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Dental
Optical
OutPatient Therapy
Specialist Consultation
Maternity/Paternity
Chiropody
Hospital
Surgical Benefits
Hospital
Medical Benefits
Day Case Surgery
Other Inpatient
You may claim for any treatment performed
by a Dental Surgeon or Qualified Orthodontist, apart
from the specific items listed below. Routine dental
checks
are
claimable,
even where no further treatment is required. Claims may
also be made for the cost of dentures and denture repairs.
Finally, you may also claim for a Dental
Hygienist, provided
that these services were received
at the practice
of the dentist recommending the treatment. We will
pay the full amount of costs incurred, up
to the annual maximum benefit.
Dental benefit is not payable for the following:
- Routine
supplies like toothbrushes, mouthwash or dental floss,
even where these have been purchased from your dental
surgery.
- Dental insurance schemes, whether or not they
are operated by a dental surgeon.
- Pre-payment or budget schemes in which dental
charges are paid in regular instalments. We only pay
for the explicit and
recognisable cost of treatment that has actually taken
place.
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You may claim for the cost of eye tests,
spectacles and contact lenses which are prescribed
and supplied by a Qualified Optician. Claims may
also be made for a Qualified Optician's charges for
spectacle frame repairs and fitting new frames to
existing lenses. Routine eye tests are claimable
whether or not they result
in
a prescription for spectacles or lenses. We will
pay 60% of the costs incurred, up to the annual maximum
benefit.
We will not pay for the following:
• Routine supplies like cleaning cloths and lens
cleaning solution, whether or not they were bought
from your optician
• The cost of optical insurance schemes, whether
or not operated by a Qualified Optician
• Contact lenses supplied exclusively for the
improvement of appearance
• Ready made spectacles unless prescribed and
supplied by a Qualified Optician.
Claims for disposable contact lenses (i.e. replaced
less than annually) may only be made for costs incurred
in every other year. In this way, if a claim is made
for disposable contact lenses paid for in 2006, charges
incurred in 2007 will not be claimable.
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You may claim for treatment performed by
a Physiotherapist, Osteopath, Chiropractor, Acupuncturist
or Homoeopath. We will pay 70% of the costs incurred,
up to the annual maximum benefit.
You may claim for up to 5 treatments in the Benefit
Year without referral by a GP. Thereafter, claims
may only be made for treatment for which the patient
has been referred by their GP.
To be eligible for benefit, the practitioner must
be one of the following:
• A practitioner registered as a physiotherapist
with the Health Professions Council.
• A practitioner registered with the General Osteopathic
Council
• A practitioner registered with the General Chiropractic
Council
• An Accredited Member of the British Medical
Acupuncture Society (Dip Med Ac)
• A Full or Associate Member of the British Acupuncture
Council (MBAcC)
• A Member of the Faculty of Homoeopathy (MFHom)
• A Registered Member of the Society of Homoeopaths
(RSHom)
We will not pay for routine supplies like ice packs,
joint supports or tubigrips, whether or not these
were bought from the practitioner who performed the
treatment.
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You may claim for consultations with a Specialist
to whom the patient is referred by their GP. We will
pay 70% of the costs incurred, up to the annual maximum
benefit. A “Specialist” is defined in
Section 1(j) of the scheme rules.
You may claim for the cost of the consultation and
any treatment performed personally by the Specialist
during the consultation. You may also claim for any
associated tests provided that
all of the following apply:
• They are performed by or recommended by the
Specialist being consulted
• The tests consist of X-rays, diagnostic ultrasound
or pathology
We pay only for X-rays and ultrasound. MRI, CT, PET
and Doppler Scans are not eligible for benefit.
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You may claim for each birth so benefit
doubles, for instance, where twins are born. Claims
must be supported by a Birth Certificate issued in
the United Kingdom. Where the parents have different
surnames, a Full Birth Certificate, rather than the
shortened version, will be required in support of
the claim.
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You may claim for treatment provided by
a Chiropodist, provided that the treatment is medically
necessary rather than for cosmetic purposes. We will
pay half of the costs incurred, up to the annual
maximum benefit.
To be eligible for benefit, the practitioner must
be registered as a chiropodist with the Health Professions
Council.
We will not pay for the cost of routine supplies
like clippers and sprays, whether or not these were
bought from your chiropodist.
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You may claim this benefit for a stay
in hospital during which an operation necessitating
the use of a fully equipped operating theatre is
performed. The establishment must be an NHS or
private hospital with full facilities for carrying
out major surgical operations (see Rule 1e). We
will pay for up to 10 nights in the Benefit Year.
The following additional benefits apply:
• In a Subscriber & Partner membership,
if both you and your partner are in hospital at the
same time and both eligible to claim Hospital Surgical
Benefit, the nightly benefit will be doubled. This
doubled rate of benefit will apply for up to 14 nights
in the Benefit Year, the number of nights to include
not only payments under this benefit, but also any
made under Hospital Medical Benefit.
• If your stay is longer than the 10 night maximum,
the additional nights may be claimed under Hospital
Medical Benefit (see below).
The following restrictions will apply:
• You may not claim this benefit for self-inflicted
conditions, including alcoholism and drug abuse.
• Children born in hospital are not covered for
the first 10 nights after birth.
• This benefit only applies to hospitals in the
United Kingdom, although you may be able to claim
for overseas hospitals under Other Inpatient Benefit (see
below).
• Benefit is not payable for cosmetic procedures
or psychiatric conditions, although you may be able
to claim the latter under Other Inpatient Benefit
(see below).
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You may claim this benefit for a stay
in hospital involving active non-surgical treatment
of a medical condition. The establishment must
be an NHS or private hospital with full facilities
for carrying out major surgical operations (see
Rule 1e). We will pay for up to 35 nights in the
Benefit Year.
The following additional benefits apply:
• In a Subscriber & Partner membership, if
both you and your partner are in hospital at the
same time and both eligible to claim Hospital Medical Benefit,
the nightly benefit will be doubled. This doubled
rate of benefit will apply for up to 14 nights in the Benefit
Year, the number of nights to include not only payments
under this benefit, but also any made under Hospital
Surgical Benefit.
• If you are hospitalised for an operation and
your stay is longer than the 10 nights payable under
Hospital Surgical Benefit, the additional nights
may be claimed under Hospital Medical Benefit.
The following restrictions will apply:
• You may not claim this benefit for self-inflicted
conditions, including alcoholism and drug abuse.
• Children born in hospital are not covered for
the first 10 nights after birth.
• This benefit only applies to hospitals in the
United Kingdom, although you may be able to claim
for overseas hospitals under Other Inpatient Benefit
(see below).
• Benefit is not payable for cosmetic procedures
or psychiatric conditions, although you may be able
to claim the latter under Other Inpatient Benefit
(see below).
• Benefit is not payable for hospital stays, the
main purpose of which is residential or custodial
care, or where the hospitalisation is necessitated by a lack
of appropriate facilities to which the patient should
be transferred.
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You may claim this benefit if you have
an operation to treat a medical condition which
is performed as a Day Case, where you are admitted
to hospital and discharged on the same day. The
benefit only applies to hospitals in the United
Kingdom and you may claim up to 35 days in the
Benefit Year.
Apart from the procedures set out below, you may
only claim where the patient signs the hospital’s
Admission Form but where an overnight stay is not
required and where the treatment received demands
the use of a fully-equipped operating theatre. In
addition, benefits may be claimed for the procedures
below, provided they are performed in a hospital
as defined by Rule 1 (e):
• Angiogram
• Cardioversion
• Facet Joint Injection
• Epidural Injections
• Any endoscopy other than hysteroscopy, sigmoidoscopy
and laryngoscopy.
You may not claim for outpatient treatment or any
treatment which is not performed in an operating
theatre.
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This benefit may be claimed for a stay
in a:
• Registered Nursing Home
• Registered Convalescent Home
• Hospital for treatment of a psychiatric condition
• Hospital outside the United Kingdom
The stay must be medically necessary and, other than
overseas hospitals, it must be recommended by the
patient’s
GP and take place at an establishment in the United
Kingdom.
We pay benefit for up to 35 nights in any period.
On reaching 35 nights, this benefit does not become
payable again for three years, after which a new
35 night entitlement begins.
You may not claim for permanent residence in a Nursing
Home, or where the stay takes place because the patient
cannot be looked after at home.
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