Introduction

Welcome to the ABC Healthcare Scheme guide.

ABC has chosen Healix Health Services Ltd. to manage this scheme. We're here to assess your medical needs and manage the care you may require.

The ABC Healthcare Scheme is designed to cover the diagnosis and / or treatment of short-term medical conditions, as long as it is medically necessary.

Please note, the scheme does not cover all medical conditions. Certain conditions, items and treatments are excluded (see your exclusions and limitations for details).

All treatment, including consultations and diagnostics, must be authorised in advance. It's essential that you contact us before to confirm it's eligible for cover under the scheme.

To include dependants under the scheme, regardless of their gender, please reach out to ABC's HR department for guidance on eligibility.

Table of benefits

Your scheme benefits are outlined in the table below.

Please note, the below benefits are:

subject to an excess, and
subject to a total benefit limit per member, per scheme year/per scheme lifetime/per claim/per claim per scheme year of £xxxxxx.

Benefit limits apply per member, per scheme year unless otherwise stated. Once a benefit limit is reached, no further cover will be provided within the scheme year specified below. Cover for continued consultations, diagnostics or treatment in the next scheme year will be subject to all healthcare scheme terms and conditions.

The scheme year will commence on the 1st MONTH YEAR to 31st MONTH YEAR.

Benefit Type	Level of Cover	Benefit Note

Outpatient Diagnostics and Treatment
Outpatient diagnostics and consultations with a specialist or practitioner following GP or specialist referral (self-referral available for specified cancer symptoms) Outpatient treatment following specialist referral (remove if full cover) Monitoring with a specialist following specified heart surgery	Up to £1,000 per scheme year (combined limit)	A
Monitoring of a chronic condition	Up to £500 per scheme year	B
Neurodevelopmental disorder assessment	Up to £2,000 per scheme lifetime	C
Neurodevelopmental disorder assessment and neurodevelopmental disorder treatment	Up to £3,000 per scheme lifetime	D
Orthotics	Up to £500 per scheme lifetime	E
Outpatient treatment and (remove if have OPA) surgical procedures	Full cover	F
Outpatient MRI, CT and PET scans following specialist referral	Full cover	G
Inpatient and Day Case Treatment
Specialist fees and hospital charges for inpatient and day case treatment	Full cover	H
Parent accommodation - hospital	Full cover	I
Parent accommodation - hotel	£100 per night up to £500 per scheme year	I2
Therapies
In-network outpatient physiotherapy (including self-referral)	Full cover	J
Out-of-network outpatient physiotherapy following GP referral	Up to £250 per scheme year	K
Out-of-network outpatient physiotherapy following specialist referral	Full cover	L
Outpatient physiotherapy (including self-referral)	Full cover	M
Outpatient complementary therapies	Up to £250 per scheme year	N
Mental Health
In-network outpatient mental health treatment (including self-referral)	Full cover	O
Out-of-network outpatient mental health treatment	Up to £1,500 per scheme year	P
Outpatient mental health treatment (including self-referral)	Full cover	Q
Outpatient mental health treatment for chronic mental health conditions (including self-referral)	Up to £500 per scheme year	R
Inpatient and day case mental health treatment	Up to 28 days per scheme year	S
Cancer Treatment
Cancer treatment	Full cover	T
Cash Benefits
NHS cash benefit	£150 each day or night	U
NHS cash alternative	Up to 25% of the costs to receive the procedure privately	V
NHS cancer cash benefit	£300 each day or night	W
NHS cancer cash benefit for oral chemotherapy and targeted therapies	£600 per month	X
Baby cash benefit	£100 per child	Y
Hospice donation	£200 per night	Z
Additional Benefits
Fertility investigations	Full cover	AA
Fertility treatment	Up to £10,000 per scheme lifetime	AB
Gender dysphoria	Up to £10,000 per scheme lifetime	AC
Women's and Men's Health benefit Remote advice service with our in-network experts (up to 4 consultations per scheme year) Diagnostics following referral from our in-network experts (up to £500 per scheme year) Access to Syrona Health to provide support for gender inclusive health journeys across life stages(remove if no access)	Limited cover	AD
Private ambulance charges	Full cover	AE
Home healthcare	Full cover	AF
Overseas emergency treatment	Limited cover	AG

Please note: the above benefits only apply when consultations, diagnostics or treatment take place in the UK unless specified otherwise.

Note A: Outpatient Diagnostics and Treatment

Outpatient Diagnostics and Treatment

We will pay in full within your overall outpatient limit for:

outpatient consultations with a specialist following GP referral
outpatient consultations with a dietician, nurse, orthoptist, podiatrist or speech therapist following GP or specialist referral. The practitioner must be registered with the correct governing body for their field, and meet our definition for a practitioner
outpatient diagnostics following GP or specialist referral
outpatient treatment following specialist referral (remove if full cover)

Cover is subject to our reasonable and customary fees.

Outpatient Consultations with a Specialist on Self-Referral for Specified Cancer Symptoms

We will pay in full within your overall outpatient limit for self-referred* consultations and diagnostics for specified cancer symptoms.

Refer to the self-referred cancer benefits section for further information on symptoms that are eligible, and how to access this benefit.

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

*Cover for self-referral is subject to your scheme underwriting.(remove this and * above if MHD)

Monitoring with a Specialist Following Specified Heart Surgery

We will pay in full within your overall outpatient limit for specialist consultations, check-ups and monitoring following the below surgeries on your heart:

coronary artery bypass
cardiac valve surgery
coronary angioplasty
implantation of a cardiac device, such as a defibrillator or pacemaker

This does not include checks that would normally be carried out by your GP.

Note B: Monitoring of a Chronic Condition

We will pay up to £500 per scheme year for the below when required to monitor a chronic condition:

outpatient consultations with a specialist following GP referral
outpatient diagnostics following GP or specialist referral

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

Please note, this benefit includes mental health treatment for mental health conditions.(remove if acute on chronic exception covers mental health)

Note C: Neurodevelopmental Disorder Assessment

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

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

Once a diagnosis has been confirmed, there will be no further cover for any additional assessments, consultations, diagnostics or neurodevelopmental disorder treatments.

Please note, this benefit is not subject to your scheme underwriting.(remove if MHD)

Note D: Neurodevelopmental Disorder Assessment and Neurodevelopmental Disorder Treatment

We will pay a combined limit of £3,000 per scheme lifetime following GP or specialist referral for:

Neurodevelopmental Disorder Assessment

The assessment of a neurodevelopmental disorder which must be carried out by a specialist or educational psychologist that we recognise for benefit purposes.

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

Neurodevelopmental Disorder Treatment

Eligible and recognised neurodevelopmental disorder treatments following diagnosis.

Supportive therapies will be reimbursed on a pay and claim basis, and neurodevelopmental disorder treatments must be carried out by a registered specialist, psychological therapist, complementary practitioner, physiotherapist, practitioner or treating provider that we recognise for benefit purposes.

Please note, this benefit is not subject to your scheme underwriting.(remove if MHD)

Note E: Orthotics

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

Note F: Outpatient Treatment and Surgical Procedures

We will pay in full for hospital charges and specialist fees for outpatient treatment (remove if have OPA), surgical procedures and drugs and dressings used during an outpatient appointment.

Cover is subject to our reasonable and customary fees.

Note G: Outpatient MRI, CT and PET Scans

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

Note H: Specialist Fees and Hospital Charges for Inpatient and Day Case Treatment

Specialist Fees

We will pay specialist fees in full for inpatient and day case treatment. Cover is subject to our reasonable and customary fees.

Hospital Charges

We will pay hospital charges in full for the following:

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

Note I: Parent Accommodation - Hospital

We 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 16thbirthday, 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, and
the treatment the child receives is covered by the scheme

Note I2: Parent Accommodation - Hotel

We will pay up to £100 a night for a maximum of £500 per scheme year 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

Note J: In-Network Outpatient Physiotherapy

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

You also have access to a digital triage service via the Member Zone / the My Healix App. This service is not subject to your excess, your scheme underwriting, or any benefit limits (if applicable) when accessed through our digital pathway provider.

Refer to the musculoskeletal pathway section for further information.

*Cover for self-referral is subject to your scheme underwriting.(remove this and * above if MHD)

Note K: Out-of-Network Outpatient Physiotherapy Following GP Referral

We will pay up to £250 per scheme year for outpatient physiotherapy following GP referral, when taken outside of our physiotherapy network. The physiotherapist must be recognised by us for benefit purposes.

Please note, you also have access to a digital triage service via the Member Zone / the My Healix App. This service is not subject to your excess, your scheme underwriting, or any benefit limits (if applicable) when accessed through our digital pathway provider. Refer to the musculoskeletal pathway section for further information.

Note L: Out-of-Network Outpatient Physiotherapy Following Specialist Referral

We will pay in full for for outpatient physiotherapy following specialist referral, when taken outside of our physiotherapy network. The physiotherapist must be recognised by us for benefit purposes.

Note M: Outpatient Physiotherapy

In-Network Physiotherapy

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

Refer to the musculoskeletal pathway section for further information.

*Cover for self-referral is subject to your scheme underwriting.(remove this and * above if MHD)

Out-of-Network Physiotherapy

We will pay in full for outpatient physiotherapy following GP or specialist referral, when taken outside of our physiotherapy network. The physiotherapist must be recognised by us for benefit purposes.

Note N: Outpatient Complementary Therapies

We will pay up to £250 per scheme year for chiropractic, osteopathy and acupuncture sessions, following GP or specialist referral. The complementary practitioner recognised by us for benefit purposes.

Note O: In-Network Outpatient Mental Health Treatment

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

Refer to the mental health pathway section for further information.

Please note, under 18s will require a referral letter from a GP or specialist.

*Cover for self-referral is subject to your scheme underwriting.(remove this and * above if MHD)

Note P: Out-of-Network Outpatient Mental Health Treatment

We will pay up to £1,500 for outpatient consultations and mental health treatment for eligible mental health conditions following GP or specialist referral, when taken outside of our mental health network. The psychological therapist must be recognised by us for benefit purposes.

Please note, you also have access to a digital triage service via the Member Zone / the My Healix App. This service is not subject to your excess, your scheme underwriting, or any benefit limits (if applicable) when accessed through our digital pathway provider. Refer to the mental health pathway section for further information.

Note Q: Outpatient Mental Health Treatment

In-Network Outpatient Mental Health Treatment

Refer to the mental health pathway section for further information.

Please note, under 18s will require a referral letter from a GP or specialist.

*Cover for self-referral is subject to your scheme underwriting.(remove this and * above if MHD)

Out-of-Network Outpatient Mental Health Treatment

We will pay in full for outpatient consultations and mental health treatment for eligible mental health conditions following GP or specialist referral when taken outside of our mental health network. The psychological therapist must be recognised by us for benefit purposes.

Please note, you also have access to a digital triage service via the Member Zone / the My Healix App. This service is not subject to your excess, your scheme underwriting, or any benefit limits (if applicable) when accessed through our digital pathway provider. Refer to the mental health pathway section for further information.

Note R: Outpatient Mental Health Treatment for Chronic Mental Health Conditions

We will pay up to £500 per scheme year for outpatient consultations and mental health treatment required as a result of a chronic mental health condition following GP, specialist or self-referral*. Self-referred outpatient mental health treatment must be via our mental health network provider. When taken outside of our mental health network, the psychological therapist must be recognised by us for benefit purposes.

Refer to the mental health pathway section for further information.

Please note, under 18s will require a referral letter from a GP or specialist.

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

*Cover for self-referral is subject to your scheme underwriting.(remove if MHD)

Note S: Inpatient and Day Case Mental Health Treatment

We will pay up to 28 days per scheme year for eligible inpatient and day case mental health treatment.

You must be under the direct care and supervision of a consultant psychiatrist, and receive authorisation from us in advance and in writing.

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

Note T: Cancer Treatment

We will pay for cancer treatment as outlined in the cancer cover explained section.

For information on additional services available, refer to the cancer support explained section.

Note U: NHS Cash Benefit

In the event that you are admitted to an NHS hospital, or you elect to receive free treatment through the NHS, we will pay a cash benefit of £150 per day or night, following inpatient or day case treatment.

This benefit will only apply to claims for inpatient or day case treatment that would otherwise have been eligible for benefit under the scheme.

Note V: NHS Cash Alternative

In the event that you require an elective surgical procedure, and you choose to receive this treatment free of charge on the NHS, we may pay you a cash lump sum. Please contact us to check if your procedure will qualify for this benefit.

Note W: NHS Cancer Cash Benefit

In the event that you elect to receive cancer treatment through the NHS, we will pay a cancer cash benefit of £300 per day or night following inpatient or day case treatment, or outpatient radiotherapy.

This benefit will only apply to claims for inpatient or day case treatment, or outpatient radiotherapy that would otherwise have been eligible for benefit under the scheme.

Note X: NHS Cancer Cash Benefit for Oral Chemotherapy and Targeted Therapies

In the event that you elect to receive oral chemotherapy or targeted therapies via the NHS as an outpatient, we will pay a cancer cash benefit of £600 per month.

Note Y: Baby Cash Benefit

We will pay a cash benefit of £100 per baby / child following birth or adoption, where either one or both parents are members of the scheme. This benefit can only be claimed once per baby / child, even if both parents are covered under the scheme.

This benefit is subject to a 12 month waiting period from the date you joined the scheme.

Note Z: Hospice Donation

In the event that you are admitted to a hospice, we will make a donation of £200 per night to the hospice, for the duration of the admission.

Note AA: Fertility Investigations

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

Once a diagnosis has been confirmed, there will be no further cover for any additional consultations, diagnostics or fertility treatment in the future.(remove if have fertility benefit)

Once a diagnosis has been confirmed, cover for eligible fertility treatment will be subject to any limits as outlined in your fertility treatment benefit.(remove if don't have fertility benefit)

Note AB: Fertility Treatment

We will pay up to £10,000 per scheme lifetime for fertility treatment as outlined in the fertility treatment explained section.

Note AC: Gender Dysphoria

We will pay up to £10,000 per scheme lifetime for gender dysphoria, as outlined in the gender dysphoria explained section.

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

Remote Advice Service with Our In-Network Experts

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

Diagnostics Following In-Network Expert Referral

We will pay up to £500 per scheme year for diagnostics that are recommended following a remote advice appointment with our in-network experts.

Refer to the women’s or men’s health services section for further information on how to access these benefits.

Once either benefit limit has been reached, the scheme rules will apply as outlined in your exclusions and limitations section.

Please note, additional cover may be available outside of these limits for eligible claims, please contact us for further information.

Syrona Health

For further information, refer to the Syrona Health section.(remove if no access)

Note AE: Private Ambulance Charges

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

Note AF: Home Healthcare

We will pay in full for home nursing charges with a registered nurse when recommended by a specialist and where it is:

medically necessary and without it you would have to receive treatment as an inpatient or day case admission, and
needed for medical reasons (i.e. not social or domestic reasons), and
under the direct supervision of a specialist

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

Note AG: Overseas Emergency Treatment

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

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

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

Benefit	Reimbursement level
Specialist fees	Within our reasonable and customary fees
MRI, CT and PET scans	Up to £100 per trip
Outpatient surgical procedures	Up to £100 per trip
Other emergency outpatient consultations, diagnostics or treatment (excluding MRI, CT and PET scans, and outpatient surgical procedures)	Up to annual outpatient benefit limits, as outlined in your table of benefits
Inpatient or day case surgical procedures	Up to £200 per trip

We will only pay up to the above limits if the following apply to your consultations, diagnostics or treatment:

it is eligible for benefit, and

it is carried out by a specialist who is:

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

the treating facility is specifically recognised or registered under the laws of the territory in which it stands for providing the care delivered, and
the costs are covered under your scheme.

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

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

The scheme will not pay for:

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

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

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

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

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

Cancer cover explained

We understand that a cancer diagnosis can be life-changing. That’s why we've included a specific section within the scheme to help you understand the level of cancer treatment cover available.

The scheme provides benefits for eligible outpatient, day case, and inpatient cancer treatment. To ensure you always receive the highest quality care, we work with centres of excellence for cancer treatment. If you are diagnosed with cancer, we may ask you to transfer to one of these centres, which could be in either the private or NHS sector.

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

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

The table below offers a summary of the cancer cover provided. Please read it alongside your table of benefits for full details.

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

Cancer support explained

We understand that a cancer diagnosis can be a life-changing event, and we're committed to supporting you through every step. That’s why we've partnered with Perci Health to provide additional support for the psychological, physical and practical impacts of cancer.

Perci Health is here to support you, no matter how cancer has affected your life:

are you currently undergoing cancer treatment?
do you need extra support after completing your cancer treatment?
are you caring for a loved one with cancer?

Whatever your situation, Perci Health can provide a personalised care plan, a dedicated cancer nurse and access to caring experts across more than 20 different types of support, including:

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

This service is available at no extra cost - it won't count towards any benefit limits, nor is it subject to your scheme underwriting or any excess.

Please note, this benefit is available to members aged 18 and over.

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

Fertility treatment explained

We understand that fertility concerns can deeply affect your life. That’s why we've developed a benefit to provide support and assistance when it matters most.

Our experienced claims team are here to guide you through the available options and support you during your fertility treatment journey.

The table below offers a summary of the fertility cover available. Please read it alongside your table of benefits for full details.

Please note, these benefits are only available to individuals covered by the scheme and under the age of 43. This benefit is subject to limit of £10,000 per scheme lifetime. If you and your spouse are both members of the scheme, funds cannot be transferred or shared between you.

For further help and support, please contact us.

Summary of fertility benefits	What's covered
Who can receive fertility treatment?	You will be covered within the benefit limit for fertility treatment provided you are a member of the scheme and under the age of 43 years. You must be under the age of 43 at the beginning of each individual cycle. Should you turn 43 during fertility treatment, cover will be available up to the end of the current cycle only.
When is cover eligible from?	You will be covered within the benefit limit after completion of a 12 month waiting period which starts from the date you join the scheme.
Where am I covered to receive fertility treatment?	You will be covered within the benefit limit for fertility treatment in the UK at a facility approved for use and licensed by the HFEA (Human Fertilisation and Embryology Authority).
What fertility treatments am I covered for?	You will be covered within the benefit limit for surgery for the following conditions where this is affecting your fertility and is recommended by a specialist: endometriosis fibroids blocked fallopian tubes polycystic ovarian syndrome You will be covered within the benefit limit for eligible fertility treatment including: IUI (intrauterine insemination) IVF (In vitro fertilisation) ICSI (Intracytoplasmic Sperm Injection) FET (Frozen embryo transfers) These fertility treatments will be eligible for cover where this has been recommended by a specialist You will also be covered for: consultations with a fertility specialist diagnostics recommended by the specialist fertility drugs to stimulate ovulation consultations and diagnostics to assess response to fertility drugs day case admission for egg retrieval fertilisation of eggs admission for embryo transfer fertility drugs to support pregnancy following embryo transfer ultrasound scan to ascertain viable pregnancy HFEA fee Most fertility treatment costs are attributed to the female. As a male claimant you will be eligible for the following: consultations diagnostics for yourself (blood tests, semen analysis) ICSI (if required) as this is used for male infertility where the sperm is injected into the egg to fertilize surgical sperm extraction (if required)
Am I covered for surgical sperm extraction?	You will be covered within the benefit limit for the costs associated with surgical sperm extraction when medically necessary and recommended by a specialist.
How many cycles of IVF / IUI am I covered for?	You will be covered within the benefit limit for repeated cycles of IUI / IVF / ICSI / FET.
Am I covered for the genetic testing of eggs / sperm / embryos?	You will not be covered for any costs associated with genetic testing (including, but not limited to, karyotype testing or pre implantation genetic testing).
Am I covered for sperm washing?	You will not be covered for the cost of sperm washing to prevent blood borne viruses from being transmitted.
Am I covered for the cost of take home drugs?	You will be covered within the benefit limit for the cost of fertility medications required for the purpose of providing the fertility treatment and prescribed by your specialist as part of your fertility treatment up until the point that a pregnancy is confirmed by ultrasound scan. Cover is available for the following: down regulation drugs (to suppress natural ovarian function) follicle stimulating hormones / gonadatrophins (to stimulate the ovaries) HCG (trigger for eggs to reach final maturation) progesterone and oestrogen (to prepare and maintain the womb lining for embryo implantation) Cover is not available for: vitamins, minerals and supplements herbal remedies folic acid any medication that is able to be prescribed by the GP Following confirmation of a viable pregnancy, the cost of any further medication required to maintain the pregnancy will not be eligible for benefit.
Am I covered for donor insemination / donor eggs?	You will not be covered for the cost of donor eggs or sperm required to achieve a pregnancy.
Am I covered for the costs of surrogacy?	You will not be covered for the costs of fertility treatment with the use of a surrogate.
Am I covered for the cost of freezing resultant embryos following IVF treatment?	You will be covered within the benefit limit for the costs of embryo freezing for a total of 12 months following a cycle of IVF – after which time any further costs associated with the continued storage of embryos will no longer be eligible for cover.
When does cover end?	Cover for fertility treatment will end at the point that a viable pregnancy is confirmed by ultrasound scan or when the benefit limit has been reached, whichever comes soonest. Once a pregnancy has been confirmed, any further scans or pregnancy related consultations, diagnostics and treatment will need to be taken on the NHS and the scheme's pregnancy exclusion will apply.
Am I covered for fertility treatment ‘add ons’ recommended by the clinic?	You will be covered within the benefit limit for the cost of fertility treatment ‘add ons’ only where there is adequate evidence as to their effectiveness as defined by the HFEA.
Am I covered to freeze my eggs / sperm to use at a later time in life?	You will not be covered for the cost of egg or sperm freezing in order to preserve fertility for use at a later time in life.
Are same sex couples and individuals not in a partnership eligible for fertility treatment?	You will be covered within the benefit limit for treatment recommended by a specialist, however, the costs of the associated donor sperm or eggs required to achieve a pregnancy will not be eligible for cover.
Can I continue fertility treatment that I started through self-pay prior to joining the scheme?	You will be covered within the benefit limit for the continuation of eligible pre-paid fertility treatment. Costs already incurred prior to the benefit being eligible will not be reimbursed.
Am I covered for reversal of sterilisation to correct infertility?	You will not be covered for the cost of sterilisation reversal where this is the cause of infertility in either partner.
Am I covered for complementary therapies related to fertility?	You will be covered for complementary therapies as outlined in your table of benefits.
Am I covered for counselling or mental health treatment related to my infertility?	You will be covered for mental health treatment as outlined in your table of benefits.
Am I covered for multi-cycle packages?	You will be covered within the benefit limit for the cost of single cycles only. We are unable to cover ‘multi-cycle package’ costs that may not be used.
Do I need to self-pay for fertility treatment?	You may be required to self-pay for fertility treatment at a clinic where they are unable to accept payment from us. Eligible fertility treatment can then be reimbursed as long as this is requested within 6 months of the treatment date. Reimbursement can only be made after the fertility treatment has taken place.

Gender dysphoria explained

We understand that gender dysphoria can cause distress for individuals who do not identify with the gender assigned at birth. That’s why we've included a specific section in the scheme to help you understand the level of cover available.

The table below provides a summary of the cover for gender dysphoria. Please read it alongside your table of benefits.

Cover is available for members aged 18 and over, with a benefit limit of £10,000 per scheme lifetime.

For further help and support, please contact us.

Summary of benefits	What’s covered	What’s not covered
Where will I be covered?	You will be covered within the benefit limit for: outpatient consultations, diagnostics and therapies in a hospital or clinic that we have approved	You will not be covered for any outpatient consultations, diagnostics and therapies: received in an unrecognised hospital or clinic received outside of the UK
What will I be covered for?	You will be covered within the benefit limit for: eligible outpatient consultations with a specialist and diagnostics following referral by your specialist eligible outpatient mental health treatment with a psychological therapist or psychiatrist	You will not be covered for: treatment received as an inpatient or day case any surgical treatment, including genital or chest surgery and associated consultations the cost of any hormone / drug therapies
What other benefits and services are available?	You will be covered within the benefit limit for: hair removal services and wigs up to a maximum of £1,000 scheme lifetime speech and language therapy up to a maximum of £1,000 per scheme lifetime	You will not be covered for: any travel costs or personal expenses any consultations, diagnostics or therapies with a provider that we do not recognise for benefit purposes

Second medical opinion

If you would like to receive a second medical opinion to feel confident with your specialist's recommendations, please contact us to discuss pre-authorisation. Our experienced claims team is here to guide and support you through the process.

Second opinions will be arranged with a specialist who is an expert in their field and is recognised for providing such consultations.

Please note, without written authorisation, we cannot cover any recommended or resulting diagnostics or treatment from a second opinion.

Virtual GP

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

You can register for this service via the Member Zone or My Healix app, or directly through their portal at:

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

The portal is the fastest and easiest way to sign up and book your consultations. If you cannot access the portal, you can also call YourHealth247 on 0204 586 5324.

To register, you will need your member number, found in your welcome or renewal email.

To register, you will need your access code which is as follows: XXXXXX

If YourHealth247 make an onward referral, we can accept this in place of a referral from your NHS GP, provided that their recommendation is eligible for cover. Contact us to confirm eligibility.

Onward referrals are subject to your scheme underwriting, any personal exclusions and scheme exclusions and limitations. If additional information about your medical history is needed, we may require your consent to contact your NHS GP.

Overseas emergency treatment

Please note, this benefit is NOT a substitute for an overseas travel insurance policy.

The cover available for overseas emergency treatment under the scheme is limited. Therefore, we strongly recommend that you take out appropriate travel insurance if you are going abroad to ensure that you have adequate cover for any healthcare needs you have, along with cover for loss of luggage etc.

We will pay for emergency overseas inpatient treatment up to the available limits as set out in your table of benefits, for unexpected acute conditions when travelling overseas, where immediate hospitalisation is medically necessary and treatment could not, in our opinion, have been reasonably anticipated or delayed.

If you wish to claim for emergency treatment received abroad, you must also send us proof of how long you were abroad, and this period should not exceed 28 consecutive days in any one year of cover.

We will pay for eligible costs incurred abroad in pounds sterling, using a suitable exchange rate, which we will decide, provided that the emergency treatment is:

eligible for benefit, and
carried out by a specialist, practitioner or complementary practitioner who is:
- fully trained and legally qualified and permitted to practice by the relevant authorities in the country in which your emergency treatment takes place, and
- is recognised by the relevant authorities in that country as having specialised knowledge of, or expertise in, treatment of the disease, illness or injury being treated, and
the treating facility is specifically recognised or registered under the laws of the territory in which it stands for providing the emergency treatment delivered, and
the costs are covered under your scheme.

If you require emergency treatment abroad, you will need to pay and claim for these costs. Therefore, it is important that you contact us at the earliest opportunity to ensure that you do not incur costs that cannot be reclaimed.

You should also send us all medical bills and receipts associated with your emergency treatment. Failure to submit receipts within six months of the treatment date may result in the claim being denied.

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

the Foreign and Commonwealth Office has advised against travel to that country or area;
if you are already in that particular country or area and have been advised to leave, unless prior written authority has been received from us;
you travelled abroad despite being given medical advice not to travel abroad;
you were told before travelling that you were suffering from a terminal illness;
you travelled abroad to receive treatment, or
you knew you would or thought you might need treatment

The scheme will not pay for some expenses including GP services / fees, outpatient prescriptions or take home drugs and dressings, which would have been paid for by the NHS in the UK.

Costs of private treatment in facilities in countries which should have been free or reduced if you had had a UK Global Health Insurance Card / European Health Insurance Card are not covered under the scheme.

Overseas emergency repatriation and evacuation

Your scheme benefits generally only apply to consultations, diagnostics and treatment received in the UK. As a result, there is no cover outside of the UK, unless specified in your table of benefits. We strongly recommend taking out travel insurance when travelling abroad.

However, if you fall ill while abroad, the scheme provides access to an overseas assistance helpline, managed by Healix International. This service is available 24/7 and offers support anywhere in the world. The helpline can provide immediate advice and may help you connect with an English-speaking doctor, where available. They will also ensure that the treatment you receive is medically appropriate and of a satisfactory standard.

Please note, while the costs of using the overseas assistance helpline are covered by the scheme, any costs related to overseas consultations, diagnostics or treatment are not covered and will be your responsibility unless you have alternative insurance in place.

If emergency repatriation is deemed necessary and approved by the overseas assistance company, the scheme will cover the repatriation as outlined below.

Additionally, if you have travel insurance, you must inform us. We reserve the right to contact your travel insurer on your behalf, and you must co-operate with all reasonable requests related to this process.

Contact the overseas assistance company line quoting 'HHS'

Tel: +44 (0) 203 8231 322

E-mail: hhsrepat@healix.com

Summary of overseas assistance benefits	What is covered?
What if I need evacuating or repatriating back to the UK?	In the event of an emergency, the scheme may also provide an emergency evacuation and repatriation service. This service is available if you should fall ill abroad and the emergency treatment you require is either: not available locally, or the local medical facilities are not of an acceptable standard in the opinion of the overseas assistance company The overseas assistance company will arrange to repatriate you by air ambulance, scheduled airline service or any other medically appropriate transport including qualified medical escort(s) where medically necessary. The evacuation and repatriation service will arrange you to be returned to the UK only. Please note, any costs for treatment prior to an emergency evacuation and repatriation will not be covered by the scheme and will be your responsibility unless specified otherwise in your table of benefits.
When am I not covered for evacuation or repatriation, including the repatriation of mortal remains?	This service is not available for cover in the following circumstances: you travelled to a country against Foreign, Commonwealth and Development Office (FCDO) advice you travelled overseas specifically for the purpose of receiving treatment you are covered by an alternative provider for this service, for example, travel insurance you are requesting cover for repatriation or evacuation against the medical advice of the overseas assistance company local treatment is of an acceptable standard in the opinion of the overseas assistance company where you require assistance as a result of a pregnancy related condition when travelling later than 36 weeks gestation where you require assistance as a result of a self-inflicted injury, suicide or attempted suicide you have organised any repatriation services that the overseas assistance company has not arranged and approved
What happens when I return to the UK?	On arrival back to the UK, cover for consultations, diagnostics or treatment will be assessed according to the terms and conditions of your scheme. Treatment should be taken within the NHS, until cover has been confirmed to prevent you incurring any unexpected costs.
What costs are covered for evacuation and /or repatriation?	You will be covered in full for any medical and transportation expenses arranged by and charged by the overseas assistance company to bring you back to the UK.
Will my family be covered to travel with me?	You will be covered for: travel and accommodation charges for one person over the age of 18 to accompany you on the evacuation / repatriation as long as they are covered by the scheme and this is deemed medically necessary by the overseas assistance company travel and accommodation charges, up to the date of repatriation, for any family members who are accompanying you on the overseas journey as long as they are covered by the scheme and this is deemed medically necessary by the overseas assistance company
What costs are not covered during an evacuation or repatriation?	You, and any eligible accompanying person, will not be covered for: the costs of any daily expenses that fall outside of travel and accommodation, including, but not limited to: food clothing personal comfort and convenience items the costs of any consultations, diagnostics or treatment required immediately before or after the evacuation and / or repatriation
What happens in the event of my death overseas?	You will be covered for the costs associated with the repatriation of your mortal remains back to the UK. This will only be covered when the transport is required for the repatriation of mortal remains and is arranged via the overseas assistance company.
Who do I contact to arrange an evacuation / repatriation?	In the event that an evacuation or repatriation is required, contact the overseas assistance company line on the number detailed above. They will be able to advise you on the cover available and, where eligible, make the necessary arrangements.

Syrona Health

At Healix, we're dedicated to supporting you through all of your health milestones.

This is why we've partnered with Syrona Health to offer you digital wellbeing support for key life stage transitions.

The Syrona Health app can be personalised to provide content relevant to various health areas, including:

menstrual health
fertility
parenthood
menopause
men’s health
cancer and heart health

Syrona Health offer a wealth of services for gender inclusive, virtual health support, available at any time:

health tracking via your smartwatch or fitness tracker
voice-AI mental wellbeing checks
unlimited 1-1 chats with expert clinicians
educational content & access to virtual events
virtual consultations with specialists
health screening tests & scans (charged separately by Syrona Health)

For more information and to get started, visit the ‘Syrona Health’ tile in the Member Zone or My Healix app.

Please note, this service is available to members aged 18 and over.

Section 9: Glossary

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

Prosthesis, Prostheses

– artificial body part(s) or device(s) which is inserted during surgery.

Acute condition

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

Annual renewal date

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

Scheme Benefit, Scheme Benefits

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

Biological therapies

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

Cancer

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

Chronic condition

- any medical condition which has at least one of the following characteristics:

requires ongoing or long-term monitoring through consultations, examinations, check-ups and / or tests
needs ongoing or long-term control or relief of symptoms
requires rehabilitation or for you to be specially trained to cope with it
continues indefinitely
has no known cure, or
comes back or is likely to come back.

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)

Day case

- treatment which requires occupation of a hospital bed for one day (not overnight)

Dependant, Dependants

- an employee's spouse, or the person the member lives with in a relationship similar to that of spouse, regardless of their gender.

- a employee's unmarried dependant children

Dialysis

- the removal of waste matter from the blood by either:

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

Disorder

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

Emergency

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

Employer

- ABC who is named as your employer

End of life care

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

Gender Dysphoria

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

General Practitioner, GP

- a registered medical practitioner in general practice.

High dependency unit, Intensive care

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

High-risk activities

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

Home healthcare

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

Hospital, Hospitals

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

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

Inpatient

- treatment which requires occupation of a hospital bed for one night or more.

Intensive care unit

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

Medical condition, Medical conditions

– any physical, mental or psychological disorder, including disease, illness, injury, genetic disorders and behavioural conditions.

Medically necessary

– treatment that is considered to be:

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

Mental health condition

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

Outpatient

- treatment that does not require occupation of a hospital bed

Partner, Partner's

- an employee's spouse, or the person the member lives with in a relationship similar to that of spouse, regardless of their gender.

Physiotherapist

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

Pre-existing condition

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

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

Private ambulance

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

Psychological therapist

- we recognise the following as psychological therapists.

a psychologist who is:

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

a therapist who is:

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

Registered nurse

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

Related condition

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

Specialist, Specialist's

- we consider a specialist to be:

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

and

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

Start date

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

Surgical appliance

– an artificial device or an artificial body part which is intended as an alternative to surgical treatment or a necessary part of your treatment following surgery

Practitioner

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

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

Treatment, Treatments

- surgical or medical services required following diagnosis of a condition. This includes but is not limited to surgical procedures and outpatient or day case non-surgical procedures (such as injections).

Trust Deed

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

Trustee, Trustees

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

United Kingdom

- England, Scotland, Wales and Northern Ireland.

Waiting Period

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

You, Your, You're, You've, You'll

- the eligible member

Pandemic

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

Epidemic

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

Diagnostic, Diagnostics

- outpatient and day case diagnostic tests included but not limited to scans, blood tests and diagnostic procedures used to reach a diagnosis of an illness or injury

Member Zone

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

Member, Members

- a person / people covered under the scheme.

Scheme lifetime

- the total time you are an active member of the scheme.

Scheme, The Scheme

- your employer's corporate healthcare scheme

Supportive Therapies

- therapeutic support designed to cover a range of therapies with the aim of improving functional skills and independence. Including but not limited to, educational support, play therapy, makaton courses and social skills groups.

Neurodevelopmental disorder, Neurodevelopmental disorders

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

We, Us, Our, We're, We've, We'll

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

Mental health treatment

- consultations, therapies and treatment to manage and improve mental health and wellbeing

Benefits

- medical services and treatments that are eligible for cover as part of your membership of the healthcare scheme, subject to all healthcare scheme terms and conditions

Main member, Main members

- the employee eligible to enrol into the healthcare scheme

Fertility treatment, Fertility treatments

- consultations and treatment to assist individuals trying to conceive a child where a reproductive challenge has been identified

Cancer treatment

- consultations, diagnostics, therapies and treatment for the symptoms of cancer and to eliminate malignant tissue / cells following diagnosis

Neurodevelopmental disorder treatment, Neurodevelopmental disorder treatments

- consultations, therapies and treatment to manage and improve the symptoms of a neurodevelopmental disorder following diagnosis

Emergency treatment

- treatment required immediately, generally within hours of onset, for a serious medical condition or symptoms resulting from a disease, illness or injury which puts your health at risk

Addiction treatment programme

- a treatment programme created to assist individuals in achieving long-term recovery for a drug or alcohol addictive disorder

Treatment date

- the day on which your eligible consultation, diagnostics, therapy or treatment takes place

Experimental treatment

- diagnostics or treatments which 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

Private hospital, Private hospitals

- 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.

NHS hospital, NHS hospitals

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

Dependant child, Dependant child's, Dependant children, Dependant children's

- a employee's unmarried dependant children

Emergency repatriation

- returning individuals to their home country or place of origin due to urgent or unforeseen circumstances, such as medical emergencies, natural disasters, or political instability.

Women's health services

At Healix, we understand the importance of quick access to healthcare. That's why we've made accessing women’s health services as easy and seamless as possible. If you're experiencing a women’s health concern, you can consult with a GP who has additional training in women’s health through the virtual GP service. For more information on how to access this, visit the virtual GP section.

Alternatively, you can contact us and our experienced claims team will guide you to the most appropriate services, including access to remote advice from a our in-network experts.

Most women’s health conditions are covered through your table of benefits, however, some conditions may not be covered by the scheme. To address this, we've introduced additional women’s health benefits to provide extra cover where needed. Our experienced claims team can advise whether your condition and / or health concern is eligible for cover under these additional benefits.

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

Women’s health concern	How to access support
If you need advice regarding any general women’s health query, including, but not limited to, menopause symptoms or contraception advice.	You can access YourHealth247 through the portal to speak with a GP directly without needing to contact us. All GPs can offer advice on common concerns, but if you prefer, you can request a consultation with a GP who specialises in women’s health. Additionally, you can self-refer by contacting us, without the need for a GP referral. Our experienced claims team will guide you to the most appropriate service for your needs. This may include remote consultations and diagnostics with one of our in-network experts (where appropriate). Cover is provided up to the limits specified in your table of benefits. Once the benefit limit is reached, the scheme rules, as outlined in your exclusions and limitations, will apply.
If you are concerned about a breast abnormality, for example a lump.	Contact us to speak with our experienced claims team, who can support you and direct you to the most appropriate specialist without the need to see your GP first. Cover is provided as outlined in your table of benefits. More 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 us to speak with our experienced claims team, who can assist in opening a new claim and directing you to the most suitable specialist. Cover is provided as outlined in your table of benefits.
If your GP has referred you for fertility investigations.	Contact us to speak with our experienced claims team, who can assist in opening a new claim. Cover will be provided through your fertility investigations benefit, as outlined in your table of benefits.
If you are experiencing complications of pregnancy.	Contact us to speak with our experienced claims team, who can advise if cover is available for you. Cover is provided for specific pregnancy complications only, as outlined in your exclusions and limitations.
If you require physiotherapy for a pelvic problem such as stress incontinence.	Contact us to speak with our experienced claims team, who will arrange a telephone-based assessment with a senior physiotherapist to determine the most appropriate pathway for you, without the need to see your GP first. Cover is provided through your physiotherapy benefit, as outlined in your table of benefits.

Men's health services

At Healix, we understand the importance of quick access to healthcare. That's why we've made accessing men's health services as easy and seamless as possible. If you're experiencing a men's health concern, you can consult with a GP who has additional training in men's health through the virtual GP service. For more information on how to access this, visit the virtual GP section.

Alternatively, you can contact us and our experienced claims team will guide you to the most appropriate services, including access to remote advice from a our in-network experts.

Most men's health conditions are covered through your table of benefits, however, some conditions may not be covered by the scheme. To address this, we've introduced additional men's health benefits to provide extra cover where needed. Our experienced claims team can advise whether your condition and / or health concern are eligible for cover under these additional benefits.

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

Men’s health concern	How to access support
If you need advice regarding any general men’s health query, including urinary symptoms, sexual health and fertility advice.	You can access YourHealth247 through the portal to speak with a GP directly without needing to contact us. All GPs can offer advice on common concerns, but if you prefer, you can request a consultation with a GP who specialises in men's health. Additionally, you can self-refer by contacting us, without the need for a GP referral. Our experienced claims team will guide you to the most appropriate service for your needs. This may include remote consultations and diagnostics with one of our in-network experts (where appropriate). Cover is provided up to the limits specified in your table of benefits. Once the benefit limit is reached, the scheme rules, as outlined in your exclusions and limitations, will apply.
If you are concerned about early signs of prostate or testicular cancer.	Contact us to speak with our experienced claims team, who can support you and direct you to the most appropriate specialist without the need to see your GP first. Cover is provided as outlined in your table of benefits. More information about early signs of cancers and self-referral can be found here.
If your GP has referred you to a specialist.	Contact us to speak with our experienced claims team, who can assist in opening a new claim and directing you to the most suitable specialist. Cover is provided as outlined in your table of benefits.
If your GP has referred you for fertility investigations.	Contact us to speak with our experienced claims team, who can assist in opening a new claim. Cover will be provided through your fertility investigations benefit, as outlined in your table of benefits.
For physiotherapy for a pelvic problem such as stress incontinence.	Contact us to speak with our experienced claims team, who will arrange a telephone-based assessment with a senior physiotherapist to determine the most appropriate pathway for you, without the need to see your GP first. Cover is provided through your physiotherapy benefit, as outlined in your table of benefits.

Self-referred cancer benefits

Experiencing symptoms that may be associated with cancer can be worrying, but it's important to remember that these symptoms don’t always indicate cancer. We are here to offer prompt support if you experience any symptoms that could potentially be related to cancer.

If you have any of the symptoms listed below, contact us to self-refer for a consultation and diagnostics. There is no need to see your GP these benefits, ensuring no delays in reaching a diagnosis.

Our experienced claims team will guide you through one of our clinical pathways with in-network providers.

Type of cancer	Signs and symptoms to watch out for
Breast cancer	hard, irregular shape lump in the breast or armpit dimpling of the skin on either breast newly inverted nipple discharge from the nipple any unusual change in size or shape of either breast
Bowel cancer	bleeding from your back passage / bottom or blood in your stool without piles / haemorrhoids persistent, unexplained change in bowel habit, including diarrhoea or change in consistency of stool persistent abdominal discomfort, such as cramps, bloating, wind or pain a feeling that your bowel doesn’t empty completely unexplained weight loss
Prostate cancer	Raised PSA level as specified below: age 40-49 >2.5ng/ml age 50-69 >3ng/ml age 70-80 >5ng/ml
Testicular cancer	painless lump or swelling on either testicle pain, discomfort or numbness in either testicle any unusual change in size or shape either testicle
Skin cancer	Any of the following changes to a mole or lesion on the skin: increase in size change of colour >7mm in diameter irregular shape irregular colour inflamed or oozing

Please remember that these symptoms can often be signs of common health issues that are not related to cancer, such as cysts, piles or infection.

If a cancer diagnosis is made, cover will be available as outlined in the cancer cover explained section. One of our nurse case managers will be there to guide you and provide information on options available to you.

As with all healthcare benefits, it’s essential that you contact us before receiving any consultations, diagnostics or treatment to confirm this is eligible and to avoid incurring any unexpected costs. For further advice, or to open a new claim, you can access the Member Zone, the My Healix app or contact us to speak with our experienced claims team.

Musculoskeletal health pathway

Musculoskeletal conditions affect the muscles, bones and joints, and are increasingly common as we age. These conditions can cause pain and discomfort causing impact to daily activities, however, early diagnosis and intervention can help ease symptoms and speed up recovery.

With this in mind, we've designed the Healix musculoskeletal pathway to provide timely and effective support.

How to make a claim

If you experience bone or joint pain, you can quickly access our digital physiotherapy triage service. Simply log into the Member Zone or the My Healix app, where you'll be directed to start your online journey. This service is available to all members over the age of 16.

Download the My Healix app

Access the Member Zone

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

This digital service is designed to assess your needs and guide you toward the best course of recovery.

Where self-managed care is appropriate, you will gain immediate access to a tailored exercise program, with in-app access to a clinician when required.

If face-to-face physiotherapy is recommended, you will be guided to physiotherapy with one of our network providers. These sessions will not be subject to an excess, your scheme underwriting, or any benefit limits (if applicable) when accessed through our digital pathway provider, however, all other healthcare scheme terms and conditions will apply.

Telephone assessment

If you are unable to access the Member Zone or the My Healix app, contact us to arrange a telephone-based clinical assessment. Our experienced claims team will take your details and arrange an initial telephone consultation with a physiotherapist at a convenient time for you, who will then recommend the most appropriate pathway.

The telephone-based clinical assessment will not be subject to an excess, but this will be applied to face-to-face physiotherapy if required. All other healthcare scheme terms and conditions will apply.

Mental health pathway

The importance of mental health and wellbeing is increasingly recognised in today’s busy world. Acknowledging feelings of stress, anxiety or other mental health challenges and seeking help are essential first steps towards developing coping strategies and reaching recovery.

If you're experiencing stress, anxiety, depression or any other mental health issues, the scheme provides several support options outlined below.

How to make a claim

Members are able to access a digital emotional wellness triage and receive immediate advice via the Member Zone or the My Healix app. This service is designed to provide an initial assessment of your mental health needs and direct you to the most appropriate mental health treatment pathway. This service is available for everyone over the age of 16.

Download the My Healix app

Access the Member Zone

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

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

If face-to-face mental health treatment is recommended, you will be directed into an initial episode of mental health treatment with our network provider. This will not be not be subject to an excess, your scheme underwriting, or any benefit limits (if applicable).

Should additional sessions be needed beyond the initial episode, the healthcare scheme terms and conditions, including excess, will apply.

Telephone assessment

If you are unable to access the Member Zone or the My Healix app, you can contact us for support and advice. There is no need to see your GP or obtain a referral letter unless you are under the age of 18*.

Our experienced claims team will take your details and arrange an initial telephone consultation with a senior psychological therapist at a convenient time for you. This consultation will allow you to discuss your concerns and determine the most suitable mental health treatment pathway, which may include:

face-to-face cognitive behavioural therapy (CBT)
guided online CBT
counselling
referral onwards to see a psychiatrist

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

The telephone-based clinical assessment will not be subject to an excess, but this will be applied to face-to-face mental health treatment if required. All other healthcare scheme terms and conditions will apply.

*Under 18s will require a referral letter from a GP or specialist.

Digital skin pathway

Changes in your skin can be concerning, though most are not cancer-related. Our digital skin pathway ensures rapid assessment and results, with recommendations for further consultations, diagnostics and treatment as needed, depending on your diagnosis. Any subsequent cover will be subject to the healthcare scheme terms and conditions.

This pathway is suitable for a variety of skin conditions, and our experienced claims team can guide you to the most appropriate pathway based on your symptoms.

The table below outlines the skin complaints best suited for referral into our digital skin pathway.

Skin conditions suitable for the skin pathway	Skin conditions not suitable for the skin pathway
change to an existing mole (itching/bleeding/increase in size) a new skin growth that has appeared and is visible a sore area of skin that has not healed	chronic skin conditions such as eczema/psoriasis new skin rashes mole mapping services required for screening purposes where there is no identifiable area of immediate concern members under the age of 18

How to access the digital skin pathway

Our digital skin pathway is designed to be simple and efficient. Follow the steps below to access fast, expert care:

Step 1

▼

Step 2

You will receive an SMS with a link to register for the service, along with instructions on how to submit your digital photographic images of the affected area

▼

Step 3

Your submitted images will be assessed by our expert dermatology partners within 2 working days

▼

Step 4

You will be notified via SMS when your results are ready, with a link to access the report containing the diagnosis and any recommended diagnostics or treatment

▼

Step 5

If a face-to-face consultation with a dermatologist is recommended, our dermatology partners will assist you in arranging an appointment at a convenient time and location for you

Pathway

Please note, face-to-face consultations with dermatologists within our network will not be subject to our reasonable and customary fees. If you choose see a specialist outside our network, these fees will apply.

Section 9: Glossary

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

Prosthesis, Prostheses

– artificial body part(s) or device(s) which is inserted during surgery.

Acute condition

Annual renewal date

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

Scheme Benefit, Scheme Benefits

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

Biological therapies

Cancer

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

Chronic condition

- any medical condition which has at least one of the following characteristics:

requires ongoing or long-term monitoring through consultations, examinations, check-ups and / or tests
needs ongoing or long-term control or relief of symptoms
requires rehabilitation or for you to be specially trained to cope with it
continues indefinitely
has no known cure, or
comes back or is likely to come back.

Complementary practitioner

Day case

- treatment which requires occupation of a hospital bed for one day (not overnight)

Dependant, Dependants

- an employee's spouse, or the person the member lives with in a relationship similar to that of spouse, regardless of their gender.

- a employee's unmarried dependant children

Dialysis

- the removal of waste matter from the blood by either:

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

Disorder

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

Emergency

Employer

- ABC who is named as your employer

End of life care

Gender Dysphoria

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

General Practitioner, GP

- a registered medical practitioner in general practice.

High dependency unit, Intensive care

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

High-risk activities

Home healthcare

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

Hospital, Hospitals

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

Inpatient

- treatment which requires occupation of a hospital bed for one night or more.

Intensive care unit

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

Medical condition, Medical conditions

– any physical, mental or psychological disorder, including disease, illness, injury, genetic disorders and behavioural conditions.

Medically necessary

– treatment that is considered to be:

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

Mental health condition

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

Outpatient

- treatment that does not require occupation of a hospital bed

Partner, Partner's

- an employee's spouse, or the person the member lives with in a relationship similar to that of spouse, regardless of their gender.

Physiotherapist

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

Pre-existing condition

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

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

Private ambulance

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

Psychological therapist

- we recognise the following as psychological therapists.

a psychologist who is:

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

a therapist who is:

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

Registered nurse

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

Related condition

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

Specialist, Specialist's

- we consider a specialist to be:

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

and

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

Start date

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

Surgical appliance

– an artificial device or an artificial body part which is intended as an alternative to surgical treatment or a necessary part of your treatment following surgery

Practitioner

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

an occupational therapist
an orthoptist
a podiatrist
a speech and language therapist
a dietician
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

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

Trustee, Trustees

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

United Kingdom

- England, Scotland, Wales and Northern Ireland.

Waiting Period

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

You, Your, You're, You've, You'll

- the eligible member

Pandemic

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

Epidemic

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

Diagnostic, Diagnostics

- outpatient and day case diagnostic tests included but not limited to scans, blood tests and diagnostic procedures used to reach a diagnosis of an illness or injury

Member Zone

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

Member, Members

- a person / people covered under the scheme.

Scheme lifetime

- the total time you are an active member of the scheme.

Scheme, The Scheme

- your employer's corporate healthcare scheme

Supportive Therapies

Neurodevelopmental disorder, Neurodevelopmental disorders

We, Us, Our, We're, We've, We'll

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

Mental health treatment

- consultations, therapies and treatment to manage and improve mental health and wellbeing

Benefits

- medical services and treatments that are eligible for cover as part of your membership of the healthcare scheme, subject to all healthcare scheme terms and conditions

Main member, Main members

- the employee eligible to enrol into the healthcare scheme

Fertility treatment, Fertility treatments

- consultations and treatment to assist individuals trying to conceive a child where a reproductive challenge has been identified

Cancer treatment

- consultations, diagnostics, therapies and treatment for the symptoms of cancer and to eliminate malignant tissue / cells following diagnosis

Neurodevelopmental disorder treatment, Neurodevelopmental disorder treatments

- consultations, therapies and treatment to manage and improve the symptoms of a neurodevelopmental disorder following diagnosis

Emergency treatment

- treatment required immediately, generally within hours of onset, for a serious medical condition or symptoms resulting from a disease, illness or injury which puts your health at risk

Addiction treatment programme

- a treatment programme created to assist individuals in achieving long-term recovery for a drug or alcohol addictive disorder

Treatment date

- the day on which your eligible consultation, diagnostics, therapy or treatment takes place

Experimental treatment

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

Private hospital, Private hospitals

NHS hospital, NHS hospitals

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

Dependant child, Dependant child's, Dependant children, Dependant children's

- a employee's unmarried dependant children

Emergency repatriation

- returning individuals to their home country or place of origin due to urgent or unforeseen circumstances, such as medical emergencies, natural disasters, or political instability.

Employee Assistance Program (EAP)

ABC employees have access to an Employee Assistance Programme (EAP) XXX through XXX.

Details on how to access this service and how to register for an account (if required) are listed below; please have this ready when accessing the service.

How to access: Search for XXX in Google Play or the App Store / URL
Access Code:
Telephone Number:

This service is not provided through Healix. For any queries, please contact XXX, on 0000 000 0000 or the ABC team.

Virtual GP - NON HEALIX

ABC employees have access to a virtual GP service called XXXX, provided by XXXX.

Details on how to access this service and how to register for an account (if required) are listed below; please have this ready when accessing the service.

How to access: Search for XXX in Google Play or the App Store / URL
Access Code:
Telephone Number:

This service is not provided through Healix. For any queries, please contact XXX, on 0000 000 0000 or the ABC team.

If XXXXX make an onward referral, we can accept this in place of a referral from your NHS GP, provided that their recommendation is eligible. Contact us to confirm eligibility.

Section 9: Glossary

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

Prosthesis, Prostheses

– artificial body part(s) or device(s) which is inserted during surgery.

Acute condition

Annual renewal date

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

Scheme Benefit, Scheme Benefits

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

Biological therapies

Cancer

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

Chronic condition

- any medical condition which has at least one of the following characteristics:

requires ongoing or long-term monitoring through consultations, examinations, check-ups and / or tests
needs ongoing or long-term control or relief of symptoms
requires rehabilitation or for you to be specially trained to cope with it
continues indefinitely
has no known cure, or
comes back or is likely to come back.

Complementary practitioner

Day case

- treatment which requires occupation of a hospital bed for one day (not overnight)

Dependant, Dependants

- an employee's spouse, or the person the member lives with in a relationship similar to that of spouse, regardless of their gender.

- a employee's unmarried dependant children

Dialysis

- the removal of waste matter from the blood by either:

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

Disorder

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

Emergency

Employer

- ABC who is named as your employer

End of life care

Gender Dysphoria

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

General Practitioner, GP

- a registered medical practitioner in general practice.

High dependency unit, Intensive care

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

High-risk activities

Home healthcare

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

Hospital, Hospitals

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

Inpatient

- treatment which requires occupation of a hospital bed for one night or more.

Intensive care unit

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

Medical condition, Medical conditions

– any physical, mental or psychological disorder, including disease, illness, injury, genetic disorders and behavioural conditions.

Medically necessary

– treatment that is considered to be:

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

Mental health condition

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

Outpatient

- treatment that does not require occupation of a hospital bed

Partner, Partner's

- an employee's spouse, or the person the member lives with in a relationship similar to that of spouse, regardless of their gender.

Physiotherapist

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

Pre-existing condition

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

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

Private ambulance

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

Psychological therapist

- we recognise the following as psychological therapists.

a psychologist who is:

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

a therapist who is:

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

Registered nurse

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

Related condition

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

Specialist, Specialist's

- we consider a specialist to be:

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

and

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

Start date

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

Surgical appliance

– an artificial device or an artificial body part which is intended as an alternative to surgical treatment or a necessary part of your treatment following surgery

Practitioner

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

an occupational therapist
an orthoptist
a podiatrist
a speech and language therapist
a dietician
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

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

Trustee, Trustees

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

United Kingdom

- England, Scotland, Wales and Northern Ireland.

Waiting Period

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

You, Your, You're, You've, You'll

- the eligible member

Pandemic

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

Epidemic

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

Diagnostic, Diagnostics

- outpatient and day case diagnostic tests included but not limited to scans, blood tests and diagnostic procedures used to reach a diagnosis of an illness or injury

Member Zone

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

Member, Members

- a person / people covered under the scheme.

Scheme lifetime

- the total time you are an active member of the scheme.

Scheme, The Scheme

- your employer's corporate healthcare scheme

Supportive Therapies

Neurodevelopmental disorder, Neurodevelopmental disorders

We, Us, Our, We're, We've, We'll

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

Mental health treatment

- consultations, therapies and treatment to manage and improve mental health and wellbeing

Benefits

- medical services and treatments that are eligible for cover as part of your membership of the healthcare scheme, subject to all healthcare scheme terms and conditions

Main member, Main members

- the employee eligible to enrol into the healthcare scheme

Fertility treatment, Fertility treatments

- consultations and treatment to assist individuals trying to conceive a child where a reproductive challenge has been identified

Cancer treatment

- consultations, diagnostics, therapies and treatment for the symptoms of cancer and to eliminate malignant tissue / cells following diagnosis

Neurodevelopmental disorder treatment, Neurodevelopmental disorder treatments

- consultations, therapies and treatment to manage and improve the symptoms of a neurodevelopmental disorder following diagnosis

Emergency treatment

- treatment required immediately, generally within hours of onset, for a serious medical condition or symptoms resulting from a disease, illness or injury which puts your health at risk

Addiction treatment programme

- a treatment programme created to assist individuals in achieving long-term recovery for a drug or alcohol addictive disorder

Treatment date

- the day on which your eligible consultation, diagnostics, therapy or treatment takes place

Experimental treatment

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

Private hospital, Private hospitals

NHS hospital, NHS hospitals

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

Dependant child, Dependant child's, Dependant children, Dependant children's

- a employee's unmarried dependant children

Emergency repatriation

- returning individuals to their home country or place of origin due to urgent or unforeseen circumstances, such as medical emergencies, natural disasters, or political instability.

Making a claim

Healthcare benefits

You can register your claim easily through the Member Zone or the My Healix app. Alternatively, you can contact us to check if your condition or referral is eligible under the terms and conditions of the scheme.

When opening a new claim, we may request a copy of your GP referral letter to allow us to accurately assess your claim.

It's essential that you contact us before receiving any consultations, diagnostics and treatment to confirm it's eligible.

Download the My Healix app

Access the Member Zone

Click here to access the Member Zone

Please note, all members over the age of 16 will need to register for their own account to comply with GDPR requirements. Dependants under the age of 16 will have their details linked to the main members account.

Contact the claims helpline:

0208 123 4567
Monday-Friday 08.00-19.00 (Excl. bank holidays)
Saturday 09.00-13.00

We will confirm:

whether your proposed treatment (including consultations, diagnostics and therapies) is eligible for cover under the scheme.
whether the costs will be covered.
any benefit limits or excess that may apply to your claim.

To assist you, we have provided a helpful how to claim summary.

Pay and claim benefits

When submitting a claim for these benefits, you are required to complete a claim form. This can be completed online via the Member Zone or the My Healix app. All reimbursement claims must be submitted within six months of the treatment date.

Pay and claim benefits include:

Optical
Dental
Dental trauma
Consultation
Therapies (physiotherapy, acupuncture, chiropractic and osteopathy)
Chiropody

Refer to the how to claim a reimbursement section, for further information.

How to claim summary

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

▼

If your GP refers you onto a specialist or therapist

▼

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

▼

Log your claim via the Member Zone, the My Healix app or contact us

▼

Log your claim via the Member Zone, the My Healix app or contact us

▼

Log your claim via the Member Zone, the My Healix app or contact us

▼

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

▼

We will advise on cover available, and authorise eligible treatment

▼

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

▼

If appropriate, we will arrange a physiotherapy referral within 24 hours, through Healix physiotherapy network provider

▼

If appropriate, we will arrange a referral through Healix mental health network provider

▼

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

How to Claim Summary

Your scheme underwriting

Medical History Disregarded (MHD)

No personal medical exclusions are applied to the scheme. However, your eligibility for cover is subject to the terms and conditions of the scheme. Refer to your exclusions and limitations for further information.

Full Medical Underwriting

The scheme is designed to cover new medical conditions that arise after you join. We will not cover treatment (including consultations, diagnostics and therapies) of pre-existing conditions, which means any medical condition for which you:

have sought advice, or
have received medication, or
have received treatment (including consultations, diagnostics or therapies), or
have had symptoms (whether the condition was diagnosed or not)

You will need to complete a Medical History Questionnaire, which will be assessed, and any exclusions or restrictions will be listed on your membership certificate. If you have any queries, contact us.

Continued Personal Medical Exclusions (CPME)

If you were a member of the scheme whilst it was administered by another provider, we may agree to transfer your existing cover and apply the same underwriting terms. Any personal medical exclusions applied to your previous cover by your previous provider will be transferred to the new scheme.

Fixed Moratorium Underwriting

The scheme is designed to cover new medical conditions that arise after you join. We will not cover treatment (including consultations, diagnostics and therapies) of a pre-existing condition, which means any medical condition for which you:

have sought advice, or
have received medication, or
have received treatment (including consultations, diagnostics or therapies), or
have had symptoms (whether the condition was diagnosed or not), or
were (to the best of your knowledge) aware existed in the five years before joining the scheme

Pre-existing conditions may become eligible for cover after two years, provided that during this time you have not received medication, treatment (including consultations, diagnostics or therapies), had symptoms, or sought advice for that condition.

If a pre-existing condition does become eligible for cover, this cover is subject to the terms and conditions of the scheme. Refer to your exclusions and limitations for further information.

Rolling Moratorium Underwriting

have sought advice, or
have received medication, or
have received treatment (including consultations, diagnostics or therapies), or
have had symptoms (whether the condition was diagnosed or not), or
were (to the best of your knowledge) aware existed in the five years before joining the scheme

Pre-existing conditions may become eligible for cover after a continuous two-year period without medication, treatment (including consultations, diagnostics or therapies), had symptoms, or sought advice for that condition.

If a pre-existing condition does become eligible for cover, this cover is subject to the terms and conditions of the scheme. Refer to your exclusions and limitations for further information.

Your excess

Per scheme year excess

All members are liable for an excess of £XXX, payable once per scheme year if you make an eligible claim.

The excess will be applied to the first eligible authorisation issued to you each scheme year, regardless of when the last excess payment was made. This applies whether the authorisation is for the same condition, a related condition, or for an entirely new condition.

To ensure clarity, contact us before receiving any treatment (including consultations, diagnostics or therapies) to confirm when the excess will apply.

Rolling excess

All members are liable for a rolling excess of £XXX, payable once every twelve months if you make an eligible claim.

This rolling excess applies to the first eligible authorisation issued to you after joining the scheme, and will then apply once every twelve months, regardless of whether the authorisation is for the same condition, a related condition, or for an entirely new condition.

To ensure clarity, contact us before receiving any treatment (including consultations, diagnostics or therapies) to confirm when the excess will apply.

Per claim excess

All members are liable for an excess of £XXX, payable once per eligible claim.

The excess will be applied to the first eligible authorisation issued to you for each claim you open whilst you are a member of the scheme.

To ensure clarity, contact us before receiving any treatment (including consultations, diagnostics or therapies) to confirm when the excess will apply.

Per claim, per scheme year excess

All members are liable for an excess of £XXX, payable once per eligible claim, per scheme year.

The excess will be applied to the first eligible authorisation you receive for each claim you open whilst you are a member of the scheme.

The excess will reapply to the first eligible authorisation you receive each scheme year for all ongoing claims, regardless of when the last excess payment for each claim was made.

To ensure clarity, contact us before receiving any treatment (including consultations, diagnostics or therapies) to confirm when the excess will apply.

Co-payment

All members and dependants are liable for a co-payment of XX% across all benefits up to a maximum of £XXX per scheme year, when you make an eligible claim.

This co-payment will be applied to the first eligible authorisation issued to you each scheme year. This is regardless of when the last co-payment was made and whether the authorisation is for the same condition, a related condition, or for an entirely new condition. Once the maximum co-payment amount is reached, any further authorisations will be paid in full, subject to any benefit limits.

To ensure clarity, contact us before receiving any treatment (including consultations, diagnostics or therapies) to confirm when the co-payment will apply.

Excess / Co-payment exemptions

Please note that your excess / co-payment does not apply to:

cash benefits
telephone triage appointments arranged by us
digital triage services

Hospital cover

Open network

The scheme offers an open network, which allows you to attend a hospital of your choice.

For assistance in finding a hospital or specialist, you can use our provider finder.

Please note, our reasonable and customary fees will apply to specialist services.

It is important that you contact us before receiving any consultations, diagnostics or treatment to confirm it's eligible for cover under the scheme.

Restricted network

The scheme covers most hospitals throughout the UK. However, there are some hospitals where treatment (including consultations, diagnostics and treatment) is excluded from cover.

Below is a list of hospitals not covered under the scheme:

[List of all hospitals which are excluded]

If you have any queries about this list, or your chosen hospital or clinic, contact us.

Please note, our reasonable and customary fees will apply to specialist services.

It is important that before receiving any consultations, diagnostics or treatment, you contact us to confirm it's eligible for cover and the hospital, clinic or specialist are covered under the scheme.

Reasonable and customary fees

We apply a schedule of reasonable and customary (R&C) fees for specialist services. These fees are aligned with the common codes and principles set out by the Clinical Classification and Schedule Development (CCSD) group. Our fee levels are carefully reviewed, based on what the majority of specialists charge for medical and surgical services, and are validated by our clinical support team, and panel of specialist advisors.

If you choose a specialist who charges above our fee schedule, you have the option to either pay the difference yourself or we can help identify an alternative specialist who charges within the approved free schedule.

Refer to our fee schedule or contact us for further information.

What happens in an emergency?

Most private hospitals are not equipped for emergency admissions. In the event of an emergency you should:

call for an NHS ambulance
visit the accident and emergency (A&E) department at your local NHS hospital

If you wish to be transferred to a private hospital after receiving emergency care, contact us to discuss your options. We will confirm if your proposed treatment is eligible under the scheme.

What is not covered :

emergency treatment costs at a private walk-in centre, A&E department, or clinic
costs for intensive care or a high dependency unit if transferred to a private hospital specifically for this care
transfer costs to a private hospital to receive treatment in an intensive care or high dependency unit

Exclusions and limitations

The following conditions and items are not eligible for cover under your scheme. If you have any queries, please contact us.

Exclusions and limitations

Ageing, menopause and puberty

We do not cover any consultations, diagnostics or treatment to relieve symptoms commonly associated with, or caused by, ageing, puberty or other natural physiological causes.

Exception: we cover remote consultations and diagnostics with our in-network experts in women’s or men's health, as outlined in your table of benefits.

Alcohol abuse, substance abuse and addiction

We do not cover any consultations, diagnostics or treatment required for alcohol, solvent or drug abuse, or any treatment arising from such abuse or addiction. This includes mental health treatment.

Exception: we cover one addiction treatment programme per scheme lifetime under the inpatient mental health benefit, as outlined in your table of benefits.

Allergies and allergic disorders

We do not cover any consultations, diagnostics or treatment to desensitise or neutralise any allergic condition or disorder.

Appliances, physical aids and devices

We do not cover the supply or fitting of any appliances, physical aids or devices including but not limited to; hearing aids, spectacles, contact lenses, external prostheses and orthotics, unless it falls within our definition of a surgical appliance. Any consultations relating to these are also not covered.

Exception: we cover medically necessary orthotics as outlined in your table of benefits.

Birth control & contraception

We do not cover any consultations, diagnostics or treatment relating to:

birth control
sterilisation and / or reversal, or
termination of pregnancy

Exception: we cover remote consultations and diagnostics with our in-network experts in women’s or men's health, as outlined in your table of benefits.

Chronic conditions

We do not cover any consultations, diagnostics or treatment related to chronic conditions that require ongoing care. A chronic condition is defined as a medical condition with at least one of the following characteristics:

requires ongoing or long-term monitoring through consultations, examinations, check-ups and / or tests
needs ongoing or long-term control or relief of symptoms
requires rehabilitation or for you to be specially trained to cope with it
continues indefinitely
has no known cure, or
comes back or is likely to come back.

This will apply to all medical conditions, whether or not a diagnosis has been made.

Exception: we cover eligible treatment (including consultations, diagnostics and therapies) arising out of a chronic condition, or treatment of acute symptoms of a chronic condition that flare-up. Such treatment will only be covered if it 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 this long-term. For example, we pay for treatment following a heart attack which is the result of chronic heart disease. This exception does not apply to mental health conditions.

In some cases, it may not be immediately clear that the disease, illness or injury being treated is a chronic condition. In such situations, even if we have previously paid for treatment, we are not obliged to cover the ongoing costs of continuing, or similar, treatment.

This exclusion does not apply to cancer treatment.

Exception: we cover consultations, diagnostics and treatment of chronic conditions as outlined in your table of benefits.

Complications from excluded/restricted conditions or treatment

We do not cover any consultations, diagnostics or treatment which arise from, or are related to any exclusion listed in this scheme guide.

Furthermore, treatment arising from or related to treatment that is not covered by the scheme will not be eligible for cover.

Contamination, wars, riots and terrorist acts

We do cover any consultations, diagnostics or treatment for medical conditions caused by or contributed to by nuclear, radioactive, biological or chemical contamination, or any of the following:

wars (whether declared or not)
act of foreign enemies
riots
revolutions
invasions
civil wars
rebellions
insurrections
overthrowing of a legally constituted government
explosions of war weapons
terrorist acts, or
military activity

Furthermore, consultations, diagnostics or treatment of any medical condition received while you are carrying out army, naval or air services duties will not be covered.

Convalescence, rehabilitation and general nursing care

We do not cover consultations, diagnostics or treatment if it is primarily used for any of the following purposes:

convalescence or rehabilitation (including therapy)
general nursing care for domestic and / or social reasons

Exception: we cover up to 28 days of inpatient, day case or outpatient rehabilitation following eligible treatment when this is aimed at restoring health or mobility with the goal of returning you to independent living. Rehabilitation must be recommended by a specialist, be an integral part of eligible treatment and take place within 12 months of you being deemed medically fit by your specialist to begin.

Cosmetic

We do not cover any consultations, diagnostics or treatment where the aim is to change your appearance, even when required for psychological reasons.

Treatment is not covered where:

the intention, whether directly or indirectly, is the reduction or removal of healthy, surplus or fat tissue - for example, weight reduction surgery / treatment
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 cover medically necessary treatment to restore your appearance in the following circumstances:

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

Please note, we use clinical guidance as a benchmark to assess eligibility for cover under these exceptions. All requests for cover must be submitted in writing along with supporting medical information.

Dental or oral

We do not cover any consultations, diagnostics or treatment when relating to dental or oral conditions.

Exception: we cover eligible treatment related to the following specified oral surgical operations only, when treatment is carried out by a specialist:

surgical removal of 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 abscess
reimplantation of a natural tooth that has been knocked out or dislodged in an accident
treatment of facial and mandibular fractures

Dialysis

We do not cover any consultations, diagnostics or treatment for or associated with dialysis.

Exception: we may cover dialysis that is required in the short-term following a complication of eligible treatment.

Drugs and dressings for outpatient or take-home use

We do not cover drugs and dressings provided or prescribed for take home use.

Exception: we may cover outpatient drugs and dressings when required as part of eligible cancer treatment. Refer to the cancer cover explained section for further information.

Emergency treatment in the UK

We do not cover any costs for:

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

End of life care (terminal care)

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

Experimental drugs and treatment

We do not cover any diagnostics or treatment (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 has 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

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

Eyesight correction

We do not cover any consultations, diagnostics or treatment to correct your eyesight due to long or short sightedness, including but not limited to; laser eye surgery, spectacles or contact lenses.

Exception: we cover eligible treatment to the eye resulting from an acute condition or injury.

Fertility

We do not cover any consultations, diagnostics or treatment relating to:

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

Exception: we cover remote consultations and diagnostics with our in-network experts in women’s or men's health, as outlined in your table of benefits. We also cover fertility treatment as outlined in your table of benefits. Refer to the fertility treatment explained section for further information.

Gender dysphoria

We do not cover any consultations, diagnostics or treatment for, arising from or relating to gender dysphoria.

Exception: we cover gender dysphoria as outlined in your table of benefits. Refer to the gender dysphoria explained section for further information.(only keep where outpatient treatment only is covered)

Remove exclusion completely if covered for for both outpatient and inpatient treatment

General practitioner consultations

We do not cover any GP consultations or visits. Charges for the completion of claim forms or referral letters are also not covered, unless we have requested these specifically to assess your claim.

Exception: we cover virtual GP consultations as outlined in your table of benefits. Refer to the virtual GP section for further information on how to access this.

Hazardous or high-risk activities

We do not cover any consultations, diagnostics or treatment directly or indirectly related to participation in hazardous or high-risk activities.

Holistic and alternative medicine

We do not cover any holistic or alternative medicine or therapies - for example, yoga, massage, spas and health resorts.

Exception: we cover alternative medicine and therapies as outlined in your table of benefits.

Illegal activity

We do not cover any consultations, diagnostics or treatment resulting from:

you carrying out an illegal act
a road accident where you were not wearing a seat belt (as required by law)

Neurodevelopmental disorders

We do not cover any consultations, diagnostics or treatment (including assessment) OR (following diagnosis) of adult or childhood neurodevelopmental disorders.

Remove exclusion completely if covered for for both assessment and treatment.

Obesity

We do not cover any consultations, diagnostics or treatment for the purpose of weight loss, this includes when required as a result of obesity.

Overseas treatment

We do not cover consultations, diagnostics and treatment outside the United Kingdom including evacuation or repatriation.

Exception: we cover overseas emergency treatment (and repatriation or evacuation) as outlined in your table of benefits.

Pandemic and / or epidemic disease

We do not cover any consultations, diagnostics or treatment for or arising from pandemic and / or epidemic disease.

Personal comfort and convenience items

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

Pregnancy and childbirth

We do not cover any consultations, diagnostics or treatment related to pregnancy or childbirth, other than as listed in the exception below.

Exception: we cover eligible treatment related to 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 postnatal depression as outlined in the outpatient mental health treatment benefit in your table of benefits
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 non-pregnancy-related medical conditions that have been made worse by pregnancy.

We will require full clinical details from your specialist to assess cover and eligibility.

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 cover 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 table of benefits and will be subject to the exclusions and limitations listed within the scheme.

Screening and preventative

We do not cover 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 cover consultations, diagnostics or treatment that is:

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

Exception: we may cover preventative cancer treatment. Refer to the cancer cover explained section for further information.

Sexual dysfunction

We do not cover any consultations, diagnostics or treatment for sexual dysfunction, sexually transmitted infections or sexual problems, whatever the cause.

Exception: we cover remote consultations and diagnostics with our in-network experts in women’s or men's health, as outlined in your table of benefits.

Sleep disorders

We do not cover any consultations, diagnostics or treatment for or arising from sleep disorders including but not limited to; sleep apnoea, snoring, insomnia, sleep walking, narcolepsy and night terrors.

Speech disorders

We do not cover any consultations, diagnostics or treatment for or relating to any speech disorder such as stammering.

Exception: we may cover short-term speech therapy for an acute condition immediately following eligible treatment. The speech therapy must be recommended by your treating specialist.

Surrogacy

We do not cover any consultations, diagnostics or treatment required by a mother / birth parent or child as a result of a surrogate pregnancy.

Please note, if the child is accepted as a member of the scheme, they will only be entitled to benefits outlined in the table of benefits and will be subject to the exclusions and limitations listed within the scheme.

Transplants and adoptive cell transfer therapies

We do not cover any transplants, adoptive cell transfer, gene therapies and / or any complications related to, or resulting from these. 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 cover consultations, diagnostics or treatment relating to:

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

Exception: we will cover recipient costs for skin or corneal grafts. We will require full clinical details from your specialist to asses cover and eligibility.

Unrecognised providers

We do not cover any consultations, diagnostics or treatment when they are carried out by:

a provider who we do not recognise as being qualified and / or registered to provide the treatment you need, or to treat the medical condition you have
sports therapists, massage therapists, or anyone who does not meet our definition of a practitioner or complementary practitioner
you, your spouse, parents or children

Section 9: Glossary

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

Prosthesis, Prostheses

– artificial body part(s) or device(s) which is inserted during surgery.

Acute condition

Annual renewal date

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

Scheme Benefit, Scheme Benefits

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

Biological therapies

Cancer

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

Chronic condition

- any medical condition which has at least one of the following characteristics:

requires ongoing or long-term monitoring through consultations, examinations, check-ups and / or tests
needs ongoing or long-term control or relief of symptoms
requires rehabilitation or for you to be specially trained to cope with it
continues indefinitely
has no known cure, or
comes back or is likely to come back.

Complementary practitioner

Day case

- treatment which requires occupation of a hospital bed for one day (not overnight)

Dependant, Dependants

- an employee's spouse, or the person the member lives with in a relationship similar to that of spouse, regardless of their gender.

- a employee's unmarried dependant children

Dialysis

- the removal of waste matter from the blood by either:

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

Disorder

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

Emergency

Employer

- ABC who is named as your employer

End of life care

Gender Dysphoria

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

General Practitioner, GP

- a registered medical practitioner in general practice.

High dependency unit, Intensive care

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

High-risk activities

Home healthcare

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

Hospital, Hospitals

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

Inpatient

- treatment which requires occupation of a hospital bed for one night or more.

Intensive care unit

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

Medical condition, Medical conditions

– any physical, mental or psychological disorder, including disease, illness, injury, genetic disorders and behavioural conditions.

Medically necessary

– treatment that is considered to be:

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

Mental health condition

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

Outpatient

- treatment that does not require occupation of a hospital bed

Partner, Partner's

- an employee's spouse, or the person the member lives with in a relationship similar to that of spouse, regardless of their gender.

Physiotherapist

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

Pre-existing condition

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

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

Private ambulance

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

Psychological therapist

- we recognise the following as psychological therapists.

a psychologist who is:

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

a therapist who is:

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

Registered nurse

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

Related condition

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

Specialist, Specialist's

- we consider a specialist to be:

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

and

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

Start date

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

Surgical appliance

– an artificial device or an artificial body part which is intended as an alternative to surgical treatment or a necessary part of your treatment following surgery

Practitioner

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

an occupational therapist
an orthoptist
a podiatrist
a speech and language therapist
a dietician
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

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

Trustee, Trustees

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

United Kingdom

- England, Scotland, Wales and Northern Ireland.

Waiting Period

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

You, Your, You're, You've, You'll

- the eligible member

Pandemic

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

Epidemic

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

Diagnostic, Diagnostics

- outpatient and day case diagnostic tests included but not limited to scans, blood tests and diagnostic procedures used to reach a diagnosis of an illness or injury

Member Zone

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

Member, Members

- a person / people covered under the scheme.

Scheme lifetime

- the total time you are an active member of the scheme.

Scheme, The Scheme

- your employer's corporate healthcare scheme

Supportive Therapies

Neurodevelopmental disorder, Neurodevelopmental disorders

We, Us, Our, We're, We've, We'll

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

Mental health treatment

- consultations, therapies and treatment to manage and improve mental health and wellbeing

Benefits

- medical services and treatments that are eligible for cover as part of your membership of the healthcare scheme, subject to all healthcare scheme terms and conditions

Main member, Main members

- the employee eligible to enrol into the healthcare scheme

Fertility treatment, Fertility treatments

- consultations and treatment to assist individuals trying to conceive a child where a reproductive challenge has been identified

Cancer treatment

- consultations, diagnostics, therapies and treatment for the symptoms of cancer and to eliminate malignant tissue / cells following diagnosis

Neurodevelopmental disorder treatment, Neurodevelopmental disorder treatments

- consultations, therapies and treatment to manage and improve the symptoms of a neurodevelopmental disorder following diagnosis

Emergency treatment

- treatment required immediately, generally within hours of onset, for a serious medical condition or symptoms resulting from a disease, illness or injury which puts your health at risk

Addiction treatment programme

- a treatment programme created to assist individuals in achieving long-term recovery for a drug or alcohol addictive disorder

Treatment date

- the day on which your eligible consultation, diagnostics, therapy or treatment takes place

Experimental treatment

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

Private hospital, Private hospitals

NHS hospital, NHS hospitals

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

Dependant child, Dependant child's, Dependant children, Dependant children's

- a employee's unmarried dependant children

Emergency repatriation

- returning individuals to their home country or place of origin due to urgent or unforeseen circumstances, such as medical emergencies, natural disasters, or political instability.

End of cover

Cover for the main member will end if:

their employment with ABC has come to an end for any reason
they no longer live full-time in the United Kingdom
they pass away
for any reason they or ABC ask us to end cover
they or any of their dependants have given us misleading information, have kept something from us, or have broken the conditions of this scheme

Please note, if the main members cover ends, their dependants cover will also end on the same day.

Cover for dependants will end in the following situations:

A partner's cover will end if:

they divorce the main member, or their civil partnership with the main member dissolves. Cover for will end as soon as the final decree / final dissolution order has been granted
they no longer live with the main member, then they will no longer be considered a dependant for the purposes of this scheme

All dependant children's cover will end:

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

Main members must inform their HR department as soon as possible of any changes related to this matter.

Please note, if treatment (including consultations, diagnostics and therapies) has been authorised but has not yet taken place, you will be responsible for all costs if the scheme terminates or you leave the scheme.

Continuation option

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

We understand the importance of your healthcare and choosing a new provider may be daunting. We work closely with two providers to offer you 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 customers 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 scheme and are available for a limited time only, usually no more than 30 days from the date of leaving. It is therefore important that you act quickly to maintain continuity of cover.

Healix Health Services Ltd is an introducer appointed representative of 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 occasion, 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 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, or
a response explaining why we are still not in a position to provide a final response and explaining when we believe we will be able to do so

If we are unable to provide a final response, due to the delay which has now occurred, you may refer your complaint to the Trustees.

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

How to claim reimbursement

How to claim for cash benefits

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

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

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

In order to claim these benefits, you must register your claim via the Member Zone or the My Healix app.

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

a copy of your NHS discharge paperwork which should confirm the following information:
- date of admission and discharge from the NHS hospital
- name and date of birth of the person admitted
- summary of the reason for admission and the treatment received
bank details for the reimbursement to be made to:
- account holder’s name
- sort code
- account number

How to claim baby cash benefit

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

Please note, this benefit can only be claimed once per baby or child, even if both parents are covered under the scheme.

In order to claim these benefits, you must register your claim via the Member Zone or the My Healix app.

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

a copy of the full birth or adoption certificate
bank details for the reimbursement to be made to:
- account holder’s name
- sort code
- account number

How to claim reimbursement of medical expenses

If you have paid your treating provider directly for eligible treatment (including consultations, diagnostics and therapies), you can claim reimbursement for these costs as long as it is eligible for cover as outlined in your table of benefits.

In order to claim these benefits, you must register your claim via the Member Zone or the My Healix app.

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

an itemised receipt confirming the following information:
- your treatment date
- details of the treatment (including consultations, diagnostics and therapies) received
- amount paid
bank details for the reimbursement to be made to
- account holder’s name
- sort code
- account number

Important to note:

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

All reimbursement claims (including cash benefits) must be submitted within six months of your treatment date / birth or adoption date.

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

Payment of invoices

It's essential that all treatment (including consultations, diagnostics and therapies) is pre-authorised. This allows us issue a pre-authorisation your treating provider confirming cover under the scheme. This authorisation is subject to any benefit limits outlined in your table of benefits and our reasonable and customary fees.

If pre-authorisation has been issued, we will settle the invoice (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. In these cases please submit a copy of your receipt via Member Zone or the My Healix App, along with your bank account details, and we will arrange reimbursement via direct bank transfer. All reimbursement claims (including cash benefits) must be submitted within six months of your treatment date.

We will not pay for claims if:

the invoice or reimbursement claim (including cash benefits) is not submitted within six months of your treatment date
the treatment (including consultations, diagnostics and therapies) takes place after you have left the scheme
you break any terms and conditions of your membership
you incur a fee for non-attendance or late cancellations.

FAQs

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

For any queries surrounding your membership rates, or how to join the scheme, contact XXXX.

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 condition / treatment (including consultations, diagnostics and therapies) you are claiming for. 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
an independent medical examination or second opinion with an alternative specialist, and the results of this. 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
results of any second opinions provided by alternative specialist you have independently sought. On such occasions, we may also request our own, independent, second opinion from an expert in that field. We will pay the costs of any second opinion we request, this includes the cost of the consultation and any diagnostics undertaken as a result of that consultation

We will liaise with you and your specialist throughout your claim, and will request medical information when we deem this to be necessary for 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 specialist recommends treatment (including further consultations, diagnostics and therapies), you should contact us as soon as possible to be sure this is eligible for cover.

Our experienced claims team will assess the level of cover available to you 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.

Duplicate cover

You must tell us if you are able to make a claim for the cost of any of your treatment (including consultations, diagnostics and therapies) from anyone else, either 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, and you are not at fault, the scheme will only pay a share of the total costs as appropriate.

If benefits are claimed for 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 here.

Section 9: Glossary

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

Prosthesis, Prostheses

– artificial body part(s) or device(s) which is inserted during surgery.

Acute condition

Annual renewal date

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

Scheme Benefit, Scheme Benefits

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

Biological therapies

Cancer

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

Chronic condition

- any medical condition which has at least one of the following characteristics:

requires ongoing or long-term monitoring through consultations, examinations, check-ups and / or tests
needs ongoing or long-term control or relief of symptoms
requires rehabilitation or for you to be specially trained to cope with it
continues indefinitely
has no known cure, or
comes back or is likely to come back.

Complementary practitioner

Day case

- treatment which requires occupation of a hospital bed for one day (not overnight)

Dependant, Dependants

- an employee's spouse, or the person the member lives with in a relationship similar to that of spouse, regardless of their gender.

- a employee's unmarried dependant children

Dialysis

- the removal of waste matter from the blood by either:

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

Disorder

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

Emergency

Employer

- ABC who is named as your employer

End of life care

Gender Dysphoria

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

General Practitioner, GP

- a registered medical practitioner in general practice.

High dependency unit, Intensive care

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

High-risk activities

Home healthcare

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

Hospital, Hospitals

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

Inpatient

- treatment which requires occupation of a hospital bed for one night or more.

Intensive care unit

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

Medical condition, Medical conditions

– any physical, mental or psychological disorder, including disease, illness, injury, genetic disorders and behavioural conditions.

Medically necessary

– treatment that is considered to be:

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

Mental health condition

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

Outpatient

- treatment that does not require occupation of a hospital bed

Partner, Partner's

- an employee's spouse, or the person the member lives with in a relationship similar to that of spouse, regardless of their gender.

Physiotherapist

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

Pre-existing condition

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

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

Private ambulance

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

Psychological therapist

- we recognise the following as psychological therapists.

a psychologist who is:

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

a therapist who is:

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

Registered nurse

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

Related condition

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

Specialist, Specialist's

- we consider a specialist to be:

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

and

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

Start date

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

Surgical appliance

– an artificial device or an artificial body part which is intended as an alternative to surgical treatment or a necessary part of your treatment following surgery

Practitioner

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

an occupational therapist
an orthoptist
a podiatrist
a speech and language therapist
a dietician
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

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

Trustee, Trustees

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

United Kingdom

- England, Scotland, Wales and Northern Ireland.

Waiting Period

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

You, Your, You're, You've, You'll

- the eligible member

Pandemic

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

Epidemic

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

Diagnostic, Diagnostics

- outpatient and day case diagnostic tests included but not limited to scans, blood tests and diagnostic procedures used to reach a diagnosis of an illness or injury

Member Zone

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

Member, Members

- a person / people covered under the scheme.

Scheme lifetime

- the total time you are an active member of the scheme.

Scheme, The Scheme

- your employer's corporate healthcare scheme

Supportive Therapies

Neurodevelopmental disorder, Neurodevelopmental disorders

We, Us, Our, We're, We've, We'll

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

Mental health treatment

- consultations, therapies and treatment to manage and improve mental health and wellbeing

Benefits

- medical services and treatments that are eligible for cover as part of your membership of the healthcare scheme, subject to all healthcare scheme terms and conditions

Main member, Main members

- the employee eligible to enrol into the healthcare scheme

Fertility treatment, Fertility treatments

- consultations and treatment to assist individuals trying to conceive a child where a reproductive challenge has been identified

Cancer treatment

- consultations, diagnostics, therapies and treatment for the symptoms of cancer and to eliminate malignant tissue / cells following diagnosis

Neurodevelopmental disorder treatment, Neurodevelopmental disorder treatments

- consultations, therapies and treatment to manage and improve the symptoms of a neurodevelopmental disorder following diagnosis

Emergency treatment

- treatment required immediately, generally within hours of onset, for a serious medical condition or symptoms resulting from a disease, illness or injury which puts your health at risk

Addiction treatment programme

- a treatment programme created to assist individuals in achieving long-term recovery for a drug or alcohol addictive disorder

Treatment date

- the day on which your eligible consultation, diagnostics, therapy or treatment takes place

Experimental treatment

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

Private hospital, Private hospitals

NHS hospital, NHS hospitals

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

Dependant child, Dependant child's, Dependant children, Dependant children's

- a employee's unmarried dependant children

Emergency repatriation

- returning individuals to their home country or place of origin due to urgent or unforeseen circumstances, such as medical emergencies, natural disasters, or political instability.

The Healix Team

Our experienced claims team are available to advise and help you, and can be contacted via the below:

Tel: 0208 123 4567
Email: abc@healix.com
Our operating hours are: Monday-Friday 08.00-19.00 (Excl. bank holidays) Saturday 09.00-13.00

Please note, telephone calls to and from our organisation are recorded for the purposes of quality and training.

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

Section 9: Glossary

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

Prosthesis, Prostheses

– artificial body part(s) or device(s) which is inserted during surgery.

Acute condition

Annual renewal date

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

Scheme Benefit, Scheme Benefits

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

Biological therapies

Cancer

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

Chronic condition

- any medical condition which has at least one of the following characteristics:

requires ongoing or long-term monitoring through consultations, examinations, check-ups and / or tests
needs ongoing or long-term control or relief of symptoms
requires rehabilitation or for you to be specially trained to cope with it
continues indefinitely
has no known cure, or
comes back or is likely to come back.

Complementary practitioner

Day case

- treatment which requires occupation of a hospital bed for one day (not overnight)

Dependant, Dependants

- an employee's spouse, or the person the member lives with in a relationship similar to that of spouse, regardless of their gender.

- a employee's unmarried dependant children

Dialysis

- the removal of waste matter from the blood by either:

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

Disorder

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

Emergency

Employer

- ABC who is named as your employer

End of life care

Gender Dysphoria

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

General Practitioner, GP

- a registered medical practitioner in general practice.

High dependency unit, Intensive care

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

High-risk activities

Home healthcare

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

Hospital, Hospitals

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

Inpatient

- treatment which requires occupation of a hospital bed for one night or more.

Intensive care unit

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

Medical condition, Medical conditions

– any physical, mental or psychological disorder, including disease, illness, injury, genetic disorders and behavioural conditions.

Medically necessary

– treatment that is considered to be:

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

Mental health condition

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

Outpatient

- treatment that does not require occupation of a hospital bed

Partner, Partner's

- an employee's spouse, or the person the member lives with in a relationship similar to that of spouse, regardless of their gender.

Physiotherapist

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

Pre-existing condition

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

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

Private ambulance

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

Psychological therapist

- we recognise the following as psychological therapists.

a psychologist who is:

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

a therapist who is:

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

Registered nurse

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

Related condition

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

Specialist, Specialist's

- we consider a specialist to be:

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

and

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

Start date

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

Surgical appliance

– an artificial device or an artificial body part which is intended as an alternative to surgical treatment or a necessary part of your treatment following surgery

Practitioner

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

an occupational therapist
an orthoptist
a podiatrist
a speech and language therapist
a dietician
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

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

Trustee, Trustees

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

United Kingdom

- England, Scotland, Wales and Northern Ireland.

Waiting Period

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

You, Your, You're, You've, You'll

- the eligible member

Pandemic

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

Epidemic

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

Diagnostic, Diagnostics

- outpatient and day case diagnostic tests included but not limited to scans, blood tests and diagnostic procedures used to reach a diagnosis of an illness or injury

Member Zone

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

Member, Members

- a person / people covered under the scheme.

Scheme lifetime

- the total time you are an active member of the scheme.

Scheme, The Scheme

- your employer's corporate healthcare scheme

Supportive Therapies

Neurodevelopmental disorder, Neurodevelopmental disorders

We, Us, Our, We're, We've, We'll

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

Mental health treatment

- consultations, therapies and treatment to manage and improve mental health and wellbeing

Benefits

- medical services and treatments that are eligible for cover as part of your membership of the healthcare scheme, subject to all healthcare scheme terms and conditions

Main member, Main members

- the employee eligible to enrol into the healthcare scheme

Fertility treatment, Fertility treatments

- consultations and treatment to assist individuals trying to conceive a child where a reproductive challenge has been identified

Cancer treatment

- consultations, diagnostics, therapies and treatment for the symptoms of cancer and to eliminate malignant tissue / cells following diagnosis

Neurodevelopmental disorder treatment, Neurodevelopmental disorder treatments

- consultations, therapies and treatment to manage and improve the symptoms of a neurodevelopmental disorder following diagnosis

Emergency treatment

- treatment required immediately, generally within hours of onset, for a serious medical condition or symptoms resulting from a disease, illness or injury which puts your health at risk

Addiction treatment programme

- a treatment programme created to assist individuals in achieving long-term recovery for a drug or alcohol addictive disorder

Treatment date

- the day on which your eligible consultation, diagnostics, therapy or treatment takes place

Experimental treatment

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

Private hospital, Private hospitals

NHS hospital, NHS hospitals

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

Dependant child, Dependant child's, Dependant children, Dependant children's

- a employee's unmarried dependant children

Emergency repatriation

- returning individuals to their home country or place of origin due to urgent or unforeseen circumstances, such as medical emergencies, natural disasters, or political instability.

Scheme Year XXXX - changes

The below changes will come into effect following the scheme renewal on 1st MONTH YEAR.

Benefit Name	Previous Benefit Wording	New Benefit Wording

New Benefit Name	Benefit Limit	Benefit Wording

Exclusion Title	Previous Exclusion Wording	New Exclusion Wording

Scheme Year XXXX- no changes (1)

The new scheme year renews on the 1st MONTH YEAR. There will be no changes made to the scheme for this year.

Section 9: Glossary

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

Prosthesis, Prostheses

– artificial body part(s) or device(s) which is inserted during surgery.

Acute condition

Annual renewal date

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

Scheme Benefit, Scheme Benefits

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

Biological therapies

Cancer

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

Chronic condition

- any medical condition which has at least one of the following characteristics:

requires ongoing or long-term monitoring through consultations, examinations, check-ups and / or tests
needs ongoing or long-term control or relief of symptoms
requires rehabilitation or for you to be specially trained to cope with it
continues indefinitely
has no known cure, or
comes back or is likely to come back.

Complementary practitioner

Day case

- treatment which requires occupation of a hospital bed for one day (not overnight)

Dependant, Dependants

- an employee's spouse, or the person the member lives with in a relationship similar to that of spouse, regardless of their gender.

- a employee's unmarried dependant children

Dialysis

- the removal of waste matter from the blood by either:

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

Disorder

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

Emergency

Employer

- ABC who is named as your employer

End of life care

Gender Dysphoria

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

General Practitioner, GP

- a registered medical practitioner in general practice.

High dependency unit, Intensive care

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

High-risk activities

Home healthcare

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

Hospital, Hospitals

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

Inpatient

- treatment which requires occupation of a hospital bed for one night or more.

Intensive care unit

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

Medical condition, Medical conditions

– any physical, mental or psychological disorder, including disease, illness, injury, genetic disorders and behavioural conditions.

Medically necessary

– treatment that is considered to be:

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

Mental health condition

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

Outpatient

- treatment that does not require occupation of a hospital bed

Partner, Partner's

- an employee's spouse, or the person the member lives with in a relationship similar to that of spouse, regardless of their gender.

Physiotherapist

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

Pre-existing condition

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

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

Private ambulance

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

Psychological therapist

- we recognise the following as psychological therapists.

a psychologist who is:

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

a therapist who is:

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

Registered nurse

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

Related condition

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

Specialist, Specialist's

- we consider a specialist to be:

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

and

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

Start date

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

Surgical appliance

– an artificial device or an artificial body part which is intended as an alternative to surgical treatment or a necessary part of your treatment following surgery

Practitioner

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

an occupational therapist
an orthoptist
a podiatrist
a speech and language therapist
a dietician
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

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

Trustee, Trustees

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

United Kingdom

- England, Scotland, Wales and Northern Ireland.

Waiting Period

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

You, Your, You're, You've, You'll

- the eligible member

Pandemic

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

Epidemic

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

Diagnostic, Diagnostics

- outpatient and day case diagnostic tests included but not limited to scans, blood tests and diagnostic procedures used to reach a diagnosis of an illness or injury

Member Zone

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

Member, Members

- a person / people covered under the scheme.

Scheme lifetime

- the total time you are an active member of the scheme.

Scheme, The Scheme

- your employer's corporate healthcare scheme

Supportive Therapies

Neurodevelopmental disorder, Neurodevelopmental disorders

We, Us, Our, We're, We've, We'll

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

Mental health treatment

- consultations, therapies and treatment to manage and improve mental health and wellbeing

Benefits

- medical services and treatments that are eligible for cover as part of your membership of the healthcare scheme, subject to all healthcare scheme terms and conditions

Main member, Main members

- the employee eligible to enrol into the healthcare scheme

Fertility treatment, Fertility treatments

- consultations and treatment to assist individuals trying to conceive a child where a reproductive challenge has been identified

Cancer treatment

- consultations, diagnostics, therapies and treatment for the symptoms of cancer and to eliminate malignant tissue / cells following diagnosis

Neurodevelopmental disorder treatment, Neurodevelopmental disorder treatments

- consultations, therapies and treatment to manage and improve the symptoms of a neurodevelopmental disorder following diagnosis

Emergency treatment

- treatment required immediately, generally within hours of onset, for a serious medical condition or symptoms resulting from a disease, illness or injury which puts your health at risk

Addiction treatment programme

- a treatment programme created to assist individuals in achieving long-term recovery for a drug or alcohol addictive disorder

Treatment date

- the day on which your eligible consultation, diagnostics, therapy or treatment takes place

Experimental treatment

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

Private hospital, Private hospitals

NHS hospital, NHS hospitals

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

Dependant child, Dependant child's, Dependant children, Dependant children's

- a employee's unmarried dependant children

Emergency repatriation

- returning individuals to their home country or place of origin due to urgent or unforeseen circumstances, such as medical emergencies, natural disasters, or political instability.