Introduction

Welcome to the ABC Healthcare Scheme guide. TEST TEST 

ABC 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 ABC 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.

If you would like your partner or dependants to be covered under the healthcare scheme, regardless of their gender, please contact your HR department who will advise you if this is possible.

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.

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

Please note the below benefits are subject to an overall benefit limit of £xxxxxx per member per scheme year. 

The scheme will commence on the 1st January 2020 to 31st December 2020.

Outpatient Diagnostics Level of cover Benefit note
Inpatient and Daycase Treatment
Cancer Treatment
Cash Benefits
Benefits for Specified Treatment
Additional Benefits
Outpatient Treatment
Outpatient Therapies

Note: The above benefits only apply when the covered person has treatment in the UK unless otherwise specified.

Virtual GP

As part of your scheme you have access to a virtual GP service, called YourHealth247, which is provided by Teladoc.

You can register for this service via their portal, which can be found at:

http://www.yourhealth247.co.uk/

The portal is the fastest and easiest way to register for the virtual GP service and book your consultations. If you do not have access to the portal, you can also call YourHealth247 on 0204 586 5324.

To register, you will need your member number. This can be found on your welcome or renewal email. **OR** To register, you will need your access code which is as follows: XXXXXX

Should YourHealth247 refer you onto a specialist, please contact us on the claims helpline to check if this is eligible under your scheme. Any onward referrals are subject to your scheme underwriting and personal exclusions (if applicable) and general scheme exclusions. Should further information on your past medical history be required, we will need your consent to contact your NHS GP.

Second medical opinion

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

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

COVID-19 cover explained

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

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

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

Summary of cancer benefits What’s covered What’s not covered
Where will I be covered to have treatment?

You will be covered up to the benefit limit for eligible outpatient, daycase or inpatient treatment:

  • at a hospital we have approved for your treatment and condition
  • at home for treatment that would otherwise have to be delivered in hospital, if your specialist agrees that this is possible and is given by a recognised provider such as a registered nurse 

You will not be covered for:

  • any acute private treatment of COVID19 including treatment in an intensive care unit, high dependency unit, acute ward setting or NHS private patient unit
  • In the event that you require immediate, acute treatment for COVID19 this must take place on the NHS and you may be able to claim NHS COVID Cash Benefit if this is detailed in your table of benefits.
What tests will I be covered for?

You will be covered up to the benefit limit for:

  • eligible tests and any associated consultations with your specialist.
  • Specialist scans that take place in a recognised facility 

You will not be covered for any tests that are:

  • arranged by anyone other than your specialist
  • not considered standard treatment in the UK 
  • preventative or screening purposes unless these are required for or as a result of eligible treatment
What other benefits and services are available?

You will be covered within the overall benefit limit for:

  • mental health treatment up to a maximum of £1,500 per member per scheme year (self-referral available through our network)
  • physiotherapy treatment, including respiratory physiotherapy up to a maximum of £500 per member per scheme year (self-referral available through our network) 
  • complementary therapies up to a maximum of £250 per member per scheme year on GP or specialist referral 

You will not be covered for:

  • any transport costs or personal expenses
  • COVID19 vaccines or antibody tests
  • COVID19 tests for travel or quarantine purposes 


Assisted Reproductive Technology (ART) cover explained

We know that fertility concerns can have a major impact on life so we have developed a benefit to offer support and assistance when it matters most.

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

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

The following benefits are only eligible for individuals who are covered by the healthcare scheme and are under the age of 43.

Summary of ART benefits What is covered

Who can receive treatment?

You will be covered within the benefit limit for ART providing you are a member of the healthcare scheme and under the age of 43 years.

When is cover eligible from?

You will be covered within the benefit limit for ART after completion of a 12 month waiting period which starts from the date you join the healthcare scheme .

Where am I covered to receive treatment?

You will be covered within the benefit limit for treatment in the UK at a facility approved for use and licensed by the HFEA (Human Fertilisation and Embryology Authority)

What treatments am I covered for?

You will be covered within the benefit limit for eligible treatment for:

  • IUI (intrauterine insemination)
  • IVF  (In vitro fertilisation)
  • ICSI (Intracytoplasmic Sperm Injection)
  • FET (Frozen embryo transfers)

These treatments will be eligible for cover where treatment has been recommended by a specialist

You will also be covered for:

  • Consultations with a fertility specialist
  • Diagnostic tests recommended by the specialist
  • Fertility drugs to stimulate ovulation
  • Consultations and diagnostic tests to assess response to fertility drugs
  • Daycase admission for egg retrieval
  • Fertilisation of eggs
  • Admission for embryo transfer
  • Fertility drugs to support pregnancy following embryo transfer
  • Ultrasound scan to ascertain viable pregnancy
  • HFEA fee

Am I covered for surgical sperm extraction?

You will be covered within the benefit limit for the costs associated with surgical sperm extraction when medically necessary and recommended by a specialist

How many cycles of IVF / IUI am I covered for?

You will be covered within the benefit limit for repeated cycles of IVF / IUI / FET.

Am I covered for the genetic testing of eggs / sperm  / embryos?

You will not be covered for any costs associated with genetic testing (including, but not limited to, karyotype testing or pre implantation genetic testing)

Am I covered for sperm washing?

You will not be covered for the cost of sperm washing to prevent blood borne viruses from being transmitted.

Am I covered for the cost of take home drugs

You will be covered within the benefit limit for the cost of fertility medications required as part of your ART up until the point that a pregnancy is confirmed by ultrasound scan.  Following confirmation of a viable pregnancy, the cost of any further medication required to maintain the pregnancy will not be eligible for benefit.

Am I covered for donor insemination / donor eggs?

You will not be covered for the cost of donor eggs or sperm required to achieve a pregnancy.

Am I covered for the costs of surrogacy?

You will not be covered for the costs of ART with the use of a surrogate.

Am I covered for the cost of freezing resultant embryos following IVF treatment?

You will be covered within the benefit limit for the costs of embryo freezing for a total of 12 months following a cycle of IVF – after which time any further costs associated with the continued storage of embryos will no longer be eligible for cover

When does cover end?

Cover for ART will end at the point that a viable pregnancy is confirmed by ultrasound scan or when the benefit limit has been reached, whichever is reached soonest.

Once a pregnancy has been confirmed, any further scans or pregnancy related treatment will need to be taken on the NHS and the pregnancy exclusion would apply

Am I covered for treatment ‘add ons’ recommended by the clinic?

You will be covered within the benefit limit for the cost of treatment ‘add ons’ only where there is adequate evidence as to their effectiveness as defined by the HFEA.

Am I covered to freeze my eggs / sperm to use at a later time in life?

You will not be covered for the cost of egg or sperm freezing in order to preserve fertility for use at a later time in life.

Are same sex couples and individuals not in a partnership eligible for ART?

You will be covered within the benefit limit for treatment recommended by a specialist, however, the costs of the associated donor sperm or eggs required to achieve a pregnancy will not be eligible for cover.

Can I continue treatment that I started through self-pay prior to joining the healthcare scheme?

You will be covered within the benefit limit for the continuation of eligible pre-paid treatment as long as the 12 month waiting period is satisfied from your start date in the healthcare scheme.  Treatment costs already incurred prior to the benefit being eligible will not be reimbursed.

Am I covered for reversal of sterilisation to correct infertility?

You will not be covered for the cost of sterilisation reversal where this is the cause of infertility in either partner.

Am I covered for complementary therapies related to fertility?

You will be covered within the benefit limit for complementary therapies as detailed in your table of benefits.

Am I covered for counselling or mental health treatment related to my infertility?

You will be covered within the benefit limit for mental health treatment as detailed in your table of benefits.

Am I covered for multi-cycle treatment packages?

You will be covered within the benefit limit for the cost of treatment as it takes place only.  We are unable to cover ‘package’ costs that may not be used.

Do I need to self-pay for treatment

You may be required to self-pay for treatment at a fertility clinic where they are unable to accept payment from Healix.  Eligible treatment can then be reimbursed from Healix as long as this is requested within 6 months of the treatment date or prior to the end of the scheme year, whichever is soonest.

 

Gender dysphoria explained

We know that gender dysphoria can cause distress and discomfort for individuals who don't identify with the gender or sex they were assigned at birth. Therefore, we have provided a specific section within your scheme to help you understand the level of cover available to you should you experience this.

This table provides a summary of the cover available and should be read alongside your healthcare table of benefits.  Cover for gender dysphoria is available for members over the age of 18 years within the overall benefit limit of £200,000 per member per scheme year. 

For help and support, please contact the claims helpline.

Summary of benefits What’s covered What’s not covered
Where will I be covered to have treatment?

You will be covered for

  • outpatient treatment in a hospital or clinic that we have approved for your treatment and condition.

You will not be covered for:

  • any treatment received in an unrecognised hospital or clinic
  • any treatment received outside of the UK
What will I be covered for?

You will be covered up to the benefit limit for

  • eligible outpatient tests and any associated consultations with a specialist
  • eligible outpatient mental health treatment with a psychological therapist or psychiatrist

You will not be covered for:

  • treatment received as an inpatient or daycase
  • any surgical treatment, including genital or chest surgery and associated consultations
  • the cost of any hormone / drug therapies
What other benefits and services are available?

You will be covered within the overall benefit limit for:

  • hair removal services and wigs up to a maximum of £1,000 per member per lifetime 
  • speech and language therapy up to a maximum of £1,000 per member per lifetime 

You will not be covered for:

  • any travel costs or personal expenses
  • any treatment with a provider that we do not recognise for benefit purposes

Overseas emergency repatriation and evacuation

The scheme benefits generally only apply when you have treatment in the UK, and as a result, there is no coverage for treatment outside of the UK. For this reason we strongly advise you to take out travel insurance when travelling abroad.

However, In the event that you should fall ill abroad your healthcare scheme does provide access to an overseas assistance company line, which is provided by Healix International.

This line is manned 24/7 to provide help and assistance in any part of the world. This service can provide immediate advice and may be able to arrange to put you in touch with an English-speaking doctor where available.  They will be able to offer support and advice to ensure that the treatment you are receiving is medically appropriate and of a satisfactory standard.

Please note that, whilst the costs of using the overseas assistance company line is covered by your healthcare scheme, any costs for overseas appointments or treatment will not be paid for by the scheme and will be your liability if you do not have alternative cover in place.

In the event that an emergency repatriation is requested and the overseas assistance company are in agreement that this is medically necessary, cover will be available as detailed below.

You must advise us of any cover held with a travel insurance policy.  The scheme shall, at its own expense, reserve the right to speak with the other insurer in any way considered appropriate in your name. You must co-operate with all reasonable requests in this respect.

Contact the overseas assistance company line quoting 'HHS'

Tel: +44 (0) 203 8231 322

E-mail:  hhsrepat@healix.com

Summary of benefits What is covered?

What if I need evacuating or repatriating back to the UK?

In the event of an emergency the scheme may also provide  an emergency  evacuation and repatriation service.  This service is available if you should fall ill abroad and the treatment you require either not be available locally or the local medical facilities not be of an acceptable standard in the opinion of the overseas assistance company.

The overseas assistance company will arrange to repatriate you by air ambulance, scheduled airline service or any other medically appropriate transport including qualified medical escort(s) where medically necessary.

The evacuation and repatriation service will arrange you to be returned to the UK only.  Any costs for treatment prior to an emergency evacuation and repatriation will not be paid for by the scheme.

When am I not covered for evacuation or repatriation, including the repatriation of mortal remains?

This service is not available for cover in the following circumstances:

  • You travelled to a country against Foreign, Commonwealth and Development Office (FCDO) advice
  • You travelled overseas specifically for the purpose of receiving treatment
  • You are covered by an alternative provider for this service (ie travel insurance)
  • You are requesting cover for repatriation or evacuation against the medical advice of the overseas assistance company
  • Local treatment is of an acceptable standard in the opinion of the overseas assistance company
  • Where you require assistance as a result of a pregnancy related condition when travelling later than 36 weeks gestation
  • Where you require assistance as a result of a self-inflicted injury, suicide or attempted suicide
  • You have organised any repatriation services that the overseas assistance company has not arranged and approved

What happens when I return to the UK?

On arrival back to the UK, cover for private treatment will be assessed according to the general terms and conditions of your healthcare scheme.  Treatment should be taken on the NHS, until cover has been confirmed, to prevent you incurring any unwanted costs.

What costs are covered for evacuation and /or repatriation

You will be covered in full for any medical and transportation expenses arranged by and charged by the overseas assistance company to bring you back to the UK

Will my family be covered to travel with me?

You will be covered for:

  • travel and accommodation charges for one person over the age of 18 to accompany you on the evacuation / repatriation where this is deemed medically necessary by the overseas assistance company
  • travel and accommodation charges, up to the date of repatriation where this is deemed medically necessary by the overseas assistance company, for any family members who are accompanying you on the overseas journey as long as they are covered by the healthcare scheme

What costs are not covered during an evacuation or repatriation

You, and any eligible accompanying person will not be covered for :

  • The costs of any daily expenses that fall outside of travel and accommodation, including, but not limited to, food, clothing or other personal comfort and convenience items
  • The costs of any treatment required immediately before or after the evacuation and/or repatriation

What happens in the event of my death overseas?

You will be covered for the costs associated with the repatriation of your mortal remains back to the UK.

This will only be covered when the transport is required for the repatriation of mortal remains and is arranged via the overseas assistance company,

Who do I contact to arrange an evacuation / repatriation?

In the event that an evacuation or repatriation is required, please contact the overseas assistance company line on the number detailed above and they will be able to advise you on the cover available and, where eligible, make the necessary arrangements.

 

Section 9: Glossary

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

Self-referred cancer benefits

Having symptoms of cancer can be a worrying time, which is why we want to be able to support you to receive timely investigations for suspected cancer symptoms.

If you experience symptoms of breast, bowel, prostate or testicular cancer 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 to the most appropriate specialist to help reach a diagnosis.

 

Type of cancer Signs and symptoms to watch out for

Breast cancer
  • Hard, irregular shape lump in the breast or armpit
  • Dimpling of the skin on the breast
  • New inverted nipple
  • Discharge from the nipple
  • Any unusual change in size or shape of the breast

Bowel cancer
  • Bleeding from your back passage/bottom or blood in your stool without piles/haemorrhoids
  • Persistent, unexplained change in bowel habit, including diarrhoea or change in consistency of stool
  • Persistent abdominal discomfort, such as cramps, bloating, wind or pain
  • A feeling that your bowel doesn’t empty completely
  • Unexplained weight loss

Prostate cancer
  • Change in urinary flow
  • Needing to urinate more, especially at night
  • Painful or burning urination
  • Blood in the urine or semen
  • New difficulty in having an erection

Testicular cancer
  • Painless lump or swelling on either testicle
  • Pain, discomfort or numbness in a testicle
  • Any unusual change in size or shape of a testicle

 

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

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

 

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

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

Cancer cover explained

If you have been diagnosed with cancer, understanding what your cover includes is an important next step.

Your scheme provides cover for eligible cancer treatment, along with access to specialist support throughout your care.

Your cover supports you through active cancer treatment, up to your overall scheme cap, as detailed in your table of benefits.

If you choose to receive eligible outpatient, inpatient or day case treatment at an NHS centre free of charge, you may be entitled to NHS cancer cash benefit, as detailed in your table of benefits.

Throughout your cancer journey, you will have access to:

•    A dedicated Healix Health nurse - they will support you throughout your treatment, liaise with your treating specialist where needed and arrange authorisation for all eligible treatment, so you always know the next steps in your claim journey.

•    A dedicated Cancer Nurse Specialist through Perci – they will give you personalised guidance to help you understand your diagnosis, navigate treatment and manage any side effects. This includes access to a range of additional eligible services to support your overall health and wellbeing. Find out more on the cancer support page.

The below sets out what is and is not covered. It should be read alongside your table of benefits.

Cancer benefits What’s covered What’s not covered
Before confirming a cancer diagnosis

Screening and prevention
  • A Health Risk Assessment that evaluates lifestyle and other non-diagnostic risk factors to help you understand your risk of cancer – this can be accessed through the My Healix app or Member Zone
  • Access to a Perci Cancer Nurse Specialist if your assessment indicates an increased risk of cancer to help you understand what steps to take to reduce your risk - see cancer support page for more information
  • Health Screening as detailed in your table of benefits (to be added where benefits apply)
  • Routine screening such as breast screens
  • Genetic tests to see whether you are likely to get cancer
  • Treatment carried out solely to prevent the development of cancer (in the absence of any disease)
  • Vaccines to prevent the development of cancer

Outpatient consultations and diagnostic tests
  • Consultations with a specialist following GP referral to reach a diagnosis where there are symptoms that could be related to a cancer diagnosis
  • Self-referral for consultations with a specialist for symptoms of breast, bowel, prostate and skin cancer – see self-referred cancer benefits page for more information
  • Diagnostic tests following specialist referral to reach a diagnosis
  • Diagnostic tests to establish the extent of disease at the point of initial diagnosis (staging)
  • Diagnostic tests arranged by anyone other than your specialist
  • Diagnostics tests that are not considered standard in the UK
Following a cancer diagnosis

Outpatient consultations and diagnostic tests
  • Consultations and tests to monitor you during your active cancer treatment
  • Diagnostic tests arranged by anyone other than your specialist
  • Diagnostic tests not considered standard in the UK

Personalised medicine and genomic testing
  • Genomic (genetic) tests to see if a cancer treatment is suitable based on your cancer type
  • Access to comprehensive genetic testing as detailed in the Precision Cancer Service page
  • Genomic testing designed to find out whether you are likely to get cancer or not

Surgery
  • Surgery to remove cancer
  • Reconstructive cancer surgery following removal of cancer
  • Reconstructive surgery to a healthy breast following breast cancer, where the primary purpose is to improve symmetry following surgery for cancer in the contralateral breast
  • Surgery that is not recommended by NICE for clinical effectiveness
  • Surgery that is considered experimental

Chemotherapy
  • Chemotherapy where it is being recommended within its license indication
  • Medications (such as anti-sickness drugs and antibiotics) to help with the side-effects of cancer treatment
  • Cover for chemotherapy drugs is limited to ………

Any medications that:

  •          can be prescribed by your GP and do not require specialist supervision
  •         are experimental or being administered as part of a clinical trial
  •         are not licensed to treat your condition

Specialised cancer drugs
  • Hormone therapies, targeted therapies and biological therapies, including immunotherapies where these are being recommended within their license indications
  • Cover for specialised cancer drugs is limited to ……

Specialised cancer drugs that:

  •         Are experimental or being administered as part of a clinical trial
  •          Are not licensed to treat your condition
  •         Can be prescribed by a GP, including but not limited to Tamoxifen

Advanced therapies

The following advanced therapies when recommended by a specialist in line with their licensing recommendation:

  • Talimogene laherparepvec (T-VEC ) for advanced melanoma
  • Tumour Treating Fields (Optune Gio)  for newly diagnosed Glioblastoma
  • Adoptive cell transfers and gene therapies (including, but not limited to CAR-T cell therapy) other than those listed and / or any complications related to, or resulting from these

Radiotherapy
  • Radiotherapy treatments, including but not limited to, IMRT, SBRT and proton beam therapy where clinically indicated and recommended by your specialist
  • Radiotherapy treatment that is not recommended by NICE for clinical effectiveness
  • Radiotherapy treatment that is considered experimental

Transplants
  • Corneal grafts and skin grafts when being used as a treatment option for a diagnosed cancer
  • Transplants other than those listed
  • Costs including donor costs, harvesting, storage
  • Administration and / or any complications / treatment arising from any of the above

Experimental treatment
  • Standard treatment for your cancer, where this is being provided alongside participation in a clinical trial or alongside experimental treatment
  • Unlicensed drugs where Phase III clinical evidence supports use for your cancer diagnosis and the treatment is recommended by your specialist and approved by the relevant multidisciplinary team
  • Where you are receiving cancer treatment solely as part of a clinical trial, we will cover consultations, investigations and diagnostics that are unrelated to the clinical trial and which are not funded or provided by the trial sponsor
  • Support from a Perci Cancer Nurse Specialist to actively signpost you into suitable clinical trials where clinically appropriate
  • Experimental treatment and treatment that is still undergoing clinical trials and / or has yet to undergo a phase III clinical trial for the indication in question
  • Any treatment required for complications of experimental treatment or clinical trials that are not eligible for benefit

Additional services
  • Parking charges, convenience items or travel costs related to the receiving of cancer treatment

Therapies for side effects of cancer treatment
  • In-network cancer therapies arranged and delivered via Perci – see cancer support page for more information

Cancer therapies delivered outside of Perci will be subject to any benefit limits as detailed in your table of benefits, including but not limited to:

  •          physiotherapy
  •         complementary therapies
  •          mental health treatment
  •          manual lymphatic drainage when delivered by a nurse or physiotherapist
  • Therapies delivered by a provider that we do not recognise for benefit purposes

Extended support benefits

Up to £5,000 per scheme lifetime for treatment related to the following specified complications required as a result of your cancer treatment:

  •          Fertility preservation prior to cancer treatment
  •          Erectile dysfunction
  •          Treatment-induced menopause
  •          Dental check ups / treatment required prior to cancer treatment

 

Support for spouse and dependents affected by diagnosis
  • Access to a Perci Cancer Nurse Specialist to provide support and guidance to help manage the practical and emotional impact of a diagnosis. – see cancer support page for more information

 
Following completion of active cancer treatment

Outpatient consultations and diagnostic tests
  • Consultations with a specialist and diagnostic tests to monitor your cancer once your active cancer treatment is complete

 

Nurse support
  • Access to a Perci Cancer Nurse Specialist for an Annual Cancer Care Review and eligible therapies arranged and delivered via Perci to help with the side effects following cancer treatment

 

End of life care
  • Eligible therapies arranged and delivered via Perci where clinically indicated
  • Therapies accessed and delivered outside of Perci
  • Treatment given solely to relieve symptoms at the end stage of cancer

Need to talk to someone?

If you’ve received a cancer diagnosis, your Healix Health Nurse is your first point of contact. They can support you and help you understand the next steps in your care.

Get in touch by phone on XXX XXXX XXX or via live chat through the My Healix app or your scheme guide.

Cancer cover explained - Up to diagnosis

If you have been told you may have cancer, or are waiting for a diagnosis, it can be an uncertain and worrying time.

Your scheme does not cover the cost of private cancer treatment. However, it does provide support to help you understand your diagnosis and the next steps in your care.

Through your cancer journey, you will have access to:

  • A dedicated Healix Health Nurse – they will support you throughout your care, including when treatment is received through the NHS, and help you understand the next steps in your care
  • A dedicated Cancer Nurse Specialist through Perci – they will provide personalised guidance to help you understand your diagnosis, navigate your treatment, and manage any side effects. This support includes access to a range of additional eligible services to support your overall health and wellbeing. Further details can be found on the cancer support page.

Once you have a confirmed cancer diagnosis, your scheme does not cover the cost of cancer treatment itself. What it does provide is the support listed below, before, during and after treatment.

The below sets out what is and is not covered. It should be read alongside your table of benefits.

Cancer benefits What’s covered What’s not covered
Before a confirmed cancer diagnosis

Screening and prevention
  • A Health Risk Assessment that evaluates lifestyle and other non-diagnostic risk factors to help you understand your risk of cancer – this can be accessed through the My Healix app or Member Zone
  • Access to a Perci Cancer Nurse Specialist if your assessment indicates an increased risk of cancer to help you understand what steps to take to reduce your risk - see cancer support page for more information
  • Health Screening as detailed in your table of benefits (to be added where benefits apply)
  • Routine screening such as breast screens
  • Genetic tests to see whether you are likely to get cancer
  • Treatment carried out solely to prevent the development of cancer (in the absence of any disease)
  • Vaccines to prevent the development of cancer

Outpatient consultations and diagnostic tests
  • Consultations with a specialist following GP referral to reach a diagnosis where there are symptoms that could be related to a cancer diagnosis
  • Self-referral for consultations with a specialist for symptoms of breast, bowel, prostate and skin cancer – see self-referred cancer benefits page for more information
  • Diagnostic tests following specialist referral to reach a diagnosis
  • Diagnostic tests to establish the extent of disease at the point of initial diagnosis (staging)
  • Diagnostic tests arranged by anyone other than your specialist
  • Diagnostics tests that are not considered standard in the UK
Following a cancer diagnosis

Outpatient consultations and diagnostic tests

  
  • Consultations with a specialist or diagnostic tests following a cancer diagnosis

Personalised medicine and genomic testing
  • Genomic testing designed to find out whether you are likely to get cancer or not

Surgery

  
  • Surgery to remove cancer or reconstructive surgery required following cancer surgery

Chemotherapy

  
  • Any chemotherapy or medications to treat a cancer diagnosis
  • Any medications for the side effects of cancer treatment following a cancer diagnosis

Specialised cancer drugs

  
  • Any hormone therapies, targeted therapies and biological therapies, including immunotherapies following a cancer diagnosis

Advanced therapies

  
  • Advanced therapies such as adoptive cell transfers and gene therapies (including, but not limited to CAR-T cell therapy) and / or any complications related to, or resulting from these

Radiotherapy

  
  • Any radiotherapy treatment following a cancer diagnosis

Transplants

  
  • Any transplants including any costs associated with donor costs, harvesting or storage

Experimental treatment
  • Support from a Perci Cancer Nurse Specialist to actively signpost you into suitable clinical trials where clinically appropriate
  • Any experimental treatment
  • Any treatment related to taking part in a clinical trial following a cancer diagnosis

Additional services
  • Parking charges, convenience items or travel costs related to the receiving of cancer treatment

Therapies for side effects of cancer treatment
  • In-network cancer therapies arranged and delivered via Perci – see cancer support page for more information
  • Therapies delivered by a provider that we do not recognise for benefit purposes
  • Any therapies or wellbeing services that are not arranged through and delivered by Perci

Extended support benefits

Up to £5,000 per scheme lifetime for treatment related to the following specified complications required as a result of your cancer treatment:

  •          Fertility preservation prior to cancer treatment
  •          Erectile dysfunction
  •          Treatment-induced menopause
  •          Dental check ups / treatment required prior to cancer treatment

 

Support for spouse and dependents affected by diagnosis
  • Access to a Perci Cancer Nurse Specialist to provide support and guidance to help manage the practical and emotional impact of a diagnosis. – see cancer support page for more information

 
Following completion of active cancer treatment

Outpatient consultations and diagnostic tests

  
  • Consultations with a specialist and diagnostic tests to monitor following cancer treatment

Nurse support
  • Access to a Perci Cancer Nurse Specialist for an Annual Cancer Care Review and eligible therapies arranged and delivered via Perci to help with the side effects following cancer treatment
  

End of life care
  • Eligible therapies arranged and delivered via Perci where clinically indicated
  • Therapies accessed and delivered outside of Perci
  • Treatment given solely to relieve symptoms at the end stage of cancer

Need to talk to someone?

If you’ve received a cancer diagnosis, your Healix Health Nurse is your first point of contact. They can support you and help you understand the next steps in your care.

Get in touch by phone on XXX XXXX XXX or via live chat through the My Healix app or your scheme guide.

Your cancer support explained

At Healix, we partner with expert cancer providers to offer comprehensive, personalised support for you at every stage of your cancer journey — from diagnosis to treatment, recovery, and beyond.

Through our partnership with Perci Health, you have access to a wide range of expert-led, evidence-based clinical services tailored to your individual needs.

What support is available?

Perci Health is here to support you, whatever stage of the cancer journey you are experiencing:

  • Are you currently undergoing active cancer treatment?
  • Do you need additional support after completing treatment?
  • Are you supporting a loved one with cancer?

Your Perci Cancer Nurse Specialist works closely with your Healix Health Nurse to ensure you receive coordinated support and guidance throughout your cancer journey, from prevention and risk assessment through to treatment, recovery and living well beyond a cancer diagnosis.

 

The support available to you depends on where you are in your cancer journey.

Your situation

What you can access

You wish to understand your risk of developing cancer

✅Access to a cancer risk assessment tool to help you understand your risk of cancer

 

✅ Access to personalised, high quality information relating to your cancer risk and how you can reduce this 


✅Access to a Perci Cancer Nurse Specialist via video consultation or supportive chat if your assessment indicates an increased risk of cancer to help you understand what steps to take to reduce your risk

 

You have symptoms that may be cancer but do not yet have a cancer diagnosis

✅Access to personalised, high quality information relating to your symptoms and concerns


✅ Unlimited access to a Perci Cancer Nurse Specialist via video consultation or supportive chat to understand your symptoms

You have been diagnosed with cancer

✅Access to personalised, high quality information relating to your diagnosis


✅Unlimited access to your Perci Cancer Nurse Specialist via video consultation or supportive chat


✅Access to a range of evidence-based cancer therapies, where clinically appropriate and recommended by your Perci Cancer Nurse Specialist, to help manage symptoms and support your physical and emotional wellbeing

You are supporting someone with cancer

✅Access to personalised, high-quality information and guidance to help you navigate and understand your loved one's cancer journey

✅ Access to a Perci Cancer Nurse Specialist via video consultation or supportive chat for advice and support

✅ Access to psychological support and counselling where medically necessary

 

Included for all members:

  • Perci Cancer Nurse Specialists (via video consultations or supportive chat) provide guidance, reassurance, and clinical support at any stage, including treatment navigation and symptom management. For members who are supporting a loved one with cancer, emotional wellbeing support via psychological support and counselling is also available through Perci

 

For members diagnosed with cancer:

The following cancer therapies are available, where clinically appropriate, and recommended by your Perci Cancer Nurse Specialist:

Physical wellbeing

  • Nutritional support and dietary management (provided by Dietitians)
  • Rehabilitation and physical recovery support (provided by Physiotherapists)
  • Support with daily activities and functional independence (provided by Occupational Therapists)
  • Cancer exercise and movement programmes (provided by Exercise Specialists)
  • Lymphoedema assessment and management (provided by Lymphoedema Specialists)
  • Chemotherapy-induced peripheral neuropathy support clinic (provided by Cancer Nurse Specialists and Specialist pain clinician)

Emotional wellbeing

  • Psychological support and counselling (provided by Psychologists and Psychotherapists)
  • Clinical hypnotherapy (provided by Clinical Hypnotherapists)
  • Mindfulness and meditation support (provided by Meditation and Mindfulness Specialists)

Specialist support

  • Menopause management and advice (provided by Menopause Specialists)
  • Communication, swallowing and speech support (provided by Speech and Language Therapists)
  • Psychosexual support (provided by Psychosexual Therapists)
  • Appearance, hair loss and body image support (provided by Hair and Image Advisors)
  • Therapeutic yoga and pilates programmes (provided by Yoga and Pilates Specialists)

 

How to access your support

You can self-refer to Perci Health through the Member Zone or My Healix app.

If you have been diagnosed with cancer, your Healix Health Nurse will refer you to a Perci Cancer Nurse Specialist for additional support.

If you are supporting a loved one with cancer, your Healix Member Advisor can also offer a referral to a Perci Cancer Nurse Specialist for advice, guidance and additional support.

This service supports your physical, emotional and practical wellbeing, helping you manage symptoms, maintain your quality of life and access the right support at the right time.

 

Please note, access to cancer therapies delivered via Perci will be subject to your overall scheme limit.  This benefit is not subject to your excess and is only available to members aged 18 and over. 

For further information and access to this service, visit the Member Zone or My Healix app.

Further - Precision Cancer Service

We know that a cancer diagnosis can be life-changing, and we’re here to support you every step of the way. That’s why we’ve partnered with Further to offer the Precision Cancer Service, giving you access to advanced genetic testing and expert advice to help guide your treatment.

The Precision Cancer Service is designed to support you in the event of an advanced or complex cancer diagnosis. The following cancers are eligible for this service:

·               cancers that haven’t responded to initial treatment (as confirmed by your oncologist)

·               advanced-stage cancers (stage III or IV)

·               cancers where the original site isn’t clear (cancer of unknown primary)

·               rare cancers

If you are diagnosed with an eligible cancer, the Precision Cancer Service provides comprehensive genetic testing, known as a Somatic test.

These somatic tests are reviewed by world-leading experts who will provide a personalised report with treatment recommendations.

The service will also offer a complementary germline test if a hereditary risk is suspected in your case. If a hereditary cancer risk is identified through germline testing, Further can arrange the same test for your biological children (and, in some cases, siblings) to determine if they might also be at risk.

If a clinical trial might be right for you, Further can also help you find one.

Please note:

·            some types of cancer may not be eligible for the service, depending on your scheme and any personal or scheme exclusions

·            cover for any treatment recommendations presented by this service will be subject to all scheme terms and conditions, including but not limited to, scheme exclusions and monetary limits where applicable

Our nurse case managers are here to guide you through your cancer treatment and provide information on your available options.

Section 9: Glossary

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

Women's health services

At Healix, we know it’s vital to receive quick access to healthcare, we have therefore made access to women’s health services as easy and smooth as possible. Whenever you are experiencing a women’s health concern, you can consult with a GP with additional training in women’s health, via the Virtual GP Service. To access this benefit, please see the Virtual GP page.

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

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

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

Women’s health concern How to access treatment

For advice regarding any general women’s health query, including, but not limited to, menopause symptoms or contraception advice

Contact TrustDoc24 directly on 0345 319 4129 to speak with a GP on the telephone without calling the claims helpline. All of the GPs are able to offer advice for common concerns, however, if you prefer you may request a consultation with a GP who specialises in women’s health.

Additionally, you may self-refer by contacting the claims helpline, without the need for a GP referral, and we will be able to direct you to the most appropriate service available to you.

This includes access to remote consultations and diagnostic tests, with our in-network specialist gynaecologists (where appropriate).

Cover is available up to the limits specified in your table of benefits.  Once this benefit limit has been reached, the scheme rules apply as detailed in your exclusions and limitations.

If you are concerned about a breast abnormality, for example a lump

Contact the claims helpline to speak to our claims team, who will be able to support you and direct you to the most appropriate specialist, without the need to see your GP first.

Cover will be available as specified in your table of benefits.

If your GP has referred you to a specialist gynaecologist, for example, for unusual bleeding

Contact the claims helpline to speak to our experienced claims team, who will be able to open a new claim.

The claims team will also be able to direct you to the most suitable specialist.

Cover will be available as specified in your table of benefits.

If your GP has referred you for fertility investigations

Contact the claims helpline to speak to our experienced claims team, who will be able to open a new claim.

Cover will be available from your fertility investigations benefit, as specified on your table of benefits.

If you are experiencing complications of pregnancy

Contact the claims helpline to speak to our experienced claims team, who will be able to advise if there is any cover available for you.

Cover will be available for specific pregnancy complications only, as specified in your table of benefits.

For physiotherapy treatment for a pelvic problem such as stress incontinence

Contact the claims helpline, without the need for a GP referral,  and speak 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.

 

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 you can speak with one of our virtual GP’s via TrustDoc24. To access this benefit, please see the Virtual GP page.

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

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

The 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.

Contact TrustDoc24 directly on 0345 319 4129 to speak with a GP on the telephone without calling the claims helpline. All of the GPs are able to help you with common concerns.

Additionally, you may self-refer by contacting the claims helpline without the need for a GP referral and we will be able to direct you to the most appropriate services available to you.

This includes access to remote consultations and diagnostic tests with our in-network men’s health specialists (where appropriate).

Cover is available up to the limits specified in your table of benefits. Once this benefit limit has been reached the scheme rules apply as detailed in your exclusions and limitations. 

If you are concerned about early signs of prostate or testicular cancer.

Contact the claims helpline to speak to a nurse case manager who will be able to support you and direct you to the most appropriate specialist without the need for seeing your GP first. Cover will be available as specified in your table of benefits.

Further information about early signs of cancers and self-referral can be found here

If your GP has referred you to a specialist.

Contact the claims helpline or access the claims portal to open a new claim. 

Cover will be available as specified in your table of benefits.

One of our experienced claims team will be able to direct you to the most suitable specialist.

If your GP has referred you for fertility investigations

Contact the claims helpline to speak to our experienced claims team, who will be able to open a new claim.

Cover will be available from your fertility investigations benefit, as specified on your table of benefits.

For physiotherapy treatment for a pelvic problem such as stress incontinence

Contact the claims helpline, without the need for a GP referral,  and speak to our experienced claims team who will arrange a telephone based assessment with a senior physiotherapist, to determine the most appropriate treatment for you.

Cover is available from your physiotherapy benefit, as specified in your table of benefits.

 

Musculoskeletal health pathway

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

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

 

How to make a claim

Employee only digital triage

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

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

Access the Member Zone

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

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

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

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

 

Telephone assessment

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

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

Mental health pathway

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

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

How to make a claim

Employee only digital triage

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

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

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

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

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

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

 

Telephone assessment

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

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

This could be one of several options including:

  • Face to face cognitive behavioural therapy (CBT)

  • Guided online CBT

  • Counselling

  • Referral onwards to see a psychiatrist.

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

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

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

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 AI supported 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 may be subject to your scheme underwriting.

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

A change to the normal skin that is of concern for you

Skin conditions on breasts or genitalia that are unsuitable for photographic assessment

 

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 by calling the claims helpline, registering a new claim via Member Zone or via the My Healix app. Please note; when opening a claim through Member Zone, please ensure that you have added your mobile number to your account details

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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 image

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Step 3

Your digital photographic image will be assessed by our experienced dermatology partners within 48 hours

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Step 4

You will receive an SMS to notify you that your results are back, along with an invitation to a phone consultation to go through your results with our dermatology partners who will provide you with any additional advice or further steps

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Step 5

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

Please note: face to face dermatology consultations  taken within our network will be covered in full (subject to your excess).  Should you wish to access a consultation outside of this network your claim will be subject to our reasonable and customary fees.

Section 9: Glossary

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

Your excess

Excess

All members and dependants are liable for an excess of £100, which is payable once every scheme year, if you make an eligible claim.

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

Rolling excess
All members and dependants are liable for an excess of £XXX. This is a rolling excess, which means it will apply once every twelve months. This is regardless of whether the treatment is for the same condition, a related condition, or for an entirely new condition. Please contact us before you receive any treatment, so that we can advise you on when your excess will apply.

Please note your excess does not apply to NHS cash benefits or telephone triage appointments arranged by us.

Reasonable and customary fees

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

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

What happens in an emergency?

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

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

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

You will not be covered for:

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

Exclusions and limitations

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

Exclusions and limitations

How to claim summary

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

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If your GP refers you onto a specialist or therapist

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

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

▼

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

▼

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

▼

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

▼

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

▼

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

▼

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

▼
▼

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

▼

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

s

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

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

How to Claim Summary

 

Your scheme underwriting

Medical History Disregarded (MHD)
We will not apply any personal medical exclusions to your scheme. However your eligibility for cover will be subject to the general terms of the scheme. Please refer to exclusions and limitations for further information.


Full Medical Underwriting
When you or your dependant apply to join the scheme you will be fully underwritten for any pre-existing medical conditions. By this we mean that any disease, illness or injury for which you have received medication, advice or treatment, or of which you have experienced symptoms (whether the condition was diagnosed or not) before your start date, will be excluded from the scheme.

You will be required to complete a medical history questionnaire which will be assessed and you will be notified of any exclusions or restrictions to your cover on your membership certificate. If you have any queries please contact your helpline.


Continued Personal Medical Exclusions (CPME)
If at the time of joining you are insured with another insurer, we may agree to provide cover on the same underwriting basis as your previous insurer. If you completed a health questionnaire with your previous insurer and have personal medical exclusions applied, we will transfer these to your cover with your new private healthcare scheme.


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

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

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


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

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

However, subject to the scheme terms and conditions, a pre-existing condition can become eligible for cover provided that when you first receive treatment under the scheme, 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 a continuous period of two years where you have not received treatment, had symptoms or asked advice for that condition.

Hospital cover

Open network
We have an open network which means you are able to attend the hospital of your choice. Please note reasonable and customary charges will apply to specialists at all hospitals. For help in finding a hospital, please refer to our hospital finder.


Restricted network
The ABC healthcare 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 ABC healthcare scheme:

• List of all hospitals which are excluded

Should you have any queries regarding this list or your chosen hospital/clinic, please contact us on the claims helpline.

Making a claim

Healthcare benefits

Register your claim using our My Healix app or Member Zone. Alternatively, you can call the claims helpline to confirm if cover is available.

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

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

Download the My Healix app

Access the Member Zone

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

Call the claims helpline:

0208 123 4567
Monday - Friday: 8am-6pm (Excl. bank holidays)
Saturday: 8am-1pm 

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

Section 9: Glossary

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

End of cover

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

  • if your employment with ABC has come to an end for any reason

  • if you no longer live full time in the United Kingdom

  • if you pass away

  • if for any reason you or ABC ask us to end cover

  • If you or any of your dependants have given us misleading information, have kept something from us, or have broken the conditions of this scheme.

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

 

Cover for dependants will end in the following situations:

Your partner's cover will end:

  • if you get divorced, or your civil partnership is dissolved. Cover for your partner will end as soon as the final decree/final dissolution order has been granted.

  • if you no longer live together, then your partner will no longer be considered a dependant for the purposes of this scheme.

Your dependant child’s cover will end:

  • after they have turned 24. They will be removed from cover on the next annual renewal date following their 24th birthday.

  • if they get married, then they will no longer be considered a dependant for the purposes of this scheme.

  • if they no longer live full time in the United Kingdom

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

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

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 claims 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.

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 NHS Cash benefit claims) must be submitted within six months of your treatment date or within six months of the end of the scheme year you wish to claim against -whichever comes soonest. Any claims submitted after this, will be assessed on a case by case basis, and paid at our discretion.

We will not pay for claims:

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

 

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 Head of Customer Delivery, asking for referral to the trustees for further consideration.

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.

Continuation option

As Healix Health Services only provides corporate group schemes, we are unable to continue your cover as an individual if you leave the ABC healthcare scheme.

We work with the largest individual health insurance intermediary in the UK, Usay Compare who are experts at finding the best cover for you. With your consent, we will pass them your details so they can contact you to conduct a review of your options.  You can find out more about Usay Compare by calling 01285 864670 and quoting HEALIX or filling in this online form. These terms are offered to you as a previous member of the healthcare scheme and are available for a limited time only, usually no more than 30 days from the date of leaving. It is therefore important that you act quickly to maintain continuity of cover.

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

How to claim reimbursement

How to claim for cash benefits

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

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

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

In order to claim these benefits you can register your claim via the Member Zone, the My Healix app or by email on ABC@healix.com

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

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

 

How to claim baby cash benefit

Following the birth or adoption of a child you may be eligible for a cash benefit as detailed in your table of benefits. 

In order to claim this benefit you can register your claim via the Member Zone, the My Healix app or by email on ABC@healix.com

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

  • A copy of the full birth or adoption certificate
  • Bank details for the reimbursement to be made to
    • Account holder’s name
    • Sort code
    • Account number

 

How to claim reimbursement of medical expenses

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

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

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

 

Please note: 

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

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

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

FAQs

Understanding your healthcare scheme is important to both us and your employer. With this in mind, we have put together a useful FAQ document which can be found here (LINK TO FAQ). Alternatively, you can contact the claims helpline and our experienced claims team will be happy to help.

For any queries surrounding your membership rates, or how to join the scheme, please click here (LINK TO INTRANET PAGE) or contact (CONTACT NAME AND INFORMATION).

Section 9: Glossary

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

Contact Us

The Healix Team

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

Tel: 0208 123 4567
Email: abc@healix.com
Monday-Friday 08.00-18.00 (Excl. bank holidays)
Saturday 08.00-13.00 

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:

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

Section 9: Glossary

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

Section 9: Glossary

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