Up to £500 per scheme lifetime

We will pay up to £500 per scheme lifetime towards medically necessary orthotics, when these are recommended by a GP, practitioner, physiotherapist or specialist.

Outpatient consultations with a practitioner 

Within outpatient limit / full cover

We will pay within your overall outpatient limit for consultations with a dietician, nurse, orthoptist, podiatrist or speech therapist following GP or specialist referral. The practitioner must be registered with the correct governing body for their field, and meet our definition for a practitioner

Inpatient and Daycase Mental Health Treatment (Platinum level only)

We will pay up to a maximum of 28 days per scheme year for eligible inpatient and daycase mental health treatment. All treatment must be under the direct control and supervision of a consultant psychiatrist, and must be authorised by us in advance and in writing.

We will pay up to a maximum of 28 days per scheme year for eligible inpatient and daycase mental health treatment. All treatment must be under the direct control and supervision of a consultant psychiatrist, and must be authorised by us in advance and in writing.

Where treatment is for an addiction treatment programme, cover is limited to once per scheme lifetime.

Long COVID Benefit

Combined overall limit of £5,000 per scheme year (up to £15,000 per scheme lifetime)

Removed

COVID-19 NHS Cash Benefit

£300 per day or night up to a maximum of 30 days

Removed

Outpatient Complementary Therapies

We will pay up to £250 per scheme year, within your overall outpatient limit, for outpatient treatment for acupuncture, chiropractic treatment, homoeopathy and osteopathy, following GP or specialist referral. 

You must be referred to a complementary practitioner we have recognised for benefit purposes.

We will pay up to £250 per scheme year, within your overall outpatient limit, for chiropractic treatment, osteopathy and acupuncture, following GP or specialist referral. You must be referred to a complementary practitioner we have recognised for benefit purposes.

Appliances, physical aids and devices 

We do not pay for the supply or fitting of appliances, physical aids or devices (including but not limited to hearing aids, spectacles, contact lenses, crutches, walking sticks, external prostheses and orthotics etc) which do not fall within our definition of surgical appliance. Any consultations relating to these are also not covered.

Exception: We will pay for appliances that fall under our definition or a surgical appliance.

We do not pay for the supply or fitting of appliances, physical aids or devices (including but not limited to hearing aids, spectacles, contact lenses, external prostheses and orthotics etc) which do not fall within our definition of a surgical appliance other than as listed in your table of benefits. Any consultations relating to these are also not covered.

Congenital conditions

We do not pay for treatment of abnormalities that are diagnosed and/or apparent from birth, regardless of the cause.

Removed

Chronic conditions

We do not pay for treatment of chronic conditions. By this we mean any medical condition which 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 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.

We will pay for eligible treatment arising out of a chronic condition, or for treatment of acute symptoms of a chronic condition that flare up. However, we only pay if the treatment is likely to lead quickly to a complete recovery or to you being fully restored to your previous state of health, without you having to receive prolonged treatment. For example, we pay for treatment following a heart attack arising out of chronic heart disease. This exception does not apply to treatment of a psychiatric condition. .At the time of your treatment it may not always be clear that your condition is chronic, however when it becomes clear that your condition is chronic, we are not obliged to continue paying the ongoing costs of treatment, even where we have previously paid for treatment.

We do not pay for treatment of chronic conditions. By this we mean any medical condition which 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 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.

Please note: this will apply to all medical conditions, whether or not a diagnosis has been made.

Exception: We will pay for eligible treatment arising out of a chronic condition, or for treatment of acute symptoms of a chronic condition that flare up. However, we only pay if the treatment is likely to lead quickly to a complete recovery or to you being fully restored to your previous state of health, without you having to receive prolonged treatment. For example, we pay for treatment following a heart attack arising out of chronic heart disease. This exception does not apply to treatment of a mental health condition.

Please note: in some cases it might not be clear, at the time of treatment, that the disease, illness or injury being treated is a chronic condition. We are not obliged to pay the ongoing costs of continuing, or similar, treatment. This is the case even where we have previously paid for this type of or similar treatment.

Please note this exclusion does not apply to the treatment of cancer.

Dental and Oral Treatment (such as fillings, gum disease or jaw shrinkage)

We do not pay for:

• consultations with a dentist or routine dental check ups

• fillings, simple extractions and treatment of gum disease

• root canal treatment

• consultations with dental specialists such as periodontists, orthodontists, endodontists, and hygienists

• the provision of dental implants, or veneers, repair or replacement of damaged teeth (including crowns, bridges, dentures or any dental prostheses), or orthodontic braces (whether fixed or removable)

• restoration of minor enamel, dentine and incisal edge fractures

• the management of or treatment (including surgical operations) of jaw shrinkage or loss as a result of dental extractions or gum disease

• treatment required for cosmetic reasons (for example orthognathic surgery and teeth whitening).

• procedures to prepare for orthodontics or prosthetic surgery

• mouth guards, gum shields, or dental appliances of any kind

Exception: we will pay for surgical operations carried out by a specialist when treating an acute condition such as:

• surgically remove a complicated, buried, infected or impacted tooth root

• apicectomy or removal of the tip of a tooth’s root

• enucleation of a cyst of the jaw (removing a cyst from the jaw bone)

• surgical drainage of a fascial space (tracking) abscess

• putting a natural tooth back into a jaw bone after it is knocked out or dislodged in an accident

• treatment of facial and mandibular fractures

We do not pay for any dental or oral treatment other than as listed in the exception below.

Exception: We will pay for eligible treatment related only to the following specified oral surgical operations when carried out by a specialist:

• surgically remove a complicated, buried, infected or impacted tooth root

• apicectomy or removal of the tip of a tooth’s root

• enucleation of a cyst of the jaw (removing a cyst from the jaw bone)

• surgical drainage of a fascial space (tracking) abscess

• putting a natural tooth back into a jaw bone after it is knocked out or dislodged in an accident

• treatment of facial and mandibular fractures.

Eyesight correction 

We do not pay for treatment to correct your sight, This includes routine eye examinations, contact lenses (including lenses following cataract surgery), spectacles or laser eye procedures.

We do not pay for ongoing or long-term treatment of eye conditions. This includes but is not limited to:

• Glaucoma

• Diabetic retinopathy

• Occlusion therapy for squint

• Astigmatism

• Myopia

• Amblyopia

Exception: We will pay for eligible acute treatment of the following conditions:

• Cataracts

• detached retina

• Surgical correction of a squint

• Drooping Eyelids (ptosis) – We will only provide benefit for ptosis (drooping eyelids), if your optometrist identifies visual impairment and you are in turn referred by your General Practitioner or optician to a consultant ophthalmologist. We will only fund surgery if visual field tests and medical photographs confirm the ptosis is at risk of threatening the visual field testing for safe driving

• Wet aged related macular degeneration, where we will pay for a short course of treatment following initial diagnosis

We do not pay for treatment to correct your eyesight due to long or short vision, including but not limited to, laser eye surgery, spectacles or contact lenses.

Exception: We will pay for eligible treatment to the eye resulting from an acute condition or injury.

Pandemic and/or epidemic disease

New exclusion

We do not pay for treatment for or arising from pandemic and / or epidemic disease.

Pregnancy and Childbirth 

We do not pay for treatment for pregnancy or childbirth, including:

• Hyperemesis (excessive and prolonged nausea and vomiting)

• Pelvic girdle pain (pelvic pain in pregnancy)

• Diastasis recti (abdominal separation)

• Pregnancy induced hypertension (high blood pressure in pregnancy)

• Pre-eclampsia

• Treatment of a foetus or embryo

• Antenatal care

• Termination of pregnancy

• Any treatment arising from assisted conception

• Any complications arising from the above condition

Exceptions: We will pay for eligible treatment of the following conditions:

• Miscarriage or when the foetus has died and remains with the placenta in the womb

• Still birth

• Hydatidiform mole (abnormal cell growth in the womb)

• Ectopic pregnancy (foetus growing outside the womb)

• Post-partum haemorrhage (heavy bleeding in the hours and days immediately after childbirth)

• Retained placental membrane (afterbirth left in the womb after the delivery of the baby)

• Eligible mental health treatment for post-natal depression subject to the conditions and limitations set out in the mental health benefit.

• Medically essential caesarean section where this is an inevitable consequence of a complication to the current pregnancy.

• Complications following any of the above conditions.

We will require full clinical details from your specialist before we can give our decision. We do not pay for any of the above if the pregnancy is a result of assisted conception.

We do not pay for any treatment related to pregnancy or childbirth, other than as listed in the exception below:

Exception: We will pay for the following eligible specified obstetric procedures / treatment:           

• pelvic girdle pain in pregnancy
• miscarriage or when the foetus has died and remains with the placenta in the womb
• still birth
• hydatidiform mole (abnormal cell growth in the womb)
• ectopic pregnancy (foetus growing outside the womb)
• diastasis recti or Rectus Abdominis (splitting of the abdominal muscles during pregnancy)
• post-partum haemorrhage (heavy bleeding in the hours and days immediately after childbirth)
• retained placental membrane (afterbirth left in the womb after the delivery of the baby)
• eligible mental health treatment for post-natal depression subject to the conditions and limitations set out in the mental health benefit.
• medically essential caesarean section where this is an inevitable consequence of a complication to the current pregnancy.
• complications following any of the above conditions.
• flare up of a non-pregnancy related medical condition that has been made worse by pregnancy.

We will require full clinical details from your specialist before we can give our decision on cover.

In the event that the newborn requires immediate treatment as a result of an eligible caesarean section, this should be administered by the NHS free of charge. If the newborn is not entitled to NHS care and is not accepted as a dependant on the scheme we will pay for treatment for up to 7 days following the birth, to allow you time to make alternative arrangements.  In cases where they are accepted as a member of the scheme they will only be entitled to benefits outlined in the benefits table and will be subject to the exclusions listed within the scheme.

Sleep problems and disorders

We do not pay for treatment for or arising from sleep disorders. This includes but is not limited to: sleep apnoea, snoring, insomnia, sleep walking, narcolepsy, and night terrors.

Removed 

Temporary relief of symptoms 

We do not pay for treatment intended to provide temporary relief of symptoms or for the ongoing management of a condition.

Removed 

Unrecognised providers or treatment facilities 

We do not pay for treatment carried out by a provider who we do not recognise as being qualified and/or registered to provide the type of treatment you need or for treating the medical condition you have.

We do not pay for treatment with sports therapists, massage therapists, or anyone who does not meet our definition of a practitioner or complementary practitioner

We do not pay for treatment carried out by a provider who we do not recognise as being qualified and/or registered to provide the type of treatment you need or for treating the medical condition you have.

We do not pay for treatment with sports therapists, massage therapists, or anyone who does not meet our definition of a practitioner or complementary practitioner.

We do not pay for any treatment carried out by you, your spouse, parents or children.

Please refer to Member Zone for further information

Please refer to your cancer support explained

Up to £2,000 per scheme lifetime

We will pay up to £2,000 per scheme lifetime for the assessment of neurodevelopmental disorders following GP or specialist referral.  Assessment must be carried out by a specialist or educational psychologist that we recognise for benefit purposes.

You must have our confirmation before any assessment is carried out and we need full clinical details from your GP or specialist before we can confirm cover.

Once a diagnosis has been confirmed, there will be no further cover for any additional investigations, assessments or treatment in the future.

Up to £10,000 per scheme lifetime

We will pay for fertility treatment as detailed in the assisted reproductive technology explained.

Women's health benefits

Remote advice service with our in-network specialist gynaecologists

We will pay for up to 4 remote advice appointments per scheme year with our in-network specialist gynaecologists on self-referral.  This service can be used to discuss any women’s health concern including conditions that are normally excluded for cover such as the menopause or for contraception/fertility advice. 

Diagnostic tests and investigations following referral from our in-network gynaecologists

We will pay up to £500 per scheme year for diagnostic tests or investigations that are recommended following a remote advice appointment with our in-network specialist gynaecologists.

Remote consultations and diagnostic tests and investigations will be covered up to the limits described above only. Once the benefit limits have been reached the scheme rules will apply as detailed in your exclusions and limitations.

Please note: additional cover may be available outside of the above limits for eligible claims, please contact the claims helpline for further information.

Please refer to the women's health services page for further information on how to access these benefits.

Women's and Men's health benefit

Remote advice service with our in-network specialist gynaecologists or men's health specialists

We will pay for up to 4 remote advice appointments per scheme year with our in-network specialist gynaecologists or men’s health specialists on self-referral.  This service can be used to discuss any health concern including conditions that are normally excluded for cover such as the menopause, andropause, sexual health concerns, fertility or contraception advice.

Diagnostic tests and investigations following referral from our in-network gynaecologists or men's health specialists

We will pay up to £500 per scheme year for diagnostic tests or investigations that are recommended following a remote advice appointment with our in-network specialist gynaecologists or men’s health specialists.

Remote consultations and diagnostic tests and investigations will be covered up to the limits described above only. Once the benefit limits have been reached the scheme rules will apply as detailed in your exclusions and limitations.

Please note: additional cover may be available outside of the above limits for eligible claims, please contact the claims helpline for further information.

Please refer to the women's  or men's health services page for further information on how to access these benefits

Developmental problems, behavioural problems or learning difficulties

We do not pay for developmental problems, behavioural problems or learning difficulties such as but not limited to dyslexia, dyspraxia, autism and ADHD. We do not pay for treatment which is in any way related to learning difficulties, behavioural problems or delay in a child’s development. This includes any diagnostic tests.

Neurodevelopmental disorder

We do not pay for the treatment of adult or childhood neurodevelopmental disorders including but not limited to dyslexia, dyspraxia, autism, ADHD or neurodevelopmental delay without diagnosis.

Please note:  You will be covered for the assessment of neurodevelopmental disorders as detailed in your table of benefits.

4 remote consultations per scheme year, via our in-network specialist gynaecologists

You can contact our virtual GP, TrustDoc24, directly on 0345 319 4129 at any time to arrange a remote consultation with a GP with additional training in women’s health.

Alternatively contact our helpline and speak with the nursing team, and if appropriate we may be able to arrange a remote consultation directly with our in-network gynaecologist. Please contact us to discuss this. 

Please note:  remote consultations with our in-network gynaecologist will be limited to 4 per scheme year. If further consultations are required, these will be subject to the general terms and conditions of the scheme. There is no limit placed on remote consultations with our virtual GP.

Please refer to the women’s health services page for further information on how to access this benefit.

Up to £500 per scheme year

We will pay up to £500 per scheme year for diagnostic tests or investigations that are recommended following a remote consultation with our in-network specialist gynaecologists.

Please refer to the women’s health services page for further information on how to access this benefit.

Up to £1,500 per scheme year within £5,000 overall limit

We will pay up to £1,500 per scheme year, for outpatient consultations for eligible mental health conditions, following GP or self-referral, when treatment is required as a result of COVID-19 (commonly referred to as “long COVID”).

If your referral is to a psychological therapist we will arrange a telephone-based clinical assessment with a senior psychological therapist from our mental health network provider who will help organise the most effective treatment for you. This could include face to face therapy, guided self-management or specialist referral. Where treatment with a psychological therapist occurs outside our network provider it must be delivered under the direct supervision of a consultant psychiatrist.

Please note this benefit is also subject to the overall benefit limit of £5,000 per scheme year for COVID-19 benefits.

Please refer to the COVID-19 Cover Explained for further information.

Up to £500 per scheme year within £5,000 overall limit

We will pay up to £500 per scheme year for outpatient physiotherapy following GP or self-referral, when treatment is required as a result of COVID-19 (commonly referred to as “long COVID”).

If this is a self-referral*, we will arrange a telephone-based clinical assessment with a senior physiotherapist who will help organise the most effective treatment for you. This could include face to face physiotherapy, guided self-management or specialist referral. The telephone-based clinical assessment will not be subject to any excess, if one applies, however it will be applied to subsequent treatment should this be required. We will continue to monitor your progress by liaising with your treatment provider and authorise additional treatment where necessary and eligible.

If treatment takes place outside our Physiotherapy network, the physiotherapist must still be recognised by us for benefit purposes.

Please note this benefit is also subject to the overall benefit limit of £5,000 per scheme year for COVID-19 benefits.

Please refer to the COVID-19 Cover Explained for further information.

Up to £250 per scheme year within £5,000 overall limit

We will pay up to £250 per scheme year for chiropractic treatment, osteopathy and acupuncture, following GP or specialist referral, when treatment is required as a result of COVID-19 (commonly referred to as “long COVID”). You must be referred to a complementary practitioner we have recognised for benefit purposes.

Please note this benefit is also subject to the overall benefit limit of £5,000 per scheme year for COVID-19 benefits.

Please refer to the COVID-19 Cover Explained for further information.

£500 per scheme year

We will pay up to £500 per scheme year for outpatient treatment required as a result of a chronic mental health condition following GP or self-referral. Please call the claims helpline to speak with one of our nurse case managers for further advice and support on accessing this benefit. All treatment must be pre-authorised to be eligible for cover. This is for outpatient treatment only and is subject to all other terms and conditions.

Gold
Platinum

Silver
Gold
Platinum

Gold - £200
Platinum - £150 

Silver - £100 
Gold - £150
Platinum - £150 

Gold - £1,000
Platinum - Full cover

Silver - £1,000
Gold - £1,500
Platinum - Full cover

Outpatient physiotherapy now includes self-referral
through our physiotherapy network provider

Silver level -
For conditions relating to muscle, bone or joint pain we will pay in full for outpatient physiotherapy when treatment is provided by our physiotherapy network provider. If you have self-referred*, we will arrange a telephone-based clinical assessment with a Senior Physiotherapist who will help organise the most effective treatment for you. This could include face to face physiotherapy, guided self-management or specialist referral. The telephone-based clinical assessment will not be subject to any excess (if one applies) however it will be applied to subsequent treatment should this be required. We will continue to monitor your progress by liaising with your treatment provider and authorise additional treatment where necessary and eligible.

*Please note, cover for self-referral is subject to the medical underwriting on your scheme.

Gold & Platinum levels -
We will pay for outpatient physiotherapy following self-referral, GP, or specialist referral. For conditions relating to muscle, bone or joint pain we will pay for outpatient physiotherapy when treatment is provided by our physiotherapy network provider. If you have self-referred*, we will arrange a telephone-based clinical assessment with a Senior Physiotherapist who will help organise the most effective treatment for you. This could include face to face physiotherapy, guided self-management or specialist referral. The telephone-based clinical assessment will not be subject to any excess (if one applies) however it will be applied to subsequent treatment should this be required. We will continue to monitor your progress by liaising with your treatment provider and authorise additional treatment where necessary and eligible.

If treatment takes place outside our physiotherapy network, the physiotherapist must still be recognised by us for benefit purposes. We will pay the costs of an initial assessment followed by three further sessions if required and pre-authorisation has been obtained from us. If further sessions are required, you must contact us on 0844 874 0611 with details of your proposed treatment plan from the physiotherapist to receive pre-authorisation.

*Please note, cover for self-referral is subject to the medical underwriting on your scheme.

Outpatient mental health now includes self-referral through our mental health network provider

We will pay for outpatient consultations for eligible mental health conditions following GP or self-referral*. This is included in your overall outpatient limit per scheme year. If your referral is to a Psychological Therapist we will arrange a telephone-based clinical assessment with a Senior Therapist from our mental health network provider who will help organise the most effective treatment for you. This could include face to face therapy, guided self-management or specialist referral. Where treatment with a Psychological Therapist occurs outside our network provider it must be delivered under the direct supervision of a Consultant Psychiatrist.

Please note: Your cover is designed to provide help for short or medium-term medical treatment that restores you back to health. Mental health conditions are often long term in nature and may become chronic conditions, for which ongoing cover will not be available on your scheme. Should your specialist/therapist recommend that treatment will be required in excess of 10 sessions the nursing team will provide guidance on making other arrangements for continued treatment after this period. Any extension in cover will be subject to a full clinical review and assessed on a case by case basis – full clinical details will be required from your treating specialist.

*Please note, cover for self-referral is subject to the medical underwriting on your scheme.

Treatment at home was previously covered up to £600 per scheme year, this benefit is now covered in full

We will pay in full for home nursing charges for registered nurses when recommended by a specialist and where treatment is:

• medically necessary and without it you would have to receive treatment as an inpatient or daycase admission

• needed for medical reasons (i.e. not social or domestic reasons)

• under the direct supervision of a consultant.

We will need full clinical details before we give our authorisation and you must have our written agreement before treatment starts.

Home nursing provided by a community mental health team is not covered by the scheme.

There was previously a 35 night limit included within the NHS cash benefit, this limit has now been removed

Silver level -
In the event that you are admitted to an NHS hospital, or you elect to receive free treatment through the NHS we will pay an NHS Cash Benefit of £150 per night or day, for inpatient or daycase treatment. This benefit will only apply to claims for daycase or inpatient treatment that would otherwise have been eligible for benefit under your scheme.

The benefit would be paid to you on completion of your treatment and receipt of the necessary documents, which must be submitted within six months of your treatment date. If you require further information on how to access this benefit, please call on 0844 874 0611.

Gold & Platinum levels -
In the event that you are admitted to an NHS hospital, or you elect to receive free treatment through the NHS we will pay an NHS Cash Benefit of £200 per night or day, for inpatient or daycase treatment. This benefit will only apply to claims for daycase or inpatient treatment that would otherwise have been eligible for benefit under your scheme.

The benefit would be paid to you on completion of your treatment and receipt of the necessary documents, which must be submitted within six months of your treatment date. If you require further information on how to access this benefit, please call on 0844 874 0611.

There was previously a 12 month limit for biological therapies for cancer, this limit has now been removed

Please see the cancer cover explained table for details of this change.

Updates have been made to the policy wording and content to ensure it remains up to date and appropriate

1st June 2019

HIV/AIDS is excluded within the chronic conditions exclusion, therefore the HIV/AIDS exclusion has been removed.

1st June 2019

The congenital conditions exclusion has been updated with the below wording:

We do not pay for treatment of abnormalities that are diagnosed and/or apparent from birth, regardless of the cause

1st June 2019

Combined limit of £1,000 per scheme year

We will pay a combined limit of £1,000 per scheme year for cancer outpatient therapies and cancer alternative therapies.

Cancer outpatient therapies
We will pay up to the benefit limit for physiotherapy, osteopathy, chiropractic treatment, manual lymphatic drainage and dietician services. 

Cancer alternative therapies
We will reimburse up to £250 on a pay and claim basis within the above combined limit of £1,000 per scheme year for acupuncture, reflexology, aromatherapy and homeopathy.

Benefits will be paid to you on receipt of the necessary documents, which must be submitted within six months of your treatment date.

These benefits are available when recommended by your specialist and required as a direct result of eligible cancer treatment. Treatment must be taken with a practitioner we recognise for benefit purposes. For more details on how to access these benefits, please call on 0844 874 0611.

£1,000 per scheme year

We will pay up to £1,000 per scheme year for outpatient mental health treatment.

Mental Health treatment must be with a Psychological Therapist or Psychiatrist for this to be eligible for cover.

This benefit is available when recommended by your specialist and required as a direct result of eligible cancer treatment. Treatment must be taken with a practitioner we recognise for benefit purposes. For more details on how to access this benefit, please call on 0844 874 0611.

 Full cover

We will pay in full for the cost of external prosthesis, wigs and medical tattooing for reconstructive purposes only.

For wigs and medical tattooing, this benefit is available on a pay and claim basis only. Benefits will be paid to you on receipt of the necessary documents, which must be submitted within six months of your treatment date.

This benefit is available when recommended by your specialist and required as a direct result of eligible cancer treatment. Treatment must be taken with a practitioner we recognise for benefit purposes. For more details on how to access this benefit, please call on 0844 874 0611.

£600 per month

In the event that you elect to receive oral chemotherapy or targeted therapies via the NHS as an outpatient, we will pay an NHS Cancer Cash benefit of £600 per month whilst receiving such treatment.

This benefit would be paid to you on completion of your treatment and receipt of the necessary documents, which must be submitted within six months of your treatment date. If you require further information on how to access this benefit, please call on 0208 481 7718.

Full cover

Please note the below preventative wording is detailed in the cancer cover explained table:

If you are being treated for cancer we may pay for medically necessary genetically-based tests to evaluate future risk of developing further cancers, as well as the resulting prophylactic surgery if it is recommended by your specialist and performed at the same time as the surgery for the original 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 and your specialist indicates that prophylactic surgery is medically necessary and will be carried at the same time as surgery to the diseased breast.

You must have our written agreement before you have tests, procedures or treatment and we will need full clinical details from your consultant before we can give our decision.

 N/A

As part of your BDB Pitmans Healthcare Scheme you have access to a virtual GP service, called TrustDoc24 which is provided by Medical Solutions.

This service can be accessed 24/7, 365 days a year by phone on: 0345 319 4129, or via the app (eConsultation service is available Mon-Fri 08:00-22:00, Sat 08:00-20:00, Sun 10:00-18:00, excluding bank holidays). For further information on the service click here, and for details on how to download the app click here.

Please note, during the phone call or eConsultation you will need to provide Medical Solutions with your employer’s name, BDB Pitmans, in order to access the service.

Should Medical Solutions refer you onto a specialist, please contact us on your help line number 0208 150 0938 to check if this is eligible under your scheme. Any onward referrals are subject to your scheme underwriting, personal exclusions (if applicable) and general scheme exclusions. Should further information on your past medical history be required we will need your consent to contact your NHS GP.

N/A

The scheme benefits are subject to an overall benefit limit of £100,000 per claim per scheme year.

£300 per day or night.

In the event that you elect to receive free cancer treatment through the NHS, we will pay an NHS cancer cash benefit of £300 per night or day following eligible inpatient or daycase treatment or outpatient radiotherapy treatment , instead of any other benefit.

This benefit will be payable for eligible treatment following the submission of the necessary documents which must include the date of admission, the date of discharge, the diagnosis and the treatment received. Please note this must be claimed within 6 months of the date of treatment.

We will pay in full, fees for outpatient psychiatric consultations or treatment under the direct supervision of a consultant psychiatrist, psychologist or a psychiatric therapist when referred by a GP, when approved by us in advance and in writing. Where treatment is with a therapist, this must be approved by us in advance and in writing. You must have been referred by and under the direct control of a psychiatrist.

These benefits are included in your overall annual limit of £1000.

We will pay for fees for outpatient consultations for mental health conditions when referred by a GP. Treatment with a psychological therapist must be under the direct supervision of a Consultant Psychiatrist unless this is delivered by a Healix Mental Health network provider.

Cover is subject to the overall annual outpatient benefit limit of £1,000 in each year of cover and also subject to our reasonable and customary guidelines. For assistance in finding a network provider please contact the Helpline and a member of the team will arrange a referral on your behalf.

Please note: Your cover is designed to provide help for short or medium-term medical treatment that restores you back to health. Mental health conditions are often long term in nature and may become chronic conditions, for which ongoing cover will not be available on your scheme. Should your specialist/therapist recommend that treatment will be required in excess of 10 sessions the nursing team will provide guidance on making other arrangements for continued treatment after this period. Any extension in cover will be subject to a full clinical review and assessed on a case by case basis – full clinical details will be required from your treating specialist.

We will pay in full for active inpatient, daycase or outpatient treatment for a diagnosed malignancy. This includes diagnostic tests, surgery, chemotherapy and radiotherapy. Please note you must contact us before your treatment starts. For further information on the cover available to you for cancer treatment please see section Cancer Cover Explained.

For more information please contact the nursing team on 0208 150 0938.

The purpose of this scheme is to help you with the costs of the treatment for an acute illness or injury, not to control or treat a long term (chronic) condition.

We define a chronic condition as a disease, illness or injury which 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 continues indefinitely
• it comes back or is likely to come back
• you need to be rehabilitated or specially trained to cope with it
• it has no known cure.

We will pay for eligible treatment arising out of a chronic condition, or for treatment of acute symptoms of a chronic condition that flare up. However, we only pay if the treatment is likely to lead quickly to a complete recovery or to you being fully restored to your previous state of health, without you having to receive prolonged treatment. For example, we pay for treatment following a heart attack arising out of chronic heart disease. This exception does not apply to treatment of a psychiatric condition.

Please note: in some cases it might not be clear, at the time of treatment that the disease, illness or injury being treated is a chronic condition. We may not pay the ongoing costs of continuing, or similar treatment even where we have previously paid for this type of or similar treatment.

If after a full review of all the medical information available, a condition is considered to have become a chronic condition, you will be given written notification that the scheme will no longer pay benefits for the continuing or recurrent treatment of the chronic condition. You will also be given time to make other arrangements for continued treatment, and the scheme will assist you and your GP to transfer management of your chronic condition to the NHS.

We define a chronic condition as a disease, illness or injury which 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 continues indefinitely
• it comes back or is likely to come back
• you need to be rehabilitated or specially trained to cope with it
• it has no known cure

Please note: this will apply to all medical conditions, whether or not a diagnosis has been made

We will pay for eligible acute conditions related to a chronic condition (this does not apply to psychiatric conditions). For example, we pay for treatment following a heart attack arising out of chronic heart disease.  However, many chronic conditions are of a relapsing and remitting nature, requiring management of recurrent episodes where symptoms deteriorate - e.g. multiple sclerosis, Crohn’s disease, long-term depressive illness, psoriasis etc. The relapses are part of the normal illness course and therefore cannot be classed as acute complications of the disease and are not eligible for benefit.

Please note: in some cases it might not be clear at the time of treatment that the disease, illness or injury being treated is a chronic condition. We may not pay the ongoing costs of continuing, or similar treatment even where we have previously paid for this type of or similar treatment. As we expect an acute condition to resolve completely within three months, we would begin to consider any condition lasting longer than this as chronic

We may ask you to provide information to help us assess your claim. For example, we may ask you for one or more of the following:

• medical reports and other information about the treatment for which you are claiming. If we request a medical report from your specialist and they charge for providing this we will pay the cost
• results of an independent medical examination we may ask you to undergo. We will pay for the cost of any independent medical examination we require you to have
• original accounts and invoices in connection with your claim including any related treatment cost covered by your excess.

We may ask you to provide information to help us assess your claim. For example we may ask you for one or more of the following:

• Medical reports and other information about the treatment for which you are claiming. If we request a medical report from your specialist and they charge for providing this we will pay the cost.
• Results of an independent medical examination or second opinion we may ask you to undergo with a consultant. We will pay for the cost of any independent medical examination or second opinion we require you to have and we will authorise this in writing, in advance.
• Results of any second opinion you have independently sought to obtain eligible treatment under the care of another consultant. On such occasions we may additionally request our own, independent, second opinion from an expert in that field to assess eligibility of cover. We will pay the costs of any second opinion we organise on your behalf, this includes the cost of the consultation and any tests undertaken as a result of that consultation.
• Original accounts and invoices in connection with your claim.

We will liaise with you and your medical specialists throughout your treatment and will request medical information, when we deem that this is required for the assessment of your claim. You will be asked for your consent before we do this.

As you undergo treatment, we will make you aware of the options that are open to you. If your medical specialist recommends treatment, you should contact the helpline as soon as possible to be sure that continued treatment is covered.

Our team of nurses will assess the level of cover available to you for planned treatment within the terms and conditions of the scheme. In some instances it may be necessary to refer your claim to our Chief Medical Officer who, along with our panel of independent specialist advisors, will advise on the level of cover available for (said) recommended treatment.

We do not pay for treatment for cancer once it becomes palliative in nature.

Exclusion has been removed.