Introduction
Welcome to the Circle Private Healthcare Scheme guide.
Circle Health Group 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 Circle Private 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.
For any queries regarding your or your dependants’ membership, please contact your HR team via e-mail at HRassist@circlehealthgroup.co.uk
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 once every 12 months, following the first eligible treatment under the scheme.
Please note the below benefits are subject to an overall benefit limit of £100,000 per member, per condition, per lifetime.
The scheme will commence on the 1st June 2023 to 31st May 2024.
| Outpatient Diagnostics | Level of cover | Benefit note |
Outpatient consultations with a specialist following GP referral Outpatient diagnostic tests and investigations following GP or specialist referral Outpatient treatment following specialist referral Outpatient consultations with a practitioner Outpatient consultations and diagnostic tests with a specialist on self-referral for breast, bowel, prostate or testicular cancer symptoms |
Full cover (75% co-pay may apply) | 1 |
| Outpatient Treatment | ||
Outpatient MRI, CT and PET scans on specialist referral |
Full cover (75% co-pay may apply) | 2a |
Outpatient surgical procedures |
Full cover (75% co-pay may apply) | 2b |
In network mental health treatment |
Full cover | 2c |
Out of network mental health treatment |
Up to 12 sessions per scheme year | 2d |
| Outpatient Therapies | ||
Outpatient physiotherapy following GP or self-referral |
Up to 8 session per scheme year (75% co-pay may apply) | 3a |
Outpatient physiotherapy following specialist referral |
Full cover (75% co-pay may apply) | 3b |
Outpatient complementary therapies on GP, specialist or self-referral |
Up to £500 per scheme year | 3c |
| Inpatient and Daycase Treatment | ||
Specialist fees for inpatient and daycase treatment |
Full cover within reasonable and customary guidelines (75% co-pay may apply) | 4a |
Hospital charges for inpatient or daycase treatment |
Full cover (75% co-pay may apply) | 4b |
Parent accommodation |
Full cover (75% co-pay may apply) | 4c |
Mental health treatment - inpatient and daycase |
Up to a maximum of 28 days per scheme year | 4d |
| Benefits for Specified Treatment | ||
Cancer treatment |
Full cover (75% co-pay may apply) | 5a |
Oral surgical procedures |
Full cover for specified treatments (75% co-pay may apply) | 5b |
Disorders of the eye |
Full cover for specified treatments (75% co-pay may apply) | 5c |
Pregnancy and childbirth |
Full cover for specified treatments (75% co-pay may apply) | 5d |
Fertility investigations |
Full cover (75% co-pay may apply) | 5e |
Women's and Men's Health Benefit Remote advice service with our in-network specialist gynaecologists or men's health specialists (up to 4 consultations per scheme year) Diagnostic tests and investigations following referral from our in-network remote gynaecologists or men's health specialists (up to £500 per scheme year) |
Limited cover (75% co-pay may apply) | 5f |
Long COVID Benefit Outpatient consultations and diagnostics required as a result of Long COVID Outpatient, daycase and inpatient treatment required as a result of Long COVID Outpatient mental health treatment required as a result of Long COVID (up to £1,500 per scheme year) Outpatient physiotherapy treatment required as a result of Long COVID (up to £500 per scheme year) Outpatient complementary therapies required as a result of Long COVID (up to £250 per scheme year) |
Combined overall limit of £5,000 per scheme year, up to £15,000 per scheme lifetime (75% co-pay may apply) | 5g |
| Additional Benefits | ||
Private ambulance charges |
Full cover | 6 |
Home healthcare |
Full cover | 7 |
Virtual GP |
Unlimited | 8 |
Note: The above benefits only apply when the covered person has treatment in the UK.
Please note; the below benefits may be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
Outpatient investigations and treatment
We will pay in full for:
- outpatient consultations with a specialist following GP referral
- outpatient diagnostics and investigations following GP or specialist referral
- outpatient treatment following specialist referral
Cover is subject to our reasonable and customary fees.
Outpatient consultations with a practitioner
We will pay in full for consultations with a dietician, nurse, orthoptist, podiatrist 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
Outpatient consultations with a specialist on self-referral for breast, bowel, prostate or testicular cancer symptoms
We will pay in full for self-referred consultations and investigations for breast, bowel, prostate or testicular cancer symptoms.
Please refer to the self-referred cancer benefits page for further information on how to access this benefit.
If a diagnosis of cancer is made, cover for eligible treatment will be subject to any limits as detailed in your cancer treatment benefit.
Back to topWe will pay in full for MRI, CT and PET scans on specialist referral.
Please note; this benefit may be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
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.
Please note; this benefit may be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
Back to topWe will pay in full for outpatient consultations for eligible mental health conditions following GP, specialist or self-referral, when treatment is provided by our mental health network provider.
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.
Please refer to the mental health pathway for further information.
Please note: Under 18’s will require a referral letter from their own GP.
Back to topWe will pay for up to 12 sessions per scheme year for outpatient consultations for eligible mental health conditions following GP or specialist referral when taken outside of the Healix network provider.
Where treatment with a psychological therapist occurs outside our network provider it must be delivered under the direct supervision of a consultant psychiatrist.
Please note; this benefit will not be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
Back to topWe will pay for up to 8 sessions per scheme year for outpatient physiotherapy following GP or self-referral. The physiotherapist must be recognised by us for benefit purposes.
This benefit will not be subject to your excess, if one applies, when treatment is taken within the Circle Health Group hospital network
Please note; this benefit may be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
Back to topWe will pay in full for outpatient physiotherapy following specialist referral. The physiotherapist must be recognised by us for benefit purposes.
This benefit will not be subject to your excess, if one applies, when treatment is taken within the Circle Health Group hospital network
Please note; this benefit may be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
Back to topWe will pay up to £500 per scheme year for chiropractic treatment, osteopathy and acupuncture, following GP, specialist or self-referral. Treatment must be taken with a complementary practitioner we have recognised for benefit purposes.
Please note; this benefit will not be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
Back to topWe will pay for specialist fees for inpatient and daycase treatment. Cover is subject to our reasonable and customary fees.
Please note; this benefit may be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
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; this benefit may be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
Back to topWe will pay reasonable hospital costs for one parent or legal guardian to stay with a child who is under 16 years old, if a child is admitted to hospital as an inpatient. Cover for this benefit will stop on the child’s 16th birthday. If your child is an inpatient on their 16th birthday, then cover will extend until they are discharged on that occasion. We will only pay the cost if:
- it is the parent or legal guardian who stays with the child
- the treatment the child receives is covered by the scheme
Please note; this benefit may be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
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.
Please note; this benefit will not be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
Back to topWe will pay for cancer treatment as detailed in the cancer cover explained table.
Please refer to your cancer support explained for information on the additional supportive services available to employees.
Please note; this benefit may be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
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
Please note; this benefit may be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
Back to topWe 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
Please note; this benefit may be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
Back to topWe will pay for the following specified obstetric procedures / treatment:
-
pelvic girdle pain in pregnancy
-
miscarriage or when the foetus has died and remains with the placenta in the womb
-
still birth
-
hydatidiform mole (abnormal cell growth in the womb)
-
ectopic pregnancy (foetus growing outside the womb)
-
Diastasis recti or Rectus Abdominis (splitting of the abdominal muscles during pregnancy)
-
post-partum haemorrhage (heavy bleeding in the hours and days immediately after childbirth)
-
retained placental membrane (afterbirth left in the womb after the delivery of the baby)
-
eligible mental health treatment for post-natal depression subject to the conditions and limitations set out in the mental health benefit.
-
medically essential caesarean section where this is an inevitable consequence of a complication to the current pregnancy.
-
complications following any of the above conditions.
-
flare up of a non-pregnancy related medical condition that has been made worse by pregnancy
We will require full clinical details from your specialist before we can give our decision on cover.
In the event that the newborn requires immediate treatment as a result of an eligible caesarean section, this should be administered by the NHS free of charge. If the newborn is not entitled to NHS care and is not accepted as a dependant on the scheme we will pay for treatment for up to 7 days following the birth, to allow you time to make alternative arrangements. In cases where they are accepted as a member of the scheme they will only be entitled to benefits outlined in the benefits table and will be subject to the exclusions listed within the scheme.
Please note; this benefit may be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
Back to topWe will pay in full for medically necessary fertility investigations following GP or specialist referral.
Once a diagnosis has been confirmed, there will be no further cover for any additional investigations or treatment in the future.
Please note; this benefit may be subject to a 75% co-pay when taken outside of the Circle Health Group hospital network.
Back to topRemote advice service with our in-network specialist gynaecologists or men's health specialists
We will pay for up to 4 remote advice appointments per scheme year with our in-network specialist gynaecologists or men’s health specialists on self-referral. This service can be used to discuss any health concern including conditions that are normally excluded for cover such as the menopause, andropause, sexual health concerns, fertility or contraception advice.
Diagnostic tests and investigations following referral from our in-network gynaecologists or men's health specialists
We will pay up to £500 per scheme year for diagnostic tests or investigations that are recommended following a remote advice appointment with our in-network specialist gynaecologists or men’s health specialists.
Remote consultations and diagnostic tests and investigations will be covered up to the limits described above only. Once the benefit limits have been reached the scheme rules will apply as detailed in your exclusions and limitations.
Please note: additional cover may be available outside of the above limits for eligible claims, please contact the claims helpline for further information.
Please refer to the women’s or men’s health services page for further information on how to access these benefits
Please note; eligible diagnostic tests may be subject to a 75% co-pay when taken outside of the Circle Health Group hospital network.
Back to topThe below benefits will be paid for when treatment is required as a result of COVID-19 (commonly referred to as 'long COVID'). The benefits have a combined limit of £5,000 per scheme year up to a maximum of £15,000 per scheme lifetime.
Outpatient consultations and diagnostics
We will pay up in full for:
- Outpatient consultations with a specialist following GP referral
- Outpatient diagnostics and investigations following GP or specialist referral
- Outpatient treatment following specialist referral
Cover is subject to our reasonable and customary fees.
Please note; this benefit may be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
Outpatient, daycase and inpatient treatment
We will pay for hospital and specialist fees, for outpatient, daycase and inpatient treatment. Please note cover is not available for acute treatment of COVID-19, including treatment in an intensive care unit, high dependency unit, acute ward setting or NHS hospital.
Please note; this benefit may be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
Outpatient mental health treatment
We will pay up to £1,500 per scheme year, for outpatient consultations for eligible mental health conditions, following GP or self-referral, when treatment is required as a result of long COVID.
If your referral is to a psychological therapist we will arrange a telephone based clinical assessment with a senior psychological therapist from our mental health network provider, who will help organise the most effective treatment for you. This could include face to face therapy, guided self-management or specialist referral. Where treatment with a psychological therapist occurs outside our network provider, it must be delivered under the direct supervision of a consultant psychiatrist.
Please note; this benefit will not be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
Outpatient physiotherapy
We will pay up to £500 per scheme year for outpatient physiotherapy following GP or self-referral, when treatment is required as a result of long COVID.
If treatment takes place outside our physiotherapy network, the physiotherapist must still be recognised by us for benefit purposes.
Please note; this benefit may be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
Outpatient complementary therapies
We will pay up to £250 per scheme year for chiropractic treatment, osteopathy and acupuncture, following GP or specialist referral, when treatment is required as a result of long COVID. You must be referred to a complementary practitioner we have recognised for benefit purpose.
Please note; this benefit will not be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network.
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 topPlease refer to the virtual GP page for further information on how to access this benefit.
Back to topCancer cover explained
We know that a cancer diagnosis can be a life changing event. Therefore we have provided a specific section within your scheme to help you understand the level of cover available to you for cancer treatment.
The scheme provides benefit for eligible outpatient, daycase and inpatient treatment for cancer. To ensure that you receive the highest quality of care at all times we identify centres of excellence for the treatment of cancer. If you are diagnosed with cancer we may require you to transfer to one of these centres. These centres may be in either the private or NHS sector.
One of our nurse case managers will be able to provide information on the treatment options available to you and support you through your treatment.
The table below provides a summary of the cancer cover available and should be read alongside your table of benefits.
| Summary of cancer benefits | What’s covered | What’s not covered |
| Where will I be covered to have treatment? |
You will be covered in full for eligible treatment:
|
You will not be covered for:
|
| What diagnostic tests will I be covered for? |
You will be covered in full for:
|
You will not be covered for any diagnostic tests that are:
|
| Will I be covered for surgery? |
You will be covered in full for:
|
You will not be covered for surgery that is:
|
|
Will I be covered for preventative treatment? |
We will be covered for prophylactic (preventative) surgery if:
For example, we will pay for a mastectomy to a healthy breast in the event that you have been diagnosed with cancer in the other breast and your specialist indicates that prophylactic surgery is medically necessary and will be carried at the same time as surgery to the diseased breast. You must have our written agreement before you have tests, procedures or treatment and we will need full clinical details from your specialist before we can give our decision. |
You will not be covered for any preventative treatment, including:
|
|
What drug treatments will I be covered for? |
You will be covered in full for:
|
You will not be covered for:
|
| Will I be covered for radiotherapy? |
You will be covered in full for radiotherapy, including when given for pain relief. |
You will not be covered for radiotherapy that is:
|
| Will I be covered for end of life care? |
|
You will not be covered for:
|
|
What cover will be available for routine monitoring when |
You will be covered for follow-up tests and specialist consultations to monitor you for a maximum of five years from the date you complete treatment for cancer. |
|
|
What other benefits and services are available? |
You will be covered for:
Please note that these are subject to any limits as detailed in your table of benefits. |
You will not be covered for:
|
|
Are there any other supportive benefits available? |
You also have access to a comprehensive support platform delivered by Perci Health to provide you with additional support for the psychological, physical and practical impacts of cancer when it is needed most. For further information please see the your cancer support explained page. |
|
Your cancer support explained
We know that a cancer diagnosis can be a life changing event and we are committed to supporting you in the event that you are impacted by cancer. This is why we have partnered with Perci Health to provide you with additional support for the psychological, physical and practical impacts of cancer.
Perci are able to offer you support regardless of how you have been impacted by cancer
- Are you receiving active treatment for a cancer diagnosis?
- Are you looking for some additional support following completion of your cancer treatment?
- Are you caring for a loved one with cancer?
Regardless of your situation, Perci are able to provide a personalised care plan, a dedicated cancer nurse, and access to caring cancer experts from over 20 different support types to help reduce the impact of cancer.
| Recovery and rehabilitation | Symptom management | Support for carers |
|
|
|
Access to this service will not be subject to an excess, scheme underwriting or any healthcare scheme benefit limits, if any apply.
Please note; this benefit is only available for employees.
For further information and to get started access the ‘your cancer support’ tile on the Member Zone.
COVID-19 cover explained
In the event that you require immediate, acute treatment for COVID-19 this must take place on the NHS.
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:
|
You will not be covered for:
|
| What tests will I be covered for? |
You will be covered up to the benefit limit for:
|
You will not be covered for any tests that are:
|
| What other benefits and services are available? |
You will be covered within the overall benefit limit for:
|
You will not be covered for:
|
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.
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.
Hospital cover
Restricted network
The Circle Private Healthcare Scheme will typically only cover eligible treatment when taken within the Circle Health Group hospital network.
For help in finding a hospital, please refer to the Circle Health Group hospital finder.
Should you have any queries regarding this list or your chosen hospital/clinic, please contact us on the claims helpline.
Please note; some of your benefits may be subject to a 75% co-payment when eligible treatment is taken outside of the Circle Health Group hospital network. Please refer to your table of benefits to see which individual benefits this applies to.
Treatment should always take place within the Circle Health Group hospital network, unless the treatment is not available or specific extenuating circumstances apply. Please contact the claims helpline where one of our experienced claims team will be able to confirm whether your claim is eligible to take place outside of the Circle Health Group hospital network.
Should an employee or dependant decide to receive treatment outside of the Circle Health Group hospital network without prior approval from the claims team, the employee or their dependants will be required to pay 75% of eligible treatment costs.
Second medical opinion
Should you decide that you would like to receive a second medical opinion to ensure you are fully confident with your specialists recommendations please contact us on the claims helpline to discuss pre-authorisation. Our team of nurse case managers will be able to advise and support you through this process.
Second medical opinions will be arranged with a specialist who is an expert in their field and is recognised for the purposes of providing such second opinions. Following your second medical opinion your nurse case manager will contact you to discuss the suggested treatment plan and eligibility for benefit. Without written authorisation for a second opinion payment cannot be made for any recommended or resulting treatment.
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide, the list of 'How to Claim' in Section 4
Neurodevelopmental disorders
Active treatment
Acute condition
Annual renewal date
Benefit
Benefits
Biological therapies
Cancer
Chronic condition
Complementary practitioner
- a practitioner who specialises in acupuncture or a practitioner in osteopathy or chiropractic who is registered under the relevant Act; and who, in all cases, meets our criteria for complementary practitioner recognition for benefit purposes in their field of practice:
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council)
Daycase
Dependant
-a member’s unmarried dependent children
Dependants
-a member’s unmarried dependent children
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Disorder
Emergency
Employer
End of life care
Gender Dysphoria
Gender Incongruence
General Practitioner
GP
High dependency unit
High risk activities
Home healthcare
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
Intensive care unit
Medical condition
Medically necessary
-
In accordance with professional standards of medical practice in the United Kingdom
-
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
-
Required for reasons other than the comfort or convenience of the patient or specialist.
-
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition.
-
Provided only for an appropriate duration of time.
-
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.
<
Members
Mental health condition
Outpatient
Palliative care
Partner
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
- An Accredited member of the Association of Child Psychotherapists (ACP); or
- A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)
Registered nurse
Related condition
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 (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
The Scheme
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. <
Treatment
Treatments
Trust Deed
Trustee, Trustees
United Kingdom
Waiting Period
We, Us, Our
You, Your
Scheme
Pandemic
Epidemic
Member Zone
Member
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 |
Access YourHealth247 through the portal to speak with a GP 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. Further information about early signs of cancers and self-referral can be found here |
|
If your GP has referred you to a specialist gynaecologist, for example, for unusual bleeding |
Contact the claims helpline to speak 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. |
|
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 consult with a GP with additional training in men’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 men’s health specialist.
The majority of men’s health conditions would be covered under your normal outpatient and inpatient benefits, however some conditions would traditionally sit outside the healthcare scheme cover. We have therefore created the additional men’s health benefits, to provide some extra cover, if this is required. Our experienced claims team will be able to advise you further on whether your condition and treatment would be covered under these extra benefits.
The below table outlines the services available, and how to access them through your healthcare scheme.
| Men’s health concern | How to access treatment |
|
For advice regarding any general men’s health query, including urinary symptoms, sexual health and fertility advice. |
Access YourHealth247 through the portal to speak with a GP 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. |
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 the claims helpline 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 |
|
|
Bowel cancer |
|
|
Prostate cancer |
|
|
Testicular cancer |
|
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 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.
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 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 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.
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 |
|
|
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 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 digital skin pathway provides fast results and recommendations for further treatment depending on your diagnosis following assessment by our dermatology partners. Please note further treatment will be subject to the terms and conditions of the scheme.
This pathway is suitable for many skin complaints, and our experienced claims team will be able to guide you to access the most suitable pathway for your symptoms.
The table below shows which skin complaints are most suitable to be referred into our digital skin pathway:
| Skin Conditions Suitable for the Skin Pathway | Skin Conditions Not Suitable for the Skin Pathway |
|
A change to an existing mole (itching/bleeding/increase in size) |
Chronic skin conditions such as eczema/psoriasis |
|
A new skin growth that has appeared and is visible |
New skin rashes |
|
A sore area of skin that has not healed |
Mole mapping services required for screening purposes where there is no identifiable area of immediate concern |
|
|
Members under the age of 18 |
This pathway is easy to use; just follow the simple steps below and access help today:
Step 1
Open a new claim with one of our claims assessors. Please see Making a claim for details of how to do this.
Step 2
You will receive an SMS to your mobile phone with a link to register for the service and details of how to submit your digital photographic images.
Step 3
Your digital photographic images will be assessed by our experienced dermatology partners within 2 working days.
Step 4
You will receive an SMS to notify you that your results are back and a link to access the report containing the diagnosis and any recommendation.
Step 5
Should a face-to-face consultation with a dermatologist be recommended, our dermatology partners will call you and assist you to arrange it at a suitable time and location for you.
Please note: face-to-face dermatology consultations taken within our network will not be subject to our reasonable and customary fees, however, these fees will apply should you wish to access a consultation outside of this network.
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide, the list of 'How to Claim' in Section 4
Neurodevelopmental disorders
Active treatment
Acute condition
Annual renewal date
Benefit
Benefits
Biological therapies
Cancer
Chronic condition
Complementary practitioner
- a practitioner who specialises in acupuncture or a practitioner in osteopathy or chiropractic who is registered under the relevant Act; and who, in all cases, meets our criteria for complementary practitioner recognition for benefit purposes in their field of practice:
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council)
Daycase
Dependant
-a member’s unmarried dependent children
Dependants
-a member’s unmarried dependent children
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Disorder
Emergency
Employer
End of life care
Gender Dysphoria
Gender Incongruence
General Practitioner
GP
High dependency unit
High risk activities
Home healthcare
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
Intensive care unit
Medical condition
Medically necessary
-
In accordance with professional standards of medical practice in the United Kingdom
-
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
-
Required for reasons other than the comfort or convenience of the patient or specialist.
-
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition.
-
Provided only for an appropriate duration of time.
-
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.
<
Members
Mental health condition
Outpatient
Palliative care
Partner
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
- An Accredited member of the Association of Child Psychotherapists (ACP); or
- A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)
Registered nurse
Related condition
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 (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
The Scheme
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. <
Treatment
Treatments
Trust Deed
Trustee, Trustees
United Kingdom
Waiting Period
We, Us, Our
You, Your
Scheme
Pandemic
Epidemic
Member Zone
Member
Employee Assistance Program (EAP)
As part of your Circle Private Healthcare Scheme you have access to an EAP service, which is provided by Vita Health. This service is available to employees only.
The EAP can offer guidance and advice on a number of topics. Please find some of these listed below:
- Work
- Money
- Retirement
- Your rights
- Health and wellbeing
- Relationships
- Emotional support
- Children
- Legal information
This service can be accessed 24 hours a day, seven days a week via the below number:
0800 111 6387
For further information on the services provided by the EAP, please click here.
Please note, during the phone call you will need to provide Vita Health with your employer’s name, Circle Group, in order to access the service. Should Vita Health advise you to seek further treatment, please contact us on the claims helpline to check if this is eligible under your scheme. Any further treatment is subject to any general scheme exclusions.
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide, the list of 'How to Claim' in Section 4
Neurodevelopmental disorders
Active treatment
Acute condition
Annual renewal date
Benefit
Benefits
Biological therapies
Cancer
Chronic condition
Complementary practitioner
- a practitioner who specialises in acupuncture or a practitioner in osteopathy or chiropractic who is registered under the relevant Act; and who, in all cases, meets our criteria for complementary practitioner recognition for benefit purposes in their field of practice:
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council)
Daycase
Dependant
-a member’s unmarried dependent children
Dependants
-a member’s unmarried dependent children
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Disorder
Emergency
Employer
End of life care
Gender Dysphoria
Gender Incongruence
General Practitioner
GP
High dependency unit
High risk activities
Home healthcare
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
Intensive care unit
Medical condition
Medically necessary
-
In accordance with professional standards of medical practice in the United Kingdom
-
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
-
Required for reasons other than the comfort or convenience of the patient or specialist.
-
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition.
-
Provided only for an appropriate duration of time.
-
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.
<
Members
Mental health condition
Outpatient
Palliative care
Partner
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
- An Accredited member of the Association of Child Psychotherapists (ACP); or
- A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)
Registered nurse
Related condition
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 (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
The Scheme
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. <
Treatment
Treatments
Trust Deed
Trustee, Trustees
United Kingdom
Waiting Period
We, Us, Our
You, Your
Scheme
Pandemic
Epidemic
Member Zone
Member
When cover starts
Once you are added onto our system, you will receive an introductory welcome email via your Circle Health Group email address. This will contain your membership number, which will enable you to register on the Member Zone. The email will also include details of your family members covered under the scheme, and their membership numbers. Please forward this email onto anyone over the age of 16 so that they can register on the Member Zone. Any dependants under the age of 16 will appear on the main member’s profile, and you will be able to open claims on their behalf.
If you do not receive your welcome email, please email MemberCommunication@healix.com and the team will forward this onto your preferred email address.
Making a claim
You must always contact our claims team before arranging or receiving any treatment.
Our claims portal – Member Zone - is a quick, convenient way to register a new claim. Alternatively, you can call us to talk it through on the phone.
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.
If you prefer to register or discuss your claim on the phone all you need to do is call the claims helpline quoting your personal details (name and date of birth).
Access the Member Zone
Click here to access the Member Zone using your individual member number
Call the claims helpline:
0208 106 4440
Monday-Friday 08.00-19.00 (Excl. bank holidays)
Saturday 09.00-13.00
We will confirm:
-
whether your proposed treatment is eligible for cover under the scheme
-
whether your proposed treatment costs will be covered under the scheme
-
any benefit limits or excess that may apply to your claim
To help you make the best possible use of the scheme, we have provided you with a how to claim summary
How to claim summary
If you believe you require physiotherapy, but you haven't seen your GP
If your GP refers you onto a specialist or therapist
If you experience mental health symptoms, but haven't seen your GP
Log your claim via the Member Zone or call the claims helpline
Log your claim via the Member Zone or call the claims helpline
Log your claim via the Member Zone 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 or call the helpline again
If further treatment is required, please visit the Member Zone or call the helpline again
If further treatment is required, please visit the Member Zone or call the helpline again
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.
Your excess
Rolling excess
All members and dependants are liable for an excess of £125. 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.
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 scheme. 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.
Please note: We will pay for remote consultations and diagnostics related to women’s or men's health concerns with a specialist gynaecologist or men's health specialist as specified in your table of benefits.
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.
We do not pay for the supply or fitting of appliances, physical aids or devices (including but not limited to hearing aids, spectacles, contact lenses, external prostheses and orthotics etc) which do not fall within our definition of a surgical appliance. Any consultations relating to these are also not covered.
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 women’s or men's health concerns with a specialist gynaecologist or men's health specialist as specified in your table of benefits.
We do not pay for treatment of chronic conditions. By this we mean any medical condition which has at least one of the following characteristics:
- it needs ongoing or long-term monitoring through consultations, examinations, check-ups and/or tests
- it needs ongoing or long-term control or relief of symptoms
- it requires rehabilitation or for you to be specially trained to cope with it
- it continues indefinitely
- it has no known cure
- it comes back or is likely to come back.
Please note: this will apply to all medical conditions, whether or not a diagnosis has been made.
Exception: We will pay for eligible treatment arising out of a chronic condition, or for treatment of acute symptoms of a chronic condition that flare up. However, we only pay if the treatment is likely to lead quickly to a complete recovery or to you being fully restored to your previous state of health, without you having to receive prolonged treatment. For example, we pay for treatment following a heart attack arising out of chronic heart disease. This exception does not apply to treatment of a mental health condition.
Please note: in some cases it might not be clear, at the time of treatment, that the disease, illness or injury being treated is a chronic condition. We are not obliged to pay the ongoing costs of continuing, or similar, treatment. This is the case even where we have previously paid for this type of or similar treatment.
Please note this exclusion does not apply to the treatment of cancer.
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 domestic and/or social reasons.
We do not pay for any treatment to change your appearance even when required for psychological reasons.
We do not pay for any treatment, including surgery:
-
where the intention of treatment, whether directly or indirectly, is the reduction or removal of healthy, surplus or fat tissue (for example, weight reduction surgery / treatment)
-
where the aim is to aesthetically enhance the appearance of the face or body where no functional condition is present (for example, botox, fillers or asymptomatic rhinoplasty)
Exception: we will pay for medically necessary treatment to restore your appearance in the following circumstances:
-
where it results from an eligible underlying disease process
-
following eligible treatment (including cancer treatment)
-
where the condition is causing a functional problem
Please note: we use NHS guidance as a benchmark for deciding whether the exceptions above are eligible for cover. All requests for cover must be submitted in writing with supporting medical information.
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 any dental or oral treatment other than listed in your table of benefits.
We do not pay for developmental problems, behavioural problems or learning difficulties in children including but not limited to dyslexia, dyspraxia, autism and ADHD.
We do not pay for treatment which is in any way related to a child’s learning difficulties, behavioural problems or delay in a child’s development. This includes any diagnostic tests.
We do not pay for treatment for or associated with dialysis.
We do not pay for drugs and dressings provided or prescribed for use as an outpatient or for you to take home, other than those outlined in the cancer cover explained.
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 a disease.
We do not pay for treatments (including medication) which in our reasonable opinion are experimental or not yet approved by the National Institute for Health and Care Excellence (NICE), are being researched or lack sufficient evidence to conclude that:
- the harmful effects are outweighed by the beneficial effects
- they are likely to lead to the same or better outcomes than available alternatives
- they are based on established medical practice in the United Kingdom.
Examples of the criteria we use for considering a treatment as experimental include:
- the treatment is still undergoing clinical trials and/or yet to undergo a phase III clinical trial for the indication in question
- the treatment does not have approval from the relevant government body
- the treatment does not conform to usual clinical practice in the view of the majority of medical practitioners in the relevant field
- the treatment is being used in a way other than that previously studied or that for which it has been granted approval by the relevant government body
- the treatment is rarely used, novel, or unknown and there is a lack of authoritative evidence of safety and efficacy.
We do not pay for any treatment required for complications arising or resulting from experimental treatment that you receive or for any subsequent treatment you may need as a result of you undergoing any experimental treatment.
We do not pay for treatment to correct your sight other than as specified in your table of benefits.
We do not pay for:
- fertility treatment
- assisted reproduction, surrogacy, harvesting of donor eggs or donor insemination
- sperm collection and storage
- complications following any of the above
Please note: We will pay for remote consultations and diagnostics related to women’s or men's health concerns with a specialist gynaecologist or men's health specialist as specified in your table of benefits.
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 any GP consultations or visits other than those specified in your table of benefits. We do not pay for any charges for the completion of claim forms or referral letters, unless we have requested these specifically to assess your claim.
We do not pay for 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 any weight loss treatment including treatment required as a result of obesity.
We do not pay for treatment outside the United Kingdom including evacuation or repatriation.
We do not pay for treatment for or arising from pandemic and / or epidemic disease.
Please note, you will be covered for treatment of Long COVID as detailed in your COVID19 Cover Explained.
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 any treatment related to pregnancy or childbirth, other than as specified in your table of benefits.
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
Please see cancer cover explained for information on preventative cancer treatment.
We do not pay for any treatment required due to sexual dysfunction, sexually transmitted infections or sexual problems, whatever the cause.
Please note: We will pay for remote consultations and diagnostics related to women’s or men's health concerns with a specialist gynaecologist or men's health specialist as specified in your table of benefits.
We do not pay for any transplants, adoptive cell transfer, gene therapies and/or any complications related to, or resulting from these treatments. This includes, but is not limited to CAR T cell therapy, Tumour Infiltrating Lymphocyte therapy and stem cell/bone marrow treatments. 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 treatment carried out by a provider who we do not recognise as being qualified and/or registered to provide the type of treatment you need or for treating the medical condition you have.
We do not pay for treatment with sports therapists, massage therapists, or anyone who does not meet our definition of a practitioner or complementary practitioner.
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide, the list of 'How to Claim' in Section 4
Neurodevelopmental disorders
Active treatment
Acute condition
Annual renewal date
Benefit
Benefits
Biological therapies
Cancer
Chronic condition
Complementary practitioner
- a practitioner who specialises in acupuncture or a practitioner in osteopathy or chiropractic who is registered under the relevant Act; and who, in all cases, meets our criteria for complementary practitioner recognition for benefit purposes in their field of practice:
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council)
Daycase
Dependant
-a member’s unmarried dependent children
Dependants
-a member’s unmarried dependent children
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Disorder
Emergency
Employer
End of life care
Gender Dysphoria
Gender Incongruence
General Practitioner
GP
High dependency unit
High risk activities
Home healthcare
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
Intensive care unit
Medical condition
Medically necessary
-
In accordance with professional standards of medical practice in the United Kingdom
-
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
-
Required for reasons other than the comfort or convenience of the patient or specialist.
-
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition.
-
Provided only for an appropriate duration of time.
-
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.
<
Members
Mental health condition
Outpatient
Palliative care
Partner
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
- An Accredited member of the Association of Child Psychotherapists (ACP); or
- A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)
Registered nurse
Related condition
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 (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
The Scheme
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. <
Treatment
Treatments
Trust Deed
Trustee, Trustees
United Kingdom
Waiting Period
We, Us, Our
You, Your
Scheme
Pandemic
Epidemic
Member Zone
Member
End of cover
Cover for you (the member) will end in the following situations:
-
if your employment with Circle Health Group 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 Circle Health Group 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 21. They will be removed from cover on the next annual renewal date following their 21st 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 team via e-mail at HRassist@circlehealthgroup.co.uk as soon as possible of any changes of this matter.
If treatment has been authorised, but has not yet taken place, you will be responsible for any treatment costs if the scheme then terminates or you leave the scheme.
Continuation option
As Healix Health only provides corporate group schemes, we are unable to continue your cover as an individual if you leave the Circle Private Healthcare Scheme.
We understand the importance of your healthcare and choosing a new provider may be daunting. We work closely with two providers to provide you with the best choice possible to take your healthcare forward.
What is a continuation option?
A continuation option allows members who resign or retire from an employer that provides workplace healthcare benefits to take out their own cover. You might be eligible to take over the benefits previously paid for by the employer, however it’s not always guaranteed that any ongoing claims will be covered.
National Friendly
Who are NF?
A Friendly Society that helps its members meet their health protection needs by offering you cover through private medical insurance policies.
How do I contact them?
Call 0333 014 6244, (8am-6pm Monday to Friday). Quote HEALIX and the team will be able to obtain the best possible terms for your transition.
What do they cover?
My Private Medical Insurance policy is a flexible product that offers cover for everyone up to age 85. You can choose between guided outpatient only cover all the way through to unlimited inpatient cover.
To find out more about National Friendly visit here.
Usay Compare
Who are Usay?
The largest individual health insurance intermediary and are experts at finding the best cover for you.
How do I contact them?
Call 01285 864670 and quote HEALIX.
What do they cover?
Usay Compare will get to know your unique individual requirements, do all the hard work comparing prices and policies for you; then advise on the best and most cost-effective quote.
To find out more about Usay Compare, fill in this online form.
These terms are offered to you as a previous member of the healthcare scheme and are available for a limited time only, usually no more than 30 days from the date of leaving. It is therefore important that you act quickly to maintain continuity of cover.
Health Services Ltd is an introducer appointed representative of both National Friendly and Usay Business Ltd, who are authorised and regulated by the Financial Conduct Authority. Calls may be recorded or monitored for quality control.
How to make a complaint
It is always our intention to provide a first class standard of service: however, we recognise that on occasions, your requirements may not have been met.
Should you have any cause for complaint, you should contact us.
How your complaint will be handled
Stage 1
You will receive a written acknowledgement of your complaint within five business days of receipt. This will include the name and job title of the individual handling the complaint.
Stage 2
Within four weeks of receiving your complaint, you will receive either:
-
A final response or
-
A holding response, explaining why we are not yet in a position to resolve the complaint and indicating when we will be making further contact (this will be within eight weeks from receiving the complaint).
Stage 3
If you have not received a final response within four weeks, by the end of eight weeks after receipt of the complaint, you will receive either:
-
A final response.
-
A response explaining why we are still not in a position to provide a final response and explaining when we believe we will be able to do so.
-
If we are unable to provide a final response, due to the delay which has now occurred, you may refer your complaint to the Trustees.
If, during stage 2 or 3, we issue our final response but you remain dissatisfied, you may refer your complaint to the Trustees. To do this, please set out your reasons fully in writing to the Head of Customer Delivery, 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 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 sooner. Any claims submitted after this, will be assessed on a case by case basis, and paid at our discretion.
We will not pay for claims:
- if the invoice or reimbursement claim (including cash benefit claims) is not submitted within six months of your treatment date / birth or adoption date or within 6 months of the end of the scheme year you wish to claim against - whichever comes soonest.
- if the treatment takes place after you have left the scheme
- if you break any terms and conditions of your membership
- if you incur a fee for non-attendance or late cancellations.
Requests for additional information
We may ask you to provide information to help us assess your claim. For example we may ask you for one or more of the following:
-
Medical reports and other information about the treatment for which you are claiming. If we request a medical report from your specialist and they charge for providing this we will pay the cost.
-
Original accounts and invoices in connection with your claim.
-
Obtain results of an independent medical examination or second opinion for which we may ask you to make an appointment with a with a specialist. We will pay for the cost of any independent medical examination or second opinion we require and we will authorise this in writing, in advance.
-
Provide results of any second opinion you have independently sought under the care of another specialist. On such occasions we may additionally request our own, independent, second opinion from an expert in that field to assess eligibility of cover. We will pay the costs of any second opinion we organise on your behalf, this includes the cost of the consultation and any tests undertaken as a result of that consultation.
We will liaise with you and your medical specialists throughout your treatment and will request medical information, when we deem this to be necessary for the assessment of your claim. You will be asked for your consent before we do this.
Throughout your claim we will make you aware of the options that are available to you. If your medical specialist recommends treatment, you should contact the helpline as soon as possible to be sure that continued treatment is covered.
Our team of case managers will assess the level of cover available to you for planned treatment within the terms and conditions of the scheme. In some instances it may be necessary to refer your claim to our specialist nurses, along with our panel of independent specialist advisors, who will advise on the level of cover available for the recommended treatment.
Duplicate cover
You must tell us if you are able to make a claim for the cost of any of your treatment from anyone else either under another healthcare scheme or under an insurance policy. For example, if you received an injury that was caused by someone else such as a road traffic accident in which you are not at fault, the scheme will only pay a share of the total costs as appropriate.
If benefits are claimed for treatment to you when the injury or medical condition was caused by a third party, the scheme shall, at its own expense, have the right to pursue such claims in any way considered appropriate in your name. You must co-operate with all reasonable requests in this respect and advise us of any amount you recover directly from the third party.
Healix privacy notice
If you would like to know more about how Healix store and process your personal data, please find our Privacy Notice by clicking here.
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide, the list of 'How to Claim' in Section 4
Neurodevelopmental disorders
Active treatment
Acute condition
Annual renewal date
Benefit
Benefits
Biological therapies
Cancer
Chronic condition
Complementary practitioner
- a practitioner who specialises in acupuncture or a practitioner in osteopathy or chiropractic who is registered under the relevant Act; and who, in all cases, meets our criteria for complementary practitioner recognition for benefit purposes in their field of practice:
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council)
Daycase
Dependant
-a member’s unmarried dependent children
Dependants
-a member’s unmarried dependent children
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Disorder
Emergency
Employer
End of life care
Gender Dysphoria
Gender Incongruence
General Practitioner
GP
High dependency unit
High risk activities
Home healthcare
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
Intensive care unit
Medical condition
Medically necessary
-
In accordance with professional standards of medical practice in the United Kingdom
-
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
-
Required for reasons other than the comfort or convenience of the patient or specialist.
-
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition.
-
Provided only for an appropriate duration of time.
-
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.
<
Members
Mental health condition
Outpatient
Palliative care
Partner
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
- An Accredited member of the Association of Child Psychotherapists (ACP); or
- A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)
Registered nurse
Related condition
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 (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
The Scheme
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. <
Treatment
Treatments
Trust Deed
Trustee, Trustees
United Kingdom
Waiting Period
We, Us, Our
You, Your
Scheme
Pandemic
Epidemic
Member Zone
Member
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: Circle@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, the list of 'How to Claim' in Section 4
Neurodevelopmental disorders
Active treatment
Acute condition
Annual renewal date
Benefit
Benefits
Biological therapies
Cancer
Chronic condition
Complementary practitioner
- a practitioner who specialises in acupuncture or a practitioner in osteopathy or chiropractic who is registered under the relevant Act; and who, in all cases, meets our criteria for complementary practitioner recognition for benefit purposes in their field of practice:
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council)
Daycase
Dependant
-a member’s unmarried dependent children
Dependants
-a member’s unmarried dependent children
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Disorder
Emergency
Employer
End of life care
Gender Dysphoria
Gender Incongruence
General Practitioner
GP
High dependency unit
High risk activities
Home healthcare
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
Intensive care unit
Medical condition
Medically necessary
-
In accordance with professional standards of medical practice in the United Kingdom
-
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
-
Required for reasons other than the comfort or convenience of the patient or specialist.
-
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition.
-
Provided only for an appropriate duration of time.
-
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.
<
Members
Mental health condition
Outpatient
Palliative care
Partner
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
- An Accredited member of the Association of Child Psychotherapists (ACP); or
- A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)
Registered nurse
Related condition
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 (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
The Scheme
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. <
Treatment
Treatments
Trust Deed
Trustee, Trustees
United Kingdom
Waiting Period
We, Us, Our
You, Your
Scheme
Pandemic
Epidemic
Member Zone
Member
Scheme Year 2023-2024
The below changes will come into effect for the new scheme year from 1st June 2023.
| New Benefits | Benefit Limit | Benefit Wording |
|
Perci Health - virtual cancer support |
Please refer to Member Zone for further information |
Please refer to your cancer support explained |
|
Digital Triage |
Please refer to Member Zone for further information |
Please refer to Musculoskeletal health pathway and Mental health pathway. |
| Benefit Changes | Previous wording | New Wording |
|
Excess |
£100 per scheme year |
£125 per scheme year |
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide, the list of 'How to Claim' in Section 4
Neurodevelopmental disorders
Active treatment
Acute condition
Annual renewal date
Benefit
Benefits
Biological therapies
Cancer
Chronic condition
Complementary practitioner
- a practitioner who specialises in acupuncture or a practitioner in osteopathy or chiropractic who is registered under the relevant Act; and who, in all cases, meets our criteria for complementary practitioner recognition for benefit purposes in their field of practice:
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council)
Daycase
Dependant
-a member’s unmarried dependent children
Dependants
-a member’s unmarried dependent children
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Disorder
Emergency
Employer
End of life care
Gender Dysphoria
Gender Incongruence
General Practitioner
GP
High dependency unit
High risk activities
Home healthcare
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
Intensive care unit
Medical condition
Medically necessary
-
In accordance with professional standards of medical practice in the United Kingdom
-
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
-
Required for reasons other than the comfort or convenience of the patient or specialist.
-
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition.
-
Provided only for an appropriate duration of time.
-
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.
<
Members
Mental health condition
Outpatient
Palliative care
Partner
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
- An Accredited member of the Association of Child Psychotherapists (ACP); or
- A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)
Registered nurse
Related condition
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 (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
The Scheme
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. <