Essential Starter_ Essential Choice_ Essential_ Essential Plus

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					               Essential Starter, Essential Choice,
Essential, Essential Plus Starter, Essential Health,
 Essential Plus, and Essential Gold Scheme rules
                             and table of benefits




Giving better value to our half a million members
ii   EssEntial schEmE rulEs and bEnEfits
                                                    EssEntial schEmE rulEs and bEnEfits    1




                              Contents

                              A reminder of your chosen schemes                       03
                              Serving you online                                      03
                              Peace of mind at home and abroad                        03
                              How to make a claim                                     03
                              Talk to us on Nurseline                                 03


                              Scheme rules and table of benefits
                              Introduction                                            04
Thanks for choosing us to
look after your healthcare    Definitions                                             04
cover. Feel free to get in
touch with us anytime.
                              Joining the scheme                                      08
                              Renewing your membership                                08
Call 1890 700 890 between
8.00am - 7.00pm Monday to     Your subscriptions                                      09
Friday and 10.00am - 3.30pm   Ending your membership                                  09
on Saturdays. Calls may be
recorded for training and     What is covered under the scheme                            10
quality purposes.             What is not covered under the scheme -
                              waiting periods                                             12
Visit our website on
www.quinn-healthcare.com      Making a claim                                              15
or email us at
info@quinn-healthcare.com
                              Changes to the agreement                                    16
                              General terms and conditions                                16
QUINN-healthcare
Eastgate Road,                Data Protection Act                                         19
Eastgate Business Park,       Tax relief                                              20
Little Island, Co. Cork.
                              The Financial Regulator                                 20
                              Making a complaint                                      20
                              Benefit 1 – Hospital charges                                21
                              Benefit 2 – Consultant fees                             22
                              Benefit 3 – Radiotherapy/Chemotherapy                   22
                              Benefit 4 – Non-surgical out-patient treatment          22
                              Excess and overall annual limits                        27
                              Benefit 5 – Maternity benefits                          28
                              Benefit 6 – Convalescence                               29
                              Benefit 7 – Treatment in the EU                         29
                              Benefit 8 - Emergency overseas cover                    29
                              Benefit 9 - Medical Tourism                             30
                              Note 1                                                      31
                              Notes 2-3                                               36
2   EssEntial schEmE rulEs and bEnEfits
                                                               EssEntial schEmE rulEs and bEnEfits   3




A reminder of your                               How to make a claim
chosen schemes                                   WhilE in hospital
                                                 We have direct settlement with almost all of
This booklet contains everything you need to     our hospitals and Consultants. This means
know about your chosen schemes.                  that when you go into hospital (for in-patient
If however, you have any questions about         or day-case treatment), you simply fill out a
your cover, please contact our customer          form when you arrive, sign it when you leave,
service team on 1890 700 890.                    and the hospital then deals directly with us.
                                                 There’s no need for you to do anything else.
                                                 We will then write to you afterwards to let you
serving you online                               know when we’ve settled your bill with the
                                                 hospital and the amount we’ve paid on your
www.quinn-healthcare.com                         behalf. It’s as simple as that.
It’s never been easier for you to get in touch   It’s a good idea to call us on 1890 700 890
with us when it suits you.                       and let us know about any upcoming
By visiting our website you can:                 treatment. Don’t forget to tell us which
                                                 hospital you’re going to and the name of your
• find information on all our schemes as well
  as frequently asked questions (FAQs) and       Consultant, so we can confirm your cover.
  answers
• update your address details                    day to day ExpEnsEs
• change your scheme to a higher level of        If you have other health expenses, like
  cover                                          physiotherapy, GP or casualty visits, just keep
• check Consultants and hospitals covered by     your receipts throughout the year. Then, at
  your scheme                                    renewal time, fill out an out-patient claim
• email us with any questions                    form, include all your receipts and send to:
• download your most up to date literature       Quinn-healthcare, Eastgate road, Eastgate
  (rules and other literature can be updated     business park, little island, co. cork.
  from time to time)
                                                 Read on for a full explanation of our rules and
To look at the details of your own scheme,       benefits.
all you need is your QUINN-healthcare
membership number to register online.
                                                 talk to us on nurseline
Peace of mind - at                               The Essential suite Nurseline lets you talk
                                                 confidentially to a health expert anytime
home and abroad                                  day or night. It’s run by qualified nurses with
It’s not always the first thing you think of     a wide range of experience, ready to lend
when planning your trip abroad. But next         a friendly sympathetic ear to any health
time, remember to take your membership           questions or concerns you have. Open 24
card with you and in the event of an             hours a day on 1850 923 500.
emergency, simply call the assistance
number + 353 25 30002 on the back of your
membership card.
4   EssEntial schEmE rulEs and bEnEfits




QUInn-healthcare                                  the time you receive your treatment. For
                                                  those persons who are members of either
essential starter,                                the QUINN-healthcare Essential Starter,
                                                  Essential Choice, Essential, Essential Plus
essential Choice,                                 Starter, Essential Health, Essential Plus and
essential, essential                              Essential Gold scheme, the QUINN-healthcare
                                                  participating hospital list means the list of
Plus starter, essential                           QUINN-healthcare participating hospitals

Health, essential Plus                            that is published by us from time to time
                                                  for the purpose of these schemes. This list
and essential Gold                                may change from time to time. Please check

scheme rules                                      with us before going to hospital that you are
                                                  properly covered for that hospital and that the
Effective from 21 st January 2011.                hospital is still listed. We will send you a copy
                                                  of the most up to date list if you ask us to.


                                                  Quinn-hEalthcarE participatinG
1. introduction                                   hospital in thE uK
You need to read these rules in conjunction       Any hospital listed as a QUINN-healthcare
with the current QUINN-healthcare Essential       participating hospital in the QUINN-
Starter, Essential Choice, Essential, Essential   healthcare participating UK hospital list.
Plus Starter, Essential Health, Essential Plus    The QUINN-healthcare participating UK
and Essential Gold scheme table of benefits,      hospital list is the list of QUINN-healthcare
including the notes (see page 31) and your        participating hospitals in the UK that is
membership certificate. Together with your        published by us from time to time for the
application form, these documents and the         purpose of our insurance schemes in Ireland.
rules make up the agreement between us,           The list of hospitals may change from time to
QUINN-healthcare and you (the member).            time. You are only covered for these hospitals
                                                  if we agree that you cannot receive the
                                                  treatment in Ireland and you must contact
2. definitions                                    us before going to hospital in order for us to
                                                  make arrangements for your treatment. We
The following words and phrases in bold italic
                                                  will send you a copy of the most up to date
have the meanings shown below.
                                                  list if you ask us to.

bEnEfits
                                                  consultant
The hospital charges, medical fees and other
                                                  Any registered medical practitioner who
benefits shown in the table of benefits.
                                                  meets all of the following requirements:
                                                  • they hold a current full registration with the
Quinn-hEalthcarE participatinG
hospital                                            Irish Medical Council

Any hospital listed as a QUINN-healthcare         • they are engaged in hospital practice by
participating hospital in the QUINN-                reason of their training, skill and experience
healthcare participating hospital list at           in a designated specialty, they are consulted
                                                                 EssEntial schEmE rulEs and bEnEfits    5




  by other registered medical practitioners        EmErGEncy dEntal trEatmEnt
  and undertake full clinical responsibility for   Restorative dental treatment urgently
  patients in their care, or that aspect of care   required in order to alleviate pain, inability to
  on which they have been consulted, without       eat or any acute dental condition caused by
  supervision in professional matters by any       an accidental external impact to the mouth
  other person                                     and which presents an immediate and serious
• they hold a public Consultant post or are        threat to a person’s general health.
  eligible to hold a public Consultant post
• they are recognised by us as a QUINN-            full covEr schEmE
  healthcare Consultant for the purpose of         The scheme known as the full cover scheme
  our insurance schemes in Ireland, (you can       under which QUINN-healthcare agrees
  phone or write to us if you would like to        limits on Consultants’ fees with participating
  know whether or not a particular registered
                                                   Consultants. A Consultant is participating in
  medical practitioner is recognised by us or
                                                   the full cover scheme if he or she is for the time
  you can check our website).
                                                   being shown in QUINN-healthcare’s list of full
If you receive treatment in a country outside      cover scheme participating Consultants as
Ireland, a Consultant refers to a surgeon,         participating in the full cover scheme, (you can
physician, or anaesthetist who is less than 70     phone or write to us if you would like to know
years of age and is legally qualified to provide   whether or not a Consultant is participating
the treatment in that country.                     in the full cover scheme or you can check our
                                                   website).
cosmEtic trEatmEnt
Treatment which is medical or surgical             GEnEral mEdical practitionEr/Gp
primarily for the purpose of improving             A registered medical practitioner who is not
appearance or self esteem.                         a Consultant and is currently practicing as a
                                                   primary care physician in the community.
day-casE trEatmEnt
Treatment which, for medical reasons, means        hEalth insurancE contract
you have to be admitted into a hospital and        Means a health insurance contract to which
occupy a bed in that hospital during the           the Irish Health Insurance Act, 1994, and the
day, but not overnight, for treatment which        regulations made under that Act, apply.
would be accepted generally by the medical
profession in Ireland as day-case treatment
                                                   hospital
as opposed to out-patient treatment.
                                                   This means a QUINN-healthcare participating
                                                   hospital.
dEpEndants
Your husband or wife or partner and any child
                                                   in-patiEnt trEatmEnt
or dependant of yours who we have agreed
                                                   Treatment which, for medical reasons, means
with you to accept into membership of one
                                                   you have to stay in a hospital overnight.
of the schemes, and who is also named on
your membership certificate as one of your         irEland
dependants.                                        Ireland excluding Northern Ireland.
6   EssEntial schEmE rulEs and bEnEfits




mEmbErship start datE                                    Language Therapists
The date on which a person begins his or her         (c) a member of the Society of Chiropodists/
current continuous period of membership                  Podiatrists, the Institute of Chiropodists
of their scheme. The membership start                    and Podiatrists, the Irish Chiropodists/
date for you and your dependants is                      Podiatrists Organisation Ltd, and/
shown for each of you individually on your               or the British Chiropody and Podiatry
current membership certificate. We will                  Association
treat a person’s cover under the scheme as
                                                     (d) a person who is either on the Professional
continuous if there is no break in membership
                                                         Register of Traditional Chinese Medicine,
of more than 13 weeks.
                                                         the Traditional Chinese Medicine Council
                                                         of Ireland (TCMCI) and/or is accredited to
minimum bEnEfit rEGulations
                                                         the British Acupuncture Council and/or the
The Irish Health Insurance Act, 1994
                                                         Academy of Chinese Culture and Medicine
(Minimum Benefit) Regulations, 1996 made
pursuant to the Irish Health Insurance Act,          (e) a person who is on the Professional
1994, as amended from time to time.                      Register of the Irish Society of
                                                         Homeopaths or the Irish Medical
northErn irEland participatinG                           Homeopathic Association
hospital                                             (f) a member of the Chiropractic Association
Any of the hospitals in Northern Ireland listed          of Ireland (CAI)
in note 1(v) of the Table of Benefits.
                                                     (g) a member of the Osteopathic Council of
nursE                                                    Ireland

A nurse who is for the time being registered         (h) a member of The Irish Association of
with An Bord Altranais for midwifery, health             Counsellors and Therapists or The Irish
visiting and/or nursing.                                 Council for Psychotherapy
                                                     (i) a member of the Psychological Society of
out-patiEnt trEatmEnt                                    Ireland
Treatment which is not in-patient treatment
                                                     (j) a member of the Association of
or day-case treatment.
                                                         Occupational Therapists of Ireland
participatinG thErapist                              (k) a member of the Irish Nutrition and
We will recognise a person who is a participating        Dietetic Institute
alternative therapist and is registered with the     (l) a member of the International Association
relevant associations at the time of treatment for       of Infant Massage
the purpose of our insurance schemes in Ireland.
                                                     (m) a member of MLD (Manual Lymph
We will also recognise registered general
                                                         Drainage) Ireland
practitioners who are participating therapists
with the relevant alternative associations. These    (n) a member of the Irish Reflexologists
are listed as follows:                                   Institute, the Federation of Holistic
                                                         Therapists Ireland and/or the National
(a) a chartered or State registered
                                                         Register of Reflexologists.
    physiotherapist
                                                     (o) a member of the British and Irish
(b) a member of the Irish Association of
                                                         Orthoptic Society and/or Fellow of the
    Speech and Language Therapists and/
                                                         Association of Optometrists of Ireland
    or the Royal College of Speech and
                                                         (F.A.O.I.)
                                                                  EssEntial schEmE rulEs and bEnEfits   7




(p) a member of the Association of                  • Shandon Street Private Hospital, Cork
    Neuromuscular Therapists (ANMT), the            • Shanakiel Private Hospital, Cork
    Irish Association of Physical Therapists, the   • St Francis, Mullingar
    Register of Physical Therapists of Ireland or   • St Joseph’s Garden Hill, Sligo
    the Irish Institute of Physical Therapists
(q) a member of the Irish society of Hearing        tiEr 2
    Aid Audiologists                                • Bon Secours Hospital (Cork, Tralee, Galway
(r) a registered midwife who is a member of           and Dublin)
    the Association of Lactation Consultants        • Cork Medical Centre
    in Ireland and who holds International          • Galway Clinic
    Board Certified Lactation Consultant            • Hermitage Medical Clinic, Dublin
    membership.                                     • Mount Carmel, Dublin
    (You can phone or write to us if you            • North West Independent Hospital, Derry
    would like to know whether or not               • St Vincent’s Private Hospital, Dublin
    someone is a participating therapist for
                                                    • Ulster Independent Clinic, Belfast
    the purpose of the scheme).
                                                    • Whitfield Clinic, Waterford
                                                    • Sports Surgery Clinic, Dublin
prE-ExistinG condition
Any disease, illness or injury which began,
                                                    tiEr 3 (hi tEch hospitals)
or the symptoms of which began before
                                                    • Blackrock Clinic, Dublin
the person with the disease, illness or injury
                                                    • Mater Private Hospital, Dublin
started his or her current continuous period of
membership of the scheme.                           • Beacon Hospital, Dublin

When deciding if a disease, illness or injury
                                                    public hospital
began before membership started it is
                                                    A publicly funded hospital, other than a
important to note that it is the date on which
                                                    nursing home, which provides services for
the disease, illness or injury began that counts.
                                                    a person pursuant to his or her entitlements
It is not the date upon which the person with
                                                    under Chapter II of Part IV of the Irish Health
the disease, illness or injury becomes aware
                                                    Act, 1970.
of it or its symptoms as the disease, illness or
injury may be present for some time before
giving rise to symptoms or being diagnosed.         rEGistErEd mEdical practitionEr
                                                    A person whose name appears in the General
privatE hospitals                                   Register of Medical Practitioners maintained
tiEr 1                                              under the Irish Medical Practitioners Acts,
• Park West Clinic, Dublin 12                       1978 and 1993.
• Auteven Hospital, Kilkenny
• Barringtons Hospital, Limerick                    rEGistErEd nursinG homE
• Cahercalla Hospital, Clare                        A nursing home registered pursuant to the
• Clane Hospital, Kildare                           Health (Nursing Homes) Act, 1990.

• Millbrook Clinic, Bandon, Cork
                                                    rEnEWal datE
• National MS Centre, Rathgar
• Northbrook Clinic, Dublin                         The renewal date shown on your membership
                                                    certificate.
8   EssEntial schEmE rulEs and bEnEfits




routinE dEntal trEatmEnt                             you/your
We refer to routine dental as being a general        This means you and your dependants.
check-up, scale or polish, routine filling or
extraction (excludes wisdom teeth) carried
out by a registered dentist.
                                                     3. Joining the scheme
schEdulE of bEnEfits                                 (a) your membership of your scheme begins
This is the schedule which we publish                    on your start date as shown on your
from time to time for the purpose of our                 membership certificate.
medical insurance schemes in Ireland. This           (b) the membership of each of your
schedule lists various surgical and diagnostic           dependants of their scheme begins
procedures and medical illnesses. It also                on their start date as shown on your
explains the amount of the benefits we shall             membership certificate.
pay for treatment provided by a Consultant
                                                     (c) if you enrol your child as a dependant
and for surgical out-patient treatment
                                                         within 13 weeks of the child’s birth, your
provided by a general practitioner (We will
make available to you a copy of the schedule             child’s membership of the scheme will be
if you ask us to).                                       treated as having begun on the date of
                                                         the child’s birth. And if you are a member
                                                         of the scheme, you can apply to enrol
schEmE
                                                         your new born child as a dependant of
Means in respect of a person, the QUINN-
                                                         their schemes free of charge until your
healthcare health insurance scheme of which
                                                         first renewal date after his or her birth.
they are a member either – Essential Starter,
Essential Choice, Essential, Essential Plus          (d) the agreement between you and us
Starter, Essential Health, Essential Plus or             for your membership of any of the
Essential Gold.                                          schemes shall be separate from any
                                                         agreement between us and you for
                                                         your membership of any other QUINN-
surGical out-patiEnt trEatmEnt
                                                         healthcare insurance scheme or schemes.
Out-patient treatment consisting of a surgical
procedure listed for the time being in the           (e) the scheme of which each of you are a
schedule of benefits.                                    member is shown on your membership
                                                         certificate.
trEatmEnt
Any health services a person needs solely for
the medical investigation, treatment, cure, or
                                                     4. renewing your
alleviation of the symptoms, of illness or injury.   membership
                                                     (a) your membership of the schemes needs
yEar
                                                         to be renewed by you at the end of each
The period starting on your membership
                                                         year in order for it to continue. Your
start date or a renewal date and ending at
                                                         membership of the schemes can be
midnight on the day before the next renewal
                                                         renewed by you at the end of each year
date.
                                                         (subject to Rule 10 on page 16) for a further
                                                         year unless we write to notify you at least
                                                                EssEntial schEmE rulEs and bEnEfits   9




    30 days before the end of the year that we        unless we agree a different period. At
    have decided to end the schemes in which          the renewal date, you can renew your
    case your membership of the schemes               contract by paying the premium we
    will end at the end of the year in which we       request.
    notify you of our decision.                   (c) you have the right to cancel your
(b) you renew your membership of the                  membership of the scheme by writing to
    schemes by continuing to pay your                 us within 14 days of you receiving your
    subscriptions after your renewal date.            first membership certificate. We will give
                                                      you a full refund of any money you have

5. your subscriptions                                 paid us as long as you have not made
                                                      any claims. If the policy is not cancelled
You must pay the subscriptions you have               within 14 days of receiving your first
agreed with us for your membership of the             membership certificate you will become
scheme. You need to pay these in advance.             liable for a pro rata charge.
We may increase the subscriptions you have        (d) you may also cancel the membership of
to pay each year (see Rule 10 on page 16).            any of your dependants of their scheme by
You must pay your subscriptions in a way              writing to us within 14 days of you receiving
which is reasonably acceptable to us. We will         your first membership certificate which
give details of the ways you can pay your             lists them as a member. We will give you a
subscriptions in our brochure and we will send        full refund of any money you have paid for
you updated details if you ask us to. A credit        those dependants, whose membership you
charge will apply for non-annual payment.             have cancelled within 14 days, as long as no
                                                      claims have been made in respect of them.

6. Ending your                                    (e) we can end or refuse to renew someone’s
                                                      membership of the scheme if they
membership                                            have at any time made a fraudulent
(a) you can end your membership of the                misrepresentation which relates to your
    scheme at any time by writing to us. You          contract with QUINN-healthcare or any
    will not be entitled to any refund if you         other health insurance contract, and
    have made an in-patient and/or day-case           which has, or could have, resulted in us,
    claim. Your contract is for a period of one       or any other registered health insurer,
    year unless we agree a different period.          suffering financial loss. This includes
    At the renewal date, you can renew your           information which could have affected
    contract by paying the premium we                 our decision to allow anyone to join the
    request.                                          scheme or what subscriptions you have
                                                      to pay or whether or not we have to pay
(b) you can also cancel the membership of
                                                      any claim for benefits.
    any of your dependants of their scheme
    at any time by writing to us. You will        (f) your membership of the scheme will end
    not be entitled to any refund if your             immediately if you stop living in Ireland
    dependants have made an in-patient                for more than 6 months per calendar year
    and/or day-case claim. Your dependants            or your membership is not renewed.
    contract is for a period of one year
10   EssEntial schEmE rulEs and bEnEfits




(g) we may end your membership of the           (b) we will only pay fees and charges for
    scheme by writing to you if you do not          treatment, services and facilities that
    pay any of your subscriptions on or             are reasonable and customary and in
    before the date they are due. If your           any event only up to the limits shown
    membership ends because you do not              in the table of benefits. By reasonable
    pay your subscriptions, we may allow you        and customary we mean that what you
    to continue your membership, as long as         are charged for and how much you
    you pay the subscriptions you owe within        are charged is not more than what the
    30 days.                                        majority of our other members of the
(h) if a person’s membership of the scheme          schemes are charged in Ireland for similar
    ends because we end their membership            treatment services or facilities.
    (eg. for fraudulent misrepresentation),     (c) we may pay benefits direct to the person
    we will give a refund of subscriptions          who provided the treatment or to you or
    paid for them for the period after their        your dependants. We will pay benefits
    membership ends.                                after deducting any withholding tax or
(i) if you cease to be a member of your             other deductions that we are required to
    scheme for any reason at any time the           make by law.
    membership of each of your dependants       (d) we will only pay benefits for costs and
    on the scheme will also end at the same         expenses that you have to pay. We will
    time unless we otherwise agree in writing       only pay benefits for treatment that you
    at the time. Your dependants will need          need and have received.
    to make their own arrangements with         (e) any benefits we pay for treatment to
    us to continue their membership of their        which you are not entitled, will still count
    schemes. They can do this by telephoning        towards the maximum amount we will
    or writing to us. We will explain to them       pay under the scheme. We may decide
    what they will need to do.                      to make these payments, but it does not
                                                    mean we will have to pay them in the
                                                    future.
7. What is covered                              (f) we will pay benefits for in-patient
under the scheme                                    treatment for psychiatric or addictive
                                                    conditions or problems up to the
(a) we will pay benefits for treatment a
                                                    following limits:
    person receives while they are a member
                                                    (i)   the maximum number of days of
    of their scheme. We will pay benefits
                                                          in-patient treatment for psychiatric
    under the scheme of which they were a
                                                          conditions (other than those referred
    member at the time they received the
                                                          to in ‘ii’) for which we shall pay benefits
    treatment and according to the rules
                                                          for any person in any calendar year
    and table of benefits of the scheme that
                                                          shall be 100 less the number of days
    applied to them at that time. We will
                                                          of such treatment received by that
    not pay benefits for treatment which a
                                                          person during the same calendar year
    person receives while he or she is not a
                                                          in respect of which a payment has
    member of the schemes.
                                                          been made by us or any other health
                                                          insurance contract.
                                                                 EssEntial schEmE rulEs and bEnEfits   11




    (ii) the maximum number of days of                 on appropriate medical advice, that the
         in-patient treatment for alcoholism,          treatment could have been received
         drugs or substance abuse for which            as out-patient treatment. However, we
         we shall pay benefits for any person          will pay benefits for such treatment as
         in any continuous period of five years        follows:
         shall be 91 less the number of days           • if you receive in-patient treatment
         of such treatment received by that              and we determine that the treatment
         person during the same five year                could have been received as day-
         contract period in respect of which             case treatment, we may treat such
         a payment has been made by us or                treatment as day-case treatment for
         any other health insurance contract.            the purpose of paying benefits
(g) the maximum number of days of                      • if you receive in-patient treatment or
    in-patient treatment and day-case                    day-case treatment and we determine
    treatment combined for which we                      that the treatment could have been
    shall pay benefits for any person in                 received as out-patient treatment,
    any calendar year shall be 180 less the              we may treat such treatment as out-
    number of days of such treatment                     patient treatment for the purpose of
    received by that person during the same              paying benefits.
    calendar year for which any payment
                                                   (j) despite anything to the contrary in these
    has been made or is payable under any
                                                       rules and the table of benefits, you may
    health insurance. Anyone who joins or
                                                       claim any benefits we are required to pay
    cancels mid year, their number of eligible
                                                       under the minimum benefit regulations.
    days for in-patient or day-case treatment
    will be calculated on a pro rata basis.        (k) colon cancer screening provided by a
                                                       participating hospital. This benefit is
(h) we will only pay benefits in relation to the
                                                       paid subject to certain clinical indicators.
    diagnosis or treatment of illness or injury
                                                       Please ask us for details.
    of a person which would be accepted
    generally by the medical profession in         (l) we will only pay benefits for Consultants’
    Ireland as appropriate and necessary               fees for in-patient treatment or day-case
    having regard to the standards of medical          treatment if the treatment is provided
    practice and to the nature and cost of any         in a QUINN-healthcare participating
    other recognised forms of treatment as             hospital.
    well as to all the circumstances relevant      (m) in the case of a person who was covered
    to the person.                                     under a health insurance contract within
(i) we do not have to pay benefits for in-             thirteen weeks before their membership
    patient treatment provided by a hospital           start date, we will only pay benefits
    if we are of the reasonable opinion, based         for treatment received during their
    on appropriate medical advice, that the            additional cover waiting period if benefits
    treatment could have been received                 for the treatment would have been
    as day-case treatment or out-patient               payable under that health insurance
    treatment. We also do not have to pay              contract. And we will only pay benefits
    benefits for day-case treatment if we              for such treatment during the additional
    are of the reasonable opinion, based               cover waiting period up to the amount
                                                       that would have been payable under that
12   EssEntial schEmE rulEs and bEnEfits




      health insurance contract if the amount is
      less than would otherwise be payable by
                                                     8. What is not covered
      us under the scheme.                           under the scheme
      A person’s additional cover waiting            WE Will not pay benefits for thE
      period for this purpose shall be:              folloWinG:
      • the first year following their               (a) treatment which a person requires during
        membership start date for benefits               any waiting period that may apply to
        under Benefit 5 on page 28.                      the treatment under their scheme. All
      • the first two years following their              waiting periods commence on a person’s
        membership start date for all other              membership start date and, except for
        benefits.                                        the maternity waiting period, the length
                                                         of a waiting period is determined by a
      This rule will not restrict cover for
                                                         person’s age on their membership start
      treatment arising out of any illness, injury
                                                         date.
      or disease which originated after the
      person’s membership start date. This rule
                                                     thErE arE thrEE WaitinG pEriods
      applies both to a person who becomes a
                                                     that apply undEr thE schEmE:
      member of the scheme for the first time
                                                     • the initial waiting period. This applies to any
      or to anyone changing their scheme to a          treatment that a person may require
      scheme which generally provides more
                                                     • the pre-existing condition waiting period.
      extensive cover.                                 This only applies to treatment which a
(n) Subject to QUINN-healthcare paying                 person requires for a pre-existing condition
    benefits up to the amount required by the        • the maternity waiting period. This only
    minimum benefit regulations, QUINN-                applies to treatment that a person requires
                                                       for pregnancy or childbirth
    healthcare shall deduct the first ¤50,
    ¤125 or ¤200 of the claim, depending on
                                                     thE initial WaitinG pEriod is:
    the hospital you choose from the benefits
                                                     • the first 26 weeks of membership for those
    payable under the QUINN-healthcare
                                                       aged under 55 on their membership start
    Essential Plus Starter, Essential Health,          date
    and the Essential Plus schemes for each          • the first 52 weeks of membership for those
    claim for hospital treatment in a private          aged 55 to 64 on their membership start
    hospital. The excesses apply on a per              date
    claim basis. This deduction will not apply       • the first 104 weeks of membership for those
    if the person receiving the treatment is a         aged 65 or over on their membership start
    member of the Essential Plus scheme and            date
    QUINN-healthcare has agreed to waive
    the excess for that person in return for a       thE prE-ExistinG condition WaitinG
    higher subscription under the scheme.            pEriod is:
    (If the excess has been waived for you or        • the first five years of membership for those
    your dependants, this will be shown on             aged under 55 on their membership start
    your membership certificate).                      date
                                                     • the first seven years of membership for
                                                       those aged 55 to 59 on their membership
                                                       start date
                                                                EssEntial schEmE rulEs and bEnEfits   13




• the first 10 years of membership for those       (d) cosmetic treatment except the correction
  aged 60 or over on their membership start            of accidental disfigurement or significant
  date                                                 congenital disfigurement or significant
                                                       disfigurement due to disease.
thE matErnity WaitinG pEriod
                                                   (e) treatment where injury or illness
• applies to Benefit 5 on page 28 and applies
  during the first 52 weeks of membership              is caused by virtue of war, civil
                                                       disobedience or any act of terrorism or
                                                       chemical, biological or nuclear disaster in
thE abovE WaitinG pEriods Will not
apply:                                                 Ireland or overseas.
• to any child of yours who becomes a              (f) treatment for symptoms which are not due
  member of the scheme within 13 weeks of              to any underlying disease, illness or injury.
  their birth; or
                                                   (g) treatment you receive outside Ireland.
• to any treatment received by a person
  resulting from an accident or injury which           This exclusion will not apply to treatment
  occurred while they were a member of the             that you receive in an emergency
  scheme or covered under another health               because of a sudden illness or injury
  insurance contract.                                  whilst travelling temporarily outside
  The waiting periods shall be reduced by              Ireland or treatment approved as part
  a person’s continuous period of cover (if            of QUINN-healthcare’s medical tourism
  any) under one or more health insurance              benefit. But we will only pay those
  contracts prior to their membership start            benefits and costs described in benefits
  date if the period of continuous cover               7, 8 and 9 of the Table of Benefits. We will
  ended within 13 weeks of their membership            not pay benefits if any of the following
  start date. (A person’s cover shall be               apply to the person who receives the
  treated by us as continuous even if there            treatment:
  is a break in cover, but only if the break in
                                                     • If you are receiving treatment at the time
  cover does not last more than 13 weeks.)
                                                       of travel and/or you know before you
  Please remember that we will not pay
                                                       travel that treatment may be required
  benefits for any treatment which a person            while temporarily overseas.
  receives whilst he or she is not a member of
                                                     • they travelled abroad despite you or they
  the scheme.
                                                       being given medical advice that they
(b) treatment directly or indirectly arising           should not travel abroad.
    from or to do with male or female
                                                     • you or they were told before travelling
    birth control, infertility or assisted
                                                       abroad that they were suffering from a
    reproduction. This exclusion will not apply
                                                       terminal illness.
    to investigations relating to infertility.
                                                     • they travelled abroad to receive
(c) treatment including drug therapy
                                                       treatment.
    which we reasonably decide, based on
                                                     • you or they knew they would need the
    established medical opinion in Ireland,
                                                       treatment before travelling abroad.
    is experimental or unproven. We may
    decide to pay for the type of treatment if       • conditions arising from deliberately
    it is offered to you, but we do not have to.       injuring yourself
                                                     • conditions arising from alcohol and drug
                                                       abuse
14   EssEntial schEmE rulEs and bEnEfits




     • conditions arising from a psychiatric             treatment if you get our permission
       condition                                         beforehand:
     • injuries caused during mountaineering,          • periodontal mucoperiosteal flap surgery
       motor competitions and competitive              • removal of buried teeth (single or multiple)
       professional sport
                                                       • removal of buried or impacted tooth/teeth
     • convalescence or rehabilitation services          Please note: routine dental is not covered
     • injuries you received while breaking the          overseas.
       Law                                           (k) preventive treatment such as check
     • pregnancy related admissions or giving            ups or screening except in relation to
       birth after 28 weeks                              colon cancer screening provided by a
     • expenses incurred once a member has               participating hospital. This benefit is
       been discharged from hospital                     paid subject to certain clinical indicators.
                                                         Please ask us for details. We will also pay
     • injuries caused by air travel unless you
                                                         for screening to the extent provided for
       are a passenger on a licensed aircraft
                                                         under Benefit 4 on pages 22 to 26 in the
       operated by an airline
                                                         QUINN-healthcare scheme’s table of
       This exclusion will not apply to treatment
                                                         benefits.
       that we have agreed you may receive
                                                     (l) treatment relating to eating disorders
       in a hospital in the EU and which has
                                                         or weight reduction other than anorexia
       been pre-approved by us, because the
                                                         nervosa or bulimia nervosa.
       treatment is not available in Ireland.
                                                     (m) convalescence in a nursing home other
(h) treatment provided by a consultant
                                                         than a registered nursing home under
    whom the Irish Medical Council does
                                                         Benefit 6 on page 29.
    not recognise as having knowledge and
    expertise in a specialty relevant to that        (n) medical reports.
    treatment.                                       (o) any penalty charge in lieu of Health Act
(i) treatment in any hospital, or by any                 contributions.
    registered medical practitioner or               (p) nursery fees.
    therapist to whom we have sent a
                                                     (q) hearing aids, spectacles and contact
    written notice saying that we no longer
                                                         lenses (except as specified in the Table
    recognise them as a QUINN-healthcare
                                                         of Benefits), dentures or orthodontic
    participating hospital, or Consultant or
                                                         appliances.
    participating therapist as the case may
                                                     (r) any treatment not specified in the
    be.
                                                         Minimum Benefit Regulations or in our
(j) any dental or orosurgical or orthodontic
                                                         schedule of benefits unless we agree
    treatment or procedure unless it is a
                                                         to do so. This exclusion will not apply to
    surgical or medical procedure listed in
                                                         Benefit 7 on page 29.
    the schedule of benefits. But we will pay
                                                     (s) charges for drugs or medication unless
    benefits for out-patient treatment for
                                                         provided as an in-patient and as agreed
    dental injuries to the extent shown under
                                                         with the hospital.
    Benefit 4 on page 22.
                                                     (t) QUINN-healthcare will have no obligation
       We will only pay benefits for the following
                                                         to pay otherwise eligible claims where
                                                                EssEntial schEmE rulEs and bEnEfits   15




    they are submitted in respect of a spouse,         whether or not you think you can recover
    parent, child, brother, sister, uncle, aunt,       the cost of the benefits from another
                                                       person or insurance company
    niece or nephew of a Consultant, dentist or
    alternative therapist, General practitioner      • details of any health insurance contract
                                                       under which you were covered prior to
    or any other provider of service.
                                                       becoming a member of the scheme
(u) vaccinations other than those specifically       • original flight/travel tickets which will act
    covered by your plan.                              as proof of your stay outside of Ireland
                                                       up to but not exceeding 180 days in each
                                                       calendar year.
9. making a claim                                  (d) In order to process a claim we require a
                                                       fully completed claim form. In the event
(a) when possible, you should tell us about            that necessary information required
    any treatment you are going to have.               to process the claim is incomplete or
    This gives us the chance to tell you if you        ambiguous on the claim form, our claims
    can claim for benefits. We may ask your            department will follow up with the
    Consultant or other registered medical             necessary party to obtain this information.
    practitioner to provide us with full written       This follow up will take place over a 6
    details of the treatment.                          month period, after which if the required
(b) we will not pay benefits while you                 information is not received the claim will be
    are breaking any of the terms of your              deemed ineligible for benefit.
    membership.
(c) you should send your claims to us              Important note
    as soon as possible. We will only pay          fraud policy:
    benefits if we receive all of the following:     • QUINN-healthcare operates a fraud
  • a written claim within twelve months               policy in respect of all claims made under
    from the date of any non surgical out-             our Health Insurance Contract.
    patient treatment and six months from            • If a claim submitted by a member, or
    the date of any other treatment (unless            someone acting on behalf of a member is
    this was not reasonably possible). You             found to be in any respect fraudulent or
    must make the claim in the way that we             dishonest and submitted with a view to
    reasonably ask you. We may change the              obtaining any benefit under this policy,
    procedure for making a claim. If we do             all benefit under this policy shall be
    change the procedure, we will write and            forfeited. For example overstatement of
    let you know                                       any medical fees incurred.
  • any proof we reasonably need to help us          • Members should note that regular audits
    to decide if you are entitled to benefits.         of claims are undertaken by QUINN-
    This can include;                                  healthcare.
                                                     • In all instances where fraud is suspected
  • any medical reports and other
                                                       in respect of a particular claim a full and
    information to do with the treatment for
                                                       comprehensive investigation will be
    which you are making a claim; and
                                                       carried out by us.
  • the results of an independent medical
                                                     • If, following that investigation, a finding
    examination on which we may ask you to
                                                       of fraud or if a claim be deemed in any
    undergo
                                                       respect fraudulent, the claim shall be
  • original accounts and invoices for the             disallowed in its entirety.
    benefits you are claiming
                                                     • Any member found guilty of submitting
  • written confirmation from you as to                a fraudulent claim shall have their health
16   EssEntial schEmE rulEs and bEnEfits




       insurance contract suspended with               the cost to us of the changes in the taxes or
       immediate effect.                               charges. We will write to tell you at least 28
     • All claims of whatever nature being             days before increasing your subscription.
       considered under that individual member
       shall be suspended with immediate           (d) we may make any changes to the terms
       effect.                                         of your membership of the scheme and
     • In addition, any claim that is submitted        your subscriptions at any time if we are
       which is in any respect fraudulent              required to do so by law. We will write to tell
       QUINN- healthcare reserves the right            you about any such change as soon as is
       to refer the matter and details of the          reasonably practical and you may end your
       claim to the appropriate authorities to
       prosecute the member.                           membership of the scheme within 14 days
                                                       of us telling you about the change. If as a
                                                       consequence you end your membership,
10. changes to the                                     we will refund any subscriptions that
                                                       you have paid for the period after your
agreement                                              membership ends.
(a) we may change any of the terms of your
    membership of your schemes each year
    on your renewal date. These changes            11. General terms and
    can include, for example, how much
    your subscription will be and how often
                                                   conditions
    you have to pay it. The changes can also       (a) your policy and all communication
    include changes to the benefits. We will           between you and us will be in English
    not add any restrictions or exclusions to      (b) these terms will be governed by Irish law
    your cover that are personal and specific          and all matters to do with the schemes
    to you to do with medical conditions               will be dealt with by the courts in Ireland.
    that started after you joined the scheme.
                                                   (c) we will not return any documents you
    Changes will only apply to you for the
                                                       send us, unless you ask us to do so at the
    period following the renewal date when
                                                       time you send them to us.
    the change was made. The changes
    will not apply to the period before the        (d) any changes to these terms will only be
    renewal date.                                      valid if they are made according to these
                                                       rules or the table of benefits, unless we
(b) we will write to tell you about any of these
                                                       agree any changes with you in writing.
    changes at least 28 days before the renewal
                                                       Nobody else can change your terms of
    date on which they are to take effect.
                                                       membership of the scheme on our behalf
(c) we can increase or reduce the subscriptions        or decide not to enforce any of our rights.
    you pay at any time if there is an increase
                                                   (e) if we do not use our legal rights it does
    or decrease in the rate of tax or any other
                                                       not mean we have given them up. We
    government or statutory charge or if any
                                                       may use them in the future.
    new tax or government or statutory charge
    is introduced which is related to your         (f) if you write to us about anything, you
    health insurance contract with QUINN-              must send it by pre-paid post or deliver
    healthcare. If we do, we will only increase        it personally to: QUINN-healthcare,
    the subscriptions you have to pay to cover         Eastgate Road, Eastgate Business Park,
                                                       Little Island, Co. Cork
                                                                   EssEntial schEmE rulEs and bEnEfits   17




    If we change this address, we will write              result of an injury caused through the
    to tell you about the change before we                fault of another person, known as a Third
    do so.                                                Party and where you propose to pursue
    We will send any letters to the address you           a legal claim against that party, QUINN-
    last told us about. You and we can assume             healthcare will pay benefit in accordance
    that the letter is received on the day after it       with these rules provided that you (or the
    has been delivered, if delivered personally,          subscriber if you are under 18 years);
    or three days after posting if it was sent by     (i) Complete in full the third party section
    pre-paid post.                                        and sign the claim form which includes an
(g) you must write and tell us as soon as                 undertaking to include all benefit paid by
    possible if you have claimed benefits                 QUINN-healthcare relating to any claim
    for any treatment which you needed                    made against another party.
    because somebody else was at fault.               (ii) Submit a fully completed undertaking,
(h) you should write to tell us if you have any            which will be relied on by QUINN-
    other insurance cover for benefits that                healthcare once a copy of the
                                                           Authorisation Form is received from the
    you have claimed from us. If you do have
                                                           Personal Injuries Assessment Board,
    insurance cover with someone other than
                                                           (refer to rule 4), or from your solicitor
    QUINN-healthcare, we will only pay our
                                                           in the form prescribed by QUINN-
    share of any benefits.
                                                           healthcare: -“In consideration of QUINN-
(i) we will pay benefits in accordance with                healthcare discharging the eligible
    the rules for treatment which was due to               hospital and medical expenses of my/
    the fault of someone else.                             our client, I/we hereby understand to
    However, if you claim benefits for                     include as part of my/our client’s claim
    treatment which was due to the fault                   the monies so paid by QUINN-healthcare
    of someone else, you must take any                     (details of which will be supplied by
                                                           QUINN-healthcare) and subject to any
    steps we may reasonably ask you to
                                                           court order to the contrary to repay to
    take to recover the cost of the benefits
                                                           QUINN-healthcare, out of proceeds that
    we have paid from the person whose
                                                           come into our hands, all such monies paid
    fault it was. You must also claim interest
                                                           by QUINN-healthcare.’’
    if you are entitled to interest. You must
    pay us the money (and any interest) that          (iii) Notify QUINN-healthcare in writing prior
    you recover from that person up to the                  to the legal closure of the case.
    amount of the benefits we have paid for           (iv) Provide QUINN-healthcare with full
    the treatment.                                         written details of any settlement.
                                                          no legal Action Proceedings - Where a
    tHIrd PArty ClAIms                                    claim is not currently being pursued by
                                                          you (or the subscriber if you are under
    Please note - Expenses which you are
                                                          18 years), but in the future should you
    entitled to recover from a third party, are
                                                          choose to proceed with a third party
    excluded from benefit, however:
                                                          claim, or in the instance where our legal
    legal Action Proceedings - Where a                    advisors advise us that expenses are
    claim is submitted to QUINN-healthcare                recoverable from a third party, we will
    in respect of treatment required as a                 require you to:
18   EssEntial schEmE rulEs and bEnEfits




(i) Complete in full and sign the claim form         provide QUINN-healthcare with a copy
    which includes an undertaking to include         of the written confirmation from the
    all benefits paid by QUINN-healthcare            Criminal Injuries Compensation Tribunal.
    in any claim which may subsequently be           The undertaking provided by you also
    made against a third party responsible           authorises QUINN-healthcare to seek
    for causing the injury and                       details of any settlement directly from the
(ii) Immediately notify QUINN-healthcare in          Criminal Injuries Compensation Tribunal
     writing of the outcome of any such claim        and for the Criminal Injuries Compensation
     and to repay the benefit paid by QUINN-         Tribunal to release this information to us.
     healthcare in full, subject to any court        In circumstances where such a case is
     order to the contrary.                          unsuccessful, QUINN-healthcare will not
                                                     seek a refund of the benefit paid.

      Personal Injuries Assessment Board -
                                                     Unsuccessful/Withdrawn Claims -
      Where you submit a claim to the Personal
      Injuries Board (PIAB), QUINN-healthcare        If a claim against a third party is not
      will pay benefit in accordance with these      successful or is withdrawn, QUINN-
      rules provided that you (or the subscriber     healthcare will not seek a refund of the
      if you are under 18 years) complete in         benefit paid provided that you arrange
      full and sign the accident section of the      for full written details of the case to be
      claim form. This undertaking provided by       supplied by you from your solicitor to the
      you also authorises QUINN-healthcare           satisfaction of QUINN-healthcare outlining
      to provide PIAB with details of all monies     the reasons why the case was unsuccessful
      paid by QUINN-healthcare relating to your      or was discontinued.
      claim, and for you to provide QUINN-
      healthcare details of PIAB’s assessment.
                                                     disclosure - It is the responsibility of a
      Where PIAB decides that the case is more
                                                     member to disclose to QUINN-healthcare
      appropriately dealt with by the court, due
                                                     full details of any action to be taken
      to some legal dispute and issues a letter of
                                                     against a third party in relation to any
      Authorisation, QUINN-healthcare will rely
                                                     incident/accident in respect of which
      on the undertaking that has been provided
      by your solicitor, in accordance with point    QUINN-healthcare has paid full benefit.
      2(ii) above, and a copy of the Authorisation   Failure to do so will result in the refusal
      from PIAB to proceed to the courts.            of any subsequent claims relating to the
                                                     accident/incident.

      Criminal Injuries Compensation
      tribunal Claims - If you are pursuing
      a claim through the Criminal Injuries
      Compensation Tribunal, QUINN-healthcare
      will pay benefit in accordance with these
      rules provided that you (or the subscriber
      if you are under 18 years) complete in
      full and sign the accident section of
      the QUINN-healthcare claim form and
                                                                EssEntial schEmE rulEs and bEnEfits   19




data protection act                                will be agreeing to us or our agents or other
                                                   insurers processing that information. Before
1988 and 2003.                                     you provide sensitive information about
                                                   others, you should make sure they have given
Quinn Insurance Ltd (Under Administration)
                                                   their express consent.
trading as QUINN-healthcare is the registered
data controller in relation to personal            Medical information will be kept confidential
information held about you for the purpose         and may be disclosed, on a strictly
of the Data Protection Acts. You should show       confidential basis to those involved with your
this notice to anyone who may be covered by        treatment or care or their health professional
your insurance policy with QUINN-healthcare.       agents. Anonymised data may however, be
                                                   used by QUINN-healthcare, or disclosed to
We will use the information you provide
                                                   others, for research or statistical purposes.
to manage and administer your insurance
policy, including underwriting and claims          Access to non-medical information may be
handling and for money laundering                  granted by QUINN-healthcare to others on a
prevention purposes. In order to provide you       strictly confidential basis in the course of and
with products and services this information        for the purpose of the efficient administration
will be held in the data systems of Quinn          of QUINN-healthcare (for example in
Insurance Ltd (Under Administration) trading       connection with audit, systems development,
as Quinn Healthcare or by our agents or            managing or improving our services.
subcontractors.                                    It is our policy to only take instructions to
Information may also be shared with other          change a policy from the main member, your
insurers, either directly or through people        spouse, civil partner or parent. In some cases
acting for the insurer such as Investigators       we may also deal with other people who call
and where we are entitled to do so under the       on your behalf with your consent. If you would
Data Protection Act. If you have agreed to         prefer that we only deal with you, please let
being contacted by QUINN-healthcare (and/          us know.
or other QUINN group companies) we may             QUINN-healthcare, QUINN-Insurance, QUINN
pass contact details of our female members         Group, and QUINN-Life would like to keep you
aged between 50-64 years to the National           informed about products and services they
Breast Screening Programme.                        provide. If you would prefer not to receive this
We may contact you with a reminder that            information from us, and have not previously
your insurance is due to be renewed. All           advised us of this, please let us know when
incoming and outgoing phone calls may be           you contact us. Your information may also be
recorded or monitored for our joint protection     used for these purposes after your policy has
and for training and quality purposes.             lapsed.

We take our security responsibilities seriously,   If you have any enquiries about your data,
                                                   please write to the Information Protection
employing the most appropriate physical and
                                                   manager, at QUInn-Insurance, eastgate
technical measures, including staff training
                                                   road, eastgate Business Park, little Island,
and awareness. We review our security              Co. Cork.
measures and procedures regularly.
It may be necessary for us to collect sensitive
information (such as medical conditions)
about you and others named on the insurance
policy. By going ahead with this insurance you
20   EssEntial schEmE rulEs and bEnEfits




12. tax relief                                     14. making a complaint
Under current Irish tax legislation you are        We intend to provide a first class service to
entitled to income tax relief in respect of your   our members at all times. However, if you are
subscription. Relief is given at the standard      in any way dissatisfied, please phone or write
rate of income tax. Relief is given by us at       to: The Head of Customer Service,
source which means all our subscriptions are       QUINN-healthcare, Eastgate Road, Eastgate
shown net of the standard rate of income tax.      Business Park, Little Island, Co. Cork.
                                                   Phone: 1890 700 890

13. the financial                                  If you remain dissatisfied you may appeal to
                                                   the Managing Director by writing to him at the
regulator                                          same address.
The financial regulator helps consumers to         QUINN-healthcare takes part in the Insurance
make informed and responsible decisions            Ombudsman Scheme. If you are not satisfied
regarding their financial affairs in a safe and    with our decision or if we haven’t given you a
fair market. If you have any questions about       decision after 40 business days, you have the
your consumer rights contact 1890 777777 or        right to refer your complaint to the Insurance
visit www.financialregulator.ie.                   Ombudsman at: The Financial Services
                                                   Ombudsman Bureau, 3rd Floor Lincoln House,
                                                   Lincoln Place, Dublin 2, Phone: 1890 882090.
                                                   The table of benefits must be read subject to
                                                   the notes which follow the table of benefits.
                                                                 EssEntial schEmE rulEs and bEnEfits   21




QUInn-healthcare                                   healthcare participating hospital list to be fully
                                                   covered under their scheme.
essential starter,                                 We will pay these charges in full for surgical

essential Choice,                                  out-patient treatment if the person receiving
                                                   the surgical out-patient treatment does so in
essential, essential                               a QUINN-healthcare participating hospital

Plus starter, essential                            and that hospital’s costs for the surgical
                                                   out-patient treatment which the person
Health, essential                                  receives are shown in the QUINN-healthcare
                                                   participating hospital list to be fully covered
Plus and essential                                 under their scheme.
Gold scheme table of                               If either the treatment or the category of the

benefits                                           room in which someone stays is not shown
                                                   to be fully covered under their scheme in the
                                                   QUINN-healthcare participating hospital list,
                                                   we will only pay the charges shown in note 1
benefit 1                                          on page 31.

Hospital charges for in-patient                    QUINN-healthcare will only pay benefits for
                                                   drugs prescribed for use whilst receiving
treatment, day-case treatment and
                                                   in-patient treatment, day-case treatment or
surgical out-patient treatment (see
                                                   surgical out-patient treatment.
note 1 on page 31)
                                                   Please remember that QUINN-healthcare
We will pay charges made by QUINN-                 shall deduct ¤50, ¤125 or ¤200 of the claim
healthcare participating hospitals for             depending on the hospital you choose from
providing in-patient treatment, day-               benefits payable under the QUINN-healthcare
case treatment and surgical out-patient            Essential Plus Starter and the Essential Plus
treatment.                                         schemes for each claim for hospital charges for
We will pay these charges in full for in-          treatment in a private hospital in accordance
patient treatment if the person receiving the      with rule 7(n) on page 12. For Essential Health
in-patient treatment does so in a QUINN-           scheme members QUINN-healthcare shall
healthcare participating hospital and that         deduct ¤50 or ¤125 of the claim depending on
hospital’s costs for the in-patient treatment      the hospital you choose from benefits payable
which the person receives are shown in the         for each claim for hospital charges for treatment
QUINN-healthcare participating hospital list       in a private hospital in accordance with rule 7(n)
to be fully covered under their scheme or          on page 12.
they stay in a public ward in a public hospital.   This deduction will not apply if the person
We will pay these charges in full for day-         receiving treatment is a member of the
case treatment if the person receiving the         Essential Plus scheme and QUINN-healthcare
day-case treatment does so in day-case             has agreed to waive the excess for that
accommodation in a QUINN-healthcare                person in return for a higher subscription
participating hospital and that hospital’s         under the scheme (if the excess has been
costs for the day-case treatment which the         waived for you or your dependants, this will
person receives are shown in the QUINN-            be shown on your membership certificate).
22   EssEntial schEmE rulEs and bEnEfits




benefit 2                                           benefit 3
Consultants’ fees for in-patient and                Hospital charges and Consultants’
day-case treatment and Consultants’                 fees for radiotherapy and
and general medical practitioners’                  chemotherapy out-patient treatment
fees for surgical out-patient treatment             (see note 2 on page 36)
(see note 2 on page 36)
                                                    We will pay the following charges for
We will pay consultants’ fees for providing         radiotherapy and chemotherapy out-patient
inpatient treatment, day-case and outpatient        treatment which is received by a person in a
surgical treatment in a QUINN-healthcare            hospital but only if they are fully covered for
participating hospital.                             in-patient treatment or day-case treatment
If a person receives this treatment from a          at that hospital under their scheme:
Consultant who is participating in the full cover    hospital charges
scheme, we will pay the Consultant’s charges
                                                     Full refund (see note 1 on page 31)
in full in accordance with the terms previously
agreed with the Consultant which is the              fees charged by Consultants participating in
                                                     the full cover scheme
amount shown as the full rate in the schedule of
                                                     Full refund in accordance with and up to the
benefits for the treatment they receive.             amount shown as the full rate in the schedule
If they receive the treatment from a                 of benefits for the treatment they receive.

Consultant who is not participating in the full      note 1: Members do not have cover for
                                                     radiotherapy treatment in the Beacon hospital
cover scheme, we will pay the Consultants’
                                                     and the Whitfield Clinic.
fees for these services in accordance with and       note 2: In the cases of chemotherapy,
up to the amount shown as the standard rate          radiotherapy and hemochromatosis carried out
                                                     in private hospitals listed as fully participating,
in the schedule of benefits for the treatment        the excesses of ¤50, ¤125 and ¤200 will apply on
they receive.                                        a per condition, per membership year basis.

We will also pay fees charged by general
medical practitioners for providing surgical
out-patient treatment to them in either a           benefit 4
QUINN-healthcare participating hospital’s           Hospital charges and Consultants’ fees
day surgery facility or in a doctor’s surgery.
                                                    for non surgical out-patient treatment
We will pay these fees in accordance with and
                                                    other than for radiotherapy or
up to the amount shown as the standard rate
in the schedule of benefits for the treatment       chemotherapy (see note 3 on page 36)
they receive.                                       We will pay up to the amount shown for
We will pay benefits under benefit 2 for            the following charges for non-surgical out-
Consultants’ fees for in-patient, day-case and      patient treatment each year other than for
surgical out-patient treatment received in          radiotherapy or chemotherapy.
Northern Ireland participating hospitals in full    We will pay these charges according to the
up to the amounts shown as the participating        scheme of which the person receiving the
rate in the QUINN-healthcare schedule of            treatment is a member subject to the excess
benefits for the treatment they receive. We         and annual limits shown on page 27.
will pay all claims in euro.
                                                                     EssEntial schEmE rulEs and bEnEfits        23




important notE
                                                       6    Consultants’ fees, for consultations other
The payment of benefits under benefits 4 (1)                than in connection with radiology and
                                                            pathology
to 4 (22) inclusive will be made subject to the
excesses shown.                                             Essential choice, Essential, Essential plus
                                                            starter, Essential health, Essential plus and
     fees charged for radiology by Consultants              Essential Gold schemes
 1                                                          Up to ¤51 for each consultation, other
     participating in the full cover scheme
                                                            than to do with maternity and up to ¤400
     Essential choice, Essential, Essential plus            relating to maternity for each pregnancy.
     starter, Essential health, Essential plus and          Essential starter
     Essential Gold schemes                                 Up to ¤51 for each consultation other than
     Full refund in accordance with and up to               to do with maternity
     the amount shown as the full rate in the
     schedule of benefits for Consultants’             7    charges by a participating therapist
     fees for such treatment.                               for homeopathy, chinese medicine/
                                                            acupuncture, chiropractic, osteopathy,
 2   fees charged for pathology by consultants              reflexology. (including baby reflexology).

     Essential choice, Essential, Essential plus            Essential, Essential plus starter, Essential plus
     starter, Essential health, Essential plus and          and Essential Gold schemes
     Essential Gold schemes                                 Up to ¤20 for each visit up to 12 visits per
     Up to ¤20 for each referral                            therapy (other than for reflexology)
                                                            Up to ¤20 for each visit to a reflexologist
3a   Hospital charges or charges by an                      for up to eight visits each year.
     approved diagnostic centre for radiology,
     and                                               8    charges by GPs other than for routine
                                                            maternity
3b   charges for out-patient mri services provided
                                                            Essential choice, Essential, Essential plus
     by an approved hospital or diagnostic centre.
                                                            starter, Essential plus and Essential Gold
     details of approved out-patient mri centres
                                                            schemes
     are available on our website or you can call us
                                                            Up to ¤20 for each consultation.
     for more information
     please note: these hospitals/centres may          9    charges for screening for cervical cancer
     change from time to time so please ask for             and breast examination at a Quinn-
     details.                                               healthcare approved centre
     Essential choice, Essential, Essential plus            Essential choice, Essential, Essential plus
     starter, Essential health, Essential plus and          starter, Essential health, Essential plus and
     Essential Gold schemes                                 Essential Gold schemes
     Full refund up to a maximum of ¤500 per                Up to ¤30 each year.
     member per year. This includes CT scans, MRIs
     and PET scans. MRI scans must be on               10   approved appliances
     GP/Consultant referral
                                                            Essential starter, Essential choice, Essential,
 4   hospital charges or charges by a Quinn-                Essential plus starter, Essential health,
     healthcare approved diagnostic centre for              Essential plus and Essential Gold schemes
     pathology.                                             We will refund up to the amount shown
                                                            for the appliance on QUINN-healthcare’s
     Essential starter, Essential choice, Essential,        list of approved appliances, some of which
     Essential plus starter, Essential health,              require a specific referral letter, please
     Essential plus and Essential Gold schemes              contact us for details.
     Full refund.
     Hospital casualty charges                         11   charges for physiotherapy by a
 5                                                          participating therapist
     Essential choice, Essential, Essential plus            Essential choice, Essential, Essential plus
     starter, Essential health, Essential plus and          starter, Essential plus and Essential Gold
     Essential Gold schemes                                 schemes
     Up to ¤20 for each episode.                            Up to ¤20 for each visit for up to 25 visits
     Essential starter                                      per year
     Up to ¤20 per year
24    EssEntial schEmE rulEs and bEnEfits




 12    home nursing by a nurse for a person                18   fee for an eye test carried out by a
       who is 18 years or over, immediately                     practitioner with the qualification f.a.o.i.
       following in-patient treatment or day-                   (fellow of the association of optometrists
       case treatment, if recommended by the                    of ireland) and/or the cost of glasses and/
       Consultant providing the treatment (see                  or the cost of contact lenses
       note 3 (d) on page 36)
                                                                Essential choice, Essential, Essential plus
       Essential choice, Essential, Essential plus              starter, Essential plus and Essential Gold
       starter, Essential health, Essential plus and            schemes
       Essential Gold schemes                                   Up to a combined maximum of ¤20 each
       Up to ¤40 for each day and up to a                       year
       maximum of 40 days each year.
       Essential starter scheme                            19   charges by a participating therapist for
       Up to ¤40 for each day and up to a                       physical therapy
       maximum of 20 days each year.
                                                                Essential, Essential plus starter, Essential plus
       Emergency dental treatment provided                      and Essential Gold schemes
 13                                                             Up to ¤20 for each visit up to a maximum
       by a dentist for restorative treatment and
       which immediately follows, (i.e. within five             of eight visits each year.
       days) and is required for, a dental injury
       caused by an accidental external impact             20   charges for a Quinn-healthcare approved
                                                                sports health screen at a Quinn-
       to the mouth
                                                                healthcare approved screening centre
       Essential choice, Essential, Essential plus
                                                                Essential, Essential plus starter, Essential
       starter, Essential health, Essential plus and
                                                                health, Essential plus and Essential Gold
       Essential Gold schemes
                                                                schemes
       Up to ¤510 for each accident.
                                                                Up to ¤150 for each visit up to a maximum
       Essential starter
                                                                of one visit every two years
       Up to ¤460 for each accident.

 14    charges for blood tests for prostate                     Additional cover for Essential Plus scheme
       cancer screening at Quinn-healthcare                     members
       approved centres
                                                           21   charges for a Gp health check
       Essential choice, Essential, Essential plus
       starter, Essential health, Essential plus and            ¤50 each year
       Essential Gold schemes
       Up to ¤20 each year.                                     Additional cover for Essential Gold scheme
                                                                members
 15    charges for dental examination
                                                           22   charges for an Executive health check
       Essential choice, Essential, Essential plus
       starter, Essential plus and Essential Gold               ¤100 each year at approved centres. These
       schemes                                                  centres may change from time to time so
       Up to ¤25 each year                                      please call us for a up to date list before
                                                                having your screening.
 16    charges by a participating therapist for
       speech and language therapy (on Gp or
                                                                The following charges will not be subject
       consultant referral), chiropody/podiatry
                                                                to the excesses shown on page 27
       and occupational therapy
       Essential choice, Essential, Essential plus         23   consultants’ fees for up to one pre and
                                                                one post operative consultation relating to
       starter, Essential plus and Essential Gold
                                                                a stay in hospital for in-patient treatment
       schemes
                                                                provided by a consultant
       Up to ¤20 for each consultation for up to
       a maximum of 12 consultations combined                   Essential Gold scheme
       each year. For Essential Gold members                    up to ¤65 for each consultation
       we allow 1 speech & language therapy
       assessment, if billed, up to ¤77.

 17    charges by a participating therapist for
       dietetic advice
       Essential, Essential plus starter, Essential plus
       and Essential Gold schemes
       Up to ¤25 for each consultation for up to a
       maximum of five consultations each year.
                                                                     EssEntial schEmE rulEs and bEnEfits      25




24   charges for mri services provided by a            29   breast prosthesis
     hospital or a Quinn-healthcare approved
     laboratory or diagnostic centre, that has              Essential starter, Essential choice, Essential,
     been approved by Quinn-healthcare for                  Essential plus starter, Essential health,
     direct payment for mri services. these may             Essential plus and Essential Gold schemes
     change from time to time. mri scans have to            Full refund for the first prosthesis following
     be on a general practitioners or consultant            receipt of an in-patient claim. Subsequent
     referral. please ask us for details                    prosthesis will be assessed in accordance
                                                            with our appliance list (please ask for
     Essential starter, Essential choice, Essential,        details). A GP/Consultant report will be
     Essential plus starter, Essential health,              required if QUINN-healthcare have no details
     Essential plus and Essential Gold schemes              of in-patient treatment.
     Full refund
                                                       30   hairpiece
25   charges for breast mri services provided
     by a hospital or a Quinn-healthcare                    Essential starter, Essential choice, Essential,
     approved diagnostic centre, that has been              Essential plus starter, Essential health,
     approved by Quinn-healthcare for direct                Essential plus and Essential Gold schemes
     payment for breast mri services. these                 Full refund for one hairpiece per year
     may change from time to time. breast mri               following cancer treatment
     scans have to be on a consultant referral.
     please ask us for details.                        31   charges by a participating therapist for
                                                            manual lymph drainage
     Essential starter, Essential choice, Essential,
     Essential plus starter, Essential health,              Essential starter, Essential choice, Essential,
     Essential plus and Essential Gold schemes              Essential plus starter, Essential health,
     Full refund                                            Essential plus and Essential Gold schemes
                                                            Up to ¤500 each year following cancer
26   charges for ct services provided by a                  treatment
     hospital or a Quinn-healthcare approved
     laboratory or diagnostic centre, that has         32   accommodation assistance grant for
     been approved by Quinn-healthcare for                  cancer patients travelling for out-patient
     direct payment for ct services. these may              radiotherapy or chemotherapy treatment
     change from time to time. please ask us
     for details                                            Essential starter, Essential choice, Essential,
                                                            Essential plus starter, Essential health,
     Essential starter, Essential choice, Essential,        Essential plus and Essential Gold schemes
     Essential plus starter, Essential health,              Up to ¤100 for each day of treatment
     Essential plus and Essential Gold schemes              travelling a minimum of 40 miles to the
     Full refund                                            treatment centre

27   charges for pEt services provided by a            33   charges for dExa services provided by a
     hospital or a Quinn-healthcare approved                hospital or a Quinn-healthcare approved
     laboratory or diagnostic centre, that has              laboratory or diagnostic centre, that has
     been approved by Quinn-healthcare for                  been approved by Quinn-healthcare for
     direct payment for pEt services. these                 direct payment for dExa services. these
     may change from time to time. please ask               may change from time to time. please ask
     us for details.                                        us for details.

     Essential starter, Essential choice, Essential,        Essential starter, Essential choice, Essential,
     Essential plus starter, Essential health,              Essential plus starter, Essential health,
     Essential plus and Essential Gold schemes              Essential plus and Essential Gold schemes
     Full refund                                            Full refund

28   home nursing by a nurse for a child under         34   charges for mammogram services
     18 years of age immediately following                  provided by a hospital or a Quinn-
     in-patient treatment of not less than five             healthcare approved laboratory or
     continuous days, if recommended by the                 diagnostic centre, that has been approved
     Consultant providing the treatment (see                by Quinn-healthcare for direct payment
     note 3(d) on page 36)                                  for mammogram services. these may
                                                            change from time to time. please ask us
     Essential choice, Essential, Essential plus            for details.
     starter, Essential health, Essential plus and
     Essential Gold schemes
     Up to ¤100 for each day up to a maximum                Essential starter, Essential choice, Essential,
     of 28 days each year                                   Essential plus starter, Essential health,
                                                            Essential plus and Essential Gold schemes
                                                            Full refund
26   EssEntial schEmE rulEs and bEnEfits
                                                                 EssEntial schEmE rulEs and bEnEfits   27




excess and overall                                  for treatment that you receive each year if
                                                    you have no dependants.
annual limits                                       EssEntial hEalth schEmE mEmbErs:
We will pay valid claims for fees and charges       If you are a member of Essential Health
covered under Benefit 4 for treatment that          scheme, your overall annual limit shall be
you and your dependants receive each                ¤6,400 a year in aggregate. Your excess shall
year up to your overall annual limit with the       be the first ¤250 of valid claims in aggregate
exception of your excess referred to below.         for treatment that you and your dependants
(Please note that your overall annual limit         receive each year if you have dependants or
and excess, which applies to both you and
                                                    the first ¤150 of valid claims for treatment
your dependents together, depends on the
                                                    that you receive each year if you have no
scheme that you hold and not the scheme
                                                    dependants.
of your dependents with the exception of
Essential Starter and Essential Health).
                                                    EssEntial plus schEmE mEmbErs:
EssEntial startEr and EssEntial                     If you are a member of the Essential Plus
choicE schEmE mEmbErs:                              scheme, your overall annual limit shall be
If you are a member of the Essential Starter and    ¤6,400 a year in aggregate. Your excess shall
Essential Choice schemes, your overall annual       be the first ¤440 of valid claims in aggregate
limit shall be ¤6,400 a year in aggregate. Your     for treatment that you and your dependants
excess shall be the first ¤300 of valid claims
                                                    receive each year if you have dependants or the
in aggregate for treatment that you and your
                                                    first ¤220 of valid claims for treatment that you
dependants receive each year if you have
                                                    receive each year if you have no dependants.
dependants or the first ¤150 of valid claims for
treatment that you receive each year if you
have no dependants.                                 ESsEntial Gold schEmE mEmbErs:
                                                    If you are a member of the Essential Gold
EssEntial schEmE mEmbErs:                           scheme, your overall annual limit shall be
If you are a member of the Essential scheme,        ¤6,400 a year in aggregate. Your excess shall
your overall annual limit shall be ¤6,400 a year    be the first ¤380 of valid claims in aggregate
in aggregate. Your excess shall be the first ¤470   for treatment that you and your dependants
of valid claims in aggregate for treatment that     receive each year if you have dependants of the
you and your dependants receive each year if        first ¤220 of valid claims for treatment that you
you have dependants or the first ¤250 of valid      receive each year if you have no dependants.
claims for treatment that you receive each year
if you have no dependants.                          spEcial notE for bEnEfits 4(1), 4(2),
                                                    4(3) and 4(4)
EssEntial plus startEr schEmE                       We will pay valid claims for fees and charges
mEmbErs:                                            for treatment covered under Benefits 4(1),
If you are a member of the Essential Plus           4(2), 4(3) and 4(4) up to an overall annual
Starter scheme, your overall annual limit           limit for all such fees and charges combined
shall be ¤6,400 a year in aggregate. Your           for such treatment each year of ¤1,650.66 (if
excess shall be the first ¤440 of valid claims      you have dependants) and ¤825.33 (if you
in aggregate for treatment that you and your        have no dependants) with the exception of
dependants or the first ¤220 of valid claims        your excess for such fees and charges. Your
28    EssEntial schEmE rulEs and bEnEfits




excess shall be the first ¤380.92 of valid              member of the Essential scheme
claims in aggregate for such treatment that           • ¤3,500 in respect of a person who is
you and your dependants receive each year,              a member of the Essential Plus Starter
if you have dependants or the first ¤190.46 of          scheme
valid claims in aggregate for such treatment          • ¤4,000 in respect of a person who is a
                                                        member of the Essential Health scheme
each year if you have no dependants.
                                                      • ¤4,000 in respect of a person who is a
The payment of any benefits under benefit               member of the Essential Plus scheme
4(1), 4(2), 4(3) and 4(4) will count towards
                                                      • ¤3,900 in respect of a person who is a
your overall annual limit under benefit 4.              member of the Essential Gold scheme
A valid claim means a claim for payment of              We will also pay Consultants’ fees for
fees and charges covered by benefit 4 of not            Consultants’ services provided in respect
more than the amount shown in the table of              of a delivery in a hospital up to the
benefits as payable by QUINN-healthcare for             amounts specified for those services in
those fees and charges.                                 the schedule of benefits, subject to the
                                                        overall maximum amount payable.
important notE                                          The overall maximum amount payable by
Please note that out-patient receipts will not be       QUINN-healthcare for services provided
returned following assessment of your claim.            by Consultants in respect of a delivery
Please retain copies of your receipts prior             in hospital is ¤846.43 in total and ¤298
to submission, if you require these. We have            for Essential Starter and Essential Choice
confirmed with the Revenue Commissioners                members. This is the total amount
that the statement of your claims may be used           payable overall and not the total amount
to claim tax relief on expenses that are not            payable for each Consultant or service.
paid by us. Simply send this statement to the           These benefits are payable in lieu of any
Revenue Commissioners with a Med 1 form,                benefits payable under Benefit 1 and 2.
which is available on www.revenue.ie/forms/
                                                    (b) we will pay benefit up to a maximum of
med1.pdf. There is no longer a need for you             ¤2,500 for a person who is a member of
to send your original receipts to the Revenue           the Essential scheme, ¤3,100 for a person
Commissioners to claim tax relief.                      who is a member of the Essential Plus
                                                        Starter scheme, ¤4,000 for a member of
                                                        the Essential Health Scheme, ¤4,000 for a
benefit 5                                               member of the Essential Plus scheme and
matErnity bEnEfits                                      ¤3,900 for a member of the Essential Gold
(a) for each delivery in a hospital we will             scheme on receipt of invoices and a signed
    pay the hospital charges for up to three            claim form from a midwife registered with
                                                        An Bord Altranais/G.P. for a normal delivery
    nights accommodation in semi-private
                                                        at home with your G.P’s or Consultant’s
    or private accommodation up to a
                                                        approval.
    maximum value of:
                                                        Benefits for a caesarean delivery are
     • ¤400 in respect of a person who is a             payable in accordance with benefits 1 and 2.
       member of the Essential Starter and
       Essential Choice schemes; or
     • ¤3,100 in respect of a person who is a
                                                                EssEntial schEmE rulEs and bEnEfits   29




benefit 6                                         Plus Starter members for each episode of
                                                  illness or injury of ¤70,000 and ¤100,000 for
convalEscEncE (Which is not in-                   Essential Health, Essential Plus and Essential
patiEnt trEatmEnt in a rEGistErEd                 Gold Scheme members for treatment received
nursinG homE)                                     outside Ireland by you or your dependants in an
We will pay nursing home fees for up to           emergency because of a sudden illness or injury
14 days convalescence which is not in-            whilst travelling temporarily outside Ireland.
patient treatment in a registered nursing         This limit applies to each episode of illness or
home following in-patient treatment but           injury. An episode means a continuous period of
only if the stay is solely for medical reasons    illness or injury. Periods of illness separated by
connected with the in-patient treatment and       less than 28 days shall be treated as continuous.
a Consultant confirms this to us in writing.
                                                  We will also pay up to ¤2,000,000 towards the
We will pay each day up to ¤32 for members
                                                  cost of repatriating a person back to Ireland, or
of the Essential Starter scheme, ¤40 per day
                                                  nearest medically appropriate country, to receive
for members of the Essential Choice scheme,
                                                  treatment for which they are covered under
¤45 for members of the Essential scheme,
                                                  the scheme if whilst travelling abroad they need
¤50 for members of the Essential Plus Starter
                                                  the treatment in a medical emergency and the
scheme, ¤55 for members of the Essential
                                                  treatment is not available in the country in which
Health scheme, ¤55 for members of the
                                                  they are travelling. This limit will apply to each
Essential Plus scheme and ¤75 for members
                                                  person per year.
of the Essential Gold scheme.
                                                  In such circumstances we will also pay up
We will only pay benefits if the convalescence
                                                  to ¤1,000 towards the reasonable cost of
follows in-patient treatment for which benefits
                                                  repatriating to Ireland, or nearest medically
were payable by us under the scheme.
                                                  appropriate country, any one relative or
                                                  companion who was travelling with them at

benefit 7                                         the time.
                                                  We will only pay the costs of repatriation if
trEatmEnt in thE Eu                               the repatriation is arranged by a QUINN-
Benefits are also payable for in-patient          healthcare approved repatriation company.
treatment received at a hospital in the EU        This company can be contacted on
which is certified by QUINN-healthcare’s          +353 25 30002.
Medical Adviser as unavailable in Ireland
                                                  If a case is being managed by QUINN-
provided that such treatment is arranged by
                                                  healthcare’s approved repatriation company,
QUINN-healthcare and the hospital is pre-
                                                  the member must indicate at the outset
approved by QUINN-healthcare. This benefit
                                                  whether they hold separate travel insurance in
needs to go through Consultant Connections.
                                                  respect of their trip abroad.
                                                  You must notify QUINN-healthcare in writing if
benefit 8                                         you wish to instigate any action against a third
                                                  party following an accident abroad. Please refer
EmErGEncy ovErsEas covEr
                                                  to the Third Party section of this booklet.
We will pay benefits for in-patient treatment
up to an overall amount in total for Essential
Starter, Essential Choice, Essential, Essential
30   EssEntial schEmE rulEs and bEnEfits




benefit 9
mEdical tourism
QUINN-healthcare will subject to pre-authorisation, provide cover for medically necessary surgical
procedures in the EU. The level of benefit will be limited to the maximum of the benefit that would
have been paid in respect of the same surgical procedures, including Consultant fees, in Ireland,
and to a maximum level of cover your plan allow or lesser amount if the overseas cost is less. The
benefit is subject to QUINN-healthcare’s normal rules and exclusions. Waiting periods and pre
existing condition waiting periods will apply. You must contact us beforehand so that we can
advise you on the steps involved in approving your treatment.
                                                                 EssEntial schEmE rulEs and bEnEfits   31




note 1                                              will refund the charges covered under benefit
                                                    1 in full for such treatment less ¤262 (¤260
We will pay benefits under benefit 1 and 3 as       on Essential Choice) for Tier 1 hospitals, ¤420
follows, if the hospital charges for treatment      (¤400 on Essential Choice) for Tier 2 hospitals
are not shown in the QUINN-healthcare               for each day of treatment.
participating hospital list to be fully covered
under the member’s chosen scheme.                   (ii) trEatmEnt rEcEivEd by EssEntial
                                                    startEr and EssEntial choicE
                                                    schEmE mEmbErs at thE matEr
(i) trEatmEnt rEcEivEd by EssEntial                 privatE hospital, thE bEacon
startEr and EssEntial choicE                        hospital or thE blacKrocK clinic.
schEmE mEmbErs at a Quinn-
                                                    There is no cover for Essential Starter and
hEalthcarE participatinG hospital
othEr than thE matEr privatE, thE                   Essential Choice members at this hospital
bEacon hospital or thE blacKrocK
clinic.                                             (iii) trEatmEnt rEcEivEd by EssEntial
If the treatment the member receives at the         schEmE mEmbErs at a Quinn-
hospital is in-patient treatment in private         hEalthcarE participatinG hospital
accommodation and the minimum plan                  othEr than thE matEr privatE, thE
                                                    bEacon hospital or thE blacKrocK
required for full cover for the hospital charges
                                                    clinic.
for such treatment as shown in the QUINN-
                                                    If the treatment the member receives at the
healthcare participating hospital list is the
                                                    hospital is in-patient treatment in private
Essential Plus or Essential Gold scheme, we
                                                    accommodation and the minimum plan
will refund the charges covered under benefit
                                                    required for full cover for the hospital charges
1 in full for such treatment less ¤262 (¤260
                                                    for such treatment as shown in the QUINN-
on Essential Choice) for Tier 1 hospitals, ¤420
                                                    healthcare participating hospital list is the
(¤400 on Essential Choice) for Tier 2 hospitals
                                                    Essential Plus or Essential Gold scheme, we
for each day of treatment if the minimum
                                                    will refund the charges covered under benefit
plan required for full cover is the Essential
                                                    1 in full for such treatment less ¤255 for each
Gold scheme or less ¤262 (¤260 on Essential
                                                    day of treatment if the minimum plan required
Choice) for Tier 1 hospitals, ¤420 (¤400 on
                                                    for full cover is the Essential Gold scheme
Essential Choice) for Tier 2 hospitals for each
                                                    or less ¤55 for each day of treatment if the
day of treatment if the minimum plan required
                                                    minimum plan required for full cover is the
for full cover is the Essential Plus scheme. If
                                                    Essential Plus scheme.
the treatment the member receives is in a
private room of a public hospital, a shortfall of   If the treatment the member receives at the
¤55 for each day of treatment will apply.           hospital is in-patient treatment in semi-
                                                    private accommodation, day-case treatment
                                                    or surgical out-patient treatment and the
If the treatment the member receives at
                                                    minimum plan required for full cover for
the hospital is in-patient treatment in semi
                                                    the hospital charges for such treatment as
private accommodation, day-case treatment
                                                    shown in the QUINN-healthcare participating
or surgical out-patient treatment and the
                                                    hospital list is the Essential Plus scheme, we
minimum plan required for full cover for
                                                    will refund the charges covered under benefit
the hospital charges for such treatment as
                                                    1 in full for such treatment less ¤255 for each
shown in the QUINN-healthcare participating
                                                    day of treatment.
hospital list is the Essential Plus scheme, we
32   EssEntial schEmE rulEs and bEnEfits




(iv) trEatmEnt rEcEivEd by EssEntial                  (vi) trEatmEnt rEcEivEd by EssEntial
schEmE mEmbErs at thE matEr privatE                   hEalth schEmE mEmbErs at a Quinn-
hospital, thE bEacon hospital or thE                  hEalthcarE participatinG hospital
blacKrocK clinic                                      othEr than thE matEr privatE
                                                      hospital, thE bEacon clinic or thE
If the member receives in-patient treatment,
                                                      blacKrocK clinic
day-case treatment or surgical out-patient
                                                      If the treatment the member receives at
treatment in the Mater Private hospital, the
                                                      the hospital is in-patient treatment in
Beacon hospital or the Blackrock Clinic, we
                                                      private accommodation and the minimum
will refund the hospital charges for such
                                                      plan required for full cover for the hospital
treatment covered under benefit 1 in full less
                                                      charges for such treatment as shown in the
¤510 for each day of treatment.
                                                      QUINN-healthcare participating hospital
                                                      list is the Essential Plus scheme, we refund
(v) trEatmEnt rEcEivEd by thE                         the charges covered under benefit 1 in full for
EssEntial plus startEr schEmE
                                                      such treatment less ¤197.00, ¤119.00, ¤38.00
mEmbErs in thE participatinG
                                                      depending on public hospital used, for each
hospitals listEd on thE tablE bEloW
                                                      day of treatment.




trEatmEnt rEcEivEd by thE EssEntial plus startEr schEmE mEmbErs
Participating Public Hospitals             Full cover for a private room in participating public hospitals

Participating Private Hospitals            Cover                         Excess     Shortfalls for Private
                                                                                       Accommodation

Galway Clinic                              semi-private and daycase        ¤125                     ¤189
St Vincents Private                        semi-private and daycase        ¤125                     ¤105
The Hermitage                              semi-private and daycase        ¤125                     ¤105
Whitfield Clinic                           semi-private and daycase        ¤125                     ¤105

Park West Clinic Dublin 12                 private accommodation            ¤50
Auteven Hospital, Kilkenny                 private accommodation            ¤50
Barringtons Hospital, Limerick             private accommodation            ¤50
Cahercalla Hospital, Co Clare              private accommodation            ¤50
Clane Hospital, Co Kildare                 private accommodation            ¤50
Millbrook Clinic, Bandon, Cork             private accommodation            ¤50
National MS Centre, Rathgar                private accommodation            ¤50
Northbrook Clinic, Dublin                  private accommodation            ¤50
Shandon Street Private Hospital, Cork      private accommodation            ¤50
Shanakiel Private Hospital, Cork           private accommodation            ¤50
St Francis Private Hospital, Mullingar     private accommodation            ¤50
St Joseph’s Garden Hill, Sligo             private accommodation            ¤50

Mater Private Hospital                     No Cover
The Blackrock Clinic                       No Cover
The Beacon Hospital                        No Cover
                                                                 EssEntial schEmE rulEs and bEnEfits   33




If the treatment the member receives at the        (ix) trEatmEnt rEcEivEd by EssEntial
hospital is in-patient treatment in semi-          plus schEmE mEmbErs at thE matEr
private accommodation and the minimum              privatE hospital, thE bEacon
                                                   hospital or thE blacKrocK clinic.
plan required for full cover for the hospital
charges for such treatment as shown in the         If the member receives in-patient treatment at
QUINN-healthcare participating hospital list       the Mater Private hospital, the Beacon hospital
is the Essential Plus scheme we will refund        or Blackrock Clinic we will refund the hospital
the charges covered under benefits 1 in full       charges covered under benefit 1 in full for such
for such treatment less ¤150 for each day of       treatment less ¤255 for each day of treatment.
treatment in the Bons Secours hospitals only.      If the member receives day-case or surgical
We will also refund the charges covered under      out-patient treatment at the Mater Private
benefit 1 in full for treatment less ¤250 for      hospital, the Beacon hospital or Blackrock Clinic
private accommodation in the Bons Secours          we will refund the hospital charges covered
hospitals for each day of treatment and less       under benefit 1 in full for such treatment, less the
¤210 for all other private accommodation in        deduction referred to below.
private hospitals.                                 Please note, QUINN-healthcare shall deduct
                                                   ¤50, ¤125 or ¤200 of the claim, depending
(vii) trEatmEnt rEcEivEd by EssEntial              on the hospital you choose from the benefits
hEalth schEmE mEmbErs at thE matEr                 payable under the QUINN-healthcare
privatE hospital, thE bEacon clinic                Essential Plus scheme for each claim for
or thE blacKrocK clinic.                           hospital charges for treatment in a private
Members on Essential Health are covered            hospital in accordance with rule 7 (n) on
for certain cardiac procedures in the Mater        page 12. This shall apply in addition to the
Private Hospital only. There is no cover           deduction referred to above.
on Essential Health for Blackrock Clinic or
                                                   This deduction will not apply if QUINN-
Beacon Hospital.
                                                   healthcare has agreed to waive the excess for
                                                   that person in return for a higher subscription
(viii) trEatmEnt rEcEivEd by                       under the scheme. If the excess has been
EssEntial plus schEmE mEmbErs at
                                                   waived, this will be shown on the person’s
a Quinn-hEalthcarE participatinG
hospital othEr than thE matEr                      membership certificate.
privatE hospital, thE bEacon                       Please note that no cover is provided at these
hospital or blacKrocK clinic                       hospitals for treatment received by Essential
If the treatment the member receives at the        Plus Starter scheme members.
hospital is in-patient treatment in private
accommodation and the minimum plan                 (x) northErn irEland
required for full cover for the hospital charges   Notwithstanding Rule 8(g) QUINN-healthcare
for such treatment as shown in the QUINN-          will pay hospital charges covered under benefit
healthcare participating hospital list is the      1 in full for in-patient, day-case or surgical
Essential Gold scheme, we will refund the          out-patient treatment received at the following
charges covered under benefit 1 in full for such   hospitals in Northern Ireland less ¤125 per claim,
treatment less ¤127 for each day of treatment.     in accordance with rule 7(n) on page 12, if the
                                                   member is an Essential Plus member and we
                                                   have not agreed to waive the excess.
34   EssEntial schEmE rulEs and bEnEfits




For members of the Essential Plus scheme we         and the Beacon hospital, Dublin for certain
will pay hospital charges, less ¤127 per night if   types of specialist cardiac surgery under the
the treatment is carried out in a private room      Essential, Essential Plus and Gold schemes.
in one of the hospitals listed below.               A list of the specialist cardiac surgery for
The North West Independent Hospital, Derry          which we will pay benefits in full at these
                                                    hospitals is available on request. *Please
The Ulster Independent Clinic, Belfast for
                                                    note: For Essential Starter, Essential Choice
members of Essential Starter and Essential
                                                    and Essential Plus Starter members we will
Choice we will pay the charges less ¤420 per
                                                    provide essential cardiac cover in the Beacon
night. For members of the Essential scheme
                                                    Hospital and the Mater Private hospital only.
we will pay the charges less ¤255 per night.
                                                    For Essential Health members we will provide
Please note, these Northern Ireland hospitals
                                                    certain cardiac cover in Mater Private hospital
are not covered on the Essential Plus Starter
                                                    only.
scheme.We will pay all claims in euro.

                                                    (xv) cahErcalla hospital, Ennis;
(xi) Regarding the amounts listed at notes          northbrooK clinic, dublin ; parK
(i) - (iiv) that we will deduct for each day        WEst clinic, dublin 12.
of treatment that you receive in a QUINN-           We will only pay benefits for day-case and
healthcare participating public hospital that       surgical out-patient treatment at these
is not shown to be fully covered under the          hospitals. This applies to the Essential Starter,
member’s chosen scheme, we reserve the              Essential Choice, Essential, Essential Plus
right to change these amounts by up to 20%          Starter, Essential Health, Essential Plus and
on an annual basis.                                 Essential Gold schemes. We will not pay for
                                                    other types of treatment at these hospitals.
(xii) Regarding the amounts listed at notes
(i) - (v) that we will deduct for each day          (xvi) st. francis, mullinGar, st.
of treatment that you receive in a QUINN-           JosEph’s, GardEn hill.
healthcare participating private hospital that      We will only pay for surgical admissions at
is not shown to be fully covered under the          these hospitals. We will not pay for other
member’s chosen scheme, we reserve the              types of treatment at these hospitals.
right to change these amounts by up to 20%
on an annual basis.
                                                    (xvii) forEst trEatmEnt cEntrE
(xiii) minimum bEnEfit rEGulations                  We will only pay benefits for up to three weeks
Despite anything to the contrary in the rules       of in-patient treatment for alcoholism, drugs
                                                    or substance abuse at this centre each year
and table of benefits of the scheme, you may
                                                    less ¤800 per claim. This is also subject to the
claim any benefits we are required to pay
                                                    maximum limit of 91 days in any continuous
under the minimum benefit regulations.
                                                    period of five years.

(xiv) matEr privatE hospital,                       (xviii) WhitE oaKs trEatmEnt cEntrE,
blacKrocK clinic, GalWay clinic and                 dErryvanE, muff, donEGal.
thE bEacon hospital
                                                    We will only pay benefits for up to 28 days of
We will provide a full refund for hospital
                                                    inpatient treatment for alcoholism, drugs or
charges for treatment received in the Mater
                                                    substance abuse at this centre each year. This is
Private hospital, the Blackrock Clinic, Dublin,     subject to the maximum limit of 91 days in any
EssEntial schEmE rulEs and bEnEfits   35
36   EssEntial schEmE rulEs and bEnEfits




continuous period of five years.                        that have been approved for MRI is also
                                                        available on request.
(xix) stanhopE cEntrE,
                                                    (c) Fees charged for radiology by
GranGEGorman; mid-WEstErn                               Consultants not participating in the full
radiation oncoloGy cEntrE, limEricK                     cover scheme.
We will only pay benefits for out-patient               If you receive such treatment from a
treatment at these hospitals. We will not pay           Consultant who is not participating in
for other types of treatment at these hospitals.        the full cover scheme, we will pay the
                                                        consultants’ fees for these services in
(xx) shandon strEEt privatE hospital                    accordance with and up to the amount
                                                        shown as the standard rate in the schedule
We will only pay for certain types of surgical
                                                        of benefits for this type of treatment.
admissions at this hospital. We will not pay for
other types of treatment at this hospital. Please
ask us for details of treatments covered.           (d) Home nursing
                                                        We will only pay benefits for home
                                                        nursing if the home nursing followed
note 2                                                  in-patient treatment for which benefits
                                                        were also payable.
If you receive treatment from a Consultant who
is not participating in the full cover scheme, we       QUINN-healthcare will only pay benefits
will pay the Consultants’ fees for these services       for receiving home nursing if the sole
in accordance with and up to the amount                 purpose of home nursing is to enable
shown as the standard rate in the schedule of           you to reduce the period of in-patient
benefits for the treatment you receive.                 treatment.


                                                    (e) Emergency dental injury treatment
note 3                                                  QUINN-healthcare will only pay
                                                        benefits for restorative dental treatment
(a) Hospital and consultants’ charges for
                                                        immediately following an accident.
    radiology and pathology
      QUINN-healthcare will only pay fees and
      charges for radiology and pathology           (f) Speech and language therapy, chiropody
      if and to the extent that the radiology           and occupational therapy
      or pathology consists of one or more              The maximum number of consultations
      radiological procedures or pathological           we say we will pay for is the overall
      investigations listed in the minimum              number of consultations we will pay for
      benefit regulations.                              any and all such treatment each year and
                                                        not for each type of treatment separately.

(b) QUINN-healthcare approved laboratory,
    screening, diagnostic centres and suppliers.
      The list of QUINN-healthcare approved
      laboratory, screening, diagnostic centres
      and suppliers is available on request.
      The list of those hospitals and centres
        EssEntial schEmE rulEs and bEnEfits   3




you should keep
your membership
certificate and booklet
together to help
answer any queries
about your policy.
                    at the Quinn Group, we take particular pride in the quality and
                    diversity of our products.

                    nowhere is this more important than in the benefits developed
                    for healthcare cover.

                    our benefits include:

                    •   Excellent maternity cover
                    •   complementary medicines
                    •   competitive prices
                    •   hospital cover
                    •   students and apprentices charged at a child rate
                    •   online services
                    •   cardiac and cancer cover

                    While every care has been taken to ensure the accuracy of the
                    information in this brochure, unfortunately Quinn-healthcare
                    cannot accept responsibility for any errors which may occur.




                    for further information:

                    Call us today on 1890 700 890,
                    visit our website on www.quinn-healthcare.com
                    or you can email info@quinn-healthcare.com
                    with any questions about your membership.
                    Calls may be recorded for training
                    and quality purposes.

                    QUInn-healthcare are proud to sponsor the
                    People of the year Awards




                    QUInn-healthcare
                    Eastgate road, Eastgate business park,
                    little island, co. cork.
                    e: info@quinn-healthcare.com
                    w: www.quinn-healthcare.com




QH-enmr-025-01/11   your insurance is provided by Quinn insurance limited (under administration), trading as
                    Quinn-healthcare, which is regulated by the central bank of ireland.

				
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