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: email@example.com 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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