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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. 20 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. 32 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. 34 Your Simply Personal Health policy document: Connections network Your Simply Personal Health policy document: Connections network 35 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. SPersH003/0415