Introduction

Welcome to the Barnett Waddingham Medical Scheme guide.

Barnett Waddingham have appointed us, Healix Health Services Ltd, to manage this scheme. Our role is to assess and manage medical needs that you might have as well as the care and treatment you receive.

The Barnett Waddingham Medical Scheme is designed to cover you for the diagnosis and/or treatment of a short term medical condition, if the treatment is medically necessary.

The scheme is not intended to cover all medical conditions. There are some medical conditions and treatments that are excluded from cover (please see exclusions and limitations for further details on this).

All treatment (including consultations and diagnostic tests) should be authorised in advance. Therefore it is essential that you call us before you receive treatment, to ensure that your proposed treatment is eligible for cover under the scheme.

Table of benefits - CORE

Your scheme benefits are set out in the table below.

Benefit limits apply to each individual member or dependant in any one year of cover, unless otherwise stated.

All claims are subject to your excess, which will be applied to the first eligible treatment within each scheme year.

The scheme will commence on the 1st January 2024 to 31st December 2024.

Outpatient Diagnostics	Level of cover	Benefit note
Outpatient consultations with a specialist following GP referral Outpatient diagnostic tests and investigations following GP or specialist referral Outpatient treatment following specialist referral Outpatient consultations with a practitioner Outpatient consultations and diagnostic tests with a specialist on self-referral for breast, bowel, prostate or testicular cancer symptoms Out of network physiotherapy on GP referral Outpatient complementary therapies (acupuncture, osteopathy and chiropractic treatment) up to a maximum of £250 within the overall annual limit	Combined overall annual limit of up to £1,500	1
Outpatient Treatment
In network mental health treatment (including self-referral)	Full cover	2a
Out of network mental health treatment	Up to £1,000 per scheme year	2b
Orthotics	Up to £500 per scheme lifetime	2c
Outpatient MRI, CT and PET scans on specialist referral	Full cover	2d
Outpatient surgical procedures	Full cover	2e
Outpatient Therapies
In-network physiotherapy (including self-referral)	Full cover	3a
Out of network physiotherapy following specialist referral	Full cover	3b
Inpatient and Daycase Treatment
Specialist fees for inpatient and daycase treatment	Full cover within reasonable and customary guidelines	4a
Hospital charges for inpatient or daycase treatment	Full cover	4b
Parent accommodation	Full cover	4c
Mental health treatment - Inpatient and daycase	Up to 28 days per scheme year	4d
Benefits for Specified Treatment
Cancer treatment Cardiac treatment	Limited cover	5a
Oral surgical procedures	Full cover for specified treatments	5b
Disorders of the eye	Full cover for specified treatments	5c
Pregnancy and childbirth	Full cover for specified treatments	5d
Fertility investigations	Full cover	5e
Women's and Men's Health Benefit Remote advice service with our in-network specialist gynaecologists or men's health specialist (up to 4 consultations per scheme year) Diagnostic tests and investigations following referral from our in-network remote gynaecologists or men's health specialist (up to £500 per scheme year)	Limited cover	5f
Long COVID Benefit Outpatient consultations and diagnostics required as a result of Long COVID Outpatient, daycase and inpatient treatment required as a result of Long COVID Outpatient mental health treatment required as a result of Long COVID (up to £1,500 per scheme year) Outpatient physiotherapy treatment required as a result of Long COVID (up to £500 per scheme year) Outpatient complementary therapies required as a result of Long COVID (up to £250 per scheme year)	Combined overall limit of £5,000 per scheme year (up to £15,000 per scheme lifetime)	5g
Additional Benefits
Private ambulance charges	Full cover	6
Home healthcare	Full cover	7
Chronic condition benefit	Up to £1,000 per scheme year	8
NHS cash benefit	£300 each day or night	9
Overseas emergency treatment	Limited cover	10

Note: The above benefits only apply when the covered person has treatment in the UK, or when temporarily abroad on holiday or business up to specified limits.

Note 1: Outpatient Investigations and Treatment

Outpatient investigations and treatment

We will pay within your overall outpatient limit for:

outpatient consultations with a specialist following GP referral
outpatient diagnostics and investigations following GP or specialist referral
outpatient treatment following specialist referral

Cover is subject to our reasonable and customary fees.

Outpatient consultations with a practitioner

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.

Outpatient consultations with a specialist on self-referral for breast, bowel, prostate or testicular cancer symptoms

We will pay within your overall outpatient limit for self-referred* consultations and investigations for breast, bowel, prostate or testicular cancer symptoms.

Please refer to the self-referred cancer benefits page for further information on how to access this benefit.

If a diagnosis of cancer is made, cover for eligible treatment will be subject to any limits as detailed in your cancer treatment benefit.

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

Out of Network Physiotherapy on GP Referral

We will pay within your overall outpatient limit for outpatient physiotherapy following GP referral, if treatment takes place outside our physiotherapy network. The physiotherapist must still be recognised by us for benefit purposes.

Outpatient Complementary Therapy

We will pay up to £250 per scheme year within your overall outpatient limit for outpatient complementary therapy following GP or specialist referral to a complementary practitioner (acupuncture, chiropractic and osteopathy only) we have recognised for benefit purposes, up to a maximum of £250 in any one year of cover.

Note 2a: In Network Mental Health Treatment

We will pay in full for outpatient consultations for eligible mental health conditions following GP, specialist or self-referral, when treatment is provided by our mental health network provider.

Please refer to the mental health pathway for further information.

Please note: Under 18’s will require a referral letter from their own GP.

Note 2b: Out of Network Mental Health Treatment

We will pay up to £1,000 per scheme year for treatment for eligible mental health conditions with a specialist or psychological therapist following GP referral when treatment is taken outside of our Mental Health Network Provider. We will pay the costs of an initial assessment followed by a maximum of five further sessions if required and pre-authorisation has been obtained from us. If further sessions are required, you must contact the claims helpline with details of your proposed treatment plan from your treating psychological therapist before any further sessions will be authorised.

Please note this benefit is not subject to your medical underwriting.

Note 2c: Orthotics

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

Note 2d: Outpatient MRI, CT and PET Scans

We will pay in full for MRI, CT and PET scans on specialist referral.

Note 2e: Outpatient Surgical Procedures

We will pay in full for hospital charges and specialist fees for outpatient surgical procedures, and drugs and dressings used during an outpatient appointment.

Cover is subject to our reasonable and customary fees.

Note 3a: In Network Physiotherapy

We will pay in full for outpatient physiotherapy following GP, specialist or self-referral when treatment is provided by our physiotherapy network provider

Please refer to the musculoskeletal pathway for further information.

Note 3b: Out of Network Physiotherapy Following Specialist Referral

We will pay in full for out of network outpatient physiotherapy when this is referred by a specialist. The physiotherapist must still be recognised by us for benefit purposes.

Note 4a: Specialist Fees for Inpatient and Daycase Treatment

We will pay for specialist fees for inpatient and daycase treatment. Cover is subject to our reasonable and customary fees.

Note 4b: Hospital Charges for Inpatient or Daycase Treatment

We will pay hospital charges in full for the following:

accommodation and nursing care for inpatient or daycase treatment
operating theatre and recovery room
prescribed medicines and dressings, for use whilst an inpatient or for daycase treatment
eligible surgical appliances - for example, a knee brace following ligament surgery
prosthesis or device which is inserted during eligible surgery
pathology, radiology, diagnostic tests, MRI, CT and PET scans
physiotherapy received during inpatient or daycase treatment
intensive care
short-term dialysis when needed temporarily for sudden kidney failure resulting from an eligible condition or treatment
skin and corneal grafts

Note 4c: Parent Accommodation

We will pay reasonable hospital costs for one parent or legal guardian to stay with a child who is under 12 years old, if a child is admitted to hospital as an inpatient. Cover for this benefit will stop on the child’s 12th birthday. If your child is an inpatient on their 12th birthday, then cover will extend until they are discharged on that occasion. We will only pay the cost if:

it is the parent or legal guardian who stays with the child
the treatment the child receives is covered by the scheme

Note 4d: Mental Health Treatment - Inpatient and Daycase

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.

Note 5a: Cancer and Cardiac Treatment

Cancer Treatment

You will be covered up to the point of diagnosis only. Following a cancer diagnosis, we will only pay for eligible treatment for cancer if the radiotherapy, chemotherapy or surgical operation you need to treat your cancer, is not available to you from the NHS.

Please refer to your cancer support explained for information on the additional supportive services available to employees.

Cardiac Treatment

You will be covered up to the point of diagnosis only. Following a diagnosis of cardiovascular disease, you will no longer be covered for any consultations, tests or treatment required.

Note 5b: Oral Surgical Procedures

We will pay for the following specified oral surgical operations 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

Note 5c: Disorders of The Eye

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 referred by your general practitioner or optician to a consultant ophthalmologist
wet aged related macular degeneration, where we will pay for a short course of treatment following initial diagnosis

Note 5d: Pregnancy and Childbirth

We will pay for the following 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. Please note; This benefit is subject to a 12 month waiting period from the date you joined the scheme.
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.

Note 5e: Fertility Investigations

We will pay in full for medically necessary fertility investigations following GP or specialist referral.

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

Please note: This benefit is subject to a 24 month waiting period from the date you joined the scheme.

Note 5f: 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.

Note 5g: Long COVID Benefit

The below benefits will be paid for when treatment is required as a result of COVID-19 (commonly referred to as 'long COVID'). The benefits have a combined limit of £5,000 per scheme year up to a maximum of £15,000 per scheme lifetime.

Outpatient consultations and diagnostics

We will pay up in full for:

Outpatient consultations with a specialist following GP referral
Outpatient diagnostics and investigations following GP or specialist referral
Outpatient treatment following specialist referral

Cover is subject to our reasonable and customary fees.

Outpatient, daycase and inpatient treatment

We will pay for hospital and specialist fees, for outpatient, daycase and inpatient treatment. Please note cover is not available for acute treatment of COVID-19, including treatment in an intensive care unit, high dependency unit, acute ward setting or NHS hospital.

Outpatient mental health treatment

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

Outpatient physiotherapy

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

Outpatient complementary therapies

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 long COVID. You must be referred to a complementary practitioner we have recognised for benefit purpose.

Note 6: Private Ambulance Charges

We will pay in full for transport by a private ambulance to and/or from a hospital when ordered for medical reasons.

Note 7: Home Healthcare

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

immediately after eligible inpatient hospital treatment
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 specialist

Mental health treatment delivered at home or in the community is not covered by the scheme.

Note 8: Chronic Condition Benefit

We will pay up to £1,000 per scheme year for consultations with a specialist and diagnostic tests for the purpose of monitoring chronic conditions.

Once this benefit limit has been reached the chronic condition rule applies as detailed in exclusions and limitations.

Please note this benefit is not subject to your medical underwriting.

Note 9: NHS Cash Benefit

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 £300 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.

Note 10: Overseas Treatment

The scheme is designed to cover treatment in the UK, and therefore provides limited cover for treatment you may require whilst abroad. We strongly recommend that you ensure you have adequate travel insurance and/or a European Health Insurance Card / Global Health Insurance Card in place before you travel abroad on holiday.

If you wish to claim for emergency treatment received abroad, you must send us proof of how long you were abroad for (this period should not exceed 28 consecutive days). You should also send us all medical bills and receipts associated with your treatment. Failure to submit receipts within six months of the date of treatment may result in the claim being denied.

We will reimburse reasonable and customary costs for overseas emergency treatment as detailed below:

Treatment:	Reimbursement level:
Specialist fees	Within our reasonable and customary fees
MRI, CT and PET scans	Up to £100 per trip
Outpatient surgical procedures	Up to £100 per trip
Other emergency outpatient treatment (excluding MRI, CT and PET scans, and outpatient surgical procedures)	Up to annual outpatient benefit limits, as detailed in the table of benefits
Inpatient or daycase surgical procedures	Up to £200 per trip

We will only pay up to the above limits if the following apply:

the treatment is eligible for benefit

the treatment is carried out by a specialist who is:

fully trained and legally qualified and permitted to practice by the relevant authorities in the country in which your treatment takes place, and
is recognised by the relevant authorities in that country as having specialised knowledge of, or expertise in, treatment of the disease, illness or injury being treated; and

the treatment facility is specifically recognised or registered under the laws of the territory in which it stands for providing the treatment delivered.

We will not pay for overseas emergency treatment in any country if:

the Foreign and Commonwealth Office has advised against travel to that country or area. If you are already in the country or area when the Foreign and Commonwealth Office advises against travel, and you require treatment, this should be claimed for under your travel insurance policy
you are already in that particular country or area and have been advised to leave unless prior written authority has been received from us. If you are unable to leave a particular country or area after being advised to do so, and you require treatment, this should be claimed for under your travel insurance policy
you travelled abroad despite being given medical advice not to travel abroad
you travelled abroad to receive treatment, or
the treatment you require is related to a pre-existing condition.

The scheme will not pay for:

GP services or fees
outpatient prescriptions
take home drugs and dressings
any costs associated with an evacuation or repatriation
any treatment that should be free or provided at a reduced cost under a reciprocal agreement or EHIC/GHIC.

Costs of private treatment in facilities in the European Union, Iceland, Liechtenstein, Norway or Switzerland or costs in state facilities in these countries which should have been free or reduced if you had had a European Health Insurance Card / Global Health Insurance Card are not covered under the scheme.

If you are a UK resident, you are entitled to medical treatment that becomes necessary, at reduced cost or sometimes free, when temporarily visiting a European Union (EU) country, Iceland, Liechtenstein, Norway or Switzerland. Only treatment provided under the state scheme (the country’s equivalent to the NHS) is covered. However, to obtain treatment you will need to take a European Health Insurance Card (EHIC) or Global Health Insurance Card (GHIC) with you.

EHIC are still valid if in date, but they have now been replaced by the GHIC. You can apply for a GHIC by clicking here.

Your scheme will not cover you for the costs of an evacuation or repatriation should you require this. Therefore we strongly recommend that you take out appropriate travel insurance if you are going abroad to ensure that you have adequate cover for any healthcare needs you have along with cover for loss of luggage etc.

Table of benefits - UPGRADE

Your scheme benefits are set out in the table below.

Benefit limits apply to each individual member or dependant in any one year of cover, unless otherwise stated.

All claims are subject to your excess, which will be applied to the first eligible treatment within each scheme year.

The scheme will commence on the 1st January 2024 to 31st December 2024.

Outpatient Diagnostics	Level of cover	Benefit note
Outpatient consultations with a specialist following GP referral Outpatient diagnostic tests and investigations following GP or specialist referral Outpatient treatment following specialist referral Outpatient consultations with a practitioner Outpatient consultations and diagnostic tests with a specialist on self-referral for breast, bowel, prostate or testicular cancer symptoms Out of network physiotherapy on GP referral Outpatient complementary therapies (acupuncture, osteopathy and chiropractic treatment) up to a maximum of £250 within the overall annual limit	Combined overall annual limit of up to £1,500	A
Outpatient Treatment
Out of network mental health treatment	Up to £1,000 per scheme year	B1
In network mental health treatment (including self-referral)	Full cover	B2
Orthotics	Up to £500 per scheme lifetime	B3
Outpatient MRI, CT and PET scans on specialist referral	Full cover	B4
Outpatient surgical procedures	Full cover	B5
Outpatient Therapies
In-network physiotherapy (including self-referral)	Full cover	C1
Out of network physiotherapy following specialist referral	Full cover	C2
Inpatient and Daycase Treatment
Specialist fees for inpatient and daycase treatment	Full cover within reasonable and customary guidelines	D1
Hospital charges for inpatient or daycase treatment	Full cover	D2
Parent accommodation	Full cover	D3
Mental health treatment - Inpatient and daycase	Up to 28 days per scheme year	D4
Cancer Treatment
Cancer treatment Cardiac treatment	Part of overall annual limit of up to £75,000	E1
Cancer outpatient therapies Cancer alternative therapies (£250 limit within the £1,000 limit per scheme year)	Combined limit of £1,000 per scheme year within above £75,000 benefit limit	E2
Cancer outpatient mental health treatment	Up to £1,000 per scheme year within above £75,000 benefit limit	E3
Cancer additional services	Full cover within above £75,000 benefit limit	E4
Benefits for Specified Treatment
Oral surgical procedures	Full cover for specified treatments	F1
Disorders of the eye	Full cover for specified treatments	F2
Pregnancy and childbirth	Full cover for specified treatments	F3
Fertility investigations	Full cover	F4
Women's and Men's Health Benefit Remote advice service with our in-network specialist gynaecologists or men's health specialist (up to 4 consultations per scheme year) Diagnostic tests and investigations following referral from our in-network remote gynaecologists or men's health specialist (up to £500 per scheme year)	Limited cover	F5
Long COVID Benefit Outpatient consultations and diagnostics required as a result of Long COVID Outpatient, daycase and inpatient treatment required as a result of Long COVID Outpatient mental health treatment required as a result of Long COVID (up to £1,500 per scheme year) Outpatient physiotherapy treatment required as a result of Long COVID (up to £500 per scheme year) Outpatient complementary therapies required as a result of Long COVID (up to £250 per scheme year)	Combined overall limit of £5,000 per scheme year (up to £15,000 per scheme lifetime)	F6
Additional Benefits
Private ambulance charges	Full cover	G1
Home healthcare	Full cover	G2
Chronic condition benefit	Up to £1,000 per scheme year	G3
NHS cash benefit	£300 each day or night	G4
Overseas emergency treatment	Limited cover	G5

Note: The above benefits only apply when the covered person has treatment in the UK, or when temporarily abroad on holiday or business up to specified limits.

Note A: Outpatient Investigations and Treatment

Outpatient investigations and treatment

We will pay within your overall outpatient limit for:

outpatient consultations with a specialist following GP referral
outpatient diagnostics and investigations following GP or specialist referral
outpatient treatment following specialist referral

Cover is subject to our reasonable and customary fees.

Outpatient consultations with a practitioner

Outpatient consultations with a specialist on self-referral for breast, bowel, prostate or testicular cancer symptoms

We will pay within your overall outpatient limit for self-referred* consultations and investigations for breast, bowel, prostate or testicular cancer symptoms.

Please refer to the self-referred cancer benefits page for further information on how to access this benefit.

If a diagnosis of cancer is made, cover for eligible treatment will be subject to any limits as detailed in your cancer treatment benefit.

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

Out of Network Physiotherapy on GP Referral

Outpatient Complementary Therapy

Note B1: Out of Network Mental Health Treatment

Please note this benefit is not subject to your medical underwriting.

Note B2: In Network Mental Health Treatment

We will pay in full for outpatient treatment for eligible mental health conditions following GP or self-referral when treatment is provided by our mental health network provider. We will arrange a telephone-based clinical assessment with a senior psychological therapist who will help organise the most effective treatment for you. This could include face to face therapy, guided self-management or specialist referral.

Please refer to the mental health pathway for further information.

Please note this benefit is not subject to your medical underwriting.

Note B3: Orthotics

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

Note B4: Outpatient MRI, CT and PET Scans

We will pay in full for MRI, CT and PET scans on specialist referral.

Note B5: Outpatient Surgical Procedures

We will pay in full for hospital charges and specialist fees for outpatient surgical procedures, and drugs and dressings used during an outpatient appointment.

Cover is subject to our reasonable and customary fees.

Note C1: In Network Physiotherapy

We will pay in full for outpatient physiotherapy following GP, specialist or self-referral when treatment is provided by our physiotherapy network provider

Please refer to the musculoskeletal pathway for further information.

Note C2: Out of Network Physiotherapy Following Specialist Referral

We will pay in full for out of network outpatient physiotherapy when this is referred by a specialist. The physiotherapist must still be recognised by us for benefit purposes.

Note D1: Specialist Fees for Inpatient and Daycase Treatment

We will pay for specialist fees for inpatient and daycase treatment. Cover is subject to our reasonable and customary fees.

Note D2: Hospital Charges for Inpatient or Daycase Treatment

We will pay hospital charges in full for the following:

accommodation and nursing care for inpatient or daycase treatment
operating theatre and recovery room
prescribed medicines and dressings, for use whilst an inpatient or for daycase treatment
eligible surgical appliances - for example, a knee brace following ligament surgery
prosthesis or device which is inserted during eligible surgery
pathology, radiology, diagnostic tests, MRI, CT and PET scans
physiotherapy received during inpatient or daycase treatment
intensive care
short-term dialysis when needed temporarily for sudden kidney failure resulting from an eligible condition or treatment
skin and corneal grafts

Note D3: Parent Accommodation

it is the parent or legal guardian who stays with the child
the treatment the child receives is covered by the scheme

Note D4: Mental health treatment - Inpatient and daycase

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

Note E1: Cancer and Cardiac Treatment

Cancer Treatment

You will be covered in full within the overall benefit limit for cancer treatment. Please see cancer cover explained for further details on the cover available.

Please refer to your cancer support explained for information on the additional supportive services available to employees.

Cardiac Treatment

You will be covered in full within the overall benefit limit for treatment following a diagnosis of cardiovascular disease.

Note E2: Cancer Outpatient & Alternative Therapies

We will pay up to a total limit of £1,000 per scheme year for the following therapies, when required as a direct result of eligible cancer treatment.

Cancer outpatient therapies on GP, specialist or self-referral
We will pay up to the benefit limit for physiotherapy, osteopathy, chiropractic treatment, manual lymphatic drainage and dietician services.

Treatment must be taken with a physiotherapist, practitioner or complementary practitioner that we recognise for benefit purposes

Cancer alternative therapies on GP, specialist or self-referral
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 and aromatherapy.

Please note this benefit is subject to the overall cancer and cardiac benefit limit of £75,000 per scheme year.

Note E3: Cancer Outpatient Mental Health Treatment

We will pay up to £1,000 per scheme year on GP, specialist or self-referral for outpatient mental health treatment required as a direct result of eligible cancer treatment.

Mental health treatment is only covered if it is provided by a psychological therapist or psychiatrist.

Please note this benefit is subject to the overall cancer and cardiac benefit limit of £75,000 per scheme year.

Note E4: Cancer Additional Services

Cancer Additional services

We will pay in full for the cost of external prosthesis, wigs, scalp cooling treatment and medical tattooing for reconstructive purposes only when recommended by your specialist and required as a direct result of eligible cancer treatment.

For wigs and medical tattooing, this benefit is available on a pay and claim basis only.

Please note this benefit is subject to the overall cancer and cardiac benefit limit of £75,000 per scheme year.

Note F1: Oral Surgical Procedures

We will pay for the following specified oral surgical operations 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

Note F2: Disorders of The Eye

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 referred by your general practitioner or optician to a consultant ophthalmologist
wet aged related macular degeneration, where we will pay for a short course of treatment following initial diagnosis

Note F3: Pregnancy and Childbirth

We will pay for the following 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. Please note; a 12 month wait period applies to the benefit from the date you joined the scheme.
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.

Note F4: Fertility Investigations

We will pay in full for medically necessary fertility investigations following GP or specialist referral.

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

Please note: This benefit is subject to a 24 month waiting period from the date you joined the scheme.

Note F5: Women's and Men's Health Benefit

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

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

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.

Note F6: Long COVID Benefit

Outpatient consultations and diagnostics

We will pay up in full for:

Outpatient consultations with a specialist following GP referral
Outpatient diagnostics and investigations following GP or specialist referral
Outpatient treatment following specialist referral

Cover is subject to our reasonable and customary fees.

Outpatient, daycase and inpatient treatment

Outpatient mental health treatment

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 long COVID.

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

Outpatient physiotherapy

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 long COVID.

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

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

Outpatient complementary therapies

Note G1: Private Ambulance Charges

We will pay in full for transport by a private ambulance to and/or from a hospital when ordered for medical reasons.

Note G2: Home Healthcare

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

immediately after eligible inpatient hospital treatment
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 specialist

Mental health treatment delivered at home or in the community is not covered by the scheme.

Note G3: Chronic Condition Benefit

We will pay up to £1,000 per scheme year for consultations with a specialist and diagnostic tests for the purpose of monitoring chronic conditions.

Once this benefit limit has been reached the chronic condition rule applies as detailed in exclusions and limitations.

Please note this benefit is not subject to your medical underwriting.

Note G4: NHS Cash Benefit

Note G5: Overseas Treatment

We will reimburse reasonable and customary costs for overseas emergency treatment as detailed below:

Treatment:	Reimbursement level:
Specialist fees	Within our reasonable and customary fees
MRI, CT and PET scans	Up to £100 per trip
Outpatient surgical procedures	Up to £100 per trip
Other emergency outpatient treatment (excluding MRI, CT and PET scans, and outpatient surgical procedures)	Up to annual outpatient benefit limits, as detailed in the table of benefits
Inpatient or daycase surgical procedures	Up to £200 per trip

We will only pay up to the above limits if the following apply:

the treatment is eligible for benefit

the treatment is carried out by a specialist who is:

fully trained and legally qualified and permitted to practice by the relevant authorities in the country in which your treatment takes place, and
is recognised by the relevant authorities in that country as having specialised knowledge of, or expertise in, treatment of the disease, illness or injury being treated; and

the treatment facility is specifically recognised or registered under the laws of the territory in which it stands for providing the treatment delivered.

We will not pay for overseas emergency treatment in any country if:

the Foreign and Commonwealth Office has advised against travel to that country or area. If you are already in the country or area when the Foreign and Commonwealth Office advises against travel, and you require treatment, this should be claimed for under your travel insurance policy
you are already in that particular country or area and have been advised to leave unless prior written authority has been received from us. If you are unable to leave a particular country or area after being advised to do so, and you require treatment, this should be claimed for under your travel insurance policy
you travelled abroad despite being given medical advice not to travel abroad
you travelled abroad to receive treatment, or
the treatment you require is related to a pre-existing condition.

The scheme will not pay for:

GP services or fees
outpatient prescriptions
take home drugs and dressings
any costs associated with an evacuation or repatriation
any treatment that should be free or provided at a reduced cost under a reciprocal agreement or EHIC/GHIC.

Cancer cover explained - UPGRADE

We know that a cancer diagnosis can be a life changing event. Therefore we have provided a specific section within your scheme to help you understand the level of cover available to you for cancer treatment.

Your scheme provides benefit for eligible outpatient, daycase and inpatient treatment for cancer. To ensure that you receive the highest quality of care at all times we identify centres of excellence for the treatment of cancer. If you are diagnosed with cancer we may require you to transfer to one of these centres. These centres may be either in the private or NHS sector.

Should you choose to receive free eligible inpatient, daycase or outpatient treatment at an NHS centre you may be eligible for the NHS cancer cash benefit as shown on your tables of benefits.

One of our nurse case managers will be able to provide information on the treatment options available to you and support you through your treatment.

The table below provides a summary of the cancer cover available and should be read alongside your table of benefits.

Please note cancer treatment is subject to the cancer and cardiac treatment benefit limit of £75,000 per person per year of cover.

Summary of cancer benefits	What’s covered	What’s not covered
Where will I be covered to have treatment?	You will be covered in full for eligible treatment: at a hospital we have approved for your treatment and condition at home for treatment that would otherwise have to be delivered in hospital, if your specialist agrees that this is possible and is given by suitably qualified medical staff recognised by us.	You will not be covered for any treatment received in a hospice.
What diagnostic tests are covered?	You will be covered in full for: eligible diagnostic tests and any associated consultations with your specialist. eligible molecular (genomic) tests that are needed to see if a particular treatment will be suitable for you. CT, MRI and PET scans that take place in a hospital or specialist cancer centre.	You will not be covered for any diagnostic tests that are: arranged by anyone other than your specialist not considered standard treatment in the UK designed to find out whether you are likely to get cancer or not that are considered to be part of normal preventative treatment
Will I be covered for surgery?	You will be covered in full for: surgery to diagnose cancer surgery to remove cancer. reconstructive surgery following removal of a tumour. Reconstructive surgery to a healthy breast following breast cancer where the primary purpose is to improve symmetry following surgery for cancer in the contralateral breast.	You will not be covered for surgery that is: Not recommended by NICE for clinical effectiveness experimental
Will I be covered for preventative treatment?	We will only pay for prophylactic (preventative) surgery if: You are currently being treated for cancer and it is: recommended by your specialist as being medically necessary and performed at the same time as the surgery for the 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.	You will not be covered for any preventative treatment, including: normal screening such as breast screens genetic tests to see whether you are likely to get cancer and/or treatment carried out solely to prevent the development of cancer (in the absence of any disease) vaccines to prevent the development of cancer
What drug treatments will I be covered for?	You will be covered in full for: drug treatments for cancer (such as chemotherapy drugs, hormone therapies and biological therapies) where the drug is being recommended within its license indication. drug treatments (such as anti-sickness drugs and antibiotics) to help with the side-effects of chemotherapy or radiotherapy	You will not be covered for: any drug treatments that can be prescribed by your GP and do not require specialist supervision drug treatments which are: experimental or being administered as part of a clinical trial not licensed to treat your condition
Will I be covered for radiotherapy?	You will be covered in full for radiotherapy, including when given for pain relief.	You will not be covered for radiotherapy that is: Not recommended by NICE for clinical effectiveness experimental
Will I be covered for end of life care?		You will not be covered for: end of life care, treatment given solely to relieve symptoms at the end stage of cancer
What cover will be available for routine monitoring when treatment has finished?	You will be covered for follow-up tests and specialist consultations to monitor you once you have completed treatment for a cancer. No time limits are placed on follow up tests and consultations as long as these are medically necessary and your specialist confirms this in writing
What other benefits and services are available?	You will be covered for additional cancer therapies and services. Please see the cancer treatment benefits section in your table of benefits for full details on the additional benefits provided.	You will not be covered for: any transport costs or personal expenses. transplants, adoptive cell transfer, gene therapies and/or any complications related to, or resulting from these treatments. This includes, but is not limited to CAR T cell therapy, tumour infiltrating lymphocyte therapy and stem cell/bone marrow treatments. You will also not be covered for: • donor costs • harvesting • storage • administration • and/or any complications/treatment arising from any of the above the cost of any experimental treatment, even where this is recommended by your specialist and there is no alternative conventional treatment available. If you have chosen to receive experimental treatment, you will not be covered for any complications you may develop following this experimental treatment. any costs associated with harvesting of eggs or sperm, their storage and any associated costs
Are there any other supportive benefits available?	You also have access to a comprehensive support platform delivered by Perci Health to provide you with additional support for the psychological, physical and practical impacts of cancer when it is needed most. For further information please see the your cancer support explained page.

Your cancer support explained

We know that a cancer diagnosis can be a life changing event and we are committed to supporting you in the event that you are impacted by cancer. This is why we have partnered with Perci Health to provide you with additional support for the psychological, physical and practical impacts of cancer.

Perci are able to offer you support regardless of how you have been impacted by cancer

Are you receiving active treatment for a cancer diagnosis?
Are you looking for some additional support following completion of your cancer treatment?
Are you caring for a loved one with cancer?

Regardless of your situation, Perci are able to provide a personalised care plan, a dedicated cancer nurse, and access to caring cancer experts from over 20 different support types to help reduce the impact of cancer.

Recovery and rehabilitation	Symptom management	Support for carers
Optimising emotional wellbeing and building resilience Optimising physical function and managing symptoms Building strong relationships and local support network Personalised care plans and a dedicated cancer care team	Support with longer-term effects of cancer treatment Evidence-based content focused on common symptoms such as anxiety and fatigue Access to educational articles and resources	Access to a dedicated cancer nurse to answer important questions Help to prepare for upcoming appointments and navigate local community care Emotional support and specialised bereavement care

Access to this service will not be subject to an excess, scheme underwriting or any healthcare scheme benefit limits, if any apply.

Please note; this benefit is available to members over the age of 18.

For further information and to get started access the ‘your cancer support’ tile on the Member Zone or My Healix App. Please note you will need to use the code HLXC22 to access this.

COVID-19 cover explained

In the event that you require immediate, acute treatment for COVID-19 this must take place on the NHS, and you may be able to claim NHS COVID Cash Benefit, if this is detailed in your table of benefits.

You will be covered for non-urgent eligible treatment arising from COVID-19 (commonly referred to as “long COVID”). One of our nurse case managers will be able to provide information on the treatment options available to you, and support you through your treatment.

The following table provides a summary of the cover available and should be read alongside your table of benefits Cover for long COVID is subject to a limit of £5,000 per member per scheme year up to a maximum lifetime benefit of £15,000.

Summary of cancer benefits	What’s covered	What’s not covered
Where will I be covered to have treatment?	You will be covered up to the benefit limit for eligible outpatient, daycase or inpatient treatment: at a hospital we have approved for your treatment and condition at home for treatment that would otherwise have to be delivered in hospital, if your specialist agrees that this is possible and is given by a recognised provider such as a registered nurse	You will not be covered for: any acute private treatment of COVID19 including treatment in an intensive care unit, high dependency unit, acute ward setting or NHS private patient unit In the event that you require immediate, acute treatment for COVID19 this must take place on the NHS and you may be able to claim NHS COVID Cash Benefit if this is detailed in your table of benefits.
What tests will I be covered for?	You will be covered up to the benefit limit for: eligible tests and any associated consultations with your specialist. Specialist scans that take place in a recognised facility	You will not be covered for any tests that are: arranged by anyone other than your specialist not considered standard treatment in the UK preventative or screening purposes unless these are required for or as a result of eligible treatment
What other benefits and services are available?	You will be covered within the overall benefit limit for: mental health treatment up to a maximum of £1,500 per member per scheme year (self-referral available through our network) physiotherapy treatment, including respiratory physiotherapy up to a maximum of £500 per member per scheme year (self-referral available through our network) complementary therapies up to a maximum of £250 per member per scheme year on GP or specialist referral	You will not be covered for: any transport costs or personal expenses COVID19 vaccines or antibody tests COVID19 tests for travel or quarantine purposes

Second medical opinion

Should you decide that you would like to receive a second medical opinion to ensure you are fully confident with your specialists recommendations please contact us on the claims helpline to discuss pre-authorisation. Our team of nurse case managers will be able to advise and support you through this process.

Second medical opinions will be arranged with a specialist who is an expert in their field and is recognised for the purposes of providing such second opinions. Following your second medical opinion your nurse case manager will contact you to discuss the suggested treatment plan and eligibility for benefit. Without written authorisation for a second opinion payment cannot be made for any recommended or resulting treatment.

Section 9: Glossary

The words and phrases below have the following meanings. They will appear in bold in this guide.

Active treatment

- Treatment of an acute medical condition that leads to recovery or restoration of a previous state of health.

Acute condition

- a disease, illness or injury which responds quickly to treatment that aims to return you to the state of health you were in immediately before suffering the disease, illness or injury, or which leads to you recovering fully.

Annual renewal date

- the anniversary of the start date each year or any other date which we and your employer may agree to in writing.

Benefit

- the benefits for which you are entitled as an individual under the scheme subject to the terms and conditions that apply to your membership including all exclusions.

Benefits

-the benefits for which you are entitled as an individual under the scheme subject to the terms and conditions that apply to your membership including all exclusions.

Biological therapies

-drugs or other substances that block the growth and spread of cancer by interfering with specific molecules that are involved in the growth, progression and spread of cancer. Biological therapies are sometimes called "molecularly targeted drugs," "molecularly targeted therapies," "precision medicines," or similar names.

Cancer

- a malignant tumour, tissues or cells, characterised by the uncontrolled growth and spread of malignant cells and invasion of tissue.

Chronic condition

Please refer to the chronic conditions exclusion.

Complementary practitioner

- a practitioner who specialises in acupuncture or a practitioner in osteopathy or chiropractic who is registered under the relevant Act; and who, in all cases, meets our criteria for complementary practitioner recognition for benefit purposes in their field of practice:

Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
Osteopaths must be registered with the GOsC (General Osteopathic Council)
Chiropractors must be registered with the GCC (General Chiropractic Council)

Daycase

- if you are required to occupy a hospital bed for one day, for medical reasons

Dependant

-a member’s partner (if a member gets divorced their partner will no longer be considered as a dependant for the purposes of this scheme)

-a member’s unmarried dependent children

Dependants

-a member’s partner (if a member gets divorced their partner will no longer be considered as a dependant for the purposes of this scheme)

-a member’s unmarried dependent children

Dialysis

The removal of waste matter from the blood by either:

haemodialysis, (through the use of a kidney machine or dialyser)
peritoneal dialysis (by introducing fluid into the abdomen to act as a filter).

Disorder

– a disturbance of function, structure or behaviour, resulting from genetic or environmental factors such as disease, illness or injury.

Emergency

- a serious medical condition or symptoms resulting from a disease, illness or injury which arises suddenly and requires immediate treatment, generally within hours of onset, and which would otherwise put your health at risk.

Employer

- ABC who is named as your employer

End of life care

– treatment for patients with advanced, progressive, and incurable illness that is aimed solely at the management of symptoms and the provision of psychological, social, spiritual and practical support.

Gender Dysphoria

- The distress experienced as a result of the mismatch between the biological gender and the gender identity.

Gender Incongruence

The mismatch between the biological gender and the gender identity. For example, transgender or non binary individuals.

General Practitioner

- a registered medical practitioner in general practice.

GP

- a registered medical practitioner in general practice

High dependency unit

– special department within a hospital designed for patients who require advanced post-operative care and/or support for a single failing organ system.

High risk activities

This includes, but is not limited to, any high-risk activity such as mountaineering, rock climbing, parachuting, hang-gliding, potholing, bungee jumping, racing of any kind, skiing or snowboarding off the designated course (off-piste), scuba diving (unless you have recognised diving qualifications or are accompanied by someone with them).

Home healthcare

- visits from a qualified nurse to your home to give you expert/skilled nursing services under the control of a specialist.

Hospital

NHS hospital - a National Health Service hospital with facilities for medical and surgical treatment, as defined in Section 1.28 of the National Health Service Act 1977 or in any future law.

Private hospital - an independent hospital which can provide acute medical, surgical or psychiatric care. It must be registered under The Registered Homes Act (1984) and approved by the Healthcare Commission or any future law. It may also include a private bed in an NHS hospital.

Inpatient

– if you are required to occupy a hospital bed for one night or more, for medical reasons.

Intensive care unit

– a specialised department within a hospital designed for patients who require support for two or more organ systems and/or advanced respiratory support.

Medical condition

style="margin: 0cm 0cm 0pt; line-height: normal;">– any physical, mental or psychological disorder, including disease, illness, injury, genetic disorders and behavioural conditions.

Medically necessary

– treatment that is considered to be:

In accordance with professional standards of medical practice in the United Kingdom
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
Required for reasons other than the comfort or convenience of the patient or specialist.
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition.
Provided only for an appropriate duration of time.
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.

Members

- an employee covered under the scheme.

Mental health condition

- a disorder that affects your mind, mental function, emotions or behaviour whether the cause is organic, traumatic or reactive.

Outpatient

- if you do not require a hospital bed for your treatment or consultation.

Palliative care

– treatment that is aimed at slowing the growth of cancer and relieving side effects and symptoms of the treatment/disease.

Partner

- a member’s husband or wife, or the person the member lives with in a relationship similar to that of husband or wife, whether the same sex or not.

Physiotherapist

- a physiotherapist regulated by and registered as practicing with the Health Professions & Care Council and recognised by us.

Pre-existing condition

- any medical condition for which, in the five years before you joined the scheme:

you have received medication, advice or treatment, or
you have experienced symptoms whether the condition was diagnosed or not.

Private ambulance

- a purpose-built vehicle run by a recognised private ambulance service.

Prosthesis

style="margin: 0cm 0cm 0pt; line-height: normal;">– an artificial body part or device which is inserted during surgery.

Psychological therapist

we recognise the following as psychological therapists.

a psychologist who is:

Registered with the Health and Care Professions Council (HCPC);
Registered with the British Psychological Society (BPS) as a chartered Psychologist

a therapist who is:

An accredited member of the British Association of Counselling and Psychotherapy (BACP); or
An Accredited Member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP); or
An Accredited Member of Scotland’s Professional Body for Counselling and Psychotherapy (COSCA); or
A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)

Registered nurse

- a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number.

Related condition

- any medical condition which is reasonably considered to be related to another medical condition.

Specialist

- we consider a specialist to be:

a medical practitioner with full current registration with the General Medical Council or
a dentist with full current registration with the General Dental Council

and

a specialist in the treatment you are referred for (this is applicable to all specialities including anaesthetics and psychiatry)
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
is or has been a National Health Service consultant or dentist
has been recognised for benefit purposes as a specialist by Healix.

Start date

- the date the scheme starts as shown in the scheme schedule.

Surgical appliance

– an artificial device or an artificial body part which is a necessary part of your treatment or surgery - for example a knee brace after you have had ligament surgery.

The Scheme

- The ABC Healthcare Scheme

Practitioner

- practitioner recognised by us and registered with the Health and Care Professions Council as:

an occupational therapist
an orthoptist
a speech and language therapist
a dietician or;
a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number.

Treatment

- surgical or medical services (including diagnostic tests and consultations). This includes but is not limited to diagnostic tests, scans, and surgical procedures.

Treatments

- surgical or medical services (including diagnostic tests and consultations). This includes but is not limited to diagnostic tests, scans, and surgical procedures.

Trust Deed

- the trust deed (including the rules of the scheme) constituting the healthcare scheme, as amended from time to time.

Trustee, Trustees

- any trustee or trustees for the time being of the healthcare scheme.

United Kingdom

- England, Scotland, Wales and Northern Ireland.

Waiting Period

- a specified period of time that must pass before a benefit becomes eligible. The waiting period is calculated from the joining date of the scheme.

We, Us, Our

- Healix Health Services Ltd, Healix House, Esher Green, Esher, Surrey KT10 8AB.

You, Your

- the eligible member and his or her dependants if they are eligible.

Scheme

- your employers Corporate Healthcare scheme, of which you are a member

Pandemic

The fast spread of infectious disease to a large number of people in a given population within a short period of time, normally weeks.

Epidemic

more cases of a disease than would be expected for that disease in that area at that time

Member Zone

The Member Zone gives you access to the claims portal and displays all the benefits of your healthcare scheme in an app accessed via your smartphone, tablet or computer.

Member

- an employee covered under the scheme.

Neurodevelopmental disorders

A group of disorders that affect the development of the nervous system, leading to altered brain function which may affect emotion, language processing, learning ability and memory. Including but not limited to Autism spectrum disorder, ADHD and dyslexia.

Women's health services

At Healix, we know it’s vital to receive quick access to healthcare, we have therefore made access to women’s health services as easy and smooth as possible.

You can contact the claims helpline, and speak to a member of our experienced claims team, they will be able to guide you to the most appropriate services, including access to a remote advice service with a gynaecologist.

The majority of women’s health conditions would be covered under your normal outpatient and inpatient benefits, however some conditions would traditionally sit outside the healthcare scheme cover. We have therefore created the additional Women’s health benefits, to provide some extra cover, if this is required. Our experienced claims team will be able to advise you further on whether your condition and treatment would be covered under these extra benefits.

The below table outlines the services available, and how to access them through your healthcare scheme.

Women’s health concern	How to access treatment
For advice regarding any general women’s health query, including, but not limited to, menopause symptoms or contraception advice	You may self-refer by contacting the claims helpline, without the need for a GP referral, and we will be able to direct you to the most appropriate service available to you. This includes access to remote consultations and diagnostic tests, with our in-network specialist gynaecologists (where appropriate). Cover is available up to the limits specified in your table of benefits. Once this benefit limit has been reached, the scheme rules apply as detailed in your exclusions and limitations.
If you are concerned about a breast abnormality, for example a lump	Contact the claims helpline to speak to our claims team, who will be able to support you and direct you to the most appropriate specialist, without the need to see your GP first. Cover will be available as specified in your table of benefits. Further information about early signs of cancers and self-referral can be found here.
If your GP has referred you to a specialist gynaecologist, for example, for unusual bleeding	Contact the claims helpline to speak with a member of our experienced claims team, who will be able to open a new claim. The claims team will also be able to direct you to the most suitable specialist. Cover will be available as specified in your table of benefits.
If your GP has referred you for fertility investigations	Contact the claims helpline to speak with a member of our experienced claims team, who will be able to open a new claim. Cover will be available from your fertility investigations benefit, as specified on your table of benefits.
If you are experiencing complications of pregnancy	Contact the claims helpline to speak with a member of our experienced claims team, who will be able to advise if there is any cover available for you. Cover will be available for specific pregnancy complications only, as specified in your table of benefits.
For physiotherapy treatment for a pelvic problem such as stress incontinence	Contact the claims helpline, without the need for a GP referral, and speak with a member of our experienced claims team who will arrange a telephone based assessment with a senior physiotherapist, to determine the most appropriate treatment for you. Cover is available from your physiotherapy benefit, as specified in your table of benefits.

Men's health services

At Healix, we know it’s vital to receive quick access to healthcare, we have therefore made access to men’s health services as easy and smooth as possible.

You can contact the claims helpline, and speak to our experienced claims team, they will be able to guide you to the most appropriate services, including access to a remote advice service with a men’s health specialist.

The majority of men’s health conditions would be covered under your normal outpatient and inpatient benefits, however some conditions would traditionally sit outside the healthcare scheme cover. We have therefore created the additional men’s health benefits, to provide some extra cover, if this is required. Our experienced claims team will be able to advise you further on whether your condition and treatment would be covered under these extra benefits.

The below table outlines the services available, and how to access them through your healthcare scheme.

Men’s health concern	How to access treatment
For advice regarding any general men’s health query, including urinary symptoms, sexual health and fertility advice.	You may self-refer by contacting the claims helpline without the need for a GP referral and we will be able to direct you to the most appropriate services available to you. This includes access to remote consultations and diagnostic tests with our in-network men’s health specialists (where appropriate). Cover is available up to the limits specified in your table of benefits. Once this benefit limit has been reached the scheme rules apply as detailed in your exclusions and limitations.
If you are concerned about early signs of prostate or testicular cancer.	Contact the claims helpline to speak to a nurse case manager who will be able to support you and direct you to the most appropriate specialist without the need for seeing your GP first. Cover will be available as specified in your table of benefits. Further information about early signs of cancers and self-referral can be found here.
If your GP has referred you to a specialist.	Contact the claims helpline or access the claims portal to open a new claim. Cover will be available as specified in your table of benefits. One of our experienced claims team will be able to direct you to the most suitable specialist.
If your GP has referred you for fertility investigations	Contact the claims helpline to speak to our experienced claims team, who will be able to open a new claim. Cover will be available from your fertility investigations benefit, as specified on your table of benefits.
For physiotherapy treatment for a pelvic problem such as stress incontinence	Contact the claims helpline, without the need for a GP referral, and speak to our experienced claims team who will arrange a telephone based assessment with a senior physiotherapist, to determine the most appropriate treatment for you. Cover is available from your physiotherapy benefit, as specified in your table of benefits.

Self-referred cancer benefits

Experiencing symptoms that can be associated with cancer can be concerning. It's important to remember that these symptoms are not definitive of cancer but may indicate a risk. We are here to support you in obtaining timely investigations for any symptoms that could potentially be related to cancer.

If you experience any of the symptoms listed below then you are able to call and speak directly to our claims team to self-refer for a consultation and diagnostic tests.

This means that you no longer need to see your GP before accessing private treatment for these concerns in order to prevent any delays in reaching a diagnosis.

If you are experiencing any of the symptoms below, call the claims helpline and our experienced claims team will be able to help direct you into one of our robust clinical pathways with our in-network providers to help reach a diagnosis.

Type of cancer	Signs and symptoms to watch out for
Breast cancer	Hard, irregular shape lump in the breast or armpit Dimpling of the skin on the breast Newly inverted nipple Discharge from the nipple Any unusual change in size or shape of the breast
Bowel cancer	Bleeding from your back passage/bottom or blood in your stool without piles/haemorrhoids Persistent, unexplained change in bowel habit, including diarrhoea or change in consistency of stool Persistent abdominal discomfort, such as cramps, bloating, wind or pain A feeling that your bowel doesn’t empty completely Unexplained weight loss
Prostate cancer	Raised PSA level as specified below: Age 40-49 >2.5ng/ml Age 50-69 >3ng/ml Age 70-80 >5ng/ml
Testicular cancer	Painless lump or swelling on either testicle Pain, discomfort or numbness in a testicle Any unusual change in size or shape of a testicle
Skin cancer	Any of the following changes to a mole or lesion on the skin: Increase in size Change of colour >7mm in diameter Irregular shape Irregular colour Inflamed or oozing

Please remember that these signs are also features of common health problems that

are not caused by cancer, such as a cyst, piles or infection.

In the event that a cancer diagnosis is made, cover will be available as detailed in your cancer cover explained and one of our nurse case managers will support you and be able to provide information on the treatment options available to you.

Please contact us via the Member Zone, the My Healix app or by calling the claims helpline to get further advice and to open a new claim. As with all of your healthcare benefits it is important that you obtain pre-authorisation before receiving any treatment to ensure your claim is eligible and to prevent you incurring any unwanted costs.

Mental health pathway

The importance of mental health and wellbeing is becoming increasingly recognised in today’s busy world. Acknowledging stress and anxiety then seeking help are the first steps to developing coping strategies and recovery.

If you are experiencing stress, anxiety or depression or any other mental health problem, please refer to the below for further information on how your scheme can support you.

How to make a claim

Employee only digital triage

Employees are able to access a digital emotional wellness triage and immediate advice via the Member Zone or the My Healix app.

Download the My Healix app

Access the Member Zone

Click here to access the Member Zone using your individual member number

Benefits	What is available?	What can you use this for?
Digital emotional wellness triage	Unlimited access to digital emotional wellness triage Tailored online support programme (where clinically appropriate) Referral through to the healthcare scheme where medically necessary	Any mental health symptoms, including stress, anxiety and low mood.

If face to face mental health treatment is recommended you will be directed into an initial episode of treatment with our network provider.

Where face to face mental health treatment takes place, this will not be subject to an excess, scheme underwriting or any scheme limits (if these apply) when treatment is taken with our digital treatment pathway provider.

Should additional sessions be required beyond the initial episode of treatment, all healthcare scheme terms and conditions, including excess, will then apply.

Telephone assessment

Should you be unable to access the Member Zone, the My Healix app or your claim is for a spouse or dependant, you can contact the claims helpline for support and advice. There is no need to see your GP or obtain a referral letter

Our experienced claims team will take your details and arrange for you to have an initial telephone consultation with a senior psychological therapist at a convenient time for you. This will give you an opportunity to talk through your concerns and agree on the best treatment pathway.

This could be one of several options including:

Face to face cognitive behavioural therapy (CBT)
Guided online CBT
Counselling
Referral onwards to see a psychiatrist.

Healix will pre-authorise your assessment and treatment (within benefit limits where applicable) and settle all invoices directly.

The telephone-based clinical assessment will not be subject to any excess, if one applies, however it will be applied to face-to-face treatment should this be required. All other healthcare scheme terms and conditions will apply.

*Under 18’s will require a referral letter from their own GP.

Musculoskeletal health pathway

Musculoskeletal conditions affect your muscles, bones and joints. They are very common and tend to increase with age.

Pain and discomfort can affect your daily activities but early diagnosis and treatment may help to ease your symptoms and improve the length of time it takes to recover. We have designed the Healix musculoskeletal pathway with this in mind.

How to make a claim

Employee only digital triage

As soon as you experience bone or joint pain you can use our digital physiotherapy triage service.

This can be accessed via the Member Zone or the My Healix app where you will be directed straight through to begin your online journey and treatment pathway without the need to contact the claims helpline.

Download the My Healix app

Access the Member Zone

Click here to access the Member Zone using your individual member number

This digital service is designed to provide an assessment of your needs and guide you to the best course of treatment.

Where self-managed care is appropriate, you are able to immediately access a tailored exercise programme with in-app access to a clinician as required. If needed, you will be guided to face-to-face physiotherapy treatment with our network provider.

If face to face physiotherapy sessions are recommended these will not be subject to an excess, scheme underwriting or any scheme limits (if these apply) when treatment is taken with our digital treatment pathway provider. All other healthcare scheme terms and conditions will apply.

Telephone assessment

If you are unable to access the Member Zone, My Healix app or your claim is for a spouse or dependant call the claims helpline to arrange a telephone based clinical assessment. Our experienced team will take your details and arrange for you to have an initial telephone consultation with a physiotherapist at a convenient time for you who will recommend the most appropriate treatment.

Digital skin pathway

Changes found to your skin can be concerning. Fortunately, in most instances, these changes are not caused by cancer, however fast detection is key to help identify the cause of these changes and provide reassurance.

Our digital skin pathway provides fast results and recommendations for further treatment depending on your diagnosis following assessment by our dermatology partners. Please note further treatment will be subject to the terms and conditions of the scheme.

This pathway is suitable for many skin complaints, and our experienced claims team will be able to guide you to access the most suitable pathway for your symptoms.

The table below shows which skin complaints are most suitable to be referred into our digital skin pathway:

Skin Conditions Suitable for the Skin Pathway	Skin Conditions Not Suitable for the Skin Pathway
A change to an existing mole (itching/bleeding/increase in size)	Chronic skin conditions such as eczema/psoriasis
A new skin growth that has appeared and is visible	New skin rashes
A sore area of skin that has not healed	Mole mapping services required for screening purposes where there is no identifiable area of immediate concern
	Members under the age of 18

This pathway is easy to use; just follow the simple steps below and access help today:

Step 1

Open a new claim with one of our claims assessors. Please see Making a claim for details of how to do this.

Step 2

You will receive an SMS to your mobile phone with a link to register for the service and details of how to submit your digital photographic images.

Step 3

Your digital photographic images will be assessed by our experienced dermatology partners within 2 working days.

Step 4

You will receive an SMS to notify you that your results are back and a link to access the report containing the diagnosis and any recommendation.

Step 5

Should a face-to-face consultation with a dermatologist be recommended, our dermatology partners will call you and assist you to arrange it at a suitable time and location for you.

Please note: face-to-face dermatology consultations taken within our network will not be subject to our reasonable and customary fees, however, these fees will apply should you wish to access a consultation outside of this network.

Section 9: Glossary

The words and phrases below have the following meanings. They will appear in bold in this guide.

Active treatment

- Treatment of an acute medical condition that leads to recovery or restoration of a previous state of health.

Acute condition

Annual renewal date

- the anniversary of the start date each year or any other date which we and your employer may agree to in writing.

Benefit

- the benefits for which you are entitled as an individual under the scheme subject to the terms and conditions that apply to your membership including all exclusions.

Benefits

-the benefits for which you are entitled as an individual under the scheme subject to the terms and conditions that apply to your membership including all exclusions.

Biological therapies

Cancer

- a malignant tumour, tissues or cells, characterised by the uncontrolled growth and spread of malignant cells and invasion of tissue.

Chronic condition

Please refer to the chronic conditions exclusion.

Complementary practitioner

Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
Osteopaths must be registered with the GOsC (General Osteopathic Council)
Chiropractors must be registered with the GCC (General Chiropractic Council)

Daycase

- if you are required to occupy a hospital bed for one day, for medical reasons

Dependant

-a member’s partner (if a member gets divorced their partner will no longer be considered as a dependant for the purposes of this scheme)

-a member’s unmarried dependent children

Dependants

-a member’s partner (if a member gets divorced their partner will no longer be considered as a dependant for the purposes of this scheme)

-a member’s unmarried dependent children

Dialysis

The removal of waste matter from the blood by either:

haemodialysis, (through the use of a kidney machine or dialyser)
peritoneal dialysis (by introducing fluid into the abdomen to act as a filter).

Disorder

– a disturbance of function, structure or behaviour, resulting from genetic or environmental factors such as disease, illness or injury.

Emergency

Employer

- ABC who is named as your employer

End of life care

Gender Dysphoria

- The distress experienced as a result of the mismatch between the biological gender and the gender identity.

Gender Incongruence

The mismatch between the biological gender and the gender identity. For example, transgender or non binary individuals.

General Practitioner

- a registered medical practitioner in general practice.

GP

- a registered medical practitioner in general practice

High dependency unit

– special department within a hospital designed for patients who require advanced post-operative care and/or support for a single failing organ system.

High risk activities

Home healthcare

- visits from a qualified nurse to your home to give you expert/skilled nursing services under the control of a specialist.

Hospital

NHS hospital - a National Health Service hospital with facilities for medical and surgical treatment, as defined in Section 1.28 of the National Health Service Act 1977 or in any future law.

Inpatient

– if you are required to occupy a hospital bed for one night or more, for medical reasons.

Intensive care unit

– a specialised department within a hospital designed for patients who require support for two or more organ systems and/or advanced respiratory support.

Medical condition

style="margin: 0cm 0cm 0pt; line-height: normal;">– any physical, mental or psychological disorder, including disease, illness, injury, genetic disorders and behavioural conditions.

Medically necessary

– treatment that is considered to be:

In accordance with professional standards of medical practice in the United Kingdom
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
Required for reasons other than the comfort or convenience of the patient or specialist.
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition.
Provided only for an appropriate duration of time.
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.

Members

- an employee covered under the scheme.

Mental health condition

- a disorder that affects your mind, mental function, emotions or behaviour whether the cause is organic, traumatic or reactive.

Outpatient

- if you do not require a hospital bed for your treatment or consultation.

Palliative care

– treatment that is aimed at slowing the growth of cancer and relieving side effects and symptoms of the treatment/disease.

Partner

- a member’s husband or wife, or the person the member lives with in a relationship similar to that of husband or wife, whether the same sex or not.

Physiotherapist

- a physiotherapist regulated by and registered as practicing with the Health Professions & Care Council and recognised by us.

Pre-existing condition

- any medical condition for which, in the five years before you joined the scheme:

you have received medication, advice or treatment, or
you have experienced symptoms whether the condition was diagnosed or not.

Private ambulance

- a purpose-built vehicle run by a recognised private ambulance service.

Prosthesis

style="margin: 0cm 0cm 0pt; line-height: normal;">– an artificial body part or device which is inserted during surgery.

Psychological therapist

we recognise the following as psychological therapists.

a psychologist who is:

Registered with the Health and Care Professions Council (HCPC);
Registered with the British Psychological Society (BPS) as a chartered Psychologist

a therapist who is:

An accredited member of the British Association of Counselling and Psychotherapy (BACP); or
An Accredited Member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP); or
An Accredited Member of Scotland’s Professional Body for Counselling and Psychotherapy (COSCA); or
A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)

Registered nurse

- a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number.

Related condition

- any medical condition which is reasonably considered to be related to another medical condition.

Specialist

- we consider a specialist to be:

a medical practitioner with full current registration with the General Medical Council or
a dentist with full current registration with the General Dental Council

and

a specialist in the treatment you are referred for (this is applicable to all specialities including anaesthetics and psychiatry)
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
is or has been a National Health Service consultant or dentist
has been recognised for benefit purposes as a specialist by Healix.

Start date

- the date the scheme starts as shown in the scheme schedule.

Surgical appliance

– an artificial device or an artificial body part which is a necessary part of your treatment or surgery - for example a knee brace after you have had ligament surgery.

The Scheme

- The ABC Healthcare Scheme

Practitioner

- practitioner recognised by us and registered with the Health and Care Professions Council as:

an occupational therapist
an orthoptist
a speech and language therapist
a dietician or;
a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number.

Treatment

- surgical or medical services (including diagnostic tests and consultations). This includes but is not limited to diagnostic tests, scans, and surgical procedures.

Treatments

- surgical or medical services (including diagnostic tests and consultations). This includes but is not limited to diagnostic tests, scans, and surgical procedures.

Trust Deed

- the trust deed (including the rules of the scheme) constituting the healthcare scheme, as amended from time to time.

Trustee, Trustees

- any trustee or trustees for the time being of the healthcare scheme.

United Kingdom

- England, Scotland, Wales and Northern Ireland.

Waiting Period

- a specified period of time that must pass before a benefit becomes eligible. The waiting period is calculated from the joining date of the scheme.

We, Us, Our

- Healix Health Services Ltd, Healix House, Esher Green, Esher, Surrey KT10 8AB.

You, Your

- the eligible member and his or her dependants if they are eligible.

Scheme

- your employers Corporate Healthcare scheme, of which you are a member

Pandemic

The fast spread of infectious disease to a large number of people in a given population within a short period of time, normally weeks.

Epidemic

more cases of a disease than would be expected for that disease in that area at that time

Member Zone

The Member Zone gives you access to the claims portal and displays all the benefits of your healthcare scheme in an app accessed via your smartphone, tablet or computer.

Member

- an employee covered under the scheme.

Neurodevelopmental disorders

Making a claim

Healthcare benefits

Register your claim using our easy online portal. Alternatively, you can call the claims helpline to confirm if cover is available.

In order for us to accurately assess cover under the terms and conditions of your scheme, we may ask to see a copy of your GP referral letter when you open a new claim.

Always contact the claims team before arranging or receiving any treatment.

Download the My Healix app

Access the MemberZone

Click here to access the claims portal using your individual member number

Call the claims helpline:

0203 640 6826
Monday-Friday 08.00-19.00 (Excl. bank holidays)
Saturday 09.00-13.00

We will confirm:

whether your proposed treatment is eligible for cover under the scheme
whether your proposed treatment costs will be covered under the scheme
any benefit limits or excess that may apply to your claim

To help you make the best possible use of the scheme, we have provided you with a how to claim summary

How to claim summary

If you believe you require physiotherapy, but you haven't seen your GP

▼

If your GP refers you onto a specialist or therapist

▼

If you experience mental health symptoms, but haven't seen your GP

▼

Log your claim via the Member Zone, the My Healix app or call the claims helpline

▼

Log your claim via the Member Zone, the My Healix app or call the claims helpline

▼

Log your claim via the Member Zone, the My Healix app or call the claims helpline

▼

We will assess your symptoms and help organise the most effective treatment

▼

We will advise on cover available, and authorise your eligible treatment

▼

We will advise on cover available, and authorise your eligible treatment

▼

If appropriate, we will arrange a physiotherapy referral within 24 hours, through Healix Physiotherapy Network Provider

▼

If appropriate, we will arrange a referral through Healix Mental Health Network Provider

▼

If further treatment is required, please visit the Member Zone, the My Healix app or call the helpline again

How to Claim Summary

Your scheme underwriting

Fixed Moratorium Underwriting

healthcare scheme is designed to cover treatment of new medical conditions that arise after you join. We will not pay for treatment of a pre-existing condition. By this we mean any medical condition or related condition for which you

have received medical treatment, or
have had symptoms, or
have sought advice, or
to the best of your knowledge were aware existed in the five years before the start of the scheme.

Pre-existing conditions become eligible two years after the joining date (subject to all other terms and conditions).

Your excess

You may be liable for an excess, applicable per person once every year of cover, which means that you are responsible for treatment costs up to the value of the excess applicable.

If applicable, the excess will be applied to the first eligible treatment that you receive in each scheme year. This is regardless of when the last excess payment was made and whether the treatment is for the same condition, a related condition, or for an entirely new condition. Please contact us before you receive any treatment, so that we can advise you on when your excess will apply.

Reasonable and customary fees

We adhere to a schedule of reasonable and customary (R&C) fees for specialist fees. These are based on a common set of codes and principles set out by the Clinical Classification and Schedule Development (CCSD) group. Our fee levels have been set after review of what the majority of specialist’s charge for medical and surgical services as well as a review by our clinical support team and our panel of specialist advisors.

We have an open referral network which means you can be referred to the specialist of your choice. Should you choose to be referred to a specialist who charges above our fee schedule you can opt to pay the difference or we can assist you in identifying an alternative specialist that charges within our fee schedule. For further information please refer to our fee schedule, or contact the claims team.

What happens in an emergency?

Most private hospitals are not set up to receive emergency admissions. In the event of an emergency you should:

call for an NHS ambulance
visit the accident and emergency department at the local NHS hospital.

If you would like to be transferred to a private facility, please contact us to discuss this. We will then be able to confirm whether your proposed treatment is eligible under the healthcare plan. Please note you must contact us before you transfer to a private facility.

You will not be covered for:

the cost of emergency treatment in a private walk-in centre, accident and emergency department or clinic
the cost of treatment in an intensive care or high dependency unit if you have been transferred specifically to receive this care
the costs of the transfer to a private facility specifically to receive treatment in an intensive care or high dependency unit.

Exclusions and limitations

The following are conditions and treatments which are not covered under your scheme. If you are unsure about anything in this section, please contact us on the claims helpline.

Exclusions and limitations

Ageing, menopause and puberty

We do not pay for treatment to relieve symptoms commonly associated with or caused by ageing, puberty or other natural physiological cause.

Please note: We will pay for remote consultations related to women’s and men's health concerns with a specialist gynaecologist or men's health specialist as specified in your table of benefits.

Alcohol abuse, substance abuse and addiction

We do not pay for any treatment required for alcohol, solvent or drug abuse, or any treatment arising from such abuse or addiction, this includes mental health treatment.

Please note: Cover is available for one addiction treatment programme per lifetime of the scheme as detailed within the inpatient mental health benefit in your table of benefits.

Allergies and allergic disorders

We do not pay for treatment to desensitise or neutralise any allergic condition or disorder.

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, external prostheses and orthotics etc) which do not fall within our definition of a surgical appliance. Any consultations relating to these are also not covered.

Birth control & contraception

We do not pay for:

birth control
sterilisation and/or reversal
termination of pregnancy

Please note: We will pay for remote consultations related to women’s or men's health concerns with a specialist gynaecologist or men's health specialist as specified in your table of benefits.

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.

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.

Complications from excluded/restricted conditions or treatment

We do not pay for treatment which arises from, or is related to any exclusion listed in this booklet or treatment which arises from or is related to a surgical procedure we do not cover.

Contamination, wars, riots and terrorist acts

We do not pay for treatment of any medical condition which is caused or contributed to by; nuclear, radioactive, biological or chemical contamination, war (whether declared or not), act of foreign enemy, riot, revolution, invasion, civil war, rebellion, insurrection, overthrow of a legally constituted government, explosions of war weapons, terrorist act or military activity. We will not pay for treatment of any medical condition which is received while you or your dependants are carrying out army, naval or air services duties.

Convalescence and general nursing care

We do not pay for treatment if it is primarily used for domestic and/or social reasons.

Cosmetic treatment

We do not pay for any treatment to change your appearance even when required for psychological reasons.

We do not pay for any treatment, including surgery:

where the intention of treatment, whether directly or indirectly, is the reduction or removal of healthy, surplus or fat tissue (for example, weight reduction surgery / treatment)
where the aim is to aesthetically enhance the appearance of the face or body where no functional condition is present (for example, botox, fillers or asymptomatic rhinoplasty)

Exception: we will pay for medically necessary treatment to restore your appearance in the following circumstances:

where it results from an eligible underlying disease process
following eligible treatment (including cancer treatment)
where the condition is causing a functional problem

Please note: we use NHS guidance as a benchmark for deciding whether the exceptions above are eligible for cover. All requests for cover must be submitted in writing with supporting medical information.

Dangerous or high risk activities

We do not pay for any treatment which is directly or indirectly related to the participation of hazardous or high risk activities.

Dental or oral treatment

We do not pay for any dental or oral treatment other than listed in your table of benefits

Dialysis

We do not pay for treatment for or associated with dialysis.

Exception: we will pay for temporary dialysis as a result of complications following an eligible procedure.

Drugs and dressings for outpatient or take-home use

We do not pay for drugs and dressings provided or prescribed for use as an outpatient or for you to take home, other than those outlined in your cancer cover explained.

Please note: this exception only applies to members with Upgrade level cover.

Emergency treatment in the UK

We do not pay for:

the cost of emergency treatment in a private walk-in centre, accident and emergency department or clinic
the cost of an emergency admission into a private hospital
the cost of treatment in an intensive care or high dependency unit if you have been transferred specifically to receive this care
the costs of the transfer to a private facility specifically to receive treatment in an intensive care or high dependency unit.

End of life care (terminal care)

We do not pay for treatment required to relieve symptoms at the end stage of a disease.

Experimental drugs and treatment

We do not pay for treatments (including medication) which in our reasonable opinion are experimental or not yet approved by the National Institute for Health and Care Excellence (NICE), are being researched or lack sufficient evidence to conclude that:

the harmful effects are outweighed by the beneficial effects
they are likely to lead to the same or better outcomes than available alternatives
they are based on established medical practice in the United Kingdom.

Examples of the criteria we use for considering a treatment as experimental include:

the treatment is still undergoing clinical trials and/or yet to undergo a phase III clinical trial for the indication in question
the treatment does not have approval from the relevant government body
the treatment does not conform to usual clinical practice in the view of the majority of medical practitioners in the relevant field
the treatment is being used in a way other than that previously studied or that for which it has been granted approval by the relevant government body
the treatment is rarely used, novel, or unknown and there is a lack of authoritative evidence of safety and efficacy.

We do not pay for any treatment required for complications arising or resulting from experimental treatment that you receive or for any subsequent treatment you may need as a result of you undergoing any experimental treatment.

Eyesight correction

We do not pay for treatment to correct your sight other than as specified in your table of benefits.

Fertility treatment

We do not pay for:

fertility treatment
assisted reproduction, surrogacy, harvesting of donor eggs or donor insemination
sperm collection and storage
complications following any of the above

Gender dysphoria

We do not pay for any treatment of gender dysphoria, or any treatment arising from or relating to gender dysphoria.

General practitioner consultations

We do not pay for any GP consultations or visits other than those specified in your table of benefits. We do not pay for any charges for the completion of claim forms or referral letters, unless we have requested these specifically to assess your claim.

Holistic and alternative medicine

We do not pay for holistic or alternative medicine or therapies, unless these are specifically listed in your table of benefits. For example yoga, massage, spas and health resorts.

Illegal activity

We do not pay for:

any treatment caused by or resulting from you carrying out an illegal act
any treatment resulting from a road accident where you were not wearing a seat belt (as required by law).

Neurodevelopmental disorders

We do not pay for any treatment (including assessment) of adult or childhood neurodevelopmental disorders.

Obesity

We do not pay for any weight loss treatment including treatment required as a result of obesity.

Overseas treatment

We do not pay for treatment outside the United Kingdom including evacuation or repatriation, other than as specified in your table of benefits.

Pandemic and/or epidemic disease

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

Please note, you will be covered for treatment of Long COVID as detailed in your COVID19 Cover Explained.

Personal comfort and convenience items

We do not pay for personal comfort and convenience items or services including but not limited to travel expenses, television, WIFI, telephone costs, newspapers, and guest meals.

Pregnancy and childbirth

We do not pay for any treatment related to pregnancy or childbirth, other than as specified in your table of benefits.

Screening and preventative treatment

We do not pay for any form of genetic testing or screening, health screening, health checks or preventative treatment, procedures or medical services where no disease is present.

We do not pay for treatment;

recommended because of a genetic predisposition towards developing a medical condition
recommended because of a family history of a medical condition

Please see cancer cover explained for information on preventative cancer treatment.

Please note: this exception only applies to members with Upgrade level cover.

Sexual dysfunction

We do not pay for any treatment required due to sexual dysfunction, sexually transmitted infections or sexual problems, whatever the cause.

Please note: we will pay for remote advice consultations related to women’s or men's health concerns with a specialist gynaecologist or men's health specialist as specified in your table of benefits.

Speech disorders

We do not pay for treatment for or relating to any speech disorder such as stammering. However we may pay for short term speech therapy for an acute condition immediately following eligible treatment. The speech therapy must be recommended by the specialist in charge of your treatment.

Surrogacy

We do not pay for treatment required by a mother or child as a result of a surrogate pregnancy until such time as the child has been accepted as an eligible dependant by the scheme, at which time the child only will be entitled to benefits outlined in your table of benfits.

Transplants and adoptive cell transfer therapies

We do not pay for any transplants, adoptive cell transfer therapies and/or gene therapy, complications related to, or resulting from these treatments. This includes, but is not limited to CAR T cell therapy, tumour infiltrating lymphocyte therapy and stem cell/bone marrow treatments.

We also do not pay for:

donor costs
harvesting
storage
administration
and/or any complications/treatment arising from any of the above

Exception: We will pay for recipient costs for skin or corneal grafts when eligible for benefit

Unrecognised providers

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.

Section 9: Glossary

The words and phrases below have the following meanings. They will appear in bold in this guide.

Active treatment

- Treatment of an acute medical condition that leads to recovery or restoration of a previous state of health.

Acute condition

Annual renewal date

- the anniversary of the start date each year or any other date which we and your employer may agree to in writing.

Benefit

- the benefits for which you are entitled as an individual under the scheme subject to the terms and conditions that apply to your membership including all exclusions.

Benefits

-the benefits for which you are entitled as an individual under the scheme subject to the terms and conditions that apply to your membership including all exclusions.

Biological therapies

Cancer

- a malignant tumour, tissues or cells, characterised by the uncontrolled growth and spread of malignant cells and invasion of tissue.

Chronic condition

Please refer to the chronic conditions exclusion.

Complementary practitioner

Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
Osteopaths must be registered with the GOsC (General Osteopathic Council)
Chiropractors must be registered with the GCC (General Chiropractic Council)

Daycase

- if you are required to occupy a hospital bed for one day, for medical reasons

Dependant

-a member’s partner (if a member gets divorced their partner will no longer be considered as a dependant for the purposes of this scheme)

-a member’s unmarried dependent children

Dependants

-a member’s partner (if a member gets divorced their partner will no longer be considered as a dependant for the purposes of this scheme)

-a member’s unmarried dependent children

Dialysis

The removal of waste matter from the blood by either:

haemodialysis, (through the use of a kidney machine or dialyser)
peritoneal dialysis (by introducing fluid into the abdomen to act as a filter).

Disorder

– a disturbance of function, structure or behaviour, resulting from genetic or environmental factors such as disease, illness or injury.

Emergency

Employer

- ABC who is named as your employer

End of life care

Gender Dysphoria

- The distress experienced as a result of the mismatch between the biological gender and the gender identity.

Gender Incongruence

The mismatch between the biological gender and the gender identity. For example, transgender or non binary individuals.

General Practitioner

- a registered medical practitioner in general practice.

GP

- a registered medical practitioner in general practice

High dependency unit

– special department within a hospital designed for patients who require advanced post-operative care and/or support for a single failing organ system.

High risk activities

Home healthcare

- visits from a qualified nurse to your home to give you expert/skilled nursing services under the control of a specialist.

Hospital

NHS hospital - a National Health Service hospital with facilities for medical and surgical treatment, as defined in Section 1.28 of the National Health Service Act 1977 or in any future law.

Inpatient

– if you are required to occupy a hospital bed for one night or more, for medical reasons.

Intensive care unit

– a specialised department within a hospital designed for patients who require support for two or more organ systems and/or advanced respiratory support.

Medical condition

style="margin: 0cm 0cm 0pt; line-height: normal;">– any physical, mental or psychological disorder, including disease, illness, injury, genetic disorders and behavioural conditions.

Medically necessary

– treatment that is considered to be:

In accordance with professional standards of medical practice in the United Kingdom
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
Required for reasons other than the comfort or convenience of the patient or specialist.
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition.
Provided only for an appropriate duration of time.
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.

Members

- an employee covered under the scheme.

Mental health condition

- a disorder that affects your mind, mental function, emotions or behaviour whether the cause is organic, traumatic or reactive.

Outpatient

- if you do not require a hospital bed for your treatment or consultation.

Palliative care

– treatment that is aimed at slowing the growth of cancer and relieving side effects and symptoms of the treatment/disease.

Partner

- a member’s husband or wife, or the person the member lives with in a relationship similar to that of husband or wife, whether the same sex or not.

Physiotherapist

- a physiotherapist regulated by and registered as practicing with the Health Professions & Care Council and recognised by us.

Pre-existing condition

- any medical condition for which, in the five years before you joined the scheme:

you have received medication, advice or treatment, or
you have experienced symptoms whether the condition was diagnosed or not.

Private ambulance

- a purpose-built vehicle run by a recognised private ambulance service.

Prosthesis

style="margin: 0cm 0cm 0pt; line-height: normal;">– an artificial body part or device which is inserted during surgery.

Psychological therapist

we recognise the following as psychological therapists.

a psychologist who is:

Registered with the Health and Care Professions Council (HCPC);
Registered with the British Psychological Society (BPS) as a chartered Psychologist

a therapist who is:

An accredited member of the British Association of Counselling and Psychotherapy (BACP); or
An Accredited Member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP); or
An Accredited Member of Scotland’s Professional Body for Counselling and Psychotherapy (COSCA); or
A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)

Registered nurse

- a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number.

Related condition

- any medical condition which is reasonably considered to be related to another medical condition.

Specialist

- we consider a specialist to be:

a medical practitioner with full current registration with the General Medical Council or
a dentist with full current registration with the General Dental Council

and

a specialist in the treatment you are referred for (this is applicable to all specialities including anaesthetics and psychiatry)
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
is or has been a National Health Service consultant or dentist
has been recognised for benefit purposes as a specialist by Healix.

Start date

- the date the scheme starts as shown in the scheme schedule.

Surgical appliance

– an artificial device or an artificial body part which is a necessary part of your treatment or surgery - for example a knee brace after you have had ligament surgery.

The Scheme

- The ABC Healthcare Scheme

Practitioner

- practitioner recognised by us and registered with the Health and Care Professions Council as:

an occupational therapist
an orthoptist
a speech and language therapist
a dietician or;
a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number.

Treatment

- surgical or medical services (including diagnostic tests and consultations). This includes but is not limited to diagnostic tests, scans, and surgical procedures.

Treatments

- surgical or medical services (including diagnostic tests and consultations). This includes but is not limited to diagnostic tests, scans, and surgical procedures.

Trust Deed

- the trust deed (including the rules of the scheme) constituting the healthcare scheme, as amended from time to time.

Trustee, Trustees

- any trustee or trustees for the time being of the healthcare scheme.

United Kingdom

- England, Scotland, Wales and Northern Ireland.

Waiting Period

- a specified period of time that must pass before a benefit becomes eligible. The waiting period is calculated from the joining date of the scheme.

We, Us, Our

- Healix Health Services Ltd, Healix House, Esher Green, Esher, Surrey KT10 8AB.

You, Your

- the eligible member and his or her dependants if they are eligible.

Scheme

- your employers Corporate Healthcare scheme, of which you are a member

Pandemic

The fast spread of infectious disease to a large number of people in a given population within a short period of time, normally weeks.

Epidemic

more cases of a disease than would be expected for that disease in that area at that time

Member Zone

The Member Zone gives you access to the claims portal and displays all the benefits of your healthcare scheme in an app accessed via your smartphone, tablet or computer.

Member

- an employee covered under the scheme.

Neurodevelopmental disorders

End of cover

Cover for you (the member) will end in the following situations:

if your employment with Barnett Waddingham has come to an end for any reason
if you no longer live full time in the United Kingdom
if you pass away
if for any reason you or Barnett Waddingham ask us to end cover
If you or any of your dependants have given us misleading information, have kept something from us, or have broken the conditions of this plan.

If your cover ends, your dependants cover will also end on the same day as your cover.

Cover for dependants will end in the following situations:

Your partner's cover will end:

if you get divorced, or your civil partnership is dissolved. Cover for your partner will end as soon as the final decree/final dissolution order has been granted.
if you no longer live together, then your partner will no longer be considered a dependant for the purposes of this scheme.

Your dependant child’s cover will end:

after they have turned 25. They will be removed from cover on the next annual renewal date following their 25^th birthday.
if they get married, then they will no longer be considered a dependant for the purposes of this scheme.
if they no longer live full time in the United Kingdom

Members must inform their HR department as soon as possible of any changes of this matter.

If treatment has been authorised, but has not yet taken place, you will be responsible for any treatment costs if the scheme then terminates or you leave the scheme.

Continuation option

As Healix Health only provides corporate group schemes, we are unable to continue your cover as an individual if you leave the Barnett Waddingham Healthcare Scheme.

We understand the importance of your healthcare and choosing a new provider may be daunting. We work closely with two providers to provide you with the best choice possible to take your healthcare forward.

What is a continuation option?
A continuation option allows members who resign or retire from an employer that provides workplace healthcare benefits to take out their own cover. You might be eligible to take over the benefits previously paid for by the employer, however it’s not always guaranteed that any ongoing claims will be covered.

National Friendly

Who are NF?
A Friendly Society that helps its members meet their health protection needs by offering you cover through private medical insurance policies.

How do I contact them?
Call 0333 014 6244, (8am-6pm Monday to Friday). Quote HEALIX and the team will be able to obtain the best possible terms for your transition.

What do they cover?
My Private Medical Insurance policy is a flexible product that offers cover for everyone up to age 85. You can choose between guided outpatient only cover all the way through to unlimited inpatient cover.

To find out more about National Friendly visit here.

Usay Compare

Who are Usay?
The largest individual health insurance intermediary and are experts at finding the best cover for you.

How do I contact them?
Call 01285 864670 and quote HEALIX.

What do they cover?
Usay Compare will get to know your unique individual requirements, do all the hard work comparing prices and policies for you; then advise on the best and most cost-effective quote.

To find out more about Usay Compare, fill in this online form.

These terms are offered to you as a previous member of the healthcare scheme and are available for a limited time only, usually no more than 30 days from the date of leaving. It is therefore important that you act quickly to maintain continuity of cover.

Health Services Ltd is an introducer appointed representative of both National Friendly and Usay Business Ltd, who are authorised and regulated by the Financial Conduct Authority. Calls may be recorded or monitored for quality control.

How to make a complaint

It is always our intention to provide a first class standard of service: however, we recognise that on occasions, your requirements may not have been met.

Should you have any cause for complaint, you should contact us.

How your complaint will be handled

Stage 1

You will receive a written acknowledgement of your complaint within five business days of receipt. This will include the name and job title of the individual handling the complaint.

Stage 2

Within four weeks of receiving your complaint, you will receive either:

A final response or
A holding response, explaining why we are not yet in a position to resolve the complaint and indicating when we will be making further contact (this will be within eight weeks from receiving the complaint).

Stage 3

If you have not received a final response within four weeks, by the end of eight weeks after receipt of the complaint, you will receive either:

A final response.
A response explaining why we are still not in a position to provide a final response and explaining when we believe we will be able to do so.
If we are unable to provide a final response, due to the delay which has now occurred, you may refer your complaint to the Trustees.

If, during stage 2 or 3, we issue our final response but you remain dissatisfied, you may refer your complaint to the Trustees. To do this, please set out your reasons fully in writing to the Operations Director, asking for referral to the trustees for further consideration.

How to claim reimbursement

How to claim for cash benefits

If you have received eligible treatment free of charge on the NHS you may be eligible to receive reimbursement of NHS cash benefits as detailed in your table of benefits.

These benefits will only be eligible if the treatment received would otherwise have been eligible for benefit under your scheme.

Please note; only one NHS cash benefit reimbursement can be claimed per admission.

In order to claim these benefits you can register your claim via the Member Zone or the My Healix App.

You will need to provide the following information for a claim to be processed

a copy of your NHS discharge paperwork which should confirm the following information:
- Date of admission and discharge from the NHS hospital
- Name and date of birth of the person admitted to hospital
- Summary of the reason for admission and the treatment received
Bank details for the reimbursement to be made to
- Account holder’s name
- Sort code
- Account number

How to claim reimbursement of medical expenses

If you have paid a provider directly for eligible medical services, you can claim a reimbursement of these costs as long as the treatment received is eligible for cover as detailed in your table of benefits.

In order to claim these benefits you can register your claim via the Member Zone or the My Healix App.

You will need to provide the following information for a claim to be processed:

An itemised receipt confirming the following information:
- Date treatment was received
- Details of the treatment received
- Amount paid for the treatment
Bank details for the reimbursement to be made to
- Account holder’s name
- Sort code
- Account number

Please note:

Once the claim has been confirmed as eligible by the claims team, reimbursement will be arranged via direct bank transfer.

All reimbursement claims (including cash benefit claims) must be submitted within six months of your treatment date / birth or adoption date or within 6 months of the end of the scheme year you wish to claim against - whichever comes soonest.

Additional information can be found in the payment of invoices page.

Payment of invoices

All treatment should be authorised in advance, so that we can place a guarantee of payment with your healthcare provider, subject to your benefit limits and our reasonable and customary guidelines. If you have pre-authorised your treatment, we will settle the bill (up to applicable limits) directly with your specialist, therapist or hospital. You are responsible for making sure we have all the information we need to pay your claims.

In some circumstances it may be necessary for you to pay for pre-authorised treatment yourself, and request a reimbursement from us for the cost of the treatment. In these cases please send us a copy of your receipt via email, along with your bank account details, and we will arrange reimbursement via bank transfer. All reimbursement claims (including cash benefit claims) must be submitted within six months of your treatment date or within six months of the end of the scheme year you wish to claim against - whichever comes soonest. Any claims submitted after this, will be assessed on a case by case basis, and paid at our discretion.

We will not pay for claims:

if the invoice or reimbursement claim (including cash benefit claims) is not submitted within six months of your treatment date / birth or adoption date or within 6 months of the end of the scheme year you wish to claim against - whichever comes soonest
if the treatment takes place after you have left the scheme
if you break any terms and conditions of your membership
if you incur a fee for non-attendance or late cancellations.

Requests for additional information

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.
Original accounts and invoices in connection with your claim.
Obtain results of an independent medical examination or second opinion for which we may ask you to make an appointment with a with a specialist. We will pay for the cost of any independent medical examination or second opinion we require and we will authorise this in writing, in advance.
Provide results of any second opinion you have independently sought under the care of another specialist. 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.

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

Throughout your claim we will make you aware of the options that are available 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 case managers 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 specialist nurses, along with our panel of independent specialist advisors, who will advise on the level of cover available for the recommended treatment.

Duplicate cover

You must tell us if you are able to make a claim for the cost of any of your treatment from anyone else either under another healthcare scheme or under an insurance policy. For example, if you received an injury that was caused by someone else such as a road traffic accident in which you are not at fault, the scheme will only pay a share of the total costs as appropriate.

If benefits are claimed for treatment to you when the injury or medical condition was caused by a third party, the scheme shall, at its own expense, have the right to pursue such claims in any way considered appropriate in your name. You must co-operate with all reasonable requests in this respect and advise us of any amount you recover directly from the third party.

Healix privacy notice

If you would like to know more about how Healix store and process your personal data, please find our Privacy Notice by clicking here.

Section 9: Glossary

The words and phrases below have the following meanings. They will appear in bold in this guide.

Active treatment

- Treatment of an acute medical condition that leads to recovery or restoration of a previous state of health.

Acute condition

Annual renewal date

- the anniversary of the start date each year or any other date which we and your employer may agree to in writing.

Benefit

- the benefits for which you are entitled as an individual under the scheme subject to the terms and conditions that apply to your membership including all exclusions.

Benefits

-the benefits for which you are entitled as an individual under the scheme subject to the terms and conditions that apply to your membership including all exclusions.

Biological therapies

Cancer

- a malignant tumour, tissues or cells, characterised by the uncontrolled growth and spread of malignant cells and invasion of tissue.

Chronic condition

Please refer to the chronic conditions exclusion.

Complementary practitioner

Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
Osteopaths must be registered with the GOsC (General Osteopathic Council)
Chiropractors must be registered with the GCC (General Chiropractic Council)

Daycase

- if you are required to occupy a hospital bed for one day, for medical reasons

Dependant

-a member’s partner (if a member gets divorced their partner will no longer be considered as a dependant for the purposes of this scheme)

-a member’s unmarried dependent children

Dependants

-a member’s partner (if a member gets divorced their partner will no longer be considered as a dependant for the purposes of this scheme)

-a member’s unmarried dependent children

Dialysis

The removal of waste matter from the blood by either:

haemodialysis, (through the use of a kidney machine or dialyser)
peritoneal dialysis (by introducing fluid into the abdomen to act as a filter).

Disorder

– a disturbance of function, structure or behaviour, resulting from genetic or environmental factors such as disease, illness or injury.

Emergency

Employer

- ABC who is named as your employer

End of life care

Gender Dysphoria

- The distress experienced as a result of the mismatch between the biological gender and the gender identity.

Gender Incongruence

The mismatch between the biological gender and the gender identity. For example, transgender or non binary individuals.

General Practitioner

- a registered medical practitioner in general practice.

GP

- a registered medical practitioner in general practice

High dependency unit

– special department within a hospital designed for patients who require advanced post-operative care and/or support for a single failing organ system.

High risk activities

Home healthcare

- visits from a qualified nurse to your home to give you expert/skilled nursing services under the control of a specialist.

Hospital

NHS hospital - a National Health Service hospital with facilities for medical and surgical treatment, as defined in Section 1.28 of the National Health Service Act 1977 or in any future law.

Inpatient

– if you are required to occupy a hospital bed for one night or more, for medical reasons.

Intensive care unit

– a specialised department within a hospital designed for patients who require support for two or more organ systems and/or advanced respiratory support.

Medical condition

style="margin: 0cm 0cm 0pt; line-height: normal;">– any physical, mental or psychological disorder, including disease, illness, injury, genetic disorders and behavioural conditions.

Medically necessary

– treatment that is considered to be:

In accordance with professional standards of medical practice in the United Kingdom
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
Required for reasons other than the comfort or convenience of the patient or specialist.
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition.
Provided only for an appropriate duration of time.
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.

Members

- an employee covered under the scheme.

Mental health condition

- a disorder that affects your mind, mental function, emotions or behaviour whether the cause is organic, traumatic or reactive.

Outpatient

- if you do not require a hospital bed for your treatment or consultation.

Palliative care

– treatment that is aimed at slowing the growth of cancer and relieving side effects and symptoms of the treatment/disease.

Partner

- a member’s husband or wife, or the person the member lives with in a relationship similar to that of husband or wife, whether the same sex or not.

Physiotherapist

- a physiotherapist regulated by and registered as practicing with the Health Professions & Care Council and recognised by us.

Pre-existing condition

- any medical condition for which, in the five years before you joined the scheme:

you have received medication, advice or treatment, or
you have experienced symptoms whether the condition was diagnosed or not.

Private ambulance

- a purpose-built vehicle run by a recognised private ambulance service.

Prosthesis

style="margin: 0cm 0cm 0pt; line-height: normal;">– an artificial body part or device which is inserted during surgery.

Psychological therapist

we recognise the following as psychological therapists.

a psychologist who is:

Registered with the Health and Care Professions Council (HCPC);
Registered with the British Psychological Society (BPS) as a chartered Psychologist

a therapist who is:

An accredited member of the British Association of Counselling and Psychotherapy (BACP); or
An Accredited Member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP); or
An Accredited Member of Scotland’s Professional Body for Counselling and Psychotherapy (COSCA); or
A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)

Registered nurse

- a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number.

Related condition

- any medical condition which is reasonably considered to be related to another medical condition.

Specialist

- we consider a specialist to be:

a medical practitioner with full current registration with the General Medical Council or
a dentist with full current registration with the General Dental Council

and

a specialist in the treatment you are referred for (this is applicable to all specialities including anaesthetics and psychiatry)
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
is or has been a National Health Service consultant or dentist
has been recognised for benefit purposes as a specialist by Healix.

Start date

- the date the scheme starts as shown in the scheme schedule.

Surgical appliance

– an artificial device or an artificial body part which is a necessary part of your treatment or surgery - for example a knee brace after you have had ligament surgery.

The Scheme

- The ABC Healthcare Scheme

Practitioner

- practitioner recognised by us and registered with the Health and Care Professions Council as:

an occupational therapist
an orthoptist
a speech and language therapist
a dietician or;
a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number.

Treatment

- surgical or medical services (including diagnostic tests and consultations). This includes but is not limited to diagnostic tests, scans, and surgical procedures.

Treatments

- surgical or medical services (including diagnostic tests and consultations). This includes but is not limited to diagnostic tests, scans, and surgical procedures.

Trust Deed

- the trust deed (including the rules of the scheme) constituting the healthcare scheme, as amended from time to time.

Trustee, Trustees

- any trustee or trustees for the time being of the healthcare scheme.

United Kingdom

- England, Scotland, Wales and Northern Ireland.

Waiting Period

- a specified period of time that must pass before a benefit becomes eligible. The waiting period is calculated from the joining date of the scheme.

We, Us, Our

- Healix Health Services Ltd, Healix House, Esher Green, Esher, Surrey KT10 8AB.

You, Your

- the eligible member and his or her dependants if they are eligible.

Scheme

- your employers Corporate Healthcare scheme, of which you are a member

Pandemic

The fast spread of infectious disease to a large number of people in a given population within a short period of time, normally weeks.

Epidemic

more cases of a disease than would be expected for that disease in that area at that time

Member Zone

The Member Zone gives you access to the claims portal and displays all the benefits of your healthcare scheme in an app accessed via your smartphone, tablet or computer.

Member

- an employee covered under the scheme.

Neurodevelopmental disorders

Contacting us

The Healix Team

We have a team of experienced case managers and nurses available to advise and help you, who can be contacted on the helpline number below:

Tel: 0203 640 6826
Email: barnettwaddingham@healix.com
Monday-Friday 08.00-19.00 (Excl. bank holidays)
Saturday 09.00-13.00

Telephone calls to and from our organisation are recorded for the purposes of quality and training.

Any correspondence should be sent to the following address:

Barnett Waddingham Healthcare Scheme
Claims Administration Department
Healix Health Services
Healix House, Esher Green
Esher, Surrey
KT10 8AB

Section 9: Glossary

The words and phrases below have the following meanings. They will appear in bold in this guide.

Active treatment

- Treatment of an acute medical condition that leads to recovery or restoration of a previous state of health.

Acute condition

Annual renewal date

- the anniversary of the start date each year or any other date which we and your employer may agree to in writing.

Benefit

- the benefits for which you are entitled as an individual under the scheme subject to the terms and conditions that apply to your membership including all exclusions.

Benefits

-the benefits for which you are entitled as an individual under the scheme subject to the terms and conditions that apply to your membership including all exclusions.

Biological therapies

Cancer

- a malignant tumour, tissues or cells, characterised by the uncontrolled growth and spread of malignant cells and invasion of tissue.

Chronic condition

Please refer to the chronic conditions exclusion.

Complementary practitioner

Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
Osteopaths must be registered with the GOsC (General Osteopathic Council)
Chiropractors must be registered with the GCC (General Chiropractic Council)

Daycase

- if you are required to occupy a hospital bed for one day, for medical reasons

Dependant

-a member’s partner (if a member gets divorced their partner will no longer be considered as a dependant for the purposes of this scheme)

-a member’s unmarried dependent children

Dependants

-a member’s partner (if a member gets divorced their partner will no longer be considered as a dependant for the purposes of this scheme)

-a member’s unmarried dependent children

Dialysis

The removal of waste matter from the blood by either:

haemodialysis, (through the use of a kidney machine or dialyser)
peritoneal dialysis (by introducing fluid into the abdomen to act as a filter).

Disorder

– a disturbance of function, structure or behaviour, resulting from genetic or environmental factors such as disease, illness or injury.

Emergency

Employer

- ABC who is named as your employer

End of life care

Gender Dysphoria

- The distress experienced as a result of the mismatch between the biological gender and the gender identity.

Gender Incongruence

The mismatch between the biological gender and the gender identity. For example, transgender or non binary individuals.

General Practitioner

- a registered medical practitioner in general practice.

GP

- a registered medical practitioner in general practice

High dependency unit

– special department within a hospital designed for patients who require advanced post-operative care and/or support for a single failing organ system.

High risk activities

Home healthcare

- visits from a qualified nurse to your home to give you expert/skilled nursing services under the control of a specialist.

Hospital

NHS hospital - a National Health Service hospital with facilities for medical and surgical treatment, as defined in Section 1.28 of the National Health Service Act 1977 or in any future law.

Inpatient

– if you are required to occupy a hospital bed for one night or more, for medical reasons.

Intensive care unit

– a specialised department within a hospital designed for patients who require support for two or more organ systems and/or advanced respiratory support.

Medical condition

style="margin: 0cm 0cm 0pt; line-height: normal;">– any physical, mental or psychological disorder, including disease, illness, injury, genetic disorders and behavioural conditions.

Medically necessary

– treatment that is considered to be:

In accordance with professional standards of medical practice in the United Kingdom
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
Required for reasons other than the comfort or convenience of the patient or specialist.
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition.
Provided only for an appropriate duration of time.
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.

Members

- an employee covered under the scheme.

Mental health condition

- a disorder that affects your mind, mental function, emotions or behaviour whether the cause is organic, traumatic or reactive.

Outpatient

- if you do not require a hospital bed for your treatment or consultation.

Palliative care

– treatment that is aimed at slowing the growth of cancer and relieving side effects and symptoms of the treatment/disease.

Partner

- a member’s husband or wife, or the person the member lives with in a relationship similar to that of husband or wife, whether the same sex or not.

Physiotherapist

- a physiotherapist regulated by and registered as practicing with the Health Professions & Care Council and recognised by us.

Pre-existing condition

- any medical condition for which, in the five years before you joined the scheme:

you have received medication, advice or treatment, or
you have experienced symptoms whether the condition was diagnosed or not.

Private ambulance

- a purpose-built vehicle run by a recognised private ambulance service.

Prosthesis

style="margin: 0cm 0cm 0pt; line-height: normal;">– an artificial body part or device which is inserted during surgery.

Psychological therapist

we recognise the following as psychological therapists.

a psychologist who is:

Registered with the Health and Care Professions Council (HCPC);
Registered with the British Psychological Society (BPS) as a chartered Psychologist

a therapist who is:

An accredited member of the British Association of Counselling and Psychotherapy (BACP); or
An Accredited Member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP); or
An Accredited Member of Scotland’s Professional Body for Counselling and Psychotherapy (COSCA); or
A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)

Registered nurse

- a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number.

Related condition

- any medical condition which is reasonably considered to be related to another medical condition.

Specialist

- we consider a specialist to be:

a medical practitioner with full current registration with the General Medical Council or
a dentist with full current registration with the General Dental Council

and

a specialist in the treatment you are referred for (this is applicable to all specialities including anaesthetics and psychiatry)
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
is or has been a National Health Service consultant or dentist
has been recognised for benefit purposes as a specialist by Healix.

Start date

- the date the scheme starts as shown in the scheme schedule.

Surgical appliance

– an artificial device or an artificial body part which is a necessary part of your treatment or surgery - for example a knee brace after you have had ligament surgery.

The Scheme

- The ABC Healthcare Scheme

Practitioner

- practitioner recognised by us and registered with the Health and Care Professions Council as:

an occupational therapist
an orthoptist
a speech and language therapist
a dietician or;
a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number.

Treatment

- surgical or medical services (including diagnostic tests and consultations). This includes but is not limited to diagnostic tests, scans, and surgical procedures.

Treatments

- surgical or medical services (including diagnostic tests and consultations). This includes but is not limited to diagnostic tests, scans, and surgical procedures.

Trust Deed

- the trust deed (including the rules of the scheme) constituting the healthcare scheme, as amended from time to time.

Trustee, Trustees

- any trustee or trustees for the time being of the healthcare scheme.

United Kingdom

- England, Scotland, Wales and Northern Ireland.

Waiting Period

- a specified period of time that must pass before a benefit becomes eligible. The waiting period is calculated from the joining date of the scheme.

We, Us, Our

- Healix Health Services Ltd, Healix House, Esher Green, Esher, Surrey KT10 8AB.

You, Your

- the eligible member and his or her dependants if they are eligible.

Scheme

- your employers Corporate Healthcare scheme, of which you are a member

Pandemic

The fast spread of infectious disease to a large number of people in a given population within a short period of time, normally weeks.

Epidemic

more cases of a disease than would be expected for that disease in that area at that time

Member Zone

The Member Zone gives you access to the claims portal and displays all the benefits of your healthcare scheme in an app accessed via your smartphone, tablet or computer.

Member

- an employee covered under the scheme.

Neurodevelopmental disorders

Scheme Year 2024

The below changes will come into effect for the new scheme year from 1st January 2024.

Benefit Changes	Previous Wording	New wording
Virtual GP	Please refer to the Virtual GP page for further information on how to access this benefit.	No longer provided by Healix. Please refer to the Barnett Waddingham homepage on Sharepoint – ‘Employee Assistance Banner’

Scheme Year 2023

The below changes will come into effect for the new scheme year from 1st January 2023.

New Benefits	Benefit Limit	Benefit Wording
Perci Health - virtual cancer support	Please refer to MemberZone for further information	Please refer to your cancer support explained
Digital Triage	Please refer to MemberZone for further information	Please refer to Musculoskeletal pathway and Mental health pathway.
Benefit Changes	Previous Wording	New Wording
Women's Health Benefit Remote advice service with our in-network specialist gynaecologists (up to 4 consultations per scheme year) Diagnostic tests and investigations following referral from our in-network remote gynaecologists (up to £500 per scheme year)	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
Outpatient consultations and diagnostic tests with a specialist on self-referral for breast, bowel or prostate cancer symptoms	Outpatient consultations with a specialist on self-referral for breast, bowel and prostate cancer symptoms We will pay within your overall outpatient limit for self-referred* consultations and investigations for breast, bowel or prostate cancer symptoms. If a diagnosis of cancer is made, cover for eligible treatment will be subject to any limits as detailed in your cancer treatment benefit. *Please note, cover for self-referral is subject to the medical underwriting on your scheme	Outpatient consultations with a specialist on self-referral for breast, bowel, prostate and testicular cancer symptoms We will pay within your overall outpatient limit for self-referred* consultations and investigations for breast, bowel, prostate or testicular cancer symptoms. If a diagnosis of cancer is made, cover for eligible treatment will be subject to any limits as detailed in your cancer treatment benefit. *Please note, cover for self-referral is subject to the medical underwriting on your scheme

Scheme Year 2022

The below changes will come into effect from 1st January 2022

New Benefit	Benefit limit	Benefit wording
Practitioner or specialist recommended orthotics	£500 per lifetime	We will pay up to £500 per scheme lifetime towards medically necessary orthotics, when these are recommended by a practitioner or specialist.
Cancer additional services UPGRADE LEVEL ONLY	Full cover	We will pay in full for the cost of external prosthesis, wigs, scalp cooling treatment and medical tattooing for reconstructive purposes only when recommended by your specialist and required as a direct result of eligible cancer treatment. For wigs and medical tattooing, this benefit is available on a pay and claim basis only.
Long COVID benefits	Combined limit of £5,000 per scheme year (up to £15,000 per lifetime)	The below benefits will be paid for when treatment is required as a result of COVID-19 (commonly referred to as 'long COVID'). The benefits have a combined limit of £5,000 per scheme year up to a maximum of £15,000 per lifetime. Outpatient consultations and diagnostics We will pay up in full for: Outpatient consultations with a specialist following GP referral Outpatient diagnostics and investigations following GP or specialist referral Outpatient treatment following specialist referral Cover is subject to our reasonable and customary fees. Outpatient, daycase and inpatient treatment We will pay for hospital and specialist fees, for outpatient, daycase and inpatient treatment. Please note cover is not available for acute treatment of COVID-19, including treatment in an intensive care unit, high dependency unit, acute ward setting or NHS hospital. Outpatient mental health treatment 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 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. Outpatient physiotherapy 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 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. Outpatient complementary therapies 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 long COVID. You must be referred to a complementary practitioner we have recognised for benefit purpose.
Benefits changes	Previous wording	New wording
Self-referral for suspected breast cancer	Outpatient consultations with a specialist on self-referral for breast cancer symptoms We will pay within your overall outpatient limit for self-referred* consultations and investigations for breast cancer symptoms. If a diagnosis of breast cancer is made, cover for eligible treatment will be subject to any limits as detailed in your cancer treatment benefit. *Please note, cover for self-referral is subject to the medical underwriting on your scheme	Outpatient consultations with a specialist on self-referral for breast, bowel and prostate cancer symptoms We will pay within your overall outpatient limit for self-referred* consultations and investigations for breast, bowel or prostate cancer symptoms. If a diagnosis of cancer is made, cover for eligible treatment will be subject to any limits as detailed in your cancer treatment benefit. *Please note, cover for self-referral is subject to the medical underwriting on your scheme
Outpatient physiotherapy	Self-referred Physiotherapy We will pay for outpatient physiotherapy, up to your overall outpatient limit of £1,500 per scheme year, without the need for a GP referral when treatment is provided by our physiotherapy network provider. 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 the outpatient limit or any excess (if one applies). Any outpatient limit and excess (where applicable) will be applied to subsequent treatment. 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 policy. For further information on how to access this benefit please click here. Outpatient Physiotherapy Following GP or Specualist Referral We will pay for outpatient physiotherapy following GP or specialist referral to a physiotherapist we have recognised for benefit purposes within your overall annual limit of £1,500 for outpatient treatment. 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 0203 640 6826 with details of your proposed treatment plan from the physiotherapist to receive pre-authorisation.	In network physiotherapy We will pay in full for outpatient physiotherapy when treatment is provided by our physiotherapy network provider. 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. Please refer to the Musculoskeletal Pathwayfor further information. Please note, cover for self-referral is subject to the medical underwriting on your scheme. Out of network physiotherapy on specialist referral We will pay in full for out of network outpatient physiotherapy when this is referred by a specialist.
Mental health treatment - inpatient and daycase	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.
Private ambulance charges	We will pay up to a maximum of £80 per trip for transport by a private ambulance, operated by a recognised private ambulance service to or from a hospital when ordered for medical reasons.	We will pay in full for transport by a private ambulance to and/or from a hospital when ordered for medical reasons.
Home nursing	We will pay in full up to an overall annual maximum of £2,000 for home nursing charges for qualified nurses if recommended by a specialist and where treatment is: immediately after eligible private inpatient hospital treatment medically necessary and without it you would be required to remain as an inpatient. needed for medical reasons. (i.e. not social or domestic reasons unless we have agreed to this as part of our healthcare services). is 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 psychiatric nurse is not covered by the scheme.	We will pay in full for home nursing charges for qualified nurses if recommended by a specialist and where treatment is: immediately after eligible private inpatient hospital treatment medically necessary and without it you would be required to remain as an inpatient. needed for medical reasons. (i.e. not social or domestic reasons unless we have agreed to this as part of our healthcare services). is 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 psychiatric nurse is not covered by the scheme.
Wording changes	Previous wording	New wording
General practitioner appointments	We do not pay for any GP consultations or visits other than those specified in your table of benefits. We do not pay for any charges for the completion of claim forms or referral letters, unless we have requested these specifically to assess your claim.	We do not pay for any GP consultations or visits other than those specified in your table of benefits. We do not pay for any charges for the completion of claim forms or referral letters, unless we have requested these specifically to assess your claim.
Sleep 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

Scheme Year 2021

The below changes will come into effect from 1st January 2021

New Benefit	Benefit limit	Policy wording
Remote consultations with our in-network specialist gynaecologists for women’s health concerns	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.
Diagnostic tests and investigations in relation to women’s health concerns	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.
Self-referral for suspected breast cancer	Covered within overall outpatient limit	Outpatient consultations with a specialist on self-referral for breast cancer symptoms We will pay within your overall outpatient limit for self-referred* consultations and investigations for breast cancer symptoms. If a diagnosis of breast cancer is made, cover for eligible treatment will be subject to any limits as detailed in your cancer treatment benefit.
Outpatient consultations and treatment with a practitioner	Covered within overall outpatient limit	Outpatient consultations with a practitioner We will pay within your overall outpatient limit for consultations with a dietician, nurse, orthoptist or speech therapist following specialist referral. The practitioner must be registered with the correct governing body for their field, and meet our definition for a practitioner
Pregnancy and childbirth	Full cover for specified treatment	We will pay for the following 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) 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.
Oral surgical procedures	Full cover for specified treatment	We will pay for the following specified oral surgical operations 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
Disorders of the eye	Full cover for specified treatment	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 referred by your general practitioner or optician to a consultant ophthalmologist wet aged related macular degeneration, where we will pay for a short course of treatment following initial diagnosis
ENHANCED ONLY Cancer outpatient and alternative therapies	Combined limit of £1,000 per scheme year	We will pay up to a total limit of £1,000 per scheme year for the following therapies, when required as a direct result of eligible cancer treatment. Cancer outpatient therapies on GP, specialist or self-referral We will pay up to the benefit limit for physiotherapy, osteopathy, chiropractic treatment, manual lymphatic drainage and dietician services. Treatment must be taken with a physiotherapist, practitioner or complementary practitioner that we recognise for benefit purposes Cancer alternative therapies on GP, specialist or self-referral 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 and aromatherapy
ENHANCED ONLY Cancer outpatient mental health	Up to £1,000 per scheme year	We will pay up to £1,000 per scheme year on GP, specialist or self-referral for outpatient mental health treatment required as a direct result of eligible cancertreatment. Mental health treatment is only covered if it is provided by a psychological therapistor psychiatrist
Benefits changes	Previous wording	New wording
Outpatient mental health treatment	We will pay up to £1,000 per scheme year 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 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 on-going cover will not be available on your scheme. Should your specialist/psychological 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. For further information on how to access this benefit please click here.	In network mental health cover We will pay in full for outpatient treatment for eligible mental health conditions following GP / self-referral when treatment is provided by our mental health network provider. We will arrange a telephone-based clinical assessment with a senior psychological therapist who will help organise the most effective treatment for you. This could include face to face therapy, guided self-management or specialist referral. Please refer to the mental health pathway for further information. Please note, cover for self-referral is subject to the medical underwriting on your scheme. Out of network mental health cover We will pay up to £1000 per scheme year for treatment for eligible mental health conditions with a specialist or psychological therapist following GP referral when treatment is taken outside of our Mental Health Network Provider. We will pay the costs of an initial assessment followed by a maximum of five further sessions if required and pre-authorisation has been obtained from us. If further sessions are required, you must contact us on 0208 150 0937 with details of your proposed treatment plan from your treating psychological therapist before any further sessions will be authorised.
Wording changes	Current wording	New wording
AIDS/HIV		Removed from exclusions
Birth control, contraception, sexual problems and sex change	Includes: any treatment needed because of male or female birth control, including sterilization or reversal of same, termination of pregnancy, sexual problems (including impotence) whatever the cause any type of investigations into fertility, fertility treatment or any pregnancy arising from any fertility treatment (except as outlined in the table of benefits). assisted reproduction, surrogacy, harvesting of donor eggs or donor insemination sex change or gender reassignment operations or any treatment needed to prepare for or recover from these operations (for example psychological counselling). or any treatment for or arising from any of the above.	Birth control, & contraception We do not pay for: birth control sterilization and reversal termination of pregnancy Fertility treatment We do not pay for: fertility treatment assisted reproduction, surrogacy, harvesting of donor eggs or donor insemination sperm collection and storage complications following any of the above Sexual dysfunction We do not pay for any treatment required due to sexual dysfunction or sexual problems, whatever the cause. Gender dysphoria We do not pay for treatment of gender dysphoria, or any treatment arising from or relating to gender dysphoria.
Congenital conditions		Removed from exclusions
Cosmetic treatment	Any form of treatment to change your appearance, plastic or reconstructive surgery, treatment of keloid scars or scar revision, even when required for psychological reasons, unless it is medically necessary as a direct result of you having an accident or because of other surgery or cancer, which itself would have been covered under the scheme. We will only pay if this was part of the original eligible treatment from the accident or cancer, and you have obtained our written authorisation before receiving the treatment. We will not pay for breast enlargement or reduction or any treatment or procedure to change the shape or appearance of your breast(s) whether or not it is required for medical or psychological reasons, for example back ache or enlarged breasts in males. We do not pay for any treatment, including surgery, which is for or involves the removal of healthy tissue (i.e. tissue which is not diseased), surplus or fat tissue where the intention of treatment, whether directly or indirectly, is the reduction or removal of surplus or fat tissue including weight loss.	We do not pay for any treatment to change your appearance even when required for psychological reasons. We do not pay for any treatment, including surgery: where the intention of treatment, whether directly or indirectly, is the reduction or removal of healthy, surplus or fat tissue (for example, weight reduction surgery / treatment) where the aim is to aesthetically enhance the appearance of the face or body where no functional condition is present (for example, botox, fillers or asymptomatic rhinoplasty) Exception: we will pay for medically necessary treatment to restore your appearance in the following circumstances: where it results from an eligible underlying disease process following eligible treatment (including cancer treatment) where the condition is causing a functional problem Please note: we use NHS guidance as a benchmark for deciding whether the exceptions above are eligible for cover. All requests for cover must be submitted in writing with supporting medical information.
Dental and oral treatment	Dental and oral treatment; the provision of dental implants or dentures, repair or replacement of damaged teeth (including crowns, bridges, dentures or any dental prostheses). The management of or treatment (including surgical operations) of jaw shrinkage or loss as a result of dental extractions or gum disease. We do not pay for surgical operations for the treatment of bone disease when related to gum disease or tooth disease or damage. Exception: we will pay for surgical operations carried out by your specialist to: put a natural tooth back into a jaw bone after it is knocked out or dislodged in an accident treat irreversible bone disease involving the jaws which cannot be treated in any other way, but not if it is related to gum disease, tooth disease or damage surgically remove a complicated, buried or impacted tooth root, for example an impacted wisdom tooth.	We do not pay for any dental or oral treatment other than listed in your table of benefits.
Dialysis	Supportive treatment for chronic kidney failure or kidney failure which cannot be cured, including dialysis of any kind. Exception: We will only pay for dialysis to treat acute reversible kidney failure or immediately before or after an eligible kidney transplant.	We do not pay for treatment for or associated with dialysis. Exception: we will pay for temporary dialysis as a result of complications following an eligible procedure.
Eyesight correction	Treatment to correct your sight, for example long or short sight or failing eyesight due to ageing, or to change the refraction of one or both eyes. We do not pay for routine eye examinations, contact lenses, spectacles or laser eye procedures such as refractive keratotomy (RK) and photorefractive keratectomy (PRK).	We do not pay for treatment to correct your sight other than as specified in your table of benefits.
Pandemic and/or epidemic disease		We do not pay for treatment for or arising from pandemic and / or epidemic disease.
Pre-existing conditions		Removed from exclusions
Pregnancy and childbirth	Treatment for, or any condition arising from pregnancy, childbirth or termination of pregnancy except where childbirth complications arise. This includes conditions such as: pre-eclampsia eclampsia pregnancy induced hypertension treatment of an embryo or foetus. Exception: We will pay for treatment of the following conditions: miscarriage or when the foetus has died and remains within the placenta in the womb hydatidiform mole (abnormal cell growth in the womb) ectopic pregnancy (foetus growing outside the womb) post-partum haemorrage (heavy bleeding in the hours and days immediately after childbirth) retained placental membrane (afterbirth left in the womb after delivery of the baby) complications following any of the above conditions medically essential caesarean section delivery. This benefit is subject to a 12 month waiting period from the date you joined the Berendsen Healthcare Scheme. However we need full clinical details from your specialist before we can give our decision.	We do not pay for any treatment related to pregnancy or childbirth, other than as specified in your table of benefits.
Ageing, menopause and puberty	We do not pay for treatment to relieve symptoms commonly associated with or caused by ageing, puberty or other natural physiological cause. This includes hormone replacement therapy (HRT).	We do not pay for treatment to relieve symptoms commonly associated with or caused by ageing, puberty or other natural physiological cause. Please note: We will pay for remote consultations related to women’s health concerns with a specialist gynaecologist as specified in your table of benefits

Scheme Year 2020

The below changes will come into effect from 1st January 2020

New Benefit	Benefit limit	Policy wording
Chronic Conditions	£1,000 per person, per scheme year	We will pay up to the benefit limit towards routine tests and consultations for chronic conditions. Once this benefit limit has been reached the chronic condition rule applies as detailed in 'What is not covered'
Benefits changes	Previous wording	New wording
Outpatient limit	You will be covered for outpatient consultations, diagnostic tests, physiotherapy, alternative and complementary therapies and outpatient mental health treatment up to an overall annual limit of £1,000 per scheme year	You will be covered for outpatient consultations, diagnostic tests, physiotherapy and alternative and complementary therapies up to an overall annual limit of £1,500 per scheme year
Outpatient mental health treatment	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.	We will pay up to £1,000 per scheme year for outpatient consultations for eligible 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 our reasonable and customary guidelines.
Other changes		New wording
Ability to upgrade cover to 'Enhanced cover'	This allows additional cover for cancer and cardiac conditions up to a benefit limit of £75,000 per person, per scheme year You will be covered in full for cancer treatment within the benefit limit. Treatments covered include surgery, drug treatments such as chemotherapy, biological therapies and hormone therapies as well as radiotherapy. You will not be covered for experimental treatment, genetic tests to see if you are likely to develop cancer and stem cell or bone marrow transplants.	Please note, if you have recently been diagnosed or received treatment for a cardiac condition or cancer under the policy in the twelve months prior to the request to increase your level of cover, it will not be possible to upgrade your cover to claim a higher level of benefit.
All members changing underwriting to a 2 year fixed moratorium		Your healthcare scheme is designed to cover treatment of new medical conditions that arise after you join. We will not pay for treatment of a pre-existing condition. By this we mean any medical condition or related condition for which you: have received medical treatment, or have had symptoms, or have sought advice, or to the best of your knowledge were aware existed in the five years before the start of the scheme. Pre-existing conditions become eligible two years after the joining date (subject to all other terms and conditions).

Scheme Year 2019

The below changes have come into effect from 1st January 2019 for the new policy year.

New Benefit	Benefit limit	New benefit limit
Virtual GP	Unlimited Cover	As part of your Barnett Waddingham Private Medical 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 It can also be accessed 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 save the app click here. Please note, during the phone call or eConsultation you will need to provide Medical Solutions with your employer’s name, Barnett Waddingham, in order to access the service. Should Medical Solutions refer you onto a specialist, please contact us on your help line number 0203 640 6826 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.

New Benefit

Benefit limit

New benefit limit

Virtual GP

Unlimited Cover

As part of your Barnett Waddingham Private Medical 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

It can also be accessed 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 save the app click here.

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

Should Medical Solutions refer you onto a specialist, please contact us on your help line number 0203 640 6826 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.

May 2018

The below changes have come into affect from May 2018.

	Amendment
Data Protection	The Data Protection page has been updated in line with the new General Data Protection Regulation (GDPR) legislation that came into effect on 25th May 2018. The Data Protection page has been changed to Healix Privacy Notice.
Phone Line	The claims line is now closed on a Saturday during bank holiday weekends. The new opening hours are: Monday-Friday 08:00-18:00 (excl. bank holidays) Saturday 08:00-13:00 (excl. bank holiday weekends)

Amendment

Data Protection

The Data Protection page has been updated in line with the new General Data Protection Regulation (GDPR) legislation that came into effect on 25th May 2018.

The Data Protection page has been changed to Healix Privacy Notice.

Phone Line

The claims line is now closed on a Saturday during bank holiday weekends.

The new opening hours are:

Monday-Friday 08:00-18:00 (excl. bank holidays)
Saturday 08:00-13:00 (excl. bank holiday weekends)

Scheme Year 2018

The below changes have come into effect from 1st January 2018 for the new policy year.

Benefit	Benefit limit	Benefit changes
Outpatient Mental Health Benefit	Part of overall annual outpatient limit of £1,000	24 month waiting period has been removed for outpatient mental health cover.
Inpatient Mental Health Benefit	28 days in one year of cover	24 month waiting period has been removed for inpatient mental health cover.

Scheme Year 2017

The new policy year renewed on the 1st January 2017. There have been no changes to the policy for this year.

Scheme Year 2016

The below changes have come into effect from 1st January 2016 for the new policy year.

New Benefit	Benefit limit	New benefit limit
Outpatient Physiotherapy on Self referral	Part of overall annual limit of £1,000	We will pay for outpatient physiotherapy when treatment is provided by our physiotherapy network provider following referral by us. You may contact the Claims Helpline without the need for referral from your GP and a nurse will assess your symptoms and help organise the most effective treatment. If appropriate, we will arrange a physiotherapy referral within hours and continue to monitor your progress by liaising with your treatment provider and assess whether you require further treatment or are ready to be discharged. This is included in your overall annual limit of £1,000 for outpatient treatment.
Benefits wording changes	Previous wording	New wording
Outpatient Psychiatric(now referred to as Outpatient Mental Health)	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, up to the overall annual limit of £1,000 in each year of cover 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. Please note: Your cover is designed to provide help for short or medium-term medical treatment that restores you back to health. Psychiatric conditions are often long term in nature and may become chronic conditions, for which ongoing cover will not be available on your scheme. This benefit is subject to a 24 month waiting period from the date you joined the Barnett Waddingham Private Medical Scheme.	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. This benefit is subject to a 24 month waiting period from the date you join the scheme. 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.
Inpatient Psychiatric(now referred to as Inpatient Mental Health)	We will pay up to a maximum of 28 days in any one year of cover for medically necessary treatment as an inpatient or daycase in an NHS or private psychiatric unit for psychiatric conditions which, we agree are eligible in writing and in advance. All treatment must be under the direct control of a Consultant Psychiatrist. Without written authorisation we may not pay any benefit. We do not pay for more than two episodes of treatment for any psychiatric condition during your membership of the Barnett Waddingham Private Medical Scheme. An episode is defined as: seven nights or more treatment received as an inpatient whether consecutive or not or 20 or more separate attendances for treatment received as a daycase patient or outpatient in any 12 month period.	We will pay up to a maximum of 28 consecutive days in any one year of cover for medically necessary treatment as an inpatient or daycase in an NHS or private psychiatric unit for mental health conditions which, we agree are eligible in writing and in advance. All treatment must be under the direct control and supervision of a Consultant Psychiatrist. Without written authorisation we may not pay any benefit. This benefit is subject to a 24 month waiting period from the date you join the scheme. Please note. 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. If after a full review of all the medical information available, the condition is considered to have become chronic the scheme will no longer pay benefits for the continuing or recurrent treatment of that condition (please refer to the What is not covered section for full details on chronic conditions). Where possible, the nursing team will also provide guidance on making other arrangements for continued treatment. Inpatient benefit will be paid once per disease occurrence.
Outpatient Physiotherapy	We will pay in full for outpatient physiotherapy, up to your overall annual limit of 10 sessions in any one year of cover, following specialist or GP referral. We will pay the costs of an initial assessment followed by a maximum of three further sessions if required and pre-authorisation has been obtained from us. If further sessions are required, you must contact us on 0203 640 6826 with details of your proposed treatment plan from the physiotherapist to receive pre-authorisation. This is included in your overall annual limit of £1,000 for outpatient treatment.	We will pay for outpatient physiotherapy following GP or specialist referral to a physiotherapist we have recognised for benefit purposes, up to your annual limit of 10 sessions per policy year, and within your overall annual limit of £1,000 for outpatient treatment. 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 0620 with details of your proposed treatment plan from the physiotherapist to receive pre-authorisation.
Oncology Treatment(now referred to as Cancer Treatment)	No change - Oncology now referred to as Cancer
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
Other wording changes	Previous wording	New wording
Requests for additional information	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. Please read this carefully before you commit yourself to any costs and follow the How to claim summary when claiming. If you are unsure about whether or not you are covered please contact us on 0203 640 6826, we will be happy to advise you.	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.
Second Opinions	Please note: we will only pay for an independent medical examination or second opinion from a specialist if we deem it to be medically necessary and we have authorised this in advance and in writing.	Should you decide that you would like to receive a second opinion to ensure you are fully confident with your specialists recommendations please contact us on 0844 874 0620 to discuss pre-authorisation. Our team of nurse case managers will be able to advise and support you through this process. Second opinions will be arranged with a consultant who is an expert in their field and whom we have recognised for the purposes of providing such second opinions. Following your second opinion one of our nurse case managers will contact you to discuss the suggested treatment plan and eligibility for benefit. Without written authorisation for a second opinion benefit will not be payable for any resulting treatment.

Section 9: Glossary

The words and phrases below have the following meanings. They will appear in bold in this guide.

Active treatment

- Treatment of an acute medical condition that leads to recovery or restoration of a previous state of health.

Acute condition

Annual renewal date

- the anniversary of the start date each year or any other date which we and your employer may agree to in writing.

Benefit

- the benefits for which you are entitled as an individual under the scheme subject to the terms and conditions that apply to your membership including all exclusions.

Benefits

-the benefits for which you are entitled as an individual under the scheme subject to the terms and conditions that apply to your membership including all exclusions.

Biological therapies

Cancer

- a malignant tumour, tissues or cells, characterised by the uncontrolled growth and spread of malignant cells and invasion of tissue.

Chronic condition

Please refer to the chronic conditions exclusion.

Complementary practitioner

Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
Osteopaths must be registered with the GOsC (General Osteopathic Council)
Chiropractors must be registered with the GCC (General Chiropractic Council)

Daycase

- if you are required to occupy a hospital bed for one day, for medical reasons

Dependant

-a member’s partner (if a member gets divorced their partner will no longer be considered as a dependant for the purposes of this scheme)

-a member’s unmarried dependent children

Dependants

-a member’s partner (if a member gets divorced their partner will no longer be considered as a dependant for the purposes of this scheme)

-a member’s unmarried dependent children

Dialysis

The removal of waste matter from the blood by either:

haemodialysis, (through the use of a kidney machine or dialyser)
peritoneal dialysis (by introducing fluid into the abdomen to act as a filter).

Disorder

– a disturbance of function, structure or behaviour, resulting from genetic or environmental factors such as disease, illness or injury.

Emergency

Employer

- ABC who is named as your employer

End of life care

Gender Dysphoria

- The distress experienced as a result of the mismatch between the biological gender and the gender identity.

Gender Incongruence

The mismatch between the biological gender and the gender identity. For example, transgender or non binary individuals.

General Practitioner

- a registered medical practitioner in general practice.

GP

- a registered medical practitioner in general practice

High dependency unit

– special department within a hospital designed for patients who require advanced post-operative care and/or support for a single failing organ system.

High risk activities

Home healthcare

- visits from a qualified nurse to your home to give you expert/skilled nursing services under the control of a specialist.

Hospital

NHS hospital - a National Health Service hospital with facilities for medical and surgical treatment, as defined in Section 1.28 of the National Health Service Act 1977 or in any future law.

Inpatient

– if you are required to occupy a hospital bed for one night or more, for medical reasons.

Intensive care unit

– a specialised department within a hospital designed for patients who require support for two or more organ systems and/or advanced respiratory support.

Medical condition

style="margin: 0cm 0cm 0pt; line-height: normal;">– any physical, mental or psychological disorder, including disease, illness, injury, genetic disorders and behavioural conditions.

Medically necessary

– treatment that is considered to be:

In accordance with professional standards of medical practice in the United Kingdom
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
Required for reasons other than the comfort or convenience of the patient or specialist.
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition.
Provided only for an appropriate duration of time.
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.

Members

- an employee covered under the scheme.

Mental health condition

- a disorder that affects your mind, mental function, emotions or behaviour whether the cause is organic, traumatic or reactive.

Outpatient

- if you do not require a hospital bed for your treatment or consultation.

Palliative care

– treatment that is aimed at slowing the growth of cancer and relieving side effects and symptoms of the treatment/disease.

Partner

- a member’s husband or wife, or the person the member lives with in a relationship similar to that of husband or wife, whether the same sex or not.

Physiotherapist

- a physiotherapist regulated by and registered as practicing with the Health Professions & Care Council and recognised by us.

Pre-existing condition

- any medical condition for which, in the five years before you joined the scheme:

you have received medication, advice or treatment, or
you have experienced symptoms whether the condition was diagnosed or not.

Private ambulance

- a purpose-built vehicle run by a recognised private ambulance service.

Prosthesis

style="margin: 0cm 0cm 0pt; line-height: normal;">– an artificial body part or device which is inserted during surgery.

Psychological therapist

we recognise the following as psychological therapists.

a psychologist who is:

Registered with the Health and Care Professions Council (HCPC);
Registered with the British Psychological Society (BPS) as a chartered Psychologist

a therapist who is:

An accredited member of the British Association of Counselling and Psychotherapy (BACP); or
An Accredited Member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP); or
An Accredited Member of Scotland’s Professional Body for Counselling and Psychotherapy (COSCA); or
A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)

Registered nurse

- a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number.

Related condition

- any medical condition which is reasonably considered to be related to another medical condition.

Specialist

- we consider a specialist to be:

a medical practitioner with full current registration with the General Medical Council or
a dentist with full current registration with the General Dental Council

and

a specialist in the treatment you are referred for (this is applicable to all specialities including anaesthetics and psychiatry)
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
is or has been a National Health Service consultant or dentist
has been recognised for benefit purposes as a specialist by Healix.

Start date

- the date the scheme starts as shown in the scheme schedule.

Surgical appliance

– an artificial device or an artificial body part which is a necessary part of your treatment or surgery - for example a knee brace after you have had ligament surgery.

The Scheme

- The ABC Healthcare Scheme

Practitioner

- practitioner recognised by us and registered with the Health and Care Professions Council as:

an occupational therapist
an orthoptist
a speech and language therapist
a dietician or;
a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number.

Treatment

- surgical or medical services (including diagnostic tests and consultations). This includes but is not limited to diagnostic tests, scans, and surgical procedures.

Treatments

- surgical or medical services (including diagnostic tests and consultations). This includes but is not limited to diagnostic tests, scans, and surgical procedures.

Trust Deed

- the trust deed (including the rules of the scheme) constituting the healthcare scheme, as amended from time to time.

Trustee, Trustees

- any trustee or trustees for the time being of the healthcare scheme.

United Kingdom

- England, Scotland, Wales and Northern Ireland.

Waiting Period

- a specified period of time that must pass before a benefit becomes eligible. The waiting period is calculated from the joining date of the scheme.

We, Us, Our

- Healix Health Services Ltd, Healix House, Esher Green, Esher, Surrey KT10 8AB.

You, Your

- the eligible member and his or her dependants if they are eligible.

Scheme

- your employers Corporate Healthcare scheme, of which you are a member

Pandemic

The fast spread of infectious disease to a large number of people in a given population within a short period of time, normally weeks.

Epidemic

more cases of a disease than would be expected for that disease in that area at that time

Member Zone

The Member Zone gives you access to the claims portal and displays all the benefits of your healthcare scheme in an app accessed via your smartphone, tablet or computer.

Member

- an employee covered under the scheme.

Private Medical Scheme

Introduction

Table of benefits - CORE

Table of benefits - UPGRADE

Cancer cover explained - UPGRADE

Your cancer support explained

COVID-19 cover explained

Second medical opinion

Section 9: Glossary

Active treatment

Acute condition

Annual renewal date

Benefit

Benefits

Biological therapies

Cancer

Chronic condition

Complementary practitioner

Daycase

Dependant

Dependants

Dialysis

Disorder

Emergency

Employer

End of life care

Gender Dysphoria

Gender Incongruence

General Practitioner

GP

High dependency unit

High risk activities

Home healthcare

Hospital

Inpatient

Intensive care unit

Medical condition

Medically necessary

Members

Mental health condition

Outpatient

Palliative care

Partner

Physiotherapist

Pre-existing condition

Private ambulance

Prosthesis

Psychological therapist

Registered nurse

Related condition

Specialist

Start date

Surgical appliance

The Scheme

Practitioner

Treatment

Treatments

Trust Deed

Trustee, Trustees

United Kingdom

Waiting Period

We, Us, Our

You, Your

Scheme

Pandemic

Epidemic

Member Zone

Member

Neurodevelopmental disorders

Women's health services

Men's health services

Self-referred cancer benefits

Mental health pathway

Musculoskeletal health pathway

Digital skin pathway

Section 9: Glossary

Active treatment

Acute condition

Annual renewal date

Benefit