1

“Subscriber”. A person who has elected to take out Medicaid cover for him/herself or who has had membership provided by a Group Sponsor without charge.

“Eligible Dependants”. The Subscriber's spouse, if included in his/her membership, and children under 18.

“Group Sponsor”. An employer or any other organisation which, on behalf of its employees or members, has agreed with PHSA to operate a Medicaid Group.

“PHSA, We”. Provincial Hospital Services Association.

“Hospital”. A National Health Service or private hospital with full facilities for carrying out major surgical operations.

“Physiotherapist”. A practitioner registered as a physiotherapist with the Health Professions Council.

“Osteopath”. A practitioner registered with the General Osteopathic Council.

“Chiropractor”. A practitioner registered with the General Chiropractic Council.

“Chiropodist”. A practitioner registered as a chiropodist with the Health Professions Council.

“Specialist”. A Registered Medical or Dental Practitioner who holds, or has held, a consultant appointment in a recognised National Health Service Hospital or who has otherwise held a consultant appointment which PHSA, on professional advice, has accepted in writing as being of equivalent status.

“Registered Convalescent Home”. An establishment registered with the appropriate authority as a convalescent home or which PHSA has accepted in writing as being eligible for benefit.

“Registered Nursing Home”. An establishment registered with the appropriate authority as a nursing home or which PHSA has accepted in writing as being eligible for benefit.

“Treatment”. Surgical or medical procedures the sole purpose of which is the cure or relief of acute illness or injury.

“Claimant”. The Subscriber or Eligible Dependant to whom the expenses or services being claimed relate.

“Benefit Year”. Unless otherwise agreed in writing by PHSA and a Group Sponsor, for the purpose of assessing benefit entitlements the “Benefit Year” will be 12 consecutive months from 1st January to 31st December.

“Chronic Medical Condition”. Any medical condition which is likely to continue or recur for which the treatment provided will only offer relief or control of symptoms and not a cure.

“Acupuncturist”. An Accredited Member of the British Medical Acupuncture Society (Dip Med Ac) or a Full or Associate Member of the British Acupuncture Council (MBAcC).

“Homoeopath”. A Member of the Faculty of Homoeopathy (MFHom) or a Registered Member of the Society of Homoeopaths (RSHom).

“Disposable Contact Lenses”. Contact lenses prescribed by a Qualified Optician which are replaced more frequently than once per year.

2

Application for membership or to amend an existing membership must be made on the prescribed form. Acceptance thereof, and the date on which cover starts, are at the discretion of PHSA.

Membership is limited to persons resident in the United Kingdom.

No-one, either as a Subscriber or an Eligible Dependant, may be simultaneously enrolled on, or claim benefits under, more than one Medicaid registration.

3

With the exception of subscriptions which are deducted from pay by a Group Sponsor, all subscriptions are payable monthly, quarterly, half-yearly or yearly in advance.

Benefits are not payable in respect of costs incurred in any period for which any subscriptions remain unpaid. In the event of subscriptions becoming more than one month overdue, the membership will be terminated.

4

New Subscribers are not entitled to claim benefits, other than for accidents (see below), in respect of treatment or services received in a period of four months from the date of joining or eight months for Subscribers over the age of 60 at the date of joining.

Hospital Surgical, Hospital Medical and Day Case Surgery Benefits may be claimed during the qualifying periods set out in (a) above for Treatment of injuries sustained as a result of an accident.

Subscribers whose cover has increased will not be entitled to claim benefit on the higher scale for treatment or services received in a period of two months from the date of transfer, or ten months for claims relating to maternity and childbirth. During this qualifying period claims will continue to be payable at the rates applicable before the increase in cover.

Benefits are not payable for new joiners in respect of any medical problem or condition known to exist, or which the applicant ought reasonably to have known or suspected to exist, at the time of acceptance of the application and to any conditions subsequently discovered to be related thereto. Similarly, where an application is made to increase cover, benefits for such conditions are restricted to the previous scale.

5

Benefits are not payable in respect of maternity or childbirth where the child is born within ten months of the date of acceptance into the scheme.

With the exception of overseas hospital claims made under Other Inpatient Benefit, benefits are payable in respect of Treatment or services received in the United Kingdom only.

Claims for inpatient treatment and also for Specialist Consultation Benefit will only be eligible in respect of Treatment recommended by the patient’s General Practitioner. This rule also applies to Outpatient Therapy Benefit, other than for the first five treatments in the Benefit Year.

In respect of Dental, Optical, Outpatient Therapy, Specialist Consultation and Chiropody, benefits are not payable in respect of expenses which are or could be the basis of a claim against a third party. Where the expenses are or could be the subject of a claim against another insurer the liability of PHSA shall be limited to its rateable proportion of the expenses incurred.

Where a hospital stay claimable under Hospital Surgical Benefit exceeds the ten nights allowed by that benefit, the remaining nights may be claimed under Hospital Medical Benefit.

Benefits will not be payable where the total amount claimed is less than £2.50.

Where both parents are members of the scheme, benefits in respect of a child will be paid under one membership only.

Benefits are not payable for claims relating to treatment or events which are more than six months old unless PHSA has accepted in writing that there were valid reasons for the delay.

Claims must be submitted with the prescribed Claim Form, the original receipted accounts for the services being claimed, and such other information as PHSA may reasonably require. Receipted accounts submitted with the claim must show the provider of the service, the patient, the amount and the date. In particular, “Till Roll” receipts will usually be unacceptable as they seldom show this information. The accounts will be retained by PHSA, unless return of the account is specifically requested.

PHSA may require a claim to be supported by evidence of age or a medical report. PHSA will pay any reasonable fee for such reports.

Benefit cheques will be payable to the Claimant or, if the claim is in respect of a child, to the Subscriber.

6

PHSA may alter the rates of subscription and benefit or the Rules and Benefit Notes from time to time and such alterations will become immediately operative.

PHSA will notify Subscribers of any alterations that it deems material, but any accidental omission or failure to send a Subscriber details shall not invalidate the alteration. A copy of the current Rules will be sent to a Subscriber on request.

A Group Sponsor may, with the agreement of PHSA, provide special variations to the benefits or Rules for its members. Such variations will be confirmed in writing by PHSA and the Group Sponsor at the start of the Benefit Year to which the variations apply, and will apply to all members of the Group for that Benefit Year.

7

This contract shall be deemed to be made in England and shall be subject to and construed in accordance with English Law.

Any complaint should be addressed in the first instance to the Head Office of PHSA at the address or telephone number shown on the back of this brochure. If you are not satisfied with the manner in which your complaint has been handled, you may request a review of your case by the Chief Executive of PHSA. Should you remain dissatisfied, you may request a further review by the Complaints Committee of the PHSA Board of Management. Once these procedures are complete, you then have a further right to refer your complaint to the Financial Ombudsman Service of the FSA, the statutory regulator of the insurance industry. These arrangements do not, of course, affect any right of action that you may have against PHSA in the matter.

We are members of the Financial Services Compensation Scheme from whom you may be able to obtain compensation if we fail to meet our liabilities. Compensation is paid at 100% of the first £2000 and 90% for the remainder.