventative treatment
                                              3.20 Routine check-ups
(and regular checks)
                                              Visits to a doctor where there is no
This includes sight tests, regular
                                              specific medical complaint are excluded
monitoring of, for example, cholesterol
                                              from cover e.g. visits to get prescriptions,
levels, and screening for early detection
                                              blood pressure checks etc.
of diseases such as diabetes, cancer etc.
The removal of healthy tissue for
                                              3.21 Treatment for obesity
prevention of disease is excluded as is
genetic testing of any type.                  We do not pay for treatment for obesity,
                                              including surgery for obesity.




                                                                                             25
     3.22 Treatment related to                      4.3 Cooling off
     developmental problems, learning               The member has 30 days in which to
     difficulties, or delayed speech                change their mind.
     disorders
                                                    They should notify PruHealth within
     For example, dyslexia, Attention Deficit
                                                    those 30 days that they do not want
     Hyperactivity Disorder (ADHD), etc.
                                                    their cover to continue. The 30 days
                                                    starts from the later of the following:
     4. Policy terms and
     conditions, general conditions,                a) the start date of the cover of the
     policy administration                             policy; or

                                                    b) receipt of the policy documentation
     4.1 Compliance with policy terms
                                                    Please contact PruHealth customer
     PruHealth’s liability under this policy will
                                                    services on 0800 434 6510.
     be conditional upon the policyholder
     and each insured member complying              During this period, a full refund of any
     with its terms and conditions and not          premiums paid less any claims is
     having misled PruHealth by                     available. Any excess of claims made
     misstatement or concealment, either            over premiums paid will be recoverable
     knowingly or unknowingly.                      by PruHealth from the policyholder and
                                                    any outstanding claims will be
     4.2 Policy duration                            cancelled. There will be no refund in
     The policy will run for one year from the      respect of any Vitality activities or points
     start date of cover until the renewal date     earned under a cancelled policy.
     and is therefore a one year contract (this     Cooling off provisions for any gym
     is defined as the “policy year”).              membership or other PruHealth Vitality
                                                    partner depends on the terms and
                                                    conditions of the Vitality partner.




26
During the policy year                        4.5 Change of risk
4.4 Amounts due to PruHealth                  Standard premium rate changes will
This includes, but is not limited to health   take effect at the end of each policy
insurance and Vitality benefit premiums       year. PruHealth reserves the right to
and policy excesses owed by the               apply plan and premium changes
policyholder or member. Premiums              during the policy year when the
include any Insurance Premium Tax             following have occurred:
(IPT) that is payable on the cover            n addition or removal of a dependant
provided, as well as other taxes, levies        or partner;
or charges that may be introduced
                                              n correction of an error that produces
which are payable by law.
                                                a change in the premium billed e.g.
Settlement is required within 30 days           correction in date of birth; or
of the date payment is due in order for
                                              n any other material changes in the
cover to be maintained. Failure to settle
                                                information or membership given as
within 30 days will result in a temporary
                                                part of the application for cover
hold being placed on the policy with the
                                                under this policy (note, this excludes
authorisation and payment of all claims
                                                underwriting information).
being suspended.

PruHealth reserves the right to cancel        4.6 Membership additions,
the policy after 30 days of payment not       withdrawals or other changes
being received. PruHealth reserves the        Dependants or partners can be added to
right to use a debt collection agency for     the policy throughout the policy year on
the collection of any unpaid amounts.         the same underwriting terms as the
If the member cancels the policy under        policyholder. If they cannot satisfy the
the terms of section 4.8 of this policy       eligibility for that underwriting type
document, they should be aware                they will be asked to select another
that premiums are billed in arrears           underwriting option. PruHealth will
and they may therefore be liable for          allow a maximum of 8 children to be
further premiums.                             added to the policy.




                                                                                         27
     Should changes be made to the policy           4.7 Changes during the year
     with an effective date prior to the            There will be no change in premiums
     requested date the policyholder will be        during the policy year unless prompted
     liable for the outstanding amount from         by a change covered in section 4.5 or
     the effective date which will be included      4.6 above.
     in the subsequent bill.
                                                    Subject to the above, PruHealth may
     New dependants or partners will be             vary the other terms and conditions
     entitled to the full amounts of benefit        of the policy during the policy year.
     limits regardless of the time of year they     PruHealth shall notify the policyholder
     joined. They can then participate in           in writing identifying any variations in
     Vitality activities and earn Vitality points   the terms and conditions at least 28 days
     up to the renewal of the policy. New           before the variations take effect. If the
     adult dependants or partners will alter        policyholder does not wish to accept the
     the Vitality status thresholds.                variations, the member can cancel the
     Dependants or partners can be                  policy within the 28 days without any
     withdrawn from the policy throughout           further liability to PruHealth.
     the policy year. PruHealth must be             Members may still be subject to the
     notified no less than 30 days in advance       notice period of any relevant Vitality
     of the termination.                            partner. Please note that alterations to
     Any member who leaves the policy               terms and conditions relating to Vitality
     before the end of the policy year will         partners, or charges due from members
     not be entitled to any pro rata share of       to access a particular Vitality benefit, do
     benefits they may have earned during           not form part of the policy terms and
     that policy year in respect of low claims      conditions and so do not fall under the
     or Vitality status. All of a member’s          scope of this term.
     Vitality benefits will cease when their
     cover ceases subject to the notice
     period of the relevant Vitality partner.
     All Vitality points earned by the member
     will be removed from the policy and
     thresholds will be adjusted accordingly.

     To make changes to your policy
     contact Customer Service Team on
     0800 092 7333.


28
4.8 Cancellation                                  of any month in order for the
a) Rights to cancel                               cancellation to be effective at the
                                                  end their policy month. If they
n (i) The policyholder is free to cancel          fail to cancel by the end of their
      the policy during the term by               policy month (for example if they
      giving notice in accordance with            called on 15th of that month),
      the terms of this section.                  they would be liable to pay a
n (ii) PruHealth may only cancel                  further monthly premium and the
       the policy during the term                 policy would be effective until
       if the policyholder fails, as              the 14th of the following month.
       detailed in this section, to        n (iii) The policyholder shall remain
       meet their obligations.                     liable for any premium payments
b) How to cancel                                   due in respect of all cover in
                                                   the periods prior to the
n (i) The policy may be cancelled with             Cancellation Point.
      effect from the end of any policy
                                           n (iv) The policyholder will remain
      month (the “Cancellation Point”).
      For example, if you joined                  liable for all payments due under
      PruHealth on the 15th of any                the policy until they instruct
      month, your policy month will               PruHealth directly (either by
      end on the 14th of the following            telephone or by writing) to cancel
      month and the months                        in accordance with this section, or
      thereafter. Please note that the            until PruHealth itself cancels the
      15th of the month is only an                policy as outlined below.
      example and you will need to
      check the date you joined
      PruHealth to calculate the
      end of your policy month.
n (ii) To cancel, the policyholder must
       contact PruHealth Customer
       Services on 0800 434 6510.
       This must be before their chosen
       Cancellation Point. Therefore,
       if they joined PruHealth on 15th
       January, they would need to call
       PruHealth no later than the 14th


                                                                                        29
     n (v) The policyholder cannot cancel        d) When PruHealth may cancel
           the policy by instructing their
                                                 n (i) PruHealth reserves the right to
           bank to cancel any applicable
                                                       cancel the policy if the
           direct debit, or by otherwise
                                                       policyholder fails to pay any due
           failing to pay any sum due, or by
                                                       sum on its payment date. Except
           failing to observe any of the terms
           and conditions of this policy.              as provided in paragraph 4.8(d)
                                                       (ii) & (iii), PruHealth will first give
     c) Effect of cancellation                         the policyholder notice that the
     n (i) The policy will end on the                  policy is suspended for one
                                                       month until the next payment
           Cancellation Date. For the
                                                       date. During such a period
           avoidance of doubt, the
                                                       PruHealth reserves the right to
           membership of all members
                                                       make no authorisations or
           will end with the policy,
                                                       payments under the policy. If,
           including the membership of
                                                       after that second payment date,
           the policyholder’s dependants.
                                                       any sums remain due, PruHealth
     n (ii) PruHealth shall not make any               will cancel the suspended policy,
            payment for treatment which is             and reserves the right to recover
            provided after the Cancellation            any outstanding sums (which, for
            Point, irrespective of whether it          the avoidance of doubt, shall not
            has been previously authorised.            include any additional premium
            Nevertheless, prior to the                 in respect of the suspended
            Cancellation Date claims may               month). Nevertheless, if any
            continue to be authorised and
                                                       outstanding sums are paid on or
            treatment provided and paid
                                                       before that second payment
            for, regardless of whether the
                                                       date, PruHealth may, at its
            policyholder has already given
                                                       discretion, reinstate the
            notice to cancel the policy.
                                                       suspended policy.




30
n (ii) If the policyholder instructs its     4.9 Claims
       bank to cancel their direct debits,   The procedure for members to follow in
       once PruHealth has received           making a claim is laid out in section 4.9b:
       notice of the direct debit
       cancellation from the bank,           a) Referral
       PruHealth will cancel the policy
                                             The member will need to be referred
       at the end of the policyholder’s
                                             by a general practitioner (GP) for a
       next policy month (“the
                                             specialist consultation or other
       Cancellation Point”). PruHealth
                                             outpatient treatment, except for
       reserves the right to recover any
                                             diagnostic scans where they need to
       unpaid premiums up until the
                                             be referred by a specialist, for that
       Cancellation Point.
                                             treatment or consultation to be covered.
n (iii) PruHealth may immediately            They will need to be referred by a
        cancel this policy or terminate an   specialist for admission to hospital in
        insured person’s cover or subject    order for treatment at that hospital to
        the cover to different terms (with   be covered.
        retrospective effect where
        appropriate) if the policyholder     b) Authorisation
        or a member has at any time:
                                             The member must call PruHealth or
       n misled PruHealth by                 go online for authorisation before any
         misstatement or                     treatment including consultations,
         concealment, whether                outpatient, day case or inpatient
         or not done knowingly;              treatment to check:

       n agreed to, assisted or              n That the intended treatment date
         concealed any attempt                 falls within the member's period
         by a third party to defraud           of cover;
         PruHealth; or
                                             n That the member is eligible for cover
       n otherwise failed to observe           for the treatment (diagnosis and
         the terms and conditions with         treatment details will be clinically
         PruHealth.                            assessed);
                                             n Whether any pre-existing conditions
                                               or other exclusions apply. PruHealth
                                               may request medical information
                                               from a GP/specialist to confirm the
                                               history and status of the condition
                                               as part of the authorisation process;
                                                                                           31
     n That the specialist or therapist is        Where the member pays fees or
       recognised by PruHealth or that the        charges, claims for reimbursement
       conditions specified in Section 1          should be submitted within 6 months
       are satisfied;                             of the treatment date to be eligible.
     n That the specialist’s fees are covered     Where the member does not obtain
       by the member's plan, if the               authorisation from PruHealth before
       specialist’s fee are higher than           being treated, they may be liable to pay
       PruHealth’s fee maxima, the member         all or part of the costs of treatment.
       will be responsible for the difference;
       and                                        We are not always able to confirm at
                                                  the time of authorisations whether or
     n That the costs of the facility to which    not total benefit limits have been
       the member is to be admitted,              exceeded. It is therefore possible that
       e.g. a hospital or day clinic, are fully   other claims submitted by a member
       covered. All authorisation requests        will have caused their benefit limits to
       are reviewed against PruHealth’s
                                                  be exceeded. In such circumstances,
       clinical protocols.
                                                  any treatment costs over and above
     The member should have to hand:              the benefit limits will not be covered.

     n the details of their condition and
                                                  c) Third party claims
       intended treatment;
                                                  The member must, without delay, give
     n their GP contact details; and              PruHealth written notification of any
     n the details of the relevant specialist     claim or right of action against any third
                                                  party for any circumstances which gave
       or therapist i.e. full name, phone
       number, number and postcode.               rise to the claim under this policy, for
                                                  example, if a member claims for
     For hospital admissions, the member will     treatment following a car accident where
     be given an authorisation number and         the third party may have been at fault.
     target length of stay, which the hospital    If the member decides to pursue a third
     will require.                                party for damages, the member must
                                                  continue to keep PruHealth fully
                                                  informed in writing and take all steps
                                                  PruHealth reasonably requires in making
                                                  a claim against the third party, which may
                                                  include recovery of PruHealth’s outlay.



32
If the member fails to inform PruHealth       4.10 Renewal
of a third party claim, and makes a
                                              a) Plan, premium changes
recovery (which includes any settlement
made) without including PruHealth’s           i) Except for the changes listed in
outlay, PruHealth reserves the right to       section 4.5, plan and premium changes
recover its outlay and any sums due           will take effect only at the end of the
from the member.                              policy year. Plan changes may be
                                              subject to underwriting requirements.
PruHealth shall be entitled to initiate
proceedings in a member’s name for            ii) PruHealth reserves the right to
recovery of its outlay or any sums due        decline a plan upgrade based on the
under this policy. PruHealth shall have       claims experience of the policyholder or
full discretion in the conduct of any such    a dependant or partner in respect of the
proceedings and in the settlement of          risk of the policy.
any such claim.                               iii) PruHealth will automatically renew
                                              the policy unless there has been
d) Prevention of fraud
                                              fraudulent activity or the policyholder
If any claim under this policy is in any      or policy dependants have misled
respect fraudulent or unfounded, all          PruHealth in any way. PruHealth will
benefit paid or due in respect of that        not decline renewal based on claims
claim will be forfeited and recoverable.      experience alone. Where a plan is
Failure to disclose material information      discontinued, PruHealth will move the
could result in the policy being cancelled.   member to the closest available
PruHealth also reserves the right to take     alternative.
appropriate legal action and/or refer the
matter to the police to seek criminal         b) Policy renewal
prosecution. Information relating to such     At the end of the policy year PruHealth
matters may be disclosed to others with a     may elect to offer to the policyholder
view to preventing fraudulent or              renewal of the policy, possibly on
improper claims.                              altered terms to those in force, for
                                              example with different cover offered or
                                              different premiums charged based on
                                              age, medical inflation and claims
                                              experience. PruHealth will send out a
                                              renewal notice detailing the terms of
                                              renewal at least one month before the


                                                                                         33
     end of the policy year. In the unlikely      The Vitality renewal reward will be
     event that the policyholder does not         based on a combination of the Vitality
     receive these terms at least one month       status and the monthly premium paid
     before the end of the policy year they       in the policy period.
     should notify customer services or
                                                  Should the policy premium have
     contact their adviser.
                                                  changed over the policy year an average
     Acceptance by the policyholder of the        will be calculated.
     renewal terms made available in this
                                                  The Vitality renewal reward can be
     way to the policyholders and members
                                                  paid as a tax-free cash lump sum or
     will be assumed unless PruHealth is
                                                  as a discount off the new policy year
     informed otherwise by the policyholder.
                                                  premium. The cash lump sum is payable
     At policy renewal, PruHealth will            only after renewal.
     allocate a no claims discount per policy
     based on claims made during the policy       The member will need to select
     year. The full twelve months of the          between a premium discount or a cash
     policy year will be reviewed. Where late     lump sum. Selection must be made
     claims are received and not taken into       within the given selection period and by
     account these will be added into the         the time this closes. If no selection is
     following renewal calculation. Claims        made the reward will fall away. The
     made by any member(s) on the policy          simplest way of making a selection
     will be taken into account.                  will be via our secure online facility.

     Any claims made with an open                 The member has 30 days after their
     authorisation for a date within the policy   renewal date in which to change their
     year will be deemed to be a claim and        mind. They should notify PruHealth
     be included for that policy year. The        within those 30 days that they do not
     no claims discount will be increased by      want their cover to continue.
     5% for each year the member does
                                                  During this period, if any claims are paid
     not claim to a maximum of 35%. It will
                                                  in respect of treatment during this
     decrease by 10% if a claim is made in
                                                  period, the member will be liable for
     the policy year.
                                                  their full premium up to the end of their
     The Vitality renewal reward will also be     policy month. The member will only be
     calculated based on a policy’s attained      able to withdraw at the start of the next
     Vitality status in the policy year. The      policy month. There will be no refund in
     Vitality status will be based on Vitality    respect of any Vitality activities or Vitality
     points earned during the policy year.        points earned under a cancelled policy.
34
4.11 Other insurance                           Treatment authorised while the policy is
If there is any other insurance covering       active and takes place after termination
                                               of the policy will not be covered.
any of the same benefits insured under
this policy, the policyholder must             Any advice, conversations, e-mails,
disclose this to PruHealth and PruHealth       leaflets, letters or similar communications
shall not be liable to pay or contribute       received by the policyholder or any
more than PruHealth’s proportionate            member in relation to the cover do not
share between the insuring parties.            form part of this policy. This is without
                                               prejudice to our rights in respect of
                                               declarations made by the policyholder or
4.12 Liability for treatment
                                               member in their completed application
Our liability under this policy is limited     form for this policy.
to the liability to pay for treatment or
                                               PruHealth makes use of Vitality partners
services in respect of claims qualifying
                                               to offer services and activities relating
for cover under this policy, in
                                               to the Vitality programme. While these
accordance with the ‘Conditions of
                                               companies are carefully selected,
cover’ and the ‘Exclusions’ set out            PruHealth cannot be held liable for any
above. The choice of provider of the           loss or harm resulting to the member
treatment or services (“provider”) is the      arising from any act or omission on the
responsibility of the member claiming          part of a Vitality partner, or as a result
under this policy. We make no                  of using any service or product provided
representations or recommendations to          by a Vitality partner.
any member regarding the availability
and standard of any treatment or               5. Complaints
services offered or provided to the
member by any provider.                        5.1 Making a complaint
                                               We hope the member never needs to
We will not be held liable to any member
                                               complain, but if they do, they must
for any loss, harm or damage of any            please write to us at:
description resulting from lack of
                                               PruHealth Customer Services
availability or from a defect in the quality
                                               Stirling FK9 4UE
of any treatment or service offered or
provided by such provider. This policy         If we cannot settle their complaint they
represents the whole and only agreement        may be entitled to refer it to the
between the policyholder and PruHealth         Financial Ombudsman Service.
relating to the provision of PMI cover.
                                                                                             35
     5.2 Our complaints process                   Website: www.financial-
     We want to deal with concerns fairly,        ombudsman.org.uk
     effectively and promptly. However,
     some complaints are more complex             5.4 Compensation
     than others and may take some time to        The policyholder or a member may have
     investigate. We will keep the member         a right to compensation if PruHealth or
     informed of the progress made to             another authority decides that the
     resolve the complaint.                       policyholder has bought a plan in which
                                                  the information provided by PruHealth
     If we have not resolved a member’s
                                                  was incorrect or misleading and resulted
     complaint within 8 weeks of receiving
                                                  in financial loss.
     it we will send the member a letter
     explaining why the complaint has not         Please contact PruHealth’s Customer
     been resolved and confirming when            Services office for more information.
     we will make contact again. We will also
                                                  If PruHealth is unable to meet its
     send the member details of their right
                                                  financial obligations in full the
     to refer the complaint to the Financial
                                                  policyholder or the members may
     Ombudsman Service, if eligible to do this.
                                                  be entitled to help from the Financial
     Our complaints process is available          Services Compensation Scheme.
     on request, by contacting us on              The limit applicable for an eligible
     0800 096 6322.                               claimant is 90% of the claim.

                                                  Further information is available by
     5.3 Escalation of complaints
                                                  contacting them at:
     If a member is not satisfied with
     PruHealth’s response they may then be        Financial Services
     eligible to take their complaint to the      Compensation Scheme
     Financial Ombudsman Service by               7th floor, Lloyds Chambers
     contacting them at:                          Portsoken Street
     The Financial Ombudsman Service              London E1 8BN
     South Quay Plaza                             Telephone: 020 7892 7300 or
     Marsh Wall                                   0800 678 1100
     London E14 9SR
                                                  Email: enquiries@fscs.org.uk Website:
     Telephone: 0845 080 1800                     www.fscs.org.uk
     Email: complaint.info@financial-
     ombudsman.org.uk
36
6. Law and interpretation                   8.1 Acute condition
                                            A disease, illness or injury that is likely
6.1 This policy will be governed by         to respond quickly to treatment which
and construed in accordance with the        aims to return you to the state of health
laws of England and Wales and will          they were in immediately before
be subject to the exclusive jurisdiction    suffering the disease, illness or injury,
of the English Courts.                      or which leads to their recovery. We
                                            consider that an acute condition would
6.2 The schedule and paragraph
                                            resolve within three months or less.
headings are for convenience only
and do not form part of the policy itself   Treatment of an acute condition should
nor do they affect its construction.        be intended to deal with the underlying
                                            condition rather than provide temporary
6.3 A person who is not party to this       relief of symptoms.
contract has no right under the
Contracts (Rights of Third Parties) Act     8.2 Admission
1999 to enforce any terms of this policy.
                                            The interval between the time a member
In addition to the policyholder,
                                            enters a hospital ward as a day case or
members covered by the policy are
                                            for an overnight stay until the time they
considered to be parties to this policy.
                                            are discharged. This does not include
                                            an admission to an Accident and
7. Currency                                 Emergency department/ward nor
Every payment to PruHealth or by            an outpatient attendance.
PruHealth under this policy shall be
payable in the lawful currency of the       8.3 Cancer
United Kingdom.
                                            A malignant tumour, tissues or cells,
                                            characterised by the uncontrolled
8. Glossary of definitions                  growth and spread of malignant cells
Words and phrases printed in italics in     and invasion of tissue.
this policy document have the meanings
set out below. The following are
standard definitions of common PMI
terms and some specific to PruHealth:




                                                                                          37
     8.4 Chronic condition                         are those which purport to offer
     A disease, illness or injury, which has at    diagnostic and therapeutic alternatives
     least one of the following                    to conventional medicine.
     characteristics:
                                                   8.7 Combined limits
     a) Continues indefinitely and has no
                                                   Claims for specialist consultations,
     known cure;
                                                   diagnostic tests, chiropractors,
     b) It comes back or is likely to come         osteopaths and physiotherapists all
     back;                                         aggregate to one limit, for each member
                                                   of the family.
     c) It is permanent;

     d) Means the member needs to be               8.8 Critical care
     rehabilitated or specially trained to cope    Any care given in an Intensive Care
     with it; or                                   Unit, Intensive Therapy Unit, Coronary
                                                   Care Unit, High Dependency Unit,
     e) Needs long-term monitoring,
                                                   Paediatric Intensive Care Unit, Neonatal
     consultations, checkups, examinations
                                                   Intensive Care Unit, Special Care Baby
     or tests.
                                                   Unit or similar level of care is considered
                                                   to be critical care.
     8.5 Children
     a) The term “children” incorporates           8.9 Day case treatment
     biological and adopted children as well
                                                   Treatment which means the member has
     as children under guardianship. The
                                                   to be admitted to hospital or a day case
     main criterion is that they are financially   unit because they need a period of
     dependent on the principal member             clinically supervised recovery but do not
     taking out the policy                         have to stay overnight.
     b) Children can remain on the policy
     until the age of 21 years, or 24 years        8.10 Diagnostic tests
     if in full time education.                    Investigations, such as x-rays or blood
                                                   tests, to find or to help find the cause of
     8.6 Complementary therapy                     your symptoms.
     Complementary disciplines are those
     which usually, if not invariably,
     complement conventional medical
     treatment, whilst alternative disciplines

38
8.11 Ectopic pregnancy                       8.16 Hospital charges
An abnormal pregnancy where the              The portion of total fees paid by
fertilised egg attaches itself outside the   PruHealth for a member’s treatment
cavity of the uterus.                        (whether inpatient or outpatient) that
                                             relates to costs incurred by the hospital.
8.12 Eligible treatment                      This includes, but is not limited to,
Treatment of an acute condition together     accommodation, meals, drugs and
with the products and equipment used         surgical dressings, nursing care,
as part of the treatment that:               operating costs, eligible intensive and
                                             high dependency care, physiotherapy
n is consistent with generally accepted      and any prosthesis used during an
  standards of medical practice and          operation.
  representative of best practices in
  the medical profession in the UK;
                                             8.17 Hydatidiform mole
n is clinically appropriate in terms of      A tumour in the placenta that occurs in
  type, frequency, extent duration and       early pregnancy.
  the facility or location where the
  services are provided; and                 8.18 Inpatient
n is demonstrated through scientific         A patient who is admitted to hospital
  evidence to be effective in                and who occupies a bed overnight or
  improving health outcomes.                 longer, for medical reasons.

8.13 Excess                                  8.19 Interaction
The amount of money a member must            A visit by a member to their healthcare
contribute towards any treatment they        provider
have in a policy year.
                                             8.20 Member
8.14 Family membership                       Refers to the people including the
A family membership covers two adult         policyholder who are covered under
members or more.                             the policy. It may also include the
                                             partner and any dependant members
8.15 General NHS ward                        who are covered.
This is a ward within an NHS hospital
where there is generally no charge for
the bed.

                                                                                          39
     8.21 Miscarriage                           8.26 Participation in professional
     Loss of a pregnancy under 24 weeks’        or semi-professional sports
     gestation.                                 Taking part (including part-time
                                                participation) in a sporting activity
     8.22 Nurse                                 as a means of livelihood or for direct
     A qualified nurse who is on the register   financial gain.
     of the Nursing and Midwifery Council
     (NMC) and holds a valid NMC personal       8.27 PMI
     identification number.                     Refers to private medical insurance

     8.23 Outpatient                            8.28 Policy
     A patient who attends a hospital,          The PruHealth contract of insurance
     consulting room, or outpatient clinic      to provide PMI cover for members,
     and is not admitted as a day patient       as detailed in this document.
     or an inpatient.
                                                8.29 Policyholder
     8.24 Out of hospital list                  Refers to the person taking out
     co-payment                                 this policy.
     Where treatment is received outside
     of the designated hospital list, a         8.30 Post partum haemorrhage
     percentage co-payment may apply            Loss of over 500ml of blood from the
     to the hospital charges.                   genital tract within 24 hours of delivery.

     8.25 Palliative care                       8.31 PPU
     Holistic therapy aimed to relieve or       Private patients unit. These can be
     reduce the symptoms of those with          separate wings or wards within an
     advanced cancer but not to produce         NHS hospital.
     a cure.




40
8.32 Pre-existing condition                8.37 Stillbirth
Either a diagnosed condition or an         Delivery of a child which has not shown
undiagnosed symptom or collection          any signs of life after the 24th week of
of symptoms that the member is             pregnancy.
experiencing or has experienced or
been treated for within the previous       8.38 Tariff
5 years. Ongoing follow-up                 The charges negotiated by PruHealth
consultations or advice sought for         and the healthcare provider in relation
conditions are classed as treatment.       to their healthcare services provided.

8.33 PruHealth fee maximum                 8.39 Therapists
The PruHealth fee maximum defines          These include physiotherapists,
the upper limit of the range of fees       chiropractors, osteopaths,
expected by PruHealth for any              acupuncturists, homeopaths, podiatrists
treatment provided by healthcare           and other practitioners as may be
provider.                                  agreed by PruHealth.

8.34 Related medical condition             8.40 Treatment
Any symptom, disease, illness or injury,   Surgical or medical services (including
which reasonable medical opinion           diagnostic tests), that is needed to
considers to be associated with another    diagnose, relieve or cure a disease,
symptom, disease, illness or injury.       illness or injury.

8.35 Retained placenta                     8.41 UK
Part or all of the placenta (afterbirth)   United Kingdom (excluding the Channel
remains in the womb during the third       Islands and Isle of Man).
stage of labour.

                                           8.42 We, us, our
8.36 Single membership
                                           Refers to PruHealth
A single membership covers one adult
member.




                                                                                      41
Your notes.




42
Your notes.




              43
Contact us.

PruHealth Customer Services
Stirling FK9 4UE

0800 092 7333

pruhealth.co.uk




                                                              INDIVIDUAL POLICY DOCUMENT PRUHM19136 03/2010




PruHealth is a trading name of Prudential Health Limited and Prudential Health Services Limited which are registered
in England and Wales. Registered office at Laurence Pountney Hill, London EC4R 0HH. Registered numbers 5051253
and 5933141 respectively. Prudential Health Limited and Prudential Health Services Limited are authorised and
regulated by the Financial Services Authority.

								
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