Introduction
Welcome to the Catholic Dioceses Healthcare Trust Scheme guide.
Catholic Dioceses 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 Catholic Dioceses Healthcare 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
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.
Please note your scheme year runs from 1st April 2024 – 31st March 2025.
| Outpatient Diagnostics | Level of cover | Benefit note |
Outpatient consultations with a specialist Outpatient diagnostic tests and investigations following specialist referral Outpatient consultations with a practitioner Outpatient consultations and diagnostic tests with a specialist for specified cancer symptoms Outpatient complementary therapies following specialist referral Out of network physiotherapy following specialist referral |
Up to £3,000 per scheme year | 1 |
| Outpatient Treatment and Therapies | ||
Orthotics |
Up to £500 per scheme lifetime | 2a |
Outpatient mental health treatment |
Up to £3,000 per scheme year | 2b |
In network physiotherapy (including self-referral) |
Full cover | 2c |
Outpatient MRI, CT and PET scans on specialist referral |
Full cover | 2d |
Outpatient surgical procedures |
Full cover | 2e |
| Inpatient and Daycase Treatment | ||
Specialist fees for inpatient and daycase treatment |
Full cover within reasonable and customary guidelines | 3a |
Hospital charges for inpatient or daycase treatment |
Full cover | 3b |
Mental health treatment - Inpatient and daycase |
Up to 28 days per scheme year | 3c |
| Benefits for Specified Treatment | ||
Oral surgical procedures |
Full cover for specified treatments | 4a |
Disorders of the eye |
Full cover for specified treatments | 4b |
Men's Health Benefit Remote advice service with our in-network men's health specialists (up to 4 consultations per scheme year) Diagnostic tests and investigations following referral from our in-network remote men's health specialists (up to £500 per scheme year) |
Limited cover | 4c |
| Additional Benefits | ||
Private ambulance charges |
Full cover | 5a |
Home healthcare |
Full cover | 5b |
Convalescence (following inpatient treatment) |
Maximum of up to £2,000 per scheme year | 5c |
Note: The above benefits only apply when the covered person has treatment in Great Britain, or when temporarily abroad on holiday or business up to specified limits.
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 and diagnostic tests with a specialist for specified cancer symptoms
We will pay within your overall outpatient limit for self-referred* consultations and investigations for specified cancer symptoms
Please refer to the self-referred cancer benefits page for further information on how to access this benefit.
Once a diagnosis has been confirmed the scheme rules apply as detailed in your exclusions and limitations.
*Please note, cover for self-referral is subject to the medical underwriting on your scheme
Outpatient complementary therapies following specialist referral
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 the claims helpline with details of your proposed treatment plan from the complementary practitioner to receive pre-authorisation. This is limited to osteopathy, acupuncture, and chiropody. You must be referred to a complementary practitioner we have recognised for benefit purposes.
Out of network physiotherapy following specialist referral
We will pay within your overall outpatient limit for out of network outpatient physiotherapy when this is referred by a specialist. The physiotherapist must still be recognised by us for benefit purposes.
Back to topWe will pay up to £500 per scheme lifetime towards medically necessary orthotics, when these are recommended by a practitioner, physiotherapist, specialist or GP.
Back to topWe will pay up to £3,000 per scheme year for outpatient consultations for eligible mental health conditions following GP or self-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 refer to the mental health pathway for further information.
*Please note, cover for self-referral is subject to the medical underwriting on your scheme and Under 18’s will require a referral letter from their own GP.
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.
*Please note, cover for self-referral is subject to the medical underwriting on your scheme
Back to topWe will pay for MRI, CT and PET scans on specialist referral.
Back to topWe 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.
Back to topWe will pay for specialist fees for inpatient and daycase treatment. Cover is subject to our reasonable and customary fees.
Back to topWe 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
Please note, you will only be covered for eligible daycase and/or inpatient treatment if it is not available on the NHS to you within 6 weeks of the treatment being recommended by a specialist.
Back to topWe 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.
Back to topWe 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
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
Remote advice service with our in-network men's health specialists
We will pay for up to 4 remote advice appointments per scheme year with our in-network 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 andropause, sexual health concerns, fertility or contraception advice.
Diagnostic tests and investigations following referral from our in-network 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 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 men's health services page for further information on how to access these benefits
Back to topWe will pay in full for transport by a private ambulance to and/or from a hospital when ordered for medical reasons.
Back to topWe will pay in full for home nursing charges for registered nurses when recommended by a specialist and where treatment is:
-
medically necessary and without it you would have to receive treatment as an inpatient or daycase admission
-
needed for medical reasons (i.e. not social or domestic reasons)
-
under the direct supervision of a specialist
Mental health treatment delivered at home or in the community is not covered by the scheme.
Back to topIn the event that you are admitted to a hospice or convalescence facility, we will make a donation of up to £2,000 per scheme year towards the cost of your stay in the facility.
Back to topSecond 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 experienced claims team 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. 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
Acute condition
Annual renewal date
Artificial life maintenance
Benefit
Benefits
Cancer
Chronic condition
- 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. 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.
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
Daycase treatment
Detoxification
Diagnostic tests
Dialysis
peritoneal dialysis – the removal of waste matter from your blood by introducing fluid into your abdomen which acts as a filter.
Disorder
Emergency
Employer
End of life care
General Practitioner
GP
High dependency unit
Home nursing
Hospital
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
Inpatient treatment
Intensive Care Unit
Medical Condition
Medical Necessity
- in accordance with generally accepted standards of medical practice
- clinically appropriate, in terms of type, frequency, extent, site and duration and thought to be effective for the patient’s illness, injury or disease
- not primarily for the patient’s or specialist’s convenience; and
- no more costly than an alternative service(s) at least as likely to produce the same therapeutic or diagnostic results. <
Medically necessary
- in accordance with generally accepted standards of medical practice
- clinically appropriate, in terms of type, frequency, extent, site and duration and thought to be effective for the patient’s illness, injury or disease
- not primarily for the patient’s or specialist’s convenience; and
- no more costly than an alternative service(s) at least as likely to produce the same therapeutic or diagnostic results. <
Employees
Mental Health Condition
Outpatient
Outpatient treatment
Physiotherapist
Pre-existing condition
-
you have received medication, advice or treatment, or
-
you have experienced symptoms whether the condition was diagnosed or not.
<
Private ambulance
Prosthesis
Psychological therapist
-
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) under one of the following Modality Sections:
- Behavioural & Cognitive;
- Psychotherapies
- Humanistic & Integrative
- Psychotherapeutic
- Counselling
- Psychoanalytic & Psychodynamic <
Registered Nurse
Registered Nurses
Related condition
Scheme
Specialist
- 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
-
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
Surgical appliance
The Scheme
Treatment
Treatments
Trust Deed
Trustee, Trustees
Great Britain
Waiting Period
We, Us, Our
Year of cover
You, Your
Practitioner
- an occupational therapist
- an orthoptist
- a podiatrist
- 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. <
Member Zone
Member
High risk activities
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. Whenever you are experiencing a men’s health concern 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 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 table below 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 our claims team 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. |
|
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 |
|
|
Bowel cancer |
|
|
Prostate cancer |
Raised PSA level as specified below:
|
|
Testicular cancer |
|
|
Skin cancer |
Any of the following changes to a mole or lesion on the skin:
|
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 treatment will need to be accessed on the NHS.
Please contact us via 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.
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
As soon as you experience bone or joint pain you can contact the helpline for support and advice. There is no need to see your GP or obtain a referral letter
Our experienced team will take your details and arrange for you to have an initial telephone consultation with a senior physiotherapist at a convenient time for you who will recommend the most appropriate treatment pathway.
This could be one of three options:
- Face to face physiotherapy with an approved physiotherapist
- Guided self-management using a bespoke, evidence-based exercise programme and regular one-to-one calls with a physiotherapist
- Referral on to a specialist – we can help locate a specialist at a hospital near you.
Musculoskeletal Health Pathway
Mental health pathway
The importance of mental health and wellbeing is becoming increasingly recognised in today’s busy world. Acknowledging stress and anxiety and seeking help are the first steps to developing coping strategies and recovery.
How to make a claim
If you are experiencing stress, anxiety or depression or any other mental health problem, you can contact the Helpline for support and advice. There is no need to see your GP or obtain a referral letter
Our experienced 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.
Mental Health Pathway
Please note: Under 18’s will require a referral letter from their own GP.
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 member advisors. 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
Acute condition
Annual renewal date
Artificial life maintenance
Benefit
Benefits
Cancer
Chronic condition
- 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. 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.
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
Daycase treatment
Detoxification
Diagnostic tests
Dialysis
peritoneal dialysis – the removal of waste matter from your blood by introducing fluid into your abdomen which acts as a filter.
Disorder
Emergency
Employer
End of life care
General Practitioner
GP
High dependency unit
Home nursing
Hospital
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
Inpatient treatment
Intensive Care Unit
Medical Condition
Medical Necessity
- in accordance with generally accepted standards of medical practice
- clinically appropriate, in terms of type, frequency, extent, site and duration and thought to be effective for the patient’s illness, injury or disease
- not primarily for the patient’s or specialist’s convenience; and
- no more costly than an alternative service(s) at least as likely to produce the same therapeutic or diagnostic results. <
Medically necessary
- in accordance with generally accepted standards of medical practice
- clinically appropriate, in terms of type, frequency, extent, site and duration and thought to be effective for the patient’s illness, injury or disease
- not primarily for the patient’s or specialist’s convenience; and
- no more costly than an alternative service(s) at least as likely to produce the same therapeutic or diagnostic results. <
Employees
Mental Health Condition
Outpatient
Outpatient treatment
Physiotherapist
Pre-existing condition
-
you have received medication, advice or treatment, or
-
you have experienced symptoms whether the condition was diagnosed or not.
<
Private ambulance
Prosthesis
Psychological therapist
-
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) under one of the following Modality Sections:
- Behavioural & Cognitive;
- Psychotherapies
- Humanistic & Integrative
- Psychotherapeutic
- Counselling
- Psychoanalytic & Psychodynamic <
Registered Nurse
Registered Nurses
Related condition
Scheme
Specialist
- 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
-
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
Surgical appliance
The Scheme
Treatment
Treatments
Trust Deed
Trustee, Trustees
Great Britain
Waiting Period
We, Us, Our
Year of cover
You, Your
Practitioner
- an occupational therapist
- an orthoptist
- a podiatrist
- 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. <
Member Zone
Member
High risk activities
Making a claim
How to make a claim
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.
Call the claims helpline:
0208 481 7733
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
Call the claims helpline
Call the claims helpline
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 call the helpline again
If further treatment is required, please call the helpline again
If further treatment is required, please call the helpline again
Your scheme underwriting
All clergy (priests and deacons) will be accepted on Medical History Disregarded underwriting. This means we will not apply any personal medical exclusions to your scheme. However your cover will still be subject to the general terms of the scheme. Please refer to the section exclusions and limitations for further information.
All Non-Clergy will be subject to Moratorium underwriting. This means 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 for, or
- had symptoms of, or
- have asked advice on, or
- to the best of your knowledge were aware existed in the five years before the start of cover.
However, subject to the scheme terms and conditions, a pre-existing condition can become eligible for cover providing that when you first receive treatment you have not: received medical treatment for, had symptoms of, or have asked advice on for two continuous years after the start of your cover
If you receive treatment, have symptoms or ask advice for that medical condition within the first two years of your start date, then the moratorium is not satisfied and you will only be covered after there has been a continuous period of two years where you have not received treatment, had symptoms or asked advice for that condition.
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.
Hospital cover
The Catholic Dioceses Healthcare Trust Scheme will cover authorised treatment at the majority of private & NHS hospitals throughout the UK, however treatment and consultations at some hospitals are excluded from cover.
Please find a list below of the hospitals which are not covered under the Catholic Dioceses Healthcare Trust Scheme:
- 234 Great Portland Street
- HCA The Harley Street Clinic Diagnostic Centre
- HCA The London Gamma Knife Centre
- HCA The Harley Street Molecular Imaging Centre
- HCA 120 Old Broad Street
- HCA The Institute of Sport Exercise and Health
- HCA 30 Devonshire Street
- HCA The Lister Hospital
- HCA 31 Old Broad Street
- HCA The London Bridge Hospital
- HCA 88 Harley Street
- HCA The London Bridge Hospital at Guy's
- HCA Chelsea Outpatient Centre
- HCA The London Hand and Wrist Unit
- HCA Chiswick Medical Centre
- HCA The Platinum Medical Centre
- HCA City of London Medical Centre
- HCA The Portland Hospital
- HCA Elstree Outpatients & Diagnostics Centre
- HCA The Princess Grace Hospital
- HCA Harley Street At The Groves
- HCA The Shard Outpatient & Diagnostic Centre
- HCA Healthcare UK at Docklands
- HCA The Wellington Hospital
- HCA Laboratories
- HCA UK at The Wilmslow Hospital
- HCA Leaders in Oncology Care
- HCA UK at University College Hospital
- HCA London Bridge Hosp Diagnostic Unit
- HCA Wellington Diagnostic and Outpatient Centre
- HCA London Digestive Centre
- Sarah Cannon Research Institute
- HCA London Knee Clinic
- The Cyberknife Centre
- HCA London Radiotherapy Unit
- Roodlane Medical New Broad Street
- HCA Sydney Street Outpatient and Diagnostics Centre
- The Prostate Centre
- HCA The Christie Clinic
- HCA The Harley Street Clinicq
- HCA The Harbourne Hospital
- HCA Battersea and Nine Elms
Should you have any queries regarding this list or your chosen hospital/clinic, please contact us on the claims helpline.
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
We do not pay for treatment to relieve symptoms commonly associated with or caused by ageing, puberty or other natural physiological cause.
Exception: We will pay for one hormone implant when carried out during or immediately following eligible surgery.
Please note: We will pay for remote consultations and diagnostics related to men's health concerns with men's health specialist as specified in your table of benefits.
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.
We do not pay for treatment to desensitise or neutralise any allergic condition or disorder.
We do not pay for the supply or fitting of appliances, physical aids or devices (including but not limited to hearing aids, spectacles, contact lenses, external prostheses and orthotics etc) which do not fall within our definition of a surgical appliance other than as listed in your table of benefits. Any consultations relating to these are also not covered.
We do not pay for artificial life maintenance (including mechanical ventilation) where such treatment will not or is not expected to result in your recovery or restore you to your previous state of health.
We do not pay for:
- birth control
- sterilisation and/or reversal
- termination of pregnancy
Please note: We will pay for remote consultations and diagnostics related to men's health concerns with a men's health specialist as specified in your table of benefits.
We do not pay for treatment of cancer or diagnostic tests required to stage cancer (check for cancer spread).
Exception: we will pay for diagnostic tests required to confirm an initial cancer diagnosis.
We do not pay for any consultations, tests or treatment following the diagnosis of cardiovascular disease.
Definition of cardiovascular disease:
Any conditions affecting the heart and blood vessels such as coronary heart disease, myocardial infarction (heart attacks), strokes, transient ischemic attacks (TIAs) peripheral arterial disease, heart arrhythmias and value diseases.
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.
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.
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.
We do not pay for treatment if it is primarily used for any of the following purposes:
- convalescence or rehabilitation (including treatment with a physiotherapist or complementary practitioner)
- home nursing
- for domestic and/or social reasons
Exception: We will pay for convalescence or nursing at home, if we have authorised this as part of your convalescence or nursing at home benefits.
We do not pay for any form of plastic or reconstructive surgery, or scar revision, even when required for psychological reasons.
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 backache or enlarged breasts in males.
We do not pay for any treatment:
- 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
- for scar revision or keloid scarring
Exception: We will pay for post-traumatic or post-surgical reconstruction to restore function or appearance if it is medically necessary as a direct result of you having an accident or because of other surgery, which itself would have been covered under the scheme.
We do not pay for any treatment which is directly or indirectly related to the participation of hazardous or high risk activities.
We do not pay for treatment for or arising from deafness caused by a congenital abnormality, maturing or ageing.
Exception: We will pay for treatment for hearing impairment or deafness that arises as a result of an acute condition diagnosed within the previous 12 months. For example, glue ear or perforated eardrum.
We do not pay for any dental or oral treatment other than listed in your table of benefits.
We do not pay for treatment for or associated with dialysis haemodialysis, (meaning the removal of waste matter from your blood by passing it through a kidney machine or dialyser). We do not pay for treatment for or associated with peritoneal dialysis (meaning the removal of waste matter from your blood by introducing fluid into your abdomen which acts as a filter).
Exception: We will pay for eligible treatment for short-term dialysis when needed temporarily for sudden kidney failure resulting from an eligible condition or treatment.
We do not pay for drugs and dressings provided or prescribed for use as an outpatient or for you to take home.
We do not pay for any treatment of eating disorders such as anorexia or bulimia, or any kind of medical condition arising from such disorders.
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.
We do not pay for treatment required to relieve symptoms at the end stage of cancer, or for any other life limiting condition.
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, 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.
We do not pay for treatment to correct your sight other than as specified in your table of benefits.
We do not pay for:
- any type of fertility investigations
- fertility treatment
- assisted reproduction, surrogacy, harvesting of donor eggs or donor insemination
- sperm collection and storage
- complications following any of the above
Please note: We will pay for remote consultations and diagnostics related to men's health concerns with a men's health specialist as specified in your table of benefits.
We do not pay for any treatment of gender dysphoria, or any treatment arising from or relating to gender dysphoria.
We do not pay for GP consultations or GP charges for the completion of claim forms or referral letters.
Exception: we will pay reasonable charges for completion of claim forms if we have requested these specifically to assess your claim.
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.
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).
We do not pay for treatment received in intensive care, unless the treatment immediately follows and is required as a result of eligible pre-authorised treatment.
We do not pay for any treatment (including assessment) of adult or childhood neurodevelopmental disorders.
We do not pay for any weight loss treatment including treatment required as a result of obesity.
We do not pay for treatment outside Great Britain, including evacuation or repatriation.
We do not pay for treatment for or arising from pandemic and / or epidemic disease.
Exception: we will pay for secondary complications arising as a result of previous pandemic and/or epidemic disease subject to all other terms and conditions of the scheme, including chronic conditions.
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.
We do not pay for treatment for pregnancy or childbirth such as:
- hyperemesis (excessive and prolonged nausea and vomiting)
- pelvic girdle pain (pelvic pain in pregnancy)
- diastasis recti (abdominal separation)
- pregnancy induced hypertension (high blood pressure in pregnancy)
- pre-eclampsia
- treatment of a foetus or embryo
- antenatal care
- termination of pregnancy
- any treatment arising from assisted conception
- any complications arising from the above condition
Exceptions: We will pay for eligible treatment of the following conditions:
- miscarriage or when the foetus has died and remains with the placenta in the womb
- still birth
- hydatidiform mole (abnormal cell growth in the womb)
- ectopic pregnancy (foetus growing outside the womb)
- post-partum haemorrhage (heavy bleeding in the hours and days immediately after childbirth)
- retained placental membrane (afterbirth left in the womb after the delivery of the baby)
- eligible mental health treatment for post-natal depression subject to the conditions and limitations set out in the mental health benefit
- medically essential caesarean section where this is an inevitable consequence of a complication to the current pregnancy
- complications following any of the above conditions.
We do not pay for treatment required as a consequence of injury sustained whist training for, or participating in, sport for which you receive payment or sponsorship (other than travel costs).
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
We do not pay for any treatment required directly or indirectly as a result of self-inflicted illness, or injury, or suicide attempt.
We do not pay for any treatment required due to sexual dysfunction or sexual problems, whatever the cause.
We do not pay for treatment for or arising from sleep disorders, such as sleep apnoea, snoring, insomnia, sleep walking, narcolepsy, and night terrors.
We do not pay for treatment for or relating to any speech disorder such as stammering.
Exception: we will 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.
We do not pay for treatment required by a mother or child as a result of a surrogate pregnancy.
We do not pay for any consultation with a specialist, when the consultation is not carried out on a face-to face basis, for example, if it is carried out by telephone or any other remote medium.
Exception: We will consider cover for remote consultations, on a case by case basis, if there is evidence to suggest that this is clinically appropriate and we have agreed this in advance. For example, telephone assessments when carried out by our preferred network providers.
We do not pay for treatment intended to provide temporary relief of symptoms or for the ongoing management of a condition.
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
We do not pay for travel costs to and from medical facilities such as parking costs.
We do not pay for any expenses which you have claimed or can claim from any other insurance or source. If another insurer provides cover, we will negotiate with them to make sure both companies pay their share of the claim.
You must tell us in writing as soon as possible about any claim or right of legal action, against any other person that arises from the claim under this policy. You must keep us fully informed of any developments.
If we ask you, you must take all steps to include the amount of benefit you are claiming from us under this policy in your claim against the other person. We can take over and defend or settle any claim or prosecute any claim, in your name for our own benefit.
We will decide how to carry out any proceedings and settlement.
We do not pay for any treatment that has not been referred by:
- your GP
- an optician for eye treatment
- an occupational health physician or GP for mental health conditions.
Please note, we do not pay for daycase and/or inpatient treatment if it is available on the NHS to you within 6 weeks of the treatment being recommended by a specialist.
We do not pay for treatment that does not fall within our definition of medical necessity.
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 physiotherapist or complementary practitioner.
We do not pay for any treatment carried out by you, your spouse, parents or children.
We do not pay for any vaccinations or immunisations.
We do not pay for treatment of varicose veins.
Exception: We will pay for treatment when:
- they are causing ankle oedema of venous origin
- there is established lipodermatosclerosis or progressive skin change
- there have been recurrent episodes of superficial thrombophlebitis
- a trial of continuous compression therapy prescribed by your GP for at least 6 months has failed
- there is active or healed venous ulceration.
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide.
Active treatment
Acute condition
Annual renewal date
Artificial life maintenance
Benefit
Benefits
Cancer
Chronic condition
- 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. 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.
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
Daycase treatment
Detoxification
Diagnostic tests
Dialysis
peritoneal dialysis – the removal of waste matter from your blood by introducing fluid into your abdomen which acts as a filter.
Disorder
Emergency
Employer
End of life care
General Practitioner
GP
High dependency unit
Home nursing
Hospital
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
Inpatient treatment
Intensive Care Unit
Medical Condition
Medical Necessity
- in accordance with generally accepted standards of medical practice
- clinically appropriate, in terms of type, frequency, extent, site and duration and thought to be effective for the patient’s illness, injury or disease
- not primarily for the patient’s or specialist’s convenience; and
- no more costly than an alternative service(s) at least as likely to produce the same therapeutic or diagnostic results. <
Medically necessary
- in accordance with generally accepted standards of medical practice
- clinically appropriate, in terms of type, frequency, extent, site and duration and thought to be effective for the patient’s illness, injury or disease
- not primarily for the patient’s or specialist’s convenience; and
- no more costly than an alternative service(s) at least as likely to produce the same therapeutic or diagnostic results. <
Employees
Mental Health Condition
Outpatient
Outpatient treatment
Physiotherapist
Pre-existing condition
-
you have received medication, advice or treatment, or
-
you have experienced symptoms whether the condition was diagnosed or not.
<
Private ambulance
Prosthesis
Psychological therapist
-
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) under one of the following Modality Sections:
- Behavioural & Cognitive;
- Psychotherapies
- Humanistic & Integrative
- Psychotherapeutic
- Counselling
- Psychoanalytic & Psychodynamic <
Registered Nurse
Registered Nurses
Related condition
Scheme
Specialist
- 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
-
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
Surgical appliance
The Scheme
Treatment
Treatments
Trust Deed
Trustee, Trustees
Great Britain
Waiting Period
We, Us, Our
Year of cover
You, Your
Practitioner
- an occupational therapist
- an orthoptist
- a podiatrist
- 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. <
Member Zone
Member
High risk activities
End of cover
We will stop cover for you (the employee) in the following situations:
- if your ministry or employment with your Diocese has come to an end for any reason
- if you have given us misleading information, have kept something from us, or have broken the conditions of this scheme
- if you no longer live full-time in Great Britain
- if you pass away
- if for any reason you, your Diocese or the trustees of the scheme ask us to end cover
If treatment has been authorised, you will be responsible for any treatment costs if the scheme then terminates or you leave the scheme and treatment has not yet taken place.
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.
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 six 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
Acute condition
Annual renewal date
Artificial life maintenance
Benefit
Benefits
Cancer
Chronic condition
- 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. 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.
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
Daycase treatment
Detoxification
Diagnostic tests
Dialysis
peritoneal dialysis – the removal of waste matter from your blood by introducing fluid into your abdomen which acts as a filter.
Disorder
Emergency
Employer
End of life care
General Practitioner
GP
High dependency unit
Home nursing
Hospital
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
Inpatient treatment
Intensive Care Unit
Medical Condition
Medical Necessity
- in accordance with generally accepted standards of medical practice
- clinically appropriate, in terms of type, frequency, extent, site and duration and thought to be effective for the patient’s illness, injury or disease
- not primarily for the patient’s or specialist’s convenience; and
- no more costly than an alternative service(s) at least as likely to produce the same therapeutic or diagnostic results. <
Medically necessary
- in accordance with generally accepted standards of medical practice
- clinically appropriate, in terms of type, frequency, extent, site and duration and thought to be effective for the patient’s illness, injury or disease
- not primarily for the patient’s or specialist’s convenience; and
- no more costly than an alternative service(s) at least as likely to produce the same therapeutic or diagnostic results. <
Employees
Mental Health Condition
Outpatient
Outpatient treatment
Physiotherapist
Pre-existing condition
-
you have received medication, advice or treatment, or
-
you have experienced symptoms whether the condition was diagnosed or not.
<
Private ambulance
Prosthesis
Psychological therapist
-
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) under one of the following Modality Sections:
- Behavioural & Cognitive;
- Psychotherapies
- Humanistic & Integrative
- Psychotherapeutic
- Counselling
- Psychoanalytic & Psychodynamic <
Registered Nurse
Registered Nurses
Related condition
Scheme
Specialist
- 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
-
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
Surgical appliance
The Scheme
Treatment
Treatments
Trust Deed
Trustee, Trustees
Great Britain
Waiting Period
We, Us, Our
Year of cover
You, Your
Practitioner
- an occupational therapist
- an orthoptist
- a podiatrist
- 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. <
Member Zone
Member
High risk activities
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:
Email: CDHT@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:
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
Acute condition
Annual renewal date
Artificial life maintenance
Benefit
Benefits
Cancer
Chronic condition
- 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. 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.
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
Daycase treatment
Detoxification
Diagnostic tests
Dialysis
peritoneal dialysis – the removal of waste matter from your blood by introducing fluid into your abdomen which acts as a filter.
Disorder
Emergency
Employer
End of life care
General Practitioner
GP
High dependency unit
Home nursing
Hospital
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
Inpatient treatment
Intensive Care Unit
Medical Condition
Medical Necessity
- in accordance with generally accepted standards of medical practice
- clinically appropriate, in terms of type, frequency, extent, site and duration and thought to be effective for the patient’s illness, injury or disease
- not primarily for the patient’s or specialist’s convenience; and
- no more costly than an alternative service(s) at least as likely to produce the same therapeutic or diagnostic results. <
Medically necessary
- in accordance with generally accepted standards of medical practice
- clinically appropriate, in terms of type, frequency, extent, site and duration and thought to be effective for the patient’s illness, injury or disease
- not primarily for the patient’s or specialist’s convenience; and
- no more costly than an alternative service(s) at least as likely to produce the same therapeutic or diagnostic results. <
Employees
Mental Health Condition
Outpatient
Outpatient treatment
Physiotherapist
Pre-existing condition
-
you have received medication, advice or treatment, or
-
you have experienced symptoms whether the condition was diagnosed or not.
<
Private ambulance
Prosthesis
Psychological therapist
-
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) under one of the following Modality Sections:
- Behavioural & Cognitive;
- Psychotherapies
- Humanistic & Integrative
- Psychotherapeutic
- Counselling
- Psychoanalytic & Psychodynamic <
Registered Nurse
Registered Nurses
Related condition
Scheme
Specialist
- 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
-
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
Surgical appliance
The Scheme
Treatment
Treatments
Trust Deed
Trustee, Trustees
Great Britain
Waiting Period
We, Us, Our
Year of cover
You, Your
Practitioner
- an occupational therapist
- an orthoptist
- a podiatrist
- 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. <
Member Zone
Member
High risk activities
Scheme Year 2024
The below changes will come into effect for the new scheme year from 1st April 2024.
| Wording Changes | Old Wording | New Wording |
|
Cardiovasuclar Disease |
We do not pay for any consultations, tests or treatment following the diagnosis of cardiovascular disease. |
We do not pay for any consultations, tests or treatment for conditions relating to the heart. Definition of Cardiovascular Disease: Any conditions affecting the heart and blood vessels such as coronary heart disease, myocardial infarction (heart attacks), strokes, transient ischemic attacks (TIAs) peripheral arterial disease, heart arrhythmias and value diseases. |
Scheme Year 2023
The below changes will come into effect for the new scheme year from 1st April 2023.
Scheme Year 2022
The below changes will come into effect for the new scheme year from 1st April 2022.
| New Benefits | Benefit Limit | Benefit Note |
|
Practitioner or specialist recommended orthotics |
£500 per scheme lifetime |
We will pay up to £500 per scheme lifetime towards medically necessary orthotics, when these are recommended by a practitioner or specialist. |
| Benefit Changes | Previous Benefit Note | New Benefit Note |
|
Inpatient and daycase mental health treatment |
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. Please note mental health conditions are often long term in nature and may be classed as chronic conditions. If after a full review of all the medical information available, the condition is considered to be chronic the scheme will not pay benefits for continuing or recurrent treatment of that condition (please refer to exclusions and limitations for full details on chronic conditions). Where possible, the nursing team will also provide guidance on making other arrangements for continued treatment. Please note, you will only be covered for eligible daycase and/or inpatient treatment if it is not available on the NHS to you within 6 weeks of the treatment being recommended by a specialist. |
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 |
£80 per trip, maximum 4 trips per scheme year |
Full cover |
| Exclusion Updates | Previous Wording | Updated Wording |
|
Appliances, physical aids and devices |
We do not pay for the supply or fitting of appliances, physical aids or devices (such as hearing aids, spectacles, contact lenses, crutches, walking sticks, external prostheses and orthotics etc) which do not fall within our definition of surgical appliance. Any consultations relating to these are also not covered. Exception: We will pay for appliances that fall under our definition or a surgical appliance. |
We do not pay for the supply or fitting of appliances, physical aids or devices (including but not limited to hearing aids, spectacles, contact lenses, external prostheses and orthotics etc) which do not fall within our definition of a surgical appliance other than as listed in your table of benefits. Any consultations relating to these are also not covered. |
|
Eyesight correction |
We do not pay for treatment to correct your sight. This includes routine eye examinations, contact lenses (including lenses following cataract surgery), spectacles or laser eye procedures. We do not pay for ongoing or long-term treatment of eye conditions. This includes but is not limited to:
Exception: We will pay for eligible acute treatment of the following conditions:
|
We do not pay for treatment to correct your sight other than as specified in your table of benefits.
|
Scheme Year 2021
The below changes will come into effect for the new scheme year from 1st April 2021.
| New Benefits | Benefit Limit | Benefit Note |
|
Outpatient consultations with a practitioner |
Full cover within outpatient limit |
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 |
|
Oral surgical procedures |
Full cover for specified treatments |
We will pay for the following specified oral surgical operations carried out by a specialist:
|
| Benefit Changes | Previous Benefit Note | New Benefit Note |
|
Outpatient therapies on specialist referral (homeopathy, osteopathy, acupuncture, chiropody) |
Outpatient therapies following specialist referral. This is limited to homeopathy, osteopathy, acupuncture, and chiropody. Youmust be referred to a complementary practitioner we have recognised for benefit purposes. We will pay the costs of an initial assessment followed by three further sessions if required and pre-authorisation has been obtained from us. If further sessions are required, you must contact us on 0208 481 7733 with details of your proposed treatment plan from the complementary practitioner to receive pre-authorisation. |
We will pay up to your overall outpatient limit for chiropractic treatment, osteopathy and acupuncture following specialist referral. You must be referred to a complementary practitioner we have recognised for benefit purposes. |
|
Outpatient mental health treatment |
We will pay up to £1,500 per scheme year, for outpatient consultations for eligible mental health conditions following GP, specialist or self-referral. 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: 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. |
We will pay up to £3,000 per scheme year, for outpatient consultations for eligible mental health conditions following GP, specialist or self-referral. 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: 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. Please refer to the mental health pathway for further information. |
| Exclusion Updates | Previous Wording | Updated Wording |
|
Congenital conditions |
We do not pay for treatment for condition which you have had from birth, whether or not these were diagnosed or evident at birth. |
Removed |
|
Dental or oral treatment |
We do not pay for:
Exception: we will pay for surgical operations carried out by a specialist when treating an acute condition such as:
|
We do not pay for any dental or oral treatment other than listed in your table of benefits
|
|
Pandemic and/or epidemic disease |
|
We do not pay for acute, immediate treatment required to treat pandemic and / or epidemic disease. |
|
Transplants and adoptive cell therapies |
We do not pay for:
Exception: we will pay for recipient costs for skin or corneal grafts when eligible for benefit.
|
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:
Exception: We will pay for recipient costs for skin or corneal grafts when eligible for benefit |
Scheme Year 2020
The below changes will come into effect for the new scheme year from 1st April 2020.
| Benefit Changes | Previous Benefit Note | New Benefit Note |
|
Outpatient consultations, investigations and treatment |
Please note the below benefits listed in Note 1 are subject to an overall limit of £1,500 per scheme year. We will pay for: • Outpatient consultations with a specialist following GP referral • Outpatient diagnostics and investigations following specialist referral • Outpatient treatment following specialist referral • Outpatient therapies following specialist referral. • Outpatient physiotherapy following specialist referral |
Please note the below benefits listed in Note 1 are subject to an overall limit of £3,000 per scheme year. We will pay for: • Outpatient consultations with a specialist following GP referral • Outpatient diagnostics and investigations following specialist referral • Outpatient treatment following specialist referral • Outpatient therapies following specialist referral. • Outpatient physiotherapy following specialist referral |
|
Policy amendment to coverage |
The above benefits only apply when the covered person has treatment in the United Kingdom |
The above benefits only apply when the covered person has treatment in Great Britain.
|
Scheme Year 2019
The below changes have come into effect for the new scheme year from 1st April 2019.
| Benefit Changes | Previous Benefit Note | New Benefit Note |
|
In-network physiotherapy |
This benefit was previously included in the £1,500 per scheme year outpatient limit. Outpatient therapies following specialist referral. This is limited to physiotherapy, homeopathy, osteopathy, acupuncture, and chiropody. You must be referred to a physiotherapist or complementary practitioner we have recognised for benefit purposes. We will pay the costs of an initial assessment followed by three further sessions if required and pre-authorisation has been obtained from us. If further sessions are required, you must contact us on 0203 819 7161 with details of your proposed treatment plan from the therapist to receive pre-authorisation. |
This benefit is now covered in full when treatment is provided by our physiotherapy network provider: In network physiotherapy (including self-referral) |
|
Out of network physiotherapy |
This benefit is still included within the £1,500 outpatient limit, but the wording has been amended to make the cover clearer. Outpatient therapies following specialist referral. This is limited to physiotherapy, homeopathy, osteopathy, acupuncture, and chiropody. You must be referred to a physiotherapist or complementary practitioner we have recognised for benefit purposes. We will pay the costs of an initial assessment followed by three further sessions if required and pre-authorisation has been obtained from us. If further sessions are required, you must contact us on 0203 819 7161 with details of your proposed treatment plan from the therapist to receive pre-authorisation. |
The below benefit is included within note 1 and subject to an overall limit of £1,500 when treatment is provided outside our physiotherapy network: Out of network physiotherapy on specialist referral
|
|
Outpatient Mental Health Treatment following GP, Specialist or Self-referral |
We will pay up to £1,000 per scheme year, 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. |
The benefit limit has been increased to £1,500 per scheme year, and the benefit now also includes self referral via our mental health network provider. We will pay up to £1,500 per scheme year, for outpatient consultations for eligible mental health conditions following GP, Specialist or self-referral. If your referral is to a Psychological Therapist we will arrange a telephone-based clinical assessment with a senior therapist from our mental health network provider who will help organise the most effective treatment for you. This could include face to face therapy, guided self-management or specialist referral. Where treatment with a psychological therapist occurs outside our network provider it must be delivered under the direct supervision of a Consultant Psychiatrist. Please note: Your cover is designed to provide help for short or medium-term medical treatment that restores you back to health. Mental health conditions are often long term in nature and may become chronic conditions, for which on-going cover will not be available on your plan. 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. |
|
Treatment at Home (previously Home Nursing) |
We will pay up to £600 per scheme year for home nursing charges for registered nurses if recommended by a specialist and where treatment is:
We will need full clinical details before we give our authorisation and you must have our written agreement before treatment starts. |
The benefit limit has been removed, and the benefit is now covered in full. The benefit name has been changed to treatment at home. We will pay in full for home nursing charges for registered nurses if recommended by a specialist and where treatment is:
We will need full clinical details before we give our authorisation and you must have our written agreement before treatment starts. Home nursing provided by a community mental health team is not covered by the scheme. |
| Exclusion | Previous exclusion wording | New exclusion wording |
|
Transplants exclusion |
Transplants
Exception: we will pay for recipient costs for skin or corneal grafts when eligible for benefit. |
Transplants and adoptive cell transfer therapies We also do not pay for
Exception: we will pay for recipient costs for skin or corneal grafts when eligible for benefit. |
|
Cancer exclusion |
We do not pay for any consultations, tests or treatment following the diagnosis of cancer. |
We will pay for diagnostic tests and investigations required to diagnose cancer. Once a diagnosis has been confirmed, we will not pay for any treatment of cancer. This includes any diagnostic tests required to stage the cancer (check for cancer spread). |
| Wording Changes | Updates to wording | Effective from |
|
General exclusions |
Updates will be made to the general exclusions and content to ensure it remains up to date and appropriate. |
1st April 2019 |
|
Spouses cover |
Spouses will no longer be covered under The Trust. Updates will be made to the booklet wording to remove references to spouses cover. |
1st April 2019 |
Scheme Year 2018
With effect from 29th September 2018, the below benefit is no longer covered by the scheme.
| Benefit | Benefit limit | Benefit note |
|
Supply Priest Benefit |
£60 per mass, maximum £5,000 per scheme year |
We will pay up to £60 per mass for a supply priest to cover the administration of a Parish, if this is required due to the eligible clergy member being unable to perform their Parish duties, because they are undergoing eligible treatment privately under this scheme or via the NHS. Please note this benefit is limited to £5,000 per scheme year. |
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) |
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide.
Active treatment
Acute condition
Annual renewal date
Artificial life maintenance
Benefit
Benefits
Cancer
Chronic condition
- 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. 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.
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
Daycase treatment
Detoxification
Diagnostic tests
Dialysis
peritoneal dialysis – the removal of waste matter from your blood by introducing fluid into your abdomen which acts as a filter.
Disorder
Emergency
Employer
End of life care
General Practitioner
GP
High dependency unit
Home nursing
Hospital
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
Inpatient treatment
Intensive Care Unit
Medical Condition
Medical Necessity
- in accordance with generally accepted standards of medical practice
- clinically appropriate, in terms of type, frequency, extent, site and duration and thought to be effective for the patient’s illness, injury or disease
- not primarily for the patient’s or specialist’s convenience; and
- no more costly than an alternative service(s) at least as likely to produce the same therapeutic or diagnostic results. <
Medically necessary
- in accordance with generally accepted standards of medical practice
- clinically appropriate, in terms of type, frequency, extent, site and duration and thought to be effective for the patient’s illness, injury or disease
- not primarily for the patient’s or specialist’s convenience; and
- no more costly than an alternative service(s) at least as likely to produce the same therapeutic or diagnostic results. <
Employees
Mental Health Condition
Outpatient
Outpatient treatment
Physiotherapist
Pre-existing condition
-
you have received medication, advice or treatment, or
-
you have experienced symptoms whether the condition was diagnosed or not.
<
Private ambulance
Prosthesis
Psychological therapist
-
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) under one of the following Modality Sections:
- Behavioural & Cognitive;
- Psychotherapies
- Humanistic & Integrative
- Psychotherapeutic
- Counselling
- Psychoanalytic & Psychodynamic <
Registered Nurse
Registered Nurses
Related condition
Scheme
Specialist
- 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
-
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
Surgical appliance
The Scheme
Treatment
Treatments
Trust Deed
Trustee, Trustees
Great Britain
Waiting Period
We, Us, Our
Year of cover
You, Your
Practitioner
- an occupational therapist
- an orthoptist
- a podiatrist
- 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. <