Download Simply Personal Health Connections

Simply Personal Health
Your policy document and guide
Connections network
Diagnosis
Treatment
Heart and cancer
Effective from 1 April 2015
Contents
3 Before joining Simplyhealth
3 Switching from another insurer
4 Your Simply Personal Health policy document
5 Section 1: Benefits
16 Section 2: General exclusions
19 Section 3: Making a claim
20 Section 4: Who can join the policy?
20 Section 5: Cancelling the policy,
cancelling membership
22 Section 6: No claims discount
23 Section 7: Legal points
24 Section 8: Definitions
26 Section 9: Data protection
26 Section 10: Customer care
28 Appendix 1 - What is a chronic condition?
30 Appendix 2 - Understanding the underwriting options
31 Appendix 3 - Explaining cover for cancer
2
Your Simply Personal Health policy document: Connections network
What is
Simply Personal Health?
Switching from another
insurer
Simply Personal Health gives the flexibility to choose cover
options that pay for diagnosis, treatment for acute heart
conditions and cancer, and treatment for other acute
conditions. Acute conditions are illnesses and injuries that
are likely to respond quickly to treatment, leading to your
full recovery and returning you to the state of health you
were in before suffering that episode of ill health. In common
with many other private medical insurance products,
Simply Personal Health does not cover treatment and
monitoring of chronic conditions. These are conditions that
tend not to be ‘cured’ but are often managed, meaning that
treatment continues indefinitely (you can find the full definition
for a chronic condition in section 8: Definitions).
If you have a private medical insurance policy with another
insurer and you wish to switch to Simply Personal Health,
we may accept your application and apply the personal
medical exclusions that your current insurer applies to the
policy you have now. If you have a moratorium policy, we
will use the date your current policy was effective from as
the start date of your Simply Personal Health policy. We
will ask you some medical questions about your health
since you bought your current policy. We’ll also need to
see a membership certificate from your current insurer.
When we have received the information that we ask for,
we will assess your application. In order for us to consider
your switch to Simply Personal Health, there must be no
break in cover between your current policy ending and the
Simply Personal Health policy starting.
Before joining
Simplyhealth
Insurance policies provide cover against an unexpected
event happening after the start of the policy. For
Simply Personal Health this usually means cover for the
cost of private medical treatment for unforeseen medical
conditions arising after the policy starts. For the purposes of
deciding whether a condition is pre-existing or not, if you are
transferring from another policy with no break in cover, we
will consider that the date your previous policy was effective
from is the start date for your Simply Personal Health policy.
Important: the cover offered by different policies
is unlikely to be the same. You should compare
the Simply Personal Health policy document with
policy information from your current insurer. If you
have any questions about the cover that we offer on
Simply Personal Health, please call us on 0800 328 1202.
The policy does not cover conditions that you already have
before the policy starts – these are called ‘pre-existing
conditions’. Conditions that are related to pre-existing
conditions are also not covered. A related condition is
one that is caused by, or could be the cause of, another
condition. For example, if you suffer from diabetes, we would
not pay for treatment of eye disorders which occur as a
result of having diabetes, for example diabetic retinopathy.
The policy will not cover all medical treatment. Please read
the policy and your membership certificate carefully to see
which benefit choices the policyholder has made, and the
‘exclusions’ section to see what the policy does not cover. If
you have any questions, please call us on 0800 328 1202.
Your Simply Personal Health policy document: Connections network
3
Your Simply Personal
Health policy document
This is your Simply Personal Health policy document. It
tells you exactly what is and isn’t covered so that you
can get the most from the policy.
This document sets out what you need to know about the
benefits as well as the terms and conditions of the policy. It
also gives you information about making changes to your
membership and how to make a claim. You should read
it together with your individual membership certificates,
which shows any personal underwriting terms that apply to
your cover. The policy document, membership certificate,
summary of cover, hospital network and the information the
policyholder gave us whilst applying for the policy, form the
contract with us.
Making information about us accessible
We aim to make information about us accessible to you,
whatever your needs, and information is available in large
print or audio.
Your benefits explained
The tables show you the wide range of benefits available
under the Simply Personal Health Connections policy – your
membership certificate will show you which benefit choices
the policyholder has made for you.
A key feature of this policy is that we will put you in contact
with a hospital in order to arrange most of the consultations,
tests and treatment that the policy covers (there are some
complementary therapies – for example acupuncture,
podiatry / chiropody which are exceptions to this rule. We
will tell you about this if you need to call us to make a claim).
If your GP feels that you need to see a specialist, we will
select a suitable local hospital for that referral. The hospital
will make an appointment with a specialist with the relevant
expertise to investigate your symptoms, at a time convenient
for you (subject to availability). We will pay the treatment
provider directly, but we only cover consultations, tests and
treatment arranged through the helpline.
Certain words are shown in bold type throughout this
policy wording. These are defined terms and have specific
meanings. The explanations for these words are in section 8:
Definitions.
How to contact us
If you need to discuss any aspect of your membership, call
our freephone number and our friendly and dedicated team
will be pleased to help you.
Membership helpline: 0800 294 6796
The helpline operates Monday - Friday from 8am – 6pm,
except Bank Holidays.
Your calls may be recorded and monitored for training and
quality assurance purposes.
Email: [email protected]
How to claim
Call our claims helpline on 0800 328 1202 before arranging
any private treatment so that we can advise you what the
policy covers. If you do not call us and then incur costs not
covered by the policy, we will not be responsible for paying
those costs.
Email: [email protected]
If the tests or treatment that you need are covered by
the policy, our helpful staff will give you authorisation over
the phone. In most cases it’s as simple as that (although
there are some circumstances when we might need more
information – we’ll send you a form with instructions for who
needs to complete it if that is the case).
We will ask you to pay the excess when you call us to claim.
We also recommend that you call us if you need any further
treatment, so you can ensure that you are still covered.
4
Your Simply Personal Health policy document: Connections network
Section 1: Benefits
We will pay for diagnostic tests and treatment (we pay for treatment provided that you have cover under the ‘Treatment
cover’ option) for an acute condition when:
• your GP has referred you to a specialist
and
• the specialist arranges the diagnostic tests and treatment.
We clearly state any circumstances where we will pay for diagnostic tests and treatment that a GP arranges without making
a referral to a specialist.
After deducting your excess we pay all benefits in full unless we have stated a specific limit.
1.1 What you’re covered for
Diagnosis cover
‘Diagnosis cover’ pays for diagnostic tests and consultations with a specialist in order for the specialist to diagnose your
condition, and some tests on GP referral. ‘Diagnosis cover’ does not pay for treatment of your symptoms or condition. We
will only pay for treatment that you receive if you have cover under the ‘Treatment cover’ option.
Important: You must arrange all consultations and diagnostic tests through our helpline. We will choose the provider (for
example the hospital – it is the hospital which will allocate a specialist with the relevant expertise to see you). If you have
consultations and diagnostic tests which you have not arranged through the helpline, we will not pay any of the costs. This
could leave you with a large bill that you will have to pay to the provider.
Diagnosis cover
Full cover
Benefit
Details of cover
1
Specialists’ fees for consultations and
diagnostic tests
We pay for consultations with a specialist and specialists’ fees
for diagnostic tests that you need in order to diagnose your
condition.
2
Diagnostic tests
If a specialist refers you for tests, we will pay for all diagnostic
tests that you need in order to diagnose your condition (this
includes tests where you need to be admitted to hospital, for
example endoscopy, laparoscopy).
We will pay for blood tests, X-rays and scans (including CT, MRI
and PET scans) on GP referral in order to diagnose your condition.
3
NHS cash benefit
We will give you £250 for each admission that you have as a daypatient or each night when you are an in-patient if you choose to
be admitted for diagnostic tests:
-- free of charge as an NHS patient rather than as a private patient
and
-- we would have paid for the tests as a private patient.
We will not pay NHS cash benefit for out-patient diagnostic tests
(for example a CT scan), or for diagnostic tests that we would not
pay for as a private patient (for example further tests after you have
been diagnosed).
Your Simply Personal Health policy document: Connections network
5
4
Pain in your joints or muscles
If you have pain or stiffness in your joints or muscles, you do not
have to see your GP in order to find out what is causing the pain
- call our Rapid Access Physiotherapy service on 0800 328 1202.
The service will arrange for a physiotherapist to call you and assess
your condition, giving you advice and appropriate exercises to
help you recover more quickly. If you need to see a physiotherapist
for face to face consultation in order to find out what is wrong, the
service will refer you to a physiotherapist near where you live or
work and we will pay the cost of one session in order to make a
diagnosis.
5
Private ambulance
We will pay for a private road ambulance if you have been admitted
to a hospital as an in-patient or day-patient for diagnostic tests
covered by the policy and:
• it is medically necessary for you to travel to another hospital for
those diagnostic tests
and
• your specialist says that you are not fit to travel by any other
form of transport.
6
Parent accompanying child
We will pay hospital charges for one parent to stay overnight in
the hospital while their child receives diagnostic tests as an
in-patient that are covered by this policy.
Exclusions that apply to ‘diagnosis cover’
Treatment – we will pay for treatment only if you have
cover under the ‘Treatment cover’ option. We will pay
for treatment of a heart condition or cancer only if you
have cover under ‘Treatment for heart and cancer’.
6
Angiogram – we will pay for an angiogram only if you
have cover under the ‘Heart and cancer cover’ option.
Consultations and diagnostic tests after your GP or
specialist has given you a diagnosis.
Routine or ongoing consultations or monitoring.
General exclusions (section 2).
Your Simply Personal Health policy document: Connections network
Choice: Treatment cover
Important: You must arrange all treatment through our helpline. We will choose the treatment provider (for example the
hospital – it is the hospital which will allocate a specialist with the relevant expertise to see you). If you receive treatment
which you have not arranged through the helpline, we will not pay any of the costs. This could leave you with a large bill that
you will have to pay to the provider.
Treatment cover
Your membership certificate will show if the policyholder has chosen ‘Treatment cover’ for you.
Benefit
7
Details of cover
Hospital charges for treatment and tests
This benefit includes:
surgery
treatment with drugs (for example intravenous antibiotics, or
injections)
treatment as an in-patient, day-patient and out-patient
tests that you need to ensure that you are well enough to
receive any planned treatment
follow-up tests that you need for up to three months
after your treatment has finished to check whether any
treatment you have received has been successful
prostheses:
-- we pay in full for prostheses implanted during an
operation, for example hip or knee replacements
-- we will pay up to £5,000 for an external prosthesis, for
example a false leg or eye (we will pay towards one
prosthesis only for each body part that is replaced).
We will not pay hospital charges for drugs and dressings
that you take home from hospital as a result of treatment
as an in-patient or day-patient.
8
Specialists’ fees for tests and treatment
9
Specialists’ fees for consultations
We pay for one consultation to plan your treatment
We pay specialists’ fees for tests and treatment in full.
We pay for consultations with your specialist whilst you are
having ongoing treatment
We pay for one follow-up consultation after your treatment
has finished.
10
Physiotherapy
If you have pain or stiffness in your joints or muscles,
you do not have to see your GP in order to get a
referral - call our Rapid Access Physiotherapy service
on 0800 328 1202. The service will arrange for a
physiotherapist to call you and assess your condition,
giving you advice and appropriate exercises to help you
recover more quickly. If you need to see a physiotherapist
for a face to face consultation the service will refer you
to a physiotherapist near where you live or work. If
physiotherapy is not suitable, or not working, the service
will ensure that you are referred towards the best clinical
pathway, for example seeing a specialist.
If you have been referred to a specialist who then
recommends physiotherapy (for example following surgery),
we will pay in full.
For GP referred physiotherapy you must use the Rapid
Access Physiotherapy service.
Your Simply Personal Health policy document: Connections network
7
11
Complementary therapies - osteopathy,
chiropody / podiatry, chiropractic, acupuncture,
homeopathy
If you have been referred to a specialist who then
recommends complementary therapy (for example following
surgery), we will pay in full.
If you have been referred for complementary therapy by a
GP, we will pay up to £500 each policy year.
For GP referred therapy you may have to pay the bill
yourself and then claim the costs back from us. If you
need physiotherapy you must use the Rapid Access
Physiotherapy service (benefit 10), and we will pay the
physiotherapist directly.
12
Dental surgery – for specific conditions only
We pay for treatment of these conditions in line with the rules for
other benefits on this policy - for example hospital charges are
paid according to the hospital charges benefit.
We pay for dental surgery for treatment of specific conditions
carried out by:
• a dentist in the Simplyhealth Denplan Network
or
• in a hospital by an oral and maxillofacial specialist.
These conditions are:
surgical removal of unerupted teeth that are impacted or
buried
surgical removal of complicated buried roots
removal of the tip of a tooth’s root (apicectomy)
which are causing you pain or causing repeated infections, and
13
Psychiatric treatment
surgical removal of cyst from the jaw bone (enucleation of
cyst)
replanting of existing teeth after an accidental dental injury.
We will refer you to the Simplyhealth Mental Health
Management service – this service will offer you a face to
face consultation to assess your condition and refer you
to the treatment pathway that you need. This may include
counselling, psychological therapy services (for example
cognitive behavioural therapy - CBT) or a referral to a
psychiatric specialist.
We will only pay for treatment that you have arranged
through this service.
If you need to be admitted to hospital as an in-patient
or day-patient we will pay for treatment, or NHS cash
benefit, for up to 28 days or nights in total each policy
year.
8
Your Simply Personal Health policy document: Connections network
14
Complications of pregnancy and childbirth –
specific conditions only
We pay for treatment of these conditions in line with the rules
for other benefits in ‘Treatment cover’ - for example hospital
charges are paid according to the hospital charges benefit. We
will pay for hospital treatment in specific circumstances only.
These are:
ectopic pregnancy
stillbirth
hydatidiform mole
post partum haemorrhage
miscarriage
retained placental membrane
caesarean sections – we will pay for an emergency caesarean
section if:
• there is an immediate risk to the life or health of the mother
or baby, or
• the baby needs to be delivered early.
If you choose to give birth as a self funded private patient and
then need an emergency caesarean section, we will only pay
the extra cost that is above the cost of a normal delivery as a
private patient.
We will pay for treatment, care and monitoring of a premature
baby, but this will be limited to 28 days from the baby’s date of
birth.
We do not pay for surgery to a foetus.
We will not pay for complications of pregnancy and
childbirth until you have been covered by the policy for 10
months.
15
NHS cash benefit
We will give you £250 for each admission that you have as
a day-patient or each night when you are an in-patient if
you choose to be admitted for tests or treatment:
• free of charge as an NHS patient rather than as a private
patient
and
• we would have paid for the tests or treatment as a
private patient.
We will not pay NHS cash benefit for tests or treatment
as an out-patient (for example a CT scan), or for tests or
treatment that we would not pay for as a private patient (for
example rehabilitation / convalescence, or an admission for
a pre-existing condition or a chronic condition).
16
Private ambulance
We will pay for a private road ambulance if you have been
admitted to a hospital as an in-patient or day-patient for
tests or treatment covered by the policy and:
• it is medically necessary for you to travel to another
hospital for those diagnostic tests or treatment
and
• your specialist says that you are not fit to travel by any
other form of transport.
Your Simply Personal Health policy document: Connections network
9
17
Home nursing
We will pay for a nurse to administer treatment to you at
home if:
• you were admitted to hospital as a day-patient or an
in-patient for treatment covered by the policy
and
• you could be discharged but need to finish treatment
that you would normally receive in a hospital - for
example, a course of intravenous antibiotics
and
• your specialist remains in charge of your treatment.
We will not pay for a nurse to provide personal care, for
example help with washing or dressing, or childcare.
18
Parent accompanying child
19
New child payment
We will pay hospital charges for one parent to stay
overnight in the hospital while their child receives tests or
treatment as an in-patient that are covered by this policy.
£150 each child
We will give the policyholder £150 when a child is born
to or adopted by them. The policyholder must have been
a member on the policy for at least 10 months when the
child is born or adopted.
We will not pay new child payment for adoption if the child is
already a member of:
• the policyholder’s family (for example a niece or a
grandchild)
or
• the policyholder’s partner’s family.
Exclusions that apply to ‘Treatment cover’
Treatment for cancer – we will pay for cancer
treatment only if you have cover under ‘Treatment for
heart and cancer’.
Treatment for a heart condition – we will pay for heart
treatment only if you have cover under ‘Treatment for
heart and cancer’.
10
Your Simply Personal Health policy document: Connections network
General exclusions (section 2).
Choice: Treatment for heart and cancer
Simply Personal Health gives the option to:
• cover heart conditions and cancer in full
• limit cover to £50,000 for heart conditions and £50,000 for cancer during the time that you are covered by the policy
or
• not cover any treatment for heart conditions or for cancer.
Important: You must arrange all treatment through our helpline. We will choose the treatment provider (for example the
hospital – it is the hospital which will allocate a specialist with the relevant expertise to see you). If you receive treatment
which you have not arranged through the helpline, we will not pay any of the costs. This could leave you with a large bill that
you will have to pay to the provider.
Treatment for heart conditions
Your membership certificate will show if the policyholder has chosen ‘Treatment for heart and cancer’ for you and, if so,
whether or not the cover is in full or limited to £50,000 for heart conditions
Benefit
20
Details of cover
Treatment for heart conditions
Treatment for heart conditions, for example open heart
surgery or angiogram (sometimes called a cardiac catheter),
stabilisation following a heart attack, prostheses implanted
during an operation, for example a pacemaker.
We pay specialists’ fees for treatment in full.
If we pay for an electronic device, we will not pay for the
replacement of consumables, for example batteries or
leads, or replacement of the device itself.
We will not pay hospital charges for drugs and dressings
that you take home from the hospital.
21
Monitoring
We will pay for post-surgery consultations and tests to
monitor you for a period of two years following treatment
that we have paid for.
22
End of life care
If your specialist confirms that you need end of life care,
we will make a payment of £500 to you to spend as you
wish.
23
NHS cash benefit
We will give you £250 for each admission that you have as
a day-patient or each night when you are an in-patient if
you choose to be admitted for tests or treatment:
• free of charge as an NHS patient rather than as a private
patient
and
• we would have paid for the tests or treatment as a
private patient.
We will not pay NHS cash benefit for tests or treatment
as an out-patient (for example a CT scan), or for tests or
treatment that we would not pay for as a private patient
(for example rehabilitation / convalescence, or an admission
for a pre-existing condition or a chronic condition).
24
Private ambulance
We will pay for a private road ambulance if you have been
admitted to a hospital as an in-patient or day-patient for
tests or treatment covered by the policy and:
• it is medically necessary for you to travel to another
hospital for those tests or treatment
and
• your specialist says that you are not fit to travel by any
other form of transport.
Your Simply Personal Health policy document: Connections network
11
25
Home nursing
We will pay for a nurse to administer treatment to you at
home if:
• you were admitted to hospital as a day-patient or an
in-patient for treatment covered by the policy
and
• you could be discharged but need to finish treatment
that you would normally receive in a hospital - for
example, a course of intravenous antibiotics
and
• your specialist remains in charge of your treatment.
We will not pay for a nurse to provide personal care, for
example help with washing or dressing, or childcare.
26
Parent accompanying child
We will pay hospital charges for one parent to stay
overnight in the hospital while their child receives tests or
treatment as an in-patient that are covered by this policy.
Treatment for cancer
Your membership certificate will show if the policyholder has chosen ‘Treatment for heart and cancer’ for you and, if so,
whether or not the cover is in full or limited to £50,000 for cancer.
We want you to have a clear understanding of what the policy does and does not cover for cancer treatment. If you ever
need treatment for cancer, we will offer you personal telephone support from a nurse case manager. We will guide you
through your treatment programme and explain what treatment is covered under the policy. Your nurse case manager
will be there to authorise treatment and support your care whether this is given privately or through the NHS. Remember,
we are always here to help. You can find examples of how cancer cover works in practice in Appendix 3: Explaining cover
for cancer.
Benefit
27
Details of cover
Surgery for cancer
We will pay for surgery for cancer. We pay specialists’ fees
for surgery in full.
We will pay up to £5,000 for an external prosthesis,
for example a false leg or eye (we will pay towards one
prosthesis only for each body part that is replaced).
28
Reconstruction
We will not pay hospital charges for drugs and dressings
that you take home from the hospital as a result of surgery
for cancer.
We will pay for one reconstruction operation within five
years of surgery for cancer, and in the case of breast
cancer:
• one operation to reconstruct that breast
and
• one further operation to improve the symmetry of your
breasts.
We will not pay for further cosmetic operations to a
reconstructed breast. We will not pay hospital charges for
drugs and dressings that you take home from the hospital
as a result of reconstructive surgery for cancer.
29
12
Radiotherapy
We will pay for radiotherapy at a hospital in your chosen
network.
Your Simply Personal Health policy document: Connections network
30
Chemotherapy
We will pay for chemotherapy:
• which aims to cure your cancer or induce a remission
and
• if the drug is licensed by the European Medicines Agency
(EMEA) and used for the purpose for which it is currently
licensed.
In addition, during the time that you are covered by the
policy we will pay up to a maximum of 12 months for
chemotherapy:
• whilst you are in remission
• to keep your cancer stable and prevent disease
progression (this is sometimes called maintenance
therapy) or as palliative treatment.
31
Side effects of treatment
Whilst you are receiving chemotherapy or radiotherapy that
we pay for, we will also pay for treatment prescribed by
your specialist that you need to deal with any side effects,
for example:
• antibiotics
• anti-sickness drugs
• steroids
• pain killers
• drugs to boost your immune system
• blood transfusions.
32
Cancer services
Treatment for cancer can mean that you need a variety of
services. If your specialist recommends it, we will pay for
treatment or advice from:
• a dietician, to stabilise your diet following surgery,
chemotherapy or radiotherapy
• a stoma nurse, to show you how to care for your stoma
• a specialist nurse to show you how to manage
lymphoedema.
33
Monitoring
We will pay for consultations with a specialist and tests to
monitor your condition for five years after the last treatment
for cancer that we paid for on this policy.
34
Wigs
If you suffer hair loss as a result of treatment for cancer
that we have paid for (or paid NHS cash benefit for), we will
pay up to £250 towards the cost of a wig. We will only pay
for one wig whilst you are covered by this policy.
35
Preventative treatment
We will pay for surgery to prevent further cancer only if we
have already paid for treatment for cancer – for example,
we will pay for a mastectomy to a healthy breast in the
event that you have been diagnosed with cancer in the
other breast.
We will not pay for treatment where you have no
symptoms of cancer, for example if you have surgery for
preventative reasons because you have a strong family
history of cancer such as breast cancer, or bowel cancer.
36
End of life care
If your specialist confirms that you need end of life care,
we will make a payment of £500 to you to spend as you
wish.
Your Simply Personal Health policy document: Connections network
13
37
NHS cash benefit
We will give you £250 for each admission that you have as
a day-patient or each night when you are an in-patient if
you choose to be admitted for tests or treatment:
• free of charge as an NHS patient rather than as a private
patient
and
• we would have paid for the tests or treatment as a
private patient.
If you choose to have chemotherapy or radiotherapy as an
NHS patient that we would pay for as a private patient, we
can offer an alternative NHS cash benefit payment. Your
nurse case manager will be able to discuss this with you.
We will not pay NHS cash benefit for tests or treatment
as an out-patient (for example a CT scan), or for tests or
treatment that we would not pay for as a private patient (for
example rehabilitation / convalescence, or an admission for
a pre-existing condition).
38
Private ambulance
We will pay for a private road ambulance if you have been
admitted to a hospital as an in-patient or day-patient for
tests or treatment covered by the policy and:
• it is medically necessary for you to travel to another
hospital for those tests or treatment
and
• your specialist says that you are not fit to travel by any
other form of transport.
39
Home nursing
We will pay for a nurse to administer treatment to you at
home if:
• you were admitted to hospital as a day-patient or an
in-patient for treatment covered by the policy
and
• you could be discharged but need to finish treatment
that you would normally receive in a hospital - for
example, a course of intravenous antibiotics
and
• your specialist remains in charge of your treatment.
We will not pay for a nurse to provide personal care, for
example help with washing or dressing, or childcare.
40
Parent accompanying child
Exclusions that apply to ‘Treatment for heart and cancer’
Any costs over £50,000 for treatment of heart
conditions during the time that you are covered by the
policy if the policyholder has chosen limited cover for
‘Treatment for heart and cancer’.
14
We will pay hospital charges for one parent to stay
overnight in the hospital while their child receives tests or
treatment as an in-patient that is covered by this policy.
Any costs over £50,000 for treatment of cancer during
the time that you are covered by the policy if the
policyholder has chosen limited cover for ‘Treatment
for heart and cancer’.
General exclusions (section 2).
Your Simply Personal Health policy document: Connections network
1.2 Excess
Your policy has an excess. This means that we will pay
for costs covered by the policy, minus the amount of the
excess. We apply the excess to each member, every policy
year (not necessarily for each claim that you make). This
means, for example, that if a claim continues from one policy
year to the next, the excess will apply again.
For example, if you have a £300 excess and you incur costs
of £1,000 in a policy year, you will pay the first £300 and
we will pay the rest. If the tests or treatment carry on into
the next policy year, another excess will apply so you will
again pay the first £300 of costs that you incur in that policy
year.
1.3 Important note on payment of
hospital charges
Simply Personal Health offers three hospital networks:
Metropolitan, National and Connections. The policyholder
has chosen Connections (your membership certificate shows
this). For details of the hospitals covered by each network
you can call us or visit: www.simplyhealth.co.uk/hospital-list
• the provider of treatment or services, for example the
specialist or hospital.
A key feature of this policy is that we will put you in contact
with a hospital in order to arrange most of the consultations,
tests and treatment that the policy covers (there are some
complementary therapies – for example acupuncture,
podiatry / chiropody which are exceptions to this rule. We
will tell you about this if you need to call us to make a claim).
If your GP feels that you need to see a specialist, we will
select a suitable local hospital for that referral. The hospital
will make an appointment with a specialist with the relevant
expertise to investigate your symptoms, at a time convenient
for you (subject to availability). We will pay the treatment
provider directly, but we only cover consultations, tests and
treatment arranged through the helpline.
We do not apply the excess to NHS cash benefits, telephone
consultations through the Rapid Access Physiotherapy
service, new child payment or end of life care benefit.
1.4 Being treated in the appropriate
clinical setting
We prefer you to pay the excess to us directly as this makes
claims payment simpler for you as you will not need to pay
the provider at a later date.
We will only pay for tests and treatment that take place
in the appropriate clinical setting. For example, we would
pay for a CT scan as an out-patient, but not for you to be
admitted as a day-patient or in-patient in order to have a
CT scan unless there was a medical reason for this and we
agreed with your specialist that it was medically necessary.
When you make your first claim in a policy year, you can
pay the excess to:
• us over the phone by debit or credit card
or
Your membership certificate will show the excess amount
that applies to your cover.
Your Simply Personal Health policy document: Connections network
15
Section 2: General
exclusions
Cosmetic treatment
We do not pay for treatment to:
If we have applied exclusions specifically to you as a result of
any pre-existing conditions that you have or have had, you
can see these on your membership certificate. We will not
pay costs for tests or treatment that you have not arranged
through our helpline.
• remove tissue that is not diseased – for example fat, or
surplus skin
AIDS and HIV
We do not pay for treatment of:
• AIDS (Acquired Immune Deficiency Syndrome)
• HIV (Human Immunodeficiency Virus)
or
• any related condition of AIDS or HIV.
Addictions and substance abuse
We do not pay for treatment - for example surgery, drugs or
psychiatric treatment – for:
• addictions - for example alcohol addiction or drug
addiction
• substance abuse - for example alcohol abuse or solvent
abuse
or
• any illness or injury you develop directly or indirectly as a
result of any substance abuse or addiction, for example:
-- hepatitis
-- cirrhosis
-- oesophageal varices
-- psychiatric conditions.
Chronic conditions
We do not pay for routine treatment of a chronic
condition, for example drugs to keep the condition stable or
consultations to monitor the condition.
We will pay for treatment for an acute flare-up of a
chronic condition if:
• you need to be admitted to hospital as an in-patient
for that treatment
and
• the treatment aims to quickly stabilise your chronic
condition
and
• the flare-up was unexpected (for example we will not
pay for recurring in-patient admissions which may be
a natural consequence of your chronic condition, and
which happen on a regular or predictable basis).
We will not pay for an acute flare up of a chronic condition
which is a pre-existing condition.
Appendix 1 at the back of this document shows examples of
how we manage claims for chronic conditions.
• change your appearance - for example a facelift, tummy
tuck or breast enlargement
• put right any past treatment to change your appearance or
remove tissue that is not diseased
whether or not you have the treatment for medical or
psychological reasons.
We will pay for one reconstructive operation to restore
your appearance if that treatment is needed as a result
of either:
• an accident that happened whilst you were covered
by this policy
or
• surgery for cancer that we paid for, or that we paid
NHS cash benefit for.
We will only pay for a reconstructive operation if it takes
place within five years of the accident or cancer treatment,
and there has been no break in cover since then.
Dental treatment
We do not pay for any dental treatment except for the
operations listed in the ‘dental surgery’ benefit.
Developmental or behavioural problems
We do not pay for treatment for developmental or
behavioural problems, or learning difficulties or delayed
speech disorders, for example:
• dyslexia including investigations and assessments
• attention deficit hyperactivity disorder (ADHD)
• autism.
Dialysis
We do not pay for regular planned kidney dialysis for
treatment of a chronic condition.
We will pay for short-term kidney dialysis:
• if you are an in-patient receiving treatment for another
condition which we are paying for and you need your
regular kidney dialysis during this admission
or
• if you need it as a result of secondary kidney failure
during treatment as an in-patient for another condition
which we are paying for.
Drugs, dressings and medical appliances
We do not pay for:
• drugs, medicines or dressings that you take home as
a result of having tests or treatment - for example,
painkillers and bandages
• surgical, medical or dental equipment - for example, neck
supports, shoe implants (orthotics), braces and dentures
• hearing aids or cochlear implants, contact lenses or
glasses
or
• mobility aids - for example wheelchairs or crutches.
16
Your Simply Personal Health policy document: Connections network
This exclusion does not apply to a prosthesis or an
electronic device such as a pacemaker. However, even
if we pay for an electronic device, we will not pay for the
replacement of consumables, for example batteries or
leads, or replacement of the device itself.
1. Moratorium
We do not cover costs for any pre-existing condition, or
any related condition, if you had:
Whilst you are receiving chemotherapy or radiotherapy
that we pay for, we will also pay for treatment prescribed
by your specialist that you need to deal with any side
effects.
• diagnostic tests for
• symptoms of
• medication for
• treatment for
or
• advice about
Experimental or unproven treatment
We do not pay for treatment that we consider to be
experimental.
that condition in the five years before you joined the policy.
However, this exclusion will not apply if you do not have:
There are a number of factors which will help us decide
whether or not your proposed treatment is experimental or
unproven. For example, we will not exclude treatment for
your condition as experimental if it:
• symptoms of
• is widely used in the NHS
or
• the National Institute for Health and Care Excellence (NICE)
has reviewed the treatment and agrees that, on both its
safety and efficacy, there is adequate evidence to support
its general use
• is a drug that has been licensed for use in the UK and that
is being used within the terms of its licence.
We will also consider information such as published clinical
evidence, and discuss the matter with your specialist to
help us make a reasonable decision.
Eyesight
We do not pay for treatment for short sight or long sight, for
example glasses, contact lenses or laser eyesight surgery.
We will pay for treatment of an eyesight problem which is
an acute condition - for example a cataract or detached
retina.
GP treatment and charges
We do not pay for tests or treatment provided by a GP.
• medication for
• diagnostic tests for
• treatment for
• advice about
that condition during a continuous two year period after you
join the policy.
2. Full medical underwriting (FMU)
We do not cover costs for any pre-existing condition,
or any related condition, unless you told us about that
condition on the application form and we did not apply an
exclusion for it.
Your membership certificate will show any personal medical
exclusions that we have applied to your cover. We will
review your personal medical exclusion(s) at the renewal
date if you ask us to. We will not alter or remove a personal
medical exclusion if the excluded medical condition (or any
related condition) is likely to need treatment in the future.
There are some medical exclusions that we will not review for example, exclusions for chronic conditions.
3. Continued personal medical exclusions (CPME or
CME)
This can only apply to members who were fully medically
underwritten on another policy and then transferred to this
policy.
Medical information, claim forms
We do not pay for charges or fees for medical information
in support of your claim, for example a GP’s charge for
completing a form or a specialists’ charge for sending us
a medical report or a treatment plan. These fees are your
responsibility.
We will pay for you to see an independent medical examiner
if we have asked for a second opinion on your condition or
proposed treatment.
Overseas treatment
We do not pay for any costs that you incur outside the UK.
Pre-existing conditions
The policyholder has chosen the underwriting which applies
to your cover - whether, and how, we will consider preexisting conditions when we assess a claim. There are
five possible methods of underwriting – your membership
certificate will show which type applies to you. Appendix
2 at the back of this document gives examples of how
moratorium and full medical underwriting work in practice.
We apply the personal medical exclusions for pre-existing
conditions that were applied by your previous insurer.
Your membership certificate will show any personal medical
exclusions that we have applied to your cover.
4. Continued moratorium
This can only apply to members who were insured on a
moratorium basis on another policy and then transferred to
this policy.
We do not cover costs for any pre-existing condition, or
any related condition, if you had:
• symptoms of
• medication for
• diagnostic tests for
• treatment for
Your Simply Personal Health policy document: Connections network
17
or
• advice about
that condition in the five years before your initial date of
cover. Your initial date of cover is the date you started cover
with your first insurer (provided there has been no break in
cover since then).
However, this exclusion will not apply if you do not have:
• symptoms of
• medication for
• diagnostic tests for
• treatment for
or
• advice about
that condition during a continuous two year period after your
initial date of cover.
5. Medical history disregarded (MHD)
We do not apply any personal medical exclusions to your
cover as a result of pre-existing conditions.
Pregnancy, childbirth and fertility treatment
We do not pay for:
• childbirth
• termination of pregnancy
• fertility treatment or diagnostic tests for fertility
• surgery on a baby that hasn’t been born (a foetus)
• any form of contraception – for example drugs, devices or
surgery.
We will pay for:
• the conditions listed in the ‘complications of pregnancy
and childbirth’ benefit
• the treatment, care and monitoring a premature baby
needs - this is limited to the first 28 days from the date
of birth.
Preventative treatment
We do not pay for treatment to prevent a disease or illness
– for example:
• a vaccination
• tests or check ups to look for a disease or illness if you do
not have symptoms – for example health screens
• genetic tests
• routine tests, check ups or consultations for a chronic
condition.
If we have paid for, or paid NHS cash benefit for, your
cancer treatment, we will pay for tests and consultations
with a specialist to monitor you for five years after you
finish treatment for the cancer.
We will pay for post-surgery tests and consultations to
monitor you for a period of two years following heart
treatment that we have paid for.
Self-inflicted injury
We do not pay any costs that you incur as a result of an
injury that you deliberately inflicted upon yourself – for
example following an attempted suicide.
Sport – professional sportsmen and women and
dangerous sports
We do not cover any costs that you incur as a result of an
injury sustained whilst you
are:
• training for or taking part in sport for which you are paid,
or funded by sponsorship or grant (unless you receive
travel costs only)
or
• taking part in a dangerous sport.
Transplants
We do not pay for any element of treatment involving any
form of transplant, for example:
• organ transplant – for example a heart, or a kidney
• stem cell or bone-marrow transplant
• body part transplant – for example a hand
• plasmapheresis.
We will pay for skin grafts and corneal grafts if you need
them for treatment of an acute condition.
War and dangerous substance contamination
We do not pay for treatment of any illness or injury caused
directly or indirectly by:
• surgery to remove a healthy breast to avoid cancer where
you have no symptoms of breast cancer whatsoever.
• war (whether war has been declared or not)
Rehabilitation, convalescence and general nursing care
We do not pay for:
• acts of terrorism
• rehabilitation
• convalescence
• nursing home care
• hospital charges if the reason you are in hospital is that
you need help with mobility, personal care or preparation
of meals, even if the policy covered your admission when
you were first admitted.
Screening and monitoring
We do not pay for:
• military or paramilitary activity
• contamination from radioactivity, or chemical or biological
agents.
Weight loss treatment
We do not pay for:
• bariatric surgery (weight loss surgery) - for example gastric
banding or a gastric bypass
• the removal of fat or surplus tissue
or
• treatment of complications from bariatric surgery or the
removal of fat or surplus tissue.
• routine medical examinations – for example sight or
hearing tests
18
Your Simply Personal Health policy document: Connections network
Section 3: Making a
claim
3.2 Confirming cover for your claim
We are here to help. We know that, when you are ill, a
friendly and efficient claims service is very important. We
want to make claiming as easy as possible.
If your GP refers you to a specialist, please call our claims
helpline on 0800 328 1202. Our helpful staff will discuss
your claim with you and put you in contact with a hospital
from our network in order to arrange tests or treatment that
the policy covers. We will only pay costs for services that
you have arranged through the helpline - we will not accept
any liability for any claims for services which you have not
arranged through this helpline. If you incur costs for services
that you have not arranged through the helpline, this could
leave you with a bill that you will have to pay to the provider.
If you need hospital tests or treatment, we will pay for
a private room if you need one, wherever possible in a
hospital within 25 miles of your home. In most cases it’s as
simple as that, although there are some circumstances when
we might ask you to complete a form.
When you call it makes the process easier if you can tell us:
• your name and policy number (we will carry out a
brief identity check by asking you to confirm personal
information that we hold about you). If the claim is for
someone else, for example a child, we will need their
details too
• the medical condition or symptoms that you are suffering
from
• your GP’s name, address and phone number
• the date that you first visited a GP about this medical
condition or symptoms
• the plan that the GP is recommending, for example the
name of the medical specialty that you are being referred
to (for example orthopaedics).
We can give you guidance on exactly what the policy will
pay for, offering you peace of mind at a worrying time. We
can also highlight any costs that we will not pay, helping you
make an informed decision about your care..
We look after the small details that can make such a big
difference, authorising and helping make arrangements at
a time to suit you (subject to availability) and then settling
accounts directly with your specialist and hospital.
3.1 Assessing your claim
If we need more medical information (for example we may
give the doctor a form to complete, or ask for a medical
report), we will ask for your consent to approach the relevant
doctor or medical professional for this. You do not have to
give your consent, but if we cannot obtain the information
that we need to assess your claim, we will not be able to
pay the costs. We will not be liable for any charges for more
medical information (although if we arrange for you to see an
independent medical examiner we will pay for this).
Once we have the information that we need to assess your
claim, we will be able to make a decision about whether
or not the policy will pay for your consultation, diagnostic
tests or treatment (based on the choices that the
policyholder has made for your cover). We will normally tell
you over the phone, although we will write to you with the
details if you ask us to.
We will ask you to pay your excess over the phone. This
means that we can settle bills with providers like hospitals
and specialists more quickly, and you will not need to pay
the provider at a later date, although you can choose to
pay the excess directly to the provider if you wish. Your
membership certificate will show the excess amount that the
policyholder has chosen for your cover.
Please call us if you need further treatment or tests. We can
then assess whether or not this is treatment or tests that
the policy will pay for. If you need treatment or a series of
treatments that will last for some time, we can offer you a
personal contact in our claims team who can help you every
step of the way.
3.3 Paying claims
We pay invoices directly and promptly to the providers (for
example the hospital or specialist). If a provider gives you
an invoice but does not ask for immediate payment, just
send it to us along with your membership details. If it is for
services that the policy covers, we will pay the provider
directly. If the provider asks you to pay immediately, please
send us the receipted invoice along with your membership
details. If it is for services that the policy covers, we will
reimburse you. We will write to you with details of any
payments we make, and to tell you how much excess you
have paid.
3.4 Second opinions
Your rights
If you have a consultation with a specialist and you and
your GP are unhappy with the outcome, we will pay for a
second opinion where there are medical grounds to support
this. Just call us and follow the steps for making a claim.
Our rights
In order to assess any claim that you make, we have the
right to obtain a second opinion from an independent
medical examiner if it is reasonable for us to do so. If the
independent medical examiner needs to examine you
personally (rather than making an assessment from a report),
we will make the arrangements at a time and place that is
suitable for you.
3.5 Claims – important notes
We will only pay for costs if the policy is ‘in force’ at the time
you incur those costs. This means that the policyholder
has paid the premium for the period of time during which
you incurred the costs. For example, if we have received the
premium covering the period until the end of January and
you have treatment in February, we will not pay the claim
if we have not received the premium for February. If your
specialist has planned a course of treatment, or a series of
treatments over a period of time, it is your responsibility to
check with us if we will pay for that continued treatment.
Your Simply Personal Health policy document: Connections network
19
We will not pay for any costs that you incur if the
policyholder has not paid the premium for the period of
time when you incur those costs – even if we have given
authorisation.
When we authorise your claim, that authorisation is
valid for three months from the date given for your first
appointment (provided that the premiums are paid). If the
original appointment is cancelled for any reason and is not
rearranged within three months of your original authorisation
date, the authorisation will lapse. We strongly recommend
that you call us for new authorisation before going on to
have any consultation, test or treatment.
We will not be responsible for any charges made for an
appointment that you do not attend.
Only we can confirm whether or not we will pay a claim.
You should not rely on the advice of a provider, for example
a specialist or a hospital, about what the policy covers.
If you are unsure whether or not the policy covers any
proposed tests or treatment please call our helpline on
0800 328 1202.
4.2 Adding newborn babies to the
policy
For babies born after the policy started and who are added
to the policy within three months of being born, we will:
• not apply any personal medical exclusions to the baby’s
cover, regardless of the baby’s health
and
• not charge a premium for that baby until the next policy
year.
Section 5: Cancelling
the policy, cancelling
membership
5.1 When we can cancel the policy
3.6 What to do in an emergency
We can cancel the policy if:
If you need emergency tests or treatment, please go to
your nearest NHS emergency department. If you have
received emergency tests or treatment in an NHS hospital
and then need further non-urgent treatment that the policy
covers, you may be able to transfer to a private hospital.
You can call us on 0800 328 1202 to check whether the
policy covers your transfer and tests or treatment.
• the policyholder has
Section 4: Who can join
the policy?
• we decide to no longer offer this product at the renewal
date. If this happens, we will offer an alternative product, if
we have one, in order for cover to continue.
The people who can be included are:
• the policyholder
• the policyholder’s husband, wife, civil partner or someone
who lives with the policyholder as if they were their
husband, wife or civil partner (the policyholder’s partner)
• the policyholder’s children (this includes children of the
policyholder’s partner).
All members on this policy must have the same hospital
list and the same excess, but members can have different
benefit choices.
This policy is for people who live in the UK. If you move
outside the UK, you must tell us because the policy may not
be suitable for your needs.
4.1 Adding members to the policy
The policyholder can ask us to add a new partner or a
child to the policy at any time. If we need the policyholder
or the potential member to complete an application form,
we will tell them. We do not have to accept an application to
join the policy.
-- not fully paid the premium within 30 days of the date it
was due to be paid
-- deliberately misled us in any way, for example given us
false information, or not given us information that we
have asked for about a person on the policy or a claim
on the policy
-- not acted honestly in any of their dealings with us.
We will not cancel your cover as a result of the number, or
the cost, of claims that you make, although we may adjust
premiums to reflect the risk of further claims.
5.2 When the policyholder can cancel
the policy
This is an annual policy.
The policyholder can cancel the policy for any reason up to
14 days from either:
• the day they receive the policy documents
or
• the day on which we receive payment of the first premium
each policy year
whichever happens later - this applies for a new policy or
following a renewal date. Provided that we have not paid
any claims during this 14 day period, we will refund in full
any premium that the policyholder has paid. If we have paid
claims, we will deduct the cost of those claims from any
refund we give. If the cost of the claims is greater than the
premium, we do not have to refund the premium.
After this 14 day ‘cooling off period’, the policyholder can
cancel the policy by giving us one month’s notice.
If the policyholder pays a monthly premium, we will not
refund that premium.
If the policyholder pays a three, six or twelve monthly
premium, we will refund any remaining premium.
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Your Simply Personal Health policy document: Connections network
5.3 Cancelling a member from the
policy
5.6 Changes to the policy
We will cancel a partner or child from the policy if the
policyholder asks us to. However, we will not backdate
the cancellation of membership to before the date that the
policyholder notifies us that the partner or child is no
longer covered by the policy. This means that we will not
refund premium to the policyholder if there is a delay in
telling us that a partner or child is no longer covered by the
policy.
If we have paid claims, we will deduct the cost of those
claims from any refund we give. If the cost of the claims is
greater than the premium, we do not have to refund the
premium.
We will cancel a member from the policy if they are involved
in a fraud against us.
We ask that you treat us in the way you wish to be treated.
If you are abusive during our contact with you, we will
terminate the contact. If you continue to be abusive, we
reserve the right to cancel your membership of the policy,
and all policies that you hold with Simplyhealth.
5.4 What happens when cover is
cancelled?
Only Simplyhealth can make changes to the terms of
the policy (for example adding or removing benefits or
exclusions). Any changes that we make will take place from
the renewal date, and we will notify the policyholder of
those changes.
The policyholder can change cover for members at the
renewal date, for example by adding ‘Treatment cover’ for
a member who does not have that cover, or changing from
a limit of £50,000 for ‘Treatment for heart and cancer’ to full
cover. If the policyholder increases cover for a member,
we will apply the pre-existing conditions exclusion to that
increased cover, using the date from which the increased
cover becomes effective as the date to decide whether or
not a condition is a pre-existing condition.
1) For example the policyholder buys ‘Diagnosis cover’
only. They are diagnosed with osteoarthritis of the hip and
need a hip replacement. At renewal they buy ‘Treatment
cover’. We will not pay for the hip replacement because
this is a pre-existing condition for the purposes of the
‘Treatment cover’. A year later they develop gallstones
and need an operation to remove their gallbladder. This
would be covered as the condition developed after they
bought the ‘Treatment cover’.
If Simplyhealth or the policyholder cancels the policy, cover
will stop for all members on the policy. The policyholder
should tell all members that the policy has been cancelled.
Cancellation of the policy, or your membership of the
policy, means that we will not pay for any costs that you
incur after the cancellation date – even if you incurred those
costs following our authorisation.
2) For example the policyholder buys ‘Heart and cancer’
cover with a £50,000 limit. After two years they decide
to remove the £50,000 limit and have full cover for heart
and cancer. Any heart condition or cancer that they
suffered before they increased their cover would be
subject to the £50,000 limit – we would consider that
it was a pre-existing condition for the purposes of
applying full cover. Any new heart condition or cancer,
unrelated to the previous one, would be covered in full.
5.5 Length of contract, renewal and
premiums
For members who have MHD underwriting, any additional
cover that the policyholder chooses for them will be on an
FMU or moratorium basis.
This is an annual policy which provides members with cover
for the policy year although our obligation to pay claims
depends on the policyholder having paid the premium in
advance. For example, if premiums are paid by monthly
instalments in advance, we will provide cover for each month
where we have received the monthly instalment. If we do
not receive the monthly premium, cover will stop until that
premium has been paid. If the policyholder has paid an
annual premium in advance, members will be covered for
the whole policy year.
5.7 Changes to circumstances
You must tell us if you change your name or address, or if
you move outside the UK.
Your Simply Personal Health policy document: Connections network
21
Section 6: No claims discount (NCD)
Simply Personal Health operates a no claims discount (NCD) on the policy premiums. Each member has their own NCD. This
means that claims by one member cannot affect the NCD of the other members on the policy. You can see the NCD level
which applies to your cover on your membership certificate.
This NCD scale shows the levels available and discounts which apply to each level:
NCD level
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Discount
applied
to your
premium
0%
7%
14%
20%
25%
30%
35%
40%
45%
50%
55%
60%
64%
68%
72%
75%
Percentage
of premium
to pay
100%
93%
86%
80%
75%
70%
65%
60%
55%
50%
45%
40%
36%
32%
28%
25%
Moving up the NCD scale
If we have paid no claims for a member during the year
before we calculate their premium for the next policy year,
their NCD level will move up the scale by one level at the next
renewal date.
Not moving on the NCD scale
If we have paid claims of no more than £250 for a member
during the year before we calculate their premium for the next
policy year, the member’s NCD will stay at its current level
at the next renewal date.
Moving down the NCD scale
There are four possible ways in which you can move down
the NCD scale, depending on the value of the claims that we
have paid:
• If we have paid claims between £1,000.01 and £3,000 in
total for a member during the year before we calculate
their premium for the next policy year, the member’s NCD
will move down the scale by two levels at the next renewal
date.
• If we have paid claims between £3,000.01 and £10,000
in total for a member during the year before we calculate
their premium for the next policy year, the member’s
NCD will move down the scale by three levels at the next
renewal date.
• If we have paid claims for more than £10,000 in total for a
member during the year before we calculate their premium
for the next policy year, the member’s NCD will move
down the scale by four levels at the next renewal date.
• If we have paid claims between £250.01 and £1,000 in
total for a member during the year before we calculate
their premium for the next policy year, the member’s NCD
will move down the scale by one level at the next renewal
date.
This is a table to show how the NCD scale works:
22
Payments made during the year before we calculate the
premium for the next policy year
Movement on the scale at the next renewal date
£0 paid
Move up the scale by 1 level
Between £0.01 - £250 paid
Stay at current level on the scale
Between £250.01 - £1,000 paid
Move down the scale by 1 level
Between £1,000.01 - £3,000 paid
Move down the scale by 2 levels
Between £3,000.01 - £10,000 paid
Move down the scale by 3 levels
More than £10,000 paid
Move down the scale by 4 levels
Your Simply Personal Health policy document: Connections network
The NCD is re-calculated before each renewal date. At
your first renewal this is based on the monetary value of the
claims that we have paid between the date that you join the
policy and the date that we recalculate your premium for
the next policy year. In subsequent years it is based on the
monetary value of the claims that we have paid between the
date that we recalculate your premium for that policy year
until the date that we recalculate your premium for the next
policy year.
If we pay a claim after we have calculated the renewal
premium, we will take this payment into account for
calculating the NCD at the next renewal date. We calculate
the renewal premiums approximately 10 months into the
policy year.
When we calculate the renewal premium we can only take
into account the claims that we have paid. This means, for
example, that if you incur costs but we have not received a
bill and therefore not paid anything by the time we calculate
your premium for the next policy year, those costs will not
affect your NCD until the following renewal date.
Claims for some benefits will not count towards calculating
your NCD. These are:
Section 7: Legal points
7.1 Third party claims (or
‘subrogation’)
If you use this policy to make a claim for medical expenses
because someone else was at fault (for example you have
been involved in a car accident), we have a legal right to
recover any medical expenses that we have paid (the other
person is described as a ‘third party’).
When you make a claim under this policy you have an
obligation to tell us if you could have a claim against a third
party. If you decide to instruct a legal representative, we will
need their details because we will need to discuss the claim
with them. Once you have told us about your claim, you,
or your legal representative, must keep us informed of the
claim’s progress.
You must:
• tell your legal representative immediately that you are
insured by Simplyhealth for medical expenses
• include all the medical expenses which you have claimed,
or will claim, from us under this policy in your personal
injury claim
• NHS cash benefit
• new child payment
• parent accompanying child benefit
• end of life care benefit
• claims which are, in total, up to the value of your policy
excess (for example, if you have a £100 excess and you
incur costs of £250 in a year, we will only take into account
£150 for the purposes of calculating your NCD).
If we decide to remove the NCD from
Simply Personal Health, we will give the policyholder at
least one year’s notice.
The NCD is applied to the remaining premium after all other
discounts have been applied to your premium (for example
the discount for taking an increased excess).
Whilst we will not discuss your medical information with
anyone without your permission, we will tell the policyholder
about the value of claims you have made when we calculate
the renewal premium for the next policy year.
• ask your legal representative to help us. You must
ensure we can contact your legal representative
and obtain copies of any correspondence, reports or
documents concerning your claim. We will pay reasonable
photocopying charges for anything we ask for
• not do anything which prejudices the recovery of medical
costs that we have paid
• not agree any final settlement of your claim or waive our
right to recover expenses paid out for medical costs unless
you or your legal representative have discussed this with
us first and obtained our approval
• ask your legal representative to repay your medical
expenses directly to us from any settlement of your claim.
Important: Simplyhealth cannot fund your personal injury
claim. You must pay the costs of making a personal injury
claim yourself. If you decide not to bring a claim against the
third party then you must give us reasonable cooperation
and assistance to enable us to bring a claim in your name.
We will be responsible for the legal costs arising out of any
claim we bring in your name.
7.2 If you have other insurance
policies
If you have other insurance that covers you for any of the
same benefits under this policy (for example a cashplan, or
medical insurance from your partner’s employer) and you
make a claim on this policy we will have the right to seek
a proportion of any costs from the other insurer. When you
make a claim you must tell us if you have other insurance
which could cover your costs and give us the other insurer’s
contact and policy details.
Your Simply Personal Health policy document: Connections network
23
7.3 Law
This policy is governed by the laws of England and Wales.
Any disputes arising in connection with the policy which are
not resolved through our complaints process can only be
dealt with by the courts of England and Wales unless you
and we agree to a different method to resolve the dispute.
In accordance with the Contracts (Rights of Third Parties) Act
1999 we and the policyholder shall be entitled to agree to
vary or rescind the policy without your consent.
7.4 Waiver
If we decide not to enforce a term of this policy, this does
not mean that the term no longer applies. We may rely on
that term at a later occasion if we decide to do so, unless we
have told you in writing that the term no longer applies.
7.5 Language
All letters and documents that we create for this policy will
be in English.
7.6 Fraud
The contract between the policyholder and us, and our
relationship with you, is based on mutual trust. To protect
our members we have rigorous anti-fraud measures. These
include:
• investigating claims through the use of private investigators
• passing details of suspected fraudulent claims to the police
or the Crown Prosecution Service for them to investigate
and prosecute through the criminal courts
• working with the NHS Counter-Fraud team, Health
Professionals’ Trade Associations, other insurance
companies and other agencies with an interest in
controlling fraud of this nature.
Fraud is a criminal offence that can result in a fine or even a
prison sentence. When we find examples of fraud, we will
always seek to prosecute offenders and recover the costs of
fraudulent claims, plus interest and our own legal costs.
If a member submits a fraudulent claim, we may cancel their
membership and cancel all their insurance policies with us
and with any other company within the Simplyhealth Group.
Examples of practices that we consider fraudulent include:
Section 8: Definitions
Acute condition
A disease, illness or injury that is likely to respond quickly to
treatment which aims to return you to the state of health
you were in immediately before suffering the disease, illness
or injury or which leads to your full recovery.
Cancer
A malignant tumour, tissues or cells, characterised by the
uncontrolled growth and spread of malignant cells and
invasion of tissue.
Chemotherapy
Drugs that are used to treat cancer. These include:
• drugs used to destroy cancer cells or prevent tumours
from growing (these could be cytotoxic drugs, targeted or
biological therapy drugs)
• drugs used to strengthen bones (these are called
bisphosphonates).
Hormone treatment is not chemotherapy for the purposes of
this policy.
Child / children
The natural or adopted child of:
• the policyholder
or
• the policyholder’s partner if that partner is a member on
the policy.
Chronic condition
A disease, illness or injury that has one or more of the
following characteristics:
• it needs ongoing or long term monitoring through
consultations, examinations, check-ups or tests
• it needs ongoing or long term control or relief of symptoms
• it requires your rehabilitation or for you to be specially
trained to cope with it
• it continues indefinitely
• it has no known cure
or
• it comes back or is likely to come back.
• deliberately giving us false information about a member or
a claim on the policy
Dangerous sports
For the purposes of this policy, dangerous sports are:
• making a claim, a statement in support of a claim or
sending us a document in support of a claim knowing that
it is false, misleading or exaggerated in any way
• ballooning, hang gliding, parachuting or bungee jumping,
flying (except where a fee paying passenger)
• making a claim under more than one insurance policy
in order to receive more than the costs that you have
incurred.
• scuba diving or free diving
• motor racing
• potholing, rock climbing, mountaineering where ropes or
guides should be used
• any form of martial arts
• off piste skiing or snowboarding.
Day-patient
A patient who is admitted to a hospital or day-patient unit
because they need a period of medically supervised recovery
but does not occupy a bed overnight.
24
Your Simply Personal Health policy document: Connections network
Diagnostic tests
Investigations, such as X-rays or blood tests, to find or to
help find the cause of your symptoms.
• you have received medication, advice or treatment
General Practitioner / GP
A doctor who is on the General Medical Council’s GP
register (a register of doctors who are able to work in general
practice in the health service in the UK) and holds a license
to practise.
whether the condition has been diagnosed or not before the
start date of your cover.
or
• you have experienced symptoms;
Hospital
Any hospital that we select for your treatment.
Renewal date
The annual anniversary of the date on which this policy
started.
In-patient
A patient who is admitted to hospital and who occupies a
bed overnight or longer for medical reasons.
Member
Anyone who we have accepted for cover under this policy.
A member must be:
• the policyholder
• a child of the policyholder or the policyholder’s partner.
Partner
Anyone in a relationship with, and who lives with, the
policyholder. This could be their:
• husband
• is included on the General Medical Council’s specialist
register (please see www.gmc-uk.org)
• holds a current licence to practise
or
Out-patient
A patient who attends a hospital, consulting room or outpatient clinic and is not admitted as a day-patient or an
in-patient.
Specialist
A doctor who:
and
• the policyholder’s partner
Nurse
A qualified nurse who is on the register of the Nursing and
Midwifery Council (NMC) and holds a valid NMC personal
identification number.
Related condition
A symptom, illness or injury which a medical professional
considers to be the cause of or arising from the illness or
injury that needs treatment.
and
• holds, has held or would be allowed to hold a substantive
appointment (that is to say, not a locum) as a consultant in
a National Health Service Hospital or the Armed Services.
Treatment
Surgical or medical services (but not including diagnostic
tests) that are needed to relieve or cure a disease, illness or
injury.
We / our / us
Simplyhealth Access trading as Simplyhealth, a company
incorporated in England and Wales.
You / your
Anyone who is a member on the policy.
• wife
• civil partner
• unmarried partner.
Policy
The insurance contract between Simplyhealth and the
policyholder to provide private medical insurance to
the members. This policy document, the application
form, summary of cover, hospital network and individual
membership certificates together form the contract.
Policyholder
The person who has bought this policy from us.
Policy year
The period of time from the start of the policy until the first
renewal date, or from one renewal date until the next.
Pre-existing condition
Any disease, illness or injury for which:
Your Simply Personal Health policy document: Connections network
25
Section 9: Data
protection
Section 10: Customer
care
9.1 How we use information about
you
10.1 Membership queries
The main purpose for which we hold and use personal
data is to enable us to provide insurance services to you in
relation to this policy. Other purposes which we use personal
data for are to identify, analyse and calculate insurance risks,
to improve our services to you and our other customers, to
comply with legal obligations which we are subject to, to
protect our interests and for fraud detection and prevention.
We may receive and share personal data with persons
appointed by you or who provide a service to you, for
example your GP and other healthcare providers. We may
provide your personal data to persons appointed by the
policyholder to enable them to obtain quotes for the provision
of insurance or other healthcare arrangements for the period
after this policy comes to an end. We may also provide your
personal data to new insurers or plan administrators who
are appointed by the policyholder to provide healthcare
insurance or other healthcare arrangements for the period
after this policy comes to an end.
We may provide personal data to persons who provide
services to us, including companies operating outside the
United Kingdom and to persons engaged in fraud prevention.
We operate strict procedures to ensure that personal data is
kept secure.
You have the right to see personal data which is held by us.
There may be a charge if you want to do this. If you have any
questions or concerns about the personal data we hold and
how we use it please write to: The Data Protection Officer,
Simplyhealth, Hambleden House, Waterloo Court, Andover,
Hampshire, SP10 1LQ.
9.2 Accuracy of personal information
To help us ensure that your details remain accurate and up to
date please tell us of any changes by calling our helpline on
0800 294 6796. Your calls may be recorded and monitored
for training and quality assurance purposes.
26
If you need to discuss any aspect of your membership, for
example a change of address or a change in cover, call our
freephone number and our friendly and dedicated team will
be pleased to help you.
Membership helpline: 0800 294 6796
The helpline operates Monday - Friday from 9am – 5pm,
except Bank Holidays.
Your calls may be recorded and monitored for training
and quality assurance purposes.
Email: [email protected]
10.2 If you need to make a complaint
We aim to provide you with the very highest levels of
customer service and care at all times. To maintain this
service standard, we have a procedure you can use to raise
any concern, complaint or recommendation you have by
contacting Customer Services on 0800 328 1202 or writing
to Simplyhealth Customer Services, Simplyhealth House,
Redland Hill, Redland, Bristol BS6 6SH. If we cannot resolve
your concerns, we will investigate and issue a final response.
If you are not satisfied with our response, or we have not
replied within eight weeks, you have the right to refer your
complaint to:
Financial Ombudsman Service, Exchange Tower, London,
E14 9SR Telephone: 0800 023 4567 or 0300 123 9123
Web: www.financial-ombudsman.org.uk
email: [email protected]
The Financial Ombudsman Service will only consider your
complaint if you have given us the opportunity to resolve
the matter first. Making a complaint to the Ombudsman will
not affect any legal rights that you may have. We will send
you full details of our complaints procedure if you ask us for
them.
Your Simply Personal Health policy document: Connections network
10.3 You are protected by the Financial
Services Compensation Scheme
Simplyhealth is a member of the Financial Services
Compensation Scheme (FSCS). If we are unable to carry
out our financial responsibilities (because, for example, we
go out of business or into liquidation), you may be entitled
to compensation from the scheme. For more details about
the FSCS please visit www.fscs.org.uk or contact the FSCS
directly on 0800 678 1100 or 020 7741 4100.
10.4 About Simplyhealth
Simplyhealth is a trading name of Simplyhealth Access,
which is authorised by the Prudential Regulation Authority
and regulated by the Financial Conduct Authority and the
Prudential Regulation Authority. Our Financial Services
Register number is 202183. You can check this on the
Financial Services Register by visiting the Financial Conduct
Authority’s website www.fsa.gov.uk/register/home.do
or by contacting the Financial Conduct Authority on
0800 111 6768.
We can only provide you with information on our own
products and you will not receive any advice or a personal
recommendation from us for our health plans. We may ask
you some questions to narrow down the product option
on which we provide you with information, but you will then
need to make your own choice about how to proceed.
Simplyhealth, Simplyhealth House, Redland Hill, Redland,
Bristol BS6 6SH
Fax: 0117 929 5539
Email: [email protected]
View our website: www.simplyhealth.co.uk
Your Simply Personal Health policy document: Connections network
27
Appendix 1: Chronic
conditions
What is a chronic condition?
A chronic condition is a disease, illness or injury that has at
least one of the following characteristics:
• it needs ongoing or long term monitoring through
consultations, examinations, check-ups, and/or tests
• it needs ongoing or long term control or relief of symptoms
• it requires your rehabilitation or for you to be specially
trained to cope with it
• it continues indefinitely
• it has no known cure
• it comes back or is likely to come back.
Exclusions that would normally apply to long term/chronic
conditions may not apply to cancer. Please refer to Appendix
3: ‘Explaining cover for cancer’.
If you have symptoms and your GP refers you to a specialist,
we will pay for consultations and diagnostic tests in order to
make a diagnosis. If you need treatment, the policy will only
pay if the policyholder has chosen ‘Treatment cover’, and the
aim of that treatment is to:
• return you to the state of health you were in immediately
before suffering the disease, illness
or
• injury, or lead to your full recovery.
What does this mean in practice?
If your condition has any one of the characteristics of a
chronic condition, we will not pay for treatment of it. Even
if we have paid for treatment in the past, it does not mean
that we will continue to pay for treatment of a condition that
has become chronic. If you are diagnosed with a chronic
condition, we will not pay for further diagnostic tests or
treatment for that condition.
What if your condition gets worse?
We do not pay for routine treatment of a chronic condition,
for example drugs to keep the condition stable or
consultations to monitor the condition. We will pay for
treatment (or NHS cash benefit) for an acute flare-up of a
chronic condition if:
• you need to be admitted to hospital as an in-patient for
treatment
and
• the treatment aims to quickly stabilise your chronic
condition
and
• the flare-up was unexpected (for example we will not pay
for recurring in-patient admissions which may be a natural
consequence of your chronic condition, and which happen
on a regular or predictable basis).
28
Examples of chronic conditions
The people described in these examples are not real but
the illnesses described, recommended treatments and the
descriptions of how the policy covers chronic conditions
are. This is to show you how the policy works in practice to
support the health and wellbeing of individual members.
Important: In all the examples, we will only pay for
treatment that each patient has arranged by calling the
helpline.
Alan
Alan has been with Simplyhealth for many years. He has
cover under all elements of the policy. He develops chest
pain and is referred by his GP to a specialist. He has a
number of investigations and is diagnosed as suffering from
a heart condition called angina. Alan is placed on medication
to control his symptoms.
We will pay for the consultations with a specialist
and diagnostic tests to diagnose Alan’s condition.
Simply Personal Health does not cover follow up
consultations for long term monitoring of Alan’s condition,
drugs taken as an out-patient or drugs taken home from
hospital, so Simplyhealth will not pay for
• the drugs that Alan takes to control his symptoms, or
• any further consultations to monitor his condition.
Two years later, Alan’s chest pain recurs more severely and
his specialist recommends that he have a heart bypass
operation.
We will pay for Alan’s consultation with the specialist and for
his heart bypass operation. Following his operation Alan may
need to have further consultations and tests to check that
the operation was a success. We will pay for consultations
and tests as an out-patient for two years after Alan’s surgery
(although if Alan’s policy has the £50,000 limit for heart cover,
these costs will be deducted from the limit).
Deirdre
Deirdre has ‘Diagnosis cover’ and ‘Treatment cover’
and has been with Simplyhealth for two years when she
develops symptoms that indicate she may have diabetes.
Her GP refers her to a specialist who organises a series of
investigations to confirm the diagnosis, and she then starts
on oral medication to control the diabetes. After several
months of regular consultations and some adjustments
made to her medication regime, the specialist confirms the
condition is now well controlled and explains he would like to
see her every four months to review the condition.
We will pay for the consultations with a specialist and
diagnostic tests to diagnose Deirdre’s condition. As Deidre
has cover under ‘Treatment cover’, we will also pay for
the consultations and tests that Deirdre’s specialist needs
to ensure that the condition is stabilised. Once Deirdre’s
diabetes has been stabilised, we will not pay for any further
consultations to monitor the condition on a long term basis.
Your Simply Personal Health policy document: Connections network
One year later, Deirdre’s diabetes becomes unstable and her
GP arranges for her to go into hospital for treatment.
Simplyhealth would pay for treatment if:
• Deirdre needed to be admitted to hospital as an in-patient
for that treatment
and
Eighteen months later, Eve has a bad asthma attack.
Simplyhealth would pay for treatment if:
• Eve needed to be admitted to hospital as an in-patient for
that treatment
and
• the treatment aimed to quickly stabilise her condition
• the treatment aimed to quickly stabilise her condition
and
and
• the flare-up was unexpected (for example we would not
pay for recurring in-patient admissions which may be a
natural consequence of Eve’s condition, and which happen
on a regular or predictable basis).
• the flare-up was unexpected (for example we would not
pay for recurring in-patient admissions which may be a
natural consequence of Deirdre’s condition, and which
happen on a regular or predictable basis).
However, we would not continue to pay benefit for Deirdre’s
diabetes indefinitely. We would strongly recommend that
Deirdre calls us before going into hospital as a private patient
so that we can advise her whether or not we will pay for the
admission.
However, we would not continue to pay benefit for Eve’s
asthma indefinitely. We would strongly recommend that Eve
calls us before going into hospital as a private patient so
that we can advise her whether or not we will pay for the
admission.
Bob
Bob has ‘Diagnosis cover’ and ‘Treatment cover’, and has
been with Simplyhealth for three years when he develops
hip pain. His GP refers him to an osteopath who treats him
every other day for two weeks and then recommends that
he return once a month for additional treatment to prevent a
recurrence of the original symptoms.
We will pay benefit for Bob’s initial two week course of
treatment. We will however apply a maximum benefit limit
under out-patient services of £500 in any one policy year
for treatment given by an osteopath where the referral has
been made by a GP. If a specialist had made the referral
the benefit limit would not apply. We will not pay for Bob’s
additional treatment as this is purely being recommended as
a preventative measure, not to cure his hip pain.
Eve
Eve has cover under ‘Diagnosis cover’ and ‘Treatment
cover’, and has been with Simplyhealth for five years when
she develops breathing difficulties. Her GP refers her to a
specialist who arranges a number of tests. These reveal that
Eve has asthma. Her specialist puts her on medication and
recommends a follow up consultation in three months to see
if her condition has improved. At that consultation Eve states
that her breathing has been much better, so the specialist
suggests she has check-ups every four months.
We will pay for the consultation with the specialist
and diagnostic tests to diagnose Eve’s condition.
Simply Personal Health does not cover follow up
consultations for long term monitoring of Eve’s condition,
drugs taken as an out-patient or drugs taken home from
hospital, so Simplyhealth will not pay for:
• the drugs that Eve takes to control her symptoms,
or
• any further consultations to monitor her condition.
Your Simply Personal Health policy document: Connections network
29
Appendix 2:
Understanding the
underwriting options
How we deal with conditions that you
have before you join the policy (called
pre-existing conditions)
Simply Personal Health provides cover for unexpected
illnesses and injuries which happen after the start of the
policy. Underwriting is the process by which we decide
whether or not to accept cover for illnesses and injuries
which you had before buying the policy. This section explains
the two most common methods of underwriting – the
type that the policyholder chooses will be shown on your
membership certificate.
Your membership is based on the information that you give
us on the application form. You should take care to give
us full and accurate answers to all the questions that we
ask. We will then write and confirm your policy details. Any
personal exclusions that we apply to your cover will be on
your membership certificate.
Moratorium
With this option you do not need to complete a health
questionnaire. Instead, we automatically exclude any preexisting conditions which you have:
• received treatment or medication for
• received advice about, or
Why some customers choose moratorium underwriting
You will only be asked to provide basic information about
yourself. We will not ask for details of your medical history
when you join the policy, but we may need to ask for medical
information if you make a claim. If you do not have any
symptoms of, advice about, or treatment or medication for a
pre-existing condition for a continuous two year period after
you join the policy, we will not apply the automatic exclusion.
Full medical underwriting
Each person has to complete a health questionnaire
before joining the policy. This will enable us to understand
their medical history. It is important that you consider the
questions carefully for each person that you want the
policy to cover, and answer them fully. We will assess the
information and decide the basis on which we can accept
you for cover. If necessary, we may ask your doctor for any
more information we need to help us do this (you will have to
pay if the doctor charges for this information). If you have a
pre-existing condition that may need treatment in the future,
we will probably exclude it from cover, and also exclude
any conditions related to it. For example, if you suffer from
diabetes we would not pay for treatment of eye disorders
which occur as a result of having diabetes, for example
diabetic retinopathy.
If the policyholder chooses full medical underwriting, we will
show any exclusions on your membership certificate.
If we exclude a pre-existing condition from the time the policy
starts we can, in some cases, review the exclusion at a later
date if you ask us to do so. It is very important that you give
full and accurate information in answer to the questions that
we ask. If you do not, it may mean that we cannot cover a
claim or even that your policy is void.
However, if you do not have any:
Why some customers choose full medical underwriting
Although this option involves more of your time when
completing your application, it does mean that when you
receive your policy documentation you will know which
conditions are excluded from cover.
• symptoms of
An example of how both options work:
• had symptoms of (whether or not those symptoms have
led to a diagnosis)
during the five years immediately before you join the policy.
• advice about, or
• treatment or medication for
those pre-existing conditions, or any directly related
conditions, for two continuous years after you join the policy,
the automatic exclusion will not apply for those conditions.
For children who are under five when their cover starts, we
will take into account all the conditions that they have had
from the day they were born until the date their cover starts.
Important: long term medical conditions, which are likely to
continue to need regular or periodic treatment, medication
or medical advice will always remain excluded from cover on
this policy.
You should not delay seeking medical advice or treatment
for a pre-existing condition simply to obtain cover for that
condition under the policy.
Lisa’s story
Lisa had an operation on her right knee recently. Will she be
covered for any further treatment to the knee after her policy
starts?
Moratorium
Not immediately. As Lisa had her operation before the policy
started, we would apply an automatic exclusion to that knee
if Lisa makes a claim for further treatment for, or diagnostic
tests and consultations about, the knee. However, we would
not apply the automatic exclusion if there was a continuous
two year period after Lisa’s policy started when she did not
have:
• treatment to the knee
• advice about the knee from a medical professional, or
• symptoms in the knee.
Full medical assessment
No. When Lisa completed her full medical assessment she
told us about her knee operation, we placed an exclusion on
her membership for any condition directly related to her knee
operation. We will show this exclusion on her membership
certificate.
30
Your Simply Personal Health policy document: Connections network
Appendix 3: Explaining cover for cancer
The options for cancer cover on Simply Personal Health are:
• full cover
• cover limited to £50,000 in total whilst you are covered by the policy
• no cover at all for the treatment of cancer.
This table shows some typical questions that customers ask about cancer cover, and shows the cover available with
Simply Personal Health. We have answered the questions on the basis that the policyholder has not removed cancer cover, or
applied a £50,000 limit. If you have any further questions, please call us on 0800 328 1202.
Are there any limits on the cover
that Simply Personal Health
offers?
The policyholder can choose various levels of cover for this policy, including removing
cover for cancer treatment altogether, or applying a monetary limit to cancer treatment
and services.
Where will
Simply Personal Health cover
me for treatment?
We will pay for you to have treatment in a hospital in your chosen network, or at home if
you would prefer this and your specialist agrees.
Will Simply Personal Health
cover me for diagnostic tests?
Yes. Once you have been diagnosed and started treatment covered by the policy, we will
pay for you to have consultations and diagnostic tests to monitor the progress of your
treatment, whether it involves surgery, radiotherapy or chemotherapy.
We will pay for tests to see if a specific treatment is likely to work for you (for example, a
test to see if breast cancer will respond to Herceptin).
We will not pay for genetic tests to see how likely you might be to get cancer, or
screening to see if you have cancer.
Will Simply Personal Health
cover me for surgery?
Yes, and if you need it we will pay for one reconstruction operation within five years
of surgery for cancer. In the case of breast cancer we will pay for an operation to
reconstruct your breast and an operation to improve the symmetry of your breasts.
Will Simply Personal Health
cover me for treatment to
prevent me getting cancer?
We will pay for surgery to prevent further cancer only if we have already paid for
treatment for that cancer – for example, we will pay for a mastectomy to a healthy breast
in the event that you have been diagnosed with cancer in the other breast.
We will not pay for surgery where you have no symptoms of cancer, for example where
you have a strong family history of cancer such as breast cancer, or bowel cancer. We
will not pay for other preventative treatment, for example screening or vaccination.
Your Simply Personal Health policy document: Connections network
31
Which drugs will
Simply Personal Health cover
me for?
With cancer treatment, patients often take a combination of several drugs.
We will pay in full for chemotherapy which aims to cure your cancer or induce a
remission, provided that the drugs are licensed by the European Medicines Agency
(EMEA) and used for the purpose for which they are licensed. During the time that you
are covered by the policy, we will pay up to a maximum of 12 months for chemotherapy:
• whilst you are in remission
• to keep your cancer stable and prevent disease progression (this is sometimes called
maintenance therapy) or as palliative treatment.
Whilst you are receiving chemotherapy or radiotherapy that we pay for, we will also pay
for treatment prescribed by your specialist that you need to cope with any side effects,
for example:
• antibiotics
• anti sickness drugs
• steroids
• pain killers
• drugs to boost your immune system
• blood transfusions.
Will Simply Personal Health
cover me for radiotherapy?
Yes, we will pay for you to have treatment in a hospital in your chosen network.
Will Simply Personal Health
cover me for palliative
treatment?
Palliative treatment is treatment which is not aimed at curing your cancer or achieving a
remission. We pay for a maximum of 12 months whilst you are covered by the policy for
palliative treatment with drugs. We would also pay for surgery or radiotherapy in order to
relieve acute pain.
Will Simply Personal Health
cover me for end of life care?
We do not pay for end of life care, but if your specialist confirms that you are receiving
end of life care we will make a payment of £500 to you to spend as you wish.
Will Simply Personal Health
cover me for monitoring of my
cancer?
We will pay for consultations and tests to monitor your condition for five years after the
last treatment for cancer that we paid for on Simply Personal Health.
Are there any other limits
on cancer cover with
Simply Personal Health?
We will not pay for any costs related to an admission to hospital that involves a stem cell
or bone marrow transplant.
Other benefits
Treatment for cancer can mean that you need a variety of services. If your specialist
recommends it, we will pay for treatment or advice from:
We do not pay for clinical research trials, or any treatment that is not widely recognised
throughout the NHS as safe and effective for treating the particular cancer that you have.
• a dietician, to stabilise your diet following surgery, chemotherapy or radiotherapy
• a stoma nurse, to show you how to care for your stoma
• a specialist nurse to show you how to manage lymphoedema.
We will also pay up to £250 for a wig if you need one as a result of your treatment for
cancer.
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Your Simply Personal Health policy document: Connections network
Examples of cancer treatment
Here are examples to show how cancer cover under
Simply Personal Health can work in practice. We have
described Beverley’s cover on the basis that the policyholder
has chosen ‘Treatment for heart and cancer’ in full. If the
policyholder had chosen the £50,000 limit for cancer cover,
any reference to paying Beverley’s costs would depend on
there being sufficient funds left from the £50,000 maximum.
Beverley
Beverley has been with Simplyhealth for five years when she
is diagnosed with breast cancer. Following discussion with
her specialists she decides to:
• have the tumour removed by surgery. As well as
removing the tumour, Beverley’s treatment will include a
reconstruction operation
• undergo a course of radiotherapy and chemotherapy
• take hormone therapy tablets for several years after the
chemotherapy has finished.
Will her policy cover this treatment plan, and are there
any limits to the cover?
We will pay for the surgery to remove the tumour and
also one operation to reconstruct Beverley’s breast. If she
needed it, we would also arrange and pay for one further
operation to improve the symmetry of Beverley’s breasts
following her reconstruction operation. We will also pay
for Beverley’s radiotherapy and chemotherapy treatment.
Simply Personal Health does not cover the hormone therapy
tablets because we consider these to be preventative
treatment. However, Beverley will be able to get these tablets
directly from her GP. We will pay for Beverley to receive follow
up consultations and monitoring for a period of five years
once she has finished treatment.
During the course of chemotherapy Beverley suffers from
anaemia. Her resistance to infection is also greatly reduced.
Her specialist:
• admits her to hospital for a blood transfusion to treat her
anaemia
• prescribes a course of injections to boost her immune
system.
Will her policy cover this treatment plan, and are there
any limits to the cover?
Whilst Beverley is receiving chemotherapy (or radiotherapy)
that we pay for, we will also pay for treatment prescribed by
her specialist that she needs to deal with their side effects.
This includes the drugs to boost her immune system and
blood transfusions. We would also pay for, for example,
antibiotics, anti sickness drugs, steroids and pain killers.
• a course of six cycles of chemotherapy aimed at
destroying cancer cells to be given over the next six
months
• monthly infusions of a drug to help protect the bones
against pain and fracture. This infusion is to be given for as
long as it is working (hopefully years)
• weekly infusions of a drug to suppress the growth of the
cancer. These infusions are to be given for as long as they
are working (hopefully years).
Will her policy cover this treatment plan, and are there
any limits to the cover?
We will pay for the chemotherapy as this is aimed at
curing Beverley’s cancer, or at least achieving a remission.
Whilst Beverley is having the chemotherapy we will also
pay for the monthly bone strengthening infusions and the
weekly infusions to suppress the growth of the cancer.
However, once Beverley’s cancer goes into remission or it
fails to respond to the chemotherapy, we will pay for the
weekly infusions for a maximum of 12 months. If, after 12
months Beverley decides not to pay for further infusions
herself, a Simplyhealth nurse case manager will work with
her specialist and the NHS to make sure that treatment
continues as an NHS patient.
David
David has been with Simplyhealth for seven years when
he is diagnosed with cancer. Following discussion with his
specialist he decides to undergo a course of high dose
chemotherapy, followed by a stem cell (sometimes called a
‘bone marrow’) transplant.
Will his policy cover this treatment plan, and are there
any limits to the cover?
Simply Personal Health does not pay for a stem cell
transplant, or the course of high dose chemotherapy which
leads to the transplant. If David decides not to pay for private
treatment himself, a Simplyhealth nurse case manager will
work with his specialist and the NHS to make sure that
treatment continues smoothly as an NHS patient.
When his treatment is finished, David’s specialist tells him
that his cancer is in remission. He would like him to have
regular check-ups for the next five years to see whether the
cancer has returned.
Will his policy cover this treatment plan, and are there
any limits to the cover?
We will pay for David’s follow up consultations and
monitoring for a period of five years from the time that he
last had treatment that we paid for. If the only treatment that
David had was the stem cell transplant, then the five year
time period will start from the date of David’s diagnosis.
Despite the injections to boost her immune system, Beverley
develops an infection and is admitted to hospital for a course
of antibiotics.
Eric
Eric would like to be admitted to a hospice for care aimed
solely at relieving symptoms.
Will her policy cover this treatment and are there any
limits to the cover?
As the infection is as a direct result of Beverley’s cancer
treatment we will pay for the admission and antibiotic
treatment.
Will his policy cover this, and are there any limits to the
cover?
Hospices do not charge for their services, but when Eric’s
specialist confirms that he needs end of life care, we will
make Eric a payment of £500 to spend as he wishes.
Five years after Beverley’s treatment finishes the cancer
returns. Unfortunately it has spread to other parts of her
body. Her specialist has recommended a treatment plan:
Your Simply Personal Health policy document: Connections network
33
Jenny
Jenny has been diagnosed with cancer. Her policy has a
£50,000 lifetime cover limit and she decides to start private
treatment.
What help will be available if the policy limit is reached and
she needs to transfer into the NHS?
If the costs that we pay for Jenny’s cancer reach the
£50,000 limit and Jenny decides not to pay further costs
herself, a Simplyhealth nurse case manager will work with
her specialist and the NHS to make sure that treatment
continues as an NHS patient.
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Your Simply Personal Health policy document: Connections network
Your Simply Personal Health policy document: Connections network
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1501081-PRO-SPersH-PD-C-0415
Simplyhealth, Simplyhealth House, Redland Hill, Redland, Bristol BS6 6SH
Simplyhealth is a trading name of Simplyhealth Access, which is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential
Regulation Authority. Simplyhealth Access is registered and incorporated in England and Wales, registered no. 183035. Registered office, Hambleden House, Waterloo Court, Andover,
Hampshire, SP10 1LQ. Your calls may be recorded and monitored for training and quality assurance purposes.
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