Introduction

Welcome to the ABC Healthcare Scheme guide.

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

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

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

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

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

Table of benefits

Your scheme benefits are outlined in the table below.

Please note:

An excess will apply to the first eligible treatment you receive each scheme year.
Benefit limits apply to each member or dependent per year, unless otherwise stated.
The total benefit limit per member, per scheme year, is £xxxxxx. Once this limit is reached, no further cover will be provided for that benefit until the scheme renews, unless specified otherwise.

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

Outpatient Investigations and Treatment	Level of cover	Benefit note
Outpatient diagnostic tests, investigations 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	Combined overall annual limit of £1,000	A
Outpatient consultations and diagnostics related to chronic conditions	£500 per scheme year	AB
Neurodevelopmental assessment	Up to £2,500 per scheme lifetime	B
Orthotics	Up to £500 per scheme lifetime	C
Outpatient treatment and (remove if have OPA) surgical procedures	Full cover	D
Outpatient MRI, CT and PET scans on specialist referral	Full cover	E
Inpatient and Daycase Treatment
Specialist fees and hospital charges for inpatient and daycase treatment	Full cover	F
Parent accommodation	Full cover	G
Therapies
In-network physiotherapy (including self-referral)	Full cover	H
Out of network physiotherapy on GP referral	Up to £250 per scheme year	I
Out of network physiotherapy on specialist referral	Full cover	J
Outpatient complementary therapies on GP or specialist referral	Up to £250 per scheme year	K
Mental Health
In-network outpatient mental health treatment	Full cover	L
Out of network outpatient mental health treatment	Up to £1,500 per scheme year	M
Inpatient and daycase mental health treatment	Up to 28 days per scheme year	N
Chronic mental health benefit	Up to £500 per scheme year	O
Cancer Treatment
Cancer treatment	Full cover	P
Cash Benefits
NHS cash benefit	£150 each day or night	Q
NHS cash alternative	Up to 25% of the costs to receive the procedure privately – please contact us to check if your procedure will be eligible	R
NHS cancer cash benefit	£300 each day or night	S
NHS cancer cash benefit for oral chemotherapy and targeted therapies	£600 per month	T
Baby cash benefit	£100 per child	U
Hospice donation	£200 per night	V
Additional Benefits
Fertility investigations	Full cover	W
Fertility treatment	£10,000 per member per scheme lifetime	X
Gender dysphoria	Up to £10,000 per scheme lifetime	Y
Women's and Men's Health Benefit Remote advice service with our in network experts (up to 4 consultations per scheme year) Diagnostic tests and investigations following referral from our in network experts (up to £500 per scheme year) For clients with Syrona Access to Syrona Health to provide support for gender inclusive health journeys across life stages	Limited cover	Z
Private ambulance charges	Full cover	1
Home healthcare	Full cover	2
Overseas emergency treatment	Limited cover	3

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

Note A: Outpatient Investigations and Treatment

Outpatient investigations and treatment

We will cover the following within your overall outpatient limit:

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 and investigations 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 within your overall outpatient limit for self-referred consultations and investigations for specified cancer symptoms.

Please refer to the self-referred cancer benefits page for further information on the 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 detailed in your cancer treatment benefit.

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

Monitoring with a specialist following specified heart surgery

We will pay 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 AB: Outpatient Consultations and Diagnostics Related to Chronic Conditions

We will pay up to £500 per scheme year for outpatient consultations with a specialist following GP referral and outpatient diagnostic tests required to monitor a chronic condition. Once this benefit limit has been reached the chronic condition rule applies as detailed in your exclusions and limitations.

Note B: Neurodevelopmental Assessment

We will pay up to £2,500 per member per scheme lifetime for the assessment of neurodevelopmental disorders following GP or specialist referral. 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 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 investigations, assessments or treatment in the future.

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

Note C: 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 D: 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 E: Outpatient MRI, CT and PET Scans

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

Note F: Specialist Fees and Hospital Charges for Inpatient and Daycase Treatment

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

We will pay hospital charges in full for the following:

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

Note G: Parent Accommodation

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
the treatment the child receives is covered by the scheme

Note H: In Network Physiotherapy

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

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

Please refer to the musculoskeletal pathway for further information.

Note I: Out of Network Physiotherapy on GP Referral

We will pay up to £250 per scheme year for outpatient physiotherapy following GP referral, if treatment takes place outside our physiotherapy network. The physiotherapist must still be recognised by us for benefit purposes.

Note J: Out of Network Physiotherapy on Specialist Referral

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

Note K: Outpatient Complementary Therapies

We will pay up to £250 per scheme year for chiropractic treatment, osteopathy and acupuncture, following GP or specialist referral. You must be referred to a complementary practitioner we have recognised for benefit purposes.

Note L: In-network Outpatient Mental Health Treatment

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

Please refer to the mental health pathway for further information.

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

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

Note M: Out of Network Outpatient Mental Health Treatment

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

Note N: Inpatient and Daycase Mental Health Treatment

We will pay up to a maximum of 28 days per scheme year for eligible inpatient and daycase mental health treatment. All treatment must be under the direct control and supervision of a consultant psychiatrist, and must be authorised by us in advance and in writing.

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

Note O: Chronic Mental Health Benefit

We will pay up to £500 per scheme year for outpatient treatment required as a result of a chronic mental health condition following GP or self-referral*. Please call the claims helpline to speak with one of our advisors for further advice and support on accessing this benefit. All treatment must be pre-authorised to be eligible for cover. This benefit is for outpatient treatment only and is subject to all other terms and conditions.

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

Note P: Cancer Treatment

We will pay for cancer treatment as detailed in the cancer cover explained table.

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

Note Q: NHS Cash Benefit

In the event that you are admitted to an NHS hospital, or you elect to receive free treatment through the NHS we will pay an NHS cash benefit of £150 per night or day, for inpatient or daycase treatment. This benefit will only apply to claims for daycase or inpatient treatment that would otherwise have been eligible for benefit under your scheme.

Note R: NHS Cash Alternative

In the event that you require an eligible 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 S: NHS Cancer Cash Benefit

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

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

Note T: 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 an NHS cancer cash benefit of £600 per month whilst you receive such treatment.

Note U: Baby Cash Benefit

We will pay a cash benefit of £100 per baby/child following birth or adoption, where either one or both parents is a member 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 V: 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 W: Fertility Investigations

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

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

Note X: Fertility Treatment

We will pay up to £10,000 per member per scheme lifetime for fertility treatment as detailed in the 'fertility treatment explained' page.

Note Y: Gender Dysphoria

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

Note Z: 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 on self-referral. This service can be used to discuss any health concern including conditions that are normally excluded for cover such as the menopause, andropause, sexual health concerns, fertility or contraception advice.

Diagnostic tests and investigations following referral from our in network experts

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

Remote consultations, diagnostic tests and investigations will be covered up to the limits described above only. Once the benefit limits have been reached the scheme rules will apply as detailed in your exclusions and limitations.

Please note: additional cover may be available outside of the above limits for eligible claims, please contact the claims helpline for further information.

Please refer to the women’s or men’s health services page for further information on how to access these benefits.

Syrona Health

For more information, please visit the Syrona Health page.

Note 1: 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 2: Home Healthcare

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

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

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

Note 3: Overseas Treatment

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

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

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

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

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

the treatment is eligible for benefit

the treatment is carried out by a specialist who is:

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

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

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

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

The scheme will not pay for:

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

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

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

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

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

Cancer cover explained

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

Your 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 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 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 treatment?	You will be covered in full for eligible treatment: at a hospital we have approved for your treatment and condition at home for treatment that would otherwise have to be delivered in hospital, if your specialist agrees that this is possible and is given by suitably qualified medical staff recognised by us	You will not be covered for: any treatment received in a hospice
What diagnostic tests will I be covered for?	You will be covered in full for: eligible diagnostic tests and any associated consultations with your specialist eligible molecular (genomic) tests that are needed to see if a particular treatment will be suitable for you CT, MRI and PET scans that take place in a hospital or specialist cancer centre	You will not be covered for any diagnostic tests that are: arranged by anyone other than your specialist not considered standard treatment in the UK designed to find out whether you are likely to get cancer or not considered to be part of normal preventative treatment
Will I be covered for surgery?	You will be covered in full for: surgery to diagnose cancer surgery to remove cancer reconstructive surgery following removal of a 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 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 tests, procedures or treatment and we will need full clinical details from your specialist before we can give our decision.	You will not be covered for any preventative treatment, including: 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 drug treatments will I be covered for?	You will be covered in full for: drug treatments for cancer (such as chemotherapy drugs, hormone therapies and biological therapies) where the drug is being recommended within its license indication drug treatments (such as anti-sickness drugs and antibiotics) to help with the side-effects of cancer treatment	You will not be covered for: any drug treatments that can be prescribed by your GP and do not require specialist supervision drug treatments which are: experimental or being administered as part of a clinical trial not licensed to treat your condition
Will I be covered for radiotherapy?	You will be covered in full for radiotherapy, including when given for pain relief.	You will not be covered for radiotherapy that is: not recommended by NICE for clinical effectiveness experimental
Will I be covered for end of life care?		You will not be covered for: end of life care, treatment given solely to relieve symptoms at the end stage of cancer
What cover will be available for routine monitoring when treatment has finished?	You will be covered for follow-up tests and specialist consultations to monitor you once you have completed treatment for a cancer. No time limits are placed on follow up tests and consultations as long as these are medically necessary and your specialist confirms this in writing.
What other benefits and services are available?	You will be covered for: eligible treatment you may need following treatment for cancer, such as consultations with a dietician, stoma or specialist nurse eligible complementary therapies if your specialist has recommended these in conjunction with treatment for cancer eligible mental health treatment if your specialist has recommended this in conjunction with treatment of cancer private ambulance charges eligible home nursing Please note that these are subject to any limits as detailed 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 treatments. This includes, but is not limited to CAR T cell therapy, tumour infiltrating lymphocyte therapy and stem cell/bone marrow treatments. You will also not be covered for: • donor costs • harvesting • storage • administration • and/or any complications/treatment arising from any of the above the cost of any experimental treatment, even where this is recommended by your specialist and there is no alternative conventional treatment available. If you have chosen to receive experimental treatment, you will not be covered for any complications you may develop following this experimental treatment. any costs associated with harvesting of eggs or sperm, their storage and any associated costs
Are there any other supportive benefits available?	You also have access to a comprehensive support platform delivered by Perci Health to provide you with additional support for the psychological, physical and practical impacts of cancer when it is needed most. For further information please see the your cancer support explained page.

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 treatments for cancer?
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 your scheme excess, underwriting, or benefit limits.

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

To learn more or get started, visit the ‘Your Cancer Support’ tile in the Member Zone or access it via the 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 assessors are here to guide you through the available treatment options and support you during your 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 healthcare scheme and under the age of 43.

Summary of benefits	What is covered
Who can receive treatment?	You will be covered within the benefit limit for fertility treatment providing you are a member of the healthcare scheme and under the age of 43 years. You must be under the age of 43 at the beginning of each individual treatment cycle. Should you turn 43 during treatment, cover will be available up to the end of the current treatment cycle only.
When is cover eligible from?	You will be covered within the benefit limit for ART after completion of a 12 month waiting period which starts from the date you join the healthcare scheme.
Where am I covered to receive treatment?	You will be covered within the benefit limit for treatment in the UK at a facility approved for use and licensed by the HFEA (Human Fertilisation and Embryology Authority)
What treatments am I covered for?	You will be covered within the benefit limit for 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 assisted reproductive technology (ART) treatment including: IUI (intrauterine insemination) IVF (In vitro fertilisation) ICSI (Intracytoplasmic Sperm Injection) FET (Frozen embryo transfers) These treatments will be eligible for cover where treatment has been recommended by a specialist You will also be covered for: Consultations with a fertility specialist Diagnostic tests recommended by the specialist Fertility drugs to stimulate ovulation Consultations and diagnostic tests to assess response to fertility drugs Daycase admission for egg retrieval Fertilisation of eggs Admission for embryo transfer Fertility drugs to support pregnancy following embryo transfer Ultrasound scan to ascertain viable pregnancy HFEA fee Most fertility treatment costs are attributed to the female. As a male claimant you will be eligible for the following treatment: Consultations Diagnostic tests 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 ART 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 medicine 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 ART with the use of a surrogate.
Am I covered for the cost of freezing resultant embryos following IVF treatment?	You will be covered within the benefit limit for the costs of embryo freezing for a total of 12 months following a cycle of IVF – after which time any further costs associated with the continued storage of embryos will no longer be eligible for cover
When does cover end?	Cover for ART will end at the point that a viable pregnancy is confirmed by ultrasound scan or when the benefit limit has been reached, whichever is reached soonest. Once a pregnancy has been confirmed, any further scans or pregnancy related treatment will need to be taken on the NHS and the pregnancy exclusion would apply
Am I covered for treatment ‘add ons’ recommended by the clinic?	You will be covered within the benefit limit for the cost of treatment ‘add ons’ only where there is adequate evidence as to their effectiveness as defined by the HFEA.
Am I covered to freeze my eggs / sperm to use at a later time in life?	You will not be covered for the cost of egg or sperm freezing in order to preserve fertility for use at a later time in life.
Are same sex couples and individuals not in a partnership eligible for ART?	You will be covered within the benefit limit for treatment recommended by a specialist, however, the costs of the associated donor sperm or eggs required to achieve a pregnancy will not be eligible for cover.
Can I continue treatment that I started through self-pay prior to joining the healthcare scheme?	You will be covered within the benefit limit for the continuation of eligible pre-paid treatment. 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 detailed 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 detailed in your table of benefits.
Am I covered for multi-cycle treatment packages?	You will be covered within the benefit limit for the cost of single cycle treatment only. We are unable to cover ‘multi-cycle package’ costs that may not be used.
Do I need to self-pay for treatment	You may be required to self-pay for treatment at a fertility clinic where they are unable to accept payment from Healix. Eligible treatment can then be reimbursed from Healix as long as this is requested within 6 months of the treatment date. Reimbursement can only be made after the 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 your 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 member, per scheme year.

For further help and support, please contact our claims helpline.

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

Second medical opinion

If you would like to receive a second medical opinion to feel confident with your specialist’s recommendations, please contact our claims helpline 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 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 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, or your access code: XXXXXX

If YourHealth247 refers you to a specialist, please contact us via the claims helpline to confirm if the referral is eligible under your scheme. Onward referrals are subject to your scheme’s underwriting, any personal exclusions, and general scheme exclusions. If additional information about your medical history is needed, we may require your consent to contact your NHS GP.

Overseas emergency treatment

Please note that this scheme is NOT a substitute for an overseas travel insurance policy.

The treatment available for emergencies overseas 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 your available annual limits as set out in the 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 these eligible costs incurred abroad in pounds sterling using a suitable exchange rate which we will decide providing:

the treatment is eligible for benefit;
the treatment is carried out by a consultant, 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 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;
the treatment facility is specifically recognised or registered under the laws of the territory in which it stands for providing the treatment delivered, and the treatment costs are covered under your scheme.

If you require treatment abroad you will need to pay and claim for these costs, therefore it is important that you contact the Healix team by following the process detailed in the How To Claim Summary at the earliest opportunity, to ensure that you do not incur costs that cannot be reclaimed.

We will only accept original bills, we cannot accept photocopies. Failure to submit original invoices within six months of the date of treatment 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 need treatment or thought you might.

The scheme will not pay for some expenses including GP services or 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 or European Health Insurance Card are not covered under the scheme.

Overseas emergency repatriation and evacuation

Your scheme benefits generally only apply to treatment received within the UK. As a result, there is no coverage for treatment outside of the UK. We strongly recommend taking out travel insurance when travelling abroad.

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

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 use the 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.

Partners

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

Active treatment

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

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.

Acute condition

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

Annual renewal date

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

Benefit

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

Benefits

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

Biological therapies

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

Cancer

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

Chronic condition

Please refer to the chronic conditions exclusion.

Complementary practitioner

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

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

Daycase

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

Dependant

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

-a member’s unmarried dependent children

Dependants

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

-a member’s unmarried dependent children

Dialysis

The removal of waste matter from the blood by either:

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

Disorder

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

Emergency

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

Employer

- ABC who is named as your employer

End of life care

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

Gender Dysphoria

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

Gender Incongruence

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

General Practitioner

- a registered medical practitioner in general practice.

GP

- a registered medical practitioner in general practice

High dependency unit

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

High risk activities

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

Home healthcare

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

Hospital

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

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

Inpatient

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

Intensive care unit

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

Medical condition

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

Medically necessary

– treatment that is considered to be:

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

Members

- an employee covered under the scheme.

Mental health condition

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

Outpatient

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

Palliative care

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

Partner

- a member’s 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.

Prosthesis

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

Psychological therapist

we recognise the following as psychological therapists.

a psychologist who is:

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

a therapist who is:

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

Registered nurse

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

Related condition

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

Specialist

- we consider a specialist to be:

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

and

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

Start date

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

Surgical appliance

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

The Scheme

- The ABC Healthcare Scheme

Practitioner

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

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

Treatment

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

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.

We, Us, Our

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

You, Your

- the eligible member and their dependants, if eligible.

Pandemic

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

Epidemic

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

Member Zone

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

Member

- an employee covered under the scheme.

Scheme lifetime

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

Scheme

- your employer's Corporate Healthcare scheme, of which you are a member

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, visit the Virtual GP page.

Alternatively, you can contact the claims helpline. Our experienced claims team will guide you to the most appropriate services, including access to remote advice from a gynaecologist.

Most women’s health conditions are covered under your standard outpatient and inpatient benefits. However, some conditions may not traditionally be covered by your healthcare scheme. To address this, we’ve introduced additional women’s health benefits to provide extra cover where needed. Our claims team can advise your condition and treatment would be covered under these additional benefits.

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

Women’s health concern	How to access treatment
For advice regarding any general women’s health query, including, but not limited to, menopause symptoms or contraception advice	You can access YourHealth247 through the portal to speak with a GP directly without needing to call the claims helpline. 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 the claims helpline, without the need for a GP referral. Our team will guide you to the most appropriate service for your needs. This may include remote consultations and diagnostic tests with one of our in-network specialist gynaecologists (where appropriate). Cover is provided up to the limits specified in your table of benefits. Once the benefit 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 the claims helpline to speak with our claims team, who can support you and direct you to the most appropriate specialist - no need to see your GP first. Cover is provided as outlined in your table of benefits. For 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 the claims helpline to speak to our experienced claims team, who can assist in opening a new claim and direct you to the most suitable specialist. Cover will be available as specified in your table of benefits.
If your GP has referred you for fertility investigations	Contact the claims helpline to speak with 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 the claims helpline to speak with our experienced claims team, who can advise if cover is available for you. Coverage is provided for specific pregnancy complications only, as outlined in your table of benefits.
For physiotherapy treatment for a pelvic problem such as stress incontinence	Contact the claims helpline, without needing a GP referral, and speak with our experienced claims team, who will arrange a telephone-based assessment with a senior physiotherapist to determine the most appropriate treatment for you. Cover is provided through your physiotherapy benefit, as outlined in your table of benefits.

Men's health services

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

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

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

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

Men’s health concern	How to access treatment
For advice regarding any general men’s health query, including urinary symptoms, sexual health and fertility advice.	Contact YourHealth247 through the portal to speak with a GP on the telephone without calling the claims helpline. All of the GPs are able to help you with common concerns. Additionally, you may self-refer by contacting the claims helpline without the need for a GP referral and we will be able to direct you to the most appropriate services available to you. This includes access to remote consultations and diagnostic tests with our in-network men’s health experts (where appropriate). Cover is available up to the limits specified in your table of benefits. Once this benefit limit has been reached the scheme rules apply as detailed in your exclusions and limitations.
If you are concerned about early signs of prostate or testicular cancer.	Contact the claims helpline to speak to our claims team who will be able to support you and direct you to the most appropriate specialist without the need for seeing your GP first. Cover will be available as specified in your table of benefits. Further information about early signs of cancers and self-referral can be found here.
If your GP has referred you to a specialist.	Contact the claims helpline or access the claims portal to open a new claim. Cover will be available as specified in your table of benefits. One of our experienced claims team will be able to direct you to the most suitable specialist.
If your GP has referred you for fertility investigations	Contact the claims helpline to speak to our experienced claims team, who will be able to open a new claim. Cover will be available from your fertility investigations benefit, as specified on your table of benefits.
For physiotherapy treatment for a pelvic problem such as stress incontinence	Contact the claims helpline, without the need for a GP referral, and speak to our experienced claims team who will arrange a telephone based assessment with a senior physiotherapist, to determine the most appropriate treatment for you. Cover is available from your physiotherapy benefit, as specified in your table of benefits.

Self-referred cancer benefits

Experiencing symptoms that 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 support you with prompt investigations if you experience any symptoms that could potentially be related to cancer.

If you have any of the symptoms listed below, you can self-refer by contacting our claims team helpline directly for a consultation and diagnostic tests. You no longer need to see your GP before accessing private treatment for these concerns, ensuring no delays in reaching a diagnosis.

Our experienced claims team will guide you through one of our clinical pathways with in-network providers to help you receive a timely diagnosis.

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

Please remember that these 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 the eligible treatment options available to you.

For further advice or to open a new claim, you can contact us via the Member Zone, the My Healix app, or by calling the claims helpline. As with all healthcare benefits, it’s essential to obtain pre-authorisation before receiving any treatment to ensure your claim is eligible and to avoid incurring any unexpected costs.

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, impacting daily activities. However, early diagnosis and treatment 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 and treatment pathway - no need to contact the claims helpline.

Download the My Healix app

Access the Member Zone

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

This digital service is designed to assess your needs and guide you toward the best course of treatment. Where self-managed care is appropriate, you will gain immediate access to a tailor exercise program, with in-app access to a clinician when required.

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

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

Telephone assessment

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

The telephone-based clinical assessment will not be subject to any excess, if one applies, but excess will be applied to face-to-face treatment 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 recovery.

If you’re experiencing stress, anxiety, depression, or any other mental health issues, your healthcare scheme provides several support options. Refer to the information below to understand how your scheme can assist you.

How to make a claim

Employees can 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 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 healthcare scheme where medically necessary	Any mental health symptoms, including stress, anxiety and low mood.

If face-to-face mental health treatment is recommended, you will be directed into an initial episode of treatment with one of our in-network providers.

For the initial treatment, any sessions taken with our digital treatment pathway provider will not be subject to an excess, scheme underwriting, or scheme limits (where applicable).

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

Telephone assessment

If you are unable to access the Member Zone, the My Healix app, or if the claim is for a spouse or dependant, you can contact the claims helpline for support and advice. There is no need to see your GP or obtain a referral letter 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 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 treatment (within benefit limits where applicable) and settle all invoices directly.

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

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

Digital skin pathway

Changes 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 treatment as needed, depending on your diagnosis. Any subsequent treatment will be subject to the scheme’s 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 care 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
A change to an existing mole (itching/bleeding/increase in size)	Chronic skin conditions such as eczema/psoriasis
A new skin growth that has appeared and is visible	New skin rashes
A sore area of skin that has not healed	Mole mapping services required for screening purposes where there is no identifiable area of immediate concern
-	Members under the age of 18

Digital skin pathway: How to access help

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

Step 1

Contact one of our member advisors to open a new claim. For more information, please refer to the making a claim section.

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 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.

Please note: Face-to-face consultations with dermatologists within our network will not be subject to reasonable and customary fees. If you choose to consult 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.

Partners

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

Active treatment

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

Neurodevelopmental disorders

Acute condition

Annual renewal date

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

Benefit

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

Benefits

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

Biological therapies

Cancer

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

Chronic condition

Please refer to the chronic conditions exclusion.

Complementary practitioner

Daycase

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

Dependant

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

-a member’s unmarried dependent children

Dependants

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

-a member’s unmarried dependent children

Dialysis

The removal of waste matter from the blood by either:

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

Disorder

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

Emergency

Employer

- ABC who is named as your employer

End of life care

Gender Dysphoria

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

Gender Incongruence

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

General Practitioner

- a registered medical practitioner in general practice.

GP

- a registered medical practitioner in general practice

High dependency unit

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

High risk activities

Home healthcare

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

Hospital

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

Inpatient

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

Intensive care unit

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

Medical condition

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

Medically necessary

– treatment that is considered to be:

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

Members

- an employee covered under the scheme.

Mental health condition

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

Outpatient

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

Palliative care

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

Partner

- a member’s 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.

Prosthesis

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

Psychological therapist

we recognise the following as psychological therapists.

a psychologist who is:

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

a therapist who is:

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

Registered nurse

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

Related condition

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

Specialist

- we consider a specialist to be:

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

and

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

Start date

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

Surgical appliance

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

The Scheme

- The ABC Healthcare Scheme

Practitioner

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

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.

We, Us, Our

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

You, Your

- the eligible member and their dependants, if eligible.

Pandemic

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

Epidemic

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

Member Zone

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

Member

- an employee covered under the scheme.

Scheme lifetime

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

Scheme

- your employer's Corporate Healthcare scheme, of which you are a member

Employee Assistance Program (EAP)

ABC employees have access to an Employee Assistance Programme (EAP) XXX through XXX. You will need to register your account before using the service

Please find the access details below, including your access code; please have this ready when accessing the service.

Access: Search for XXX in your Google Play or App Store
Access Code:
Telephone Number:

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

Virtual GP

As part of your employment with ABC, you have access to a virtual GP service provided by *****

You can register for this service through their portal, which can be accessed at:

*********

The portal is the quickest and easiest way to register and book consultations with the virtual GP. If you do not have access to the portal, you can also call ****** on 0204 123 4567.

To register, you will need [specify registration requirements].

If ***** refers you to a specialist; please contact the claims helpline to confirm if this is covered under your scheme. All onward referrals are subject to your scheme underwriting, personal exclusions (if applicable), and general scheme exclusions. Should further details of your past medical history be required, your consent will be needed to contact your NHS GP.

Section 9: Glossary

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

Partners

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

Active treatment

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

Neurodevelopmental disorders

Acute condition

Annual renewal date

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

Benefit

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

Benefits

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

Biological therapies

Cancer

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

Chronic condition

Please refer to the chronic conditions exclusion.

Complementary practitioner

Daycase

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

Dependant

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

-a member’s unmarried dependent children

Dependants

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

-a member’s unmarried dependent children

Dialysis

The removal of waste matter from the blood by either:

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

Disorder

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

Emergency

Employer

- ABC who is named as your employer

End of life care

Gender Dysphoria

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

Gender Incongruence

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

General Practitioner

- a registered medical practitioner in general practice.

GP

- a registered medical practitioner in general practice

High dependency unit

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

High risk activities

Home healthcare

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

Hospital

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

Inpatient

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

Intensive care unit

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

Medical condition

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

Medically necessary

– treatment that is considered to be:

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

Members

- an employee covered under the scheme.

Mental health condition

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

Outpatient

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

Palliative care

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

Partner

- a member’s 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.

Prosthesis

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

Psychological therapist

we recognise the following as psychological therapists.

a psychologist who is:

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

a therapist who is:

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

Registered nurse

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

Related condition

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

Specialist

- we consider a specialist to be:

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

and

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

Start date

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

Surgical appliance

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

The Scheme

- The ABC Healthcare Scheme

Practitioner

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

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.

We, Us, Our

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

You, Your

- the eligible member and their dependants, if eligible.

Pandemic

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

Epidemic

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

Member Zone

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

Member

- an employee covered under the scheme.

Scheme lifetime

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

Scheme

- your employer's Corporate Healthcare scheme, of which you are a member

Making a claim

Healthcare benefits

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

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

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

Download the My Healix app

Access the Member Zone

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

Call the claims helpline:

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

We will confirm:

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

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

How to claim summary

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

▼

If your GP refers you onto a specialist or therapist

▼

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

▼

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

▼

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

▼

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

▼

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

▼

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

▼

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

▼

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

▼

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

▼

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

How to Claim Summary

Your scheme underwriting

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

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

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

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

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

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

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

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

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

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

If you receive treatment, have symptoms or ask advice for that medical condition within the first two years of your start date then the moratorium is not satisfied and you will only be covered after a continuous period of two years where you have not received treatment, had symptoms or asked advice for that condition.

Your excess

Excess

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

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

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

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

Reasonable and customary fees

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

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

Hospital cover

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

Restricted network
The ABC healthcare scheme will cover authorised treatment at the majority of private & NHS hospitals throughout the UK, however treatment and consultations at some hospitals are excluded from cover. Please find a list below of the hospitals which are not covered under the ABC healthcare scheme:

• List of all hospitals which are excluded

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

What happens in an emergency?

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

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

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

You will not be covered for:

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

Exclusions and limitations

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

Exclusions and limitations

Ageing, menopause and puberty

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

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

Alcohol abuse, substance abuse and addiction

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

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

Allergies and allergic disorders

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

Appliances, physical aids and devices

We do not pay for the supply or fitting of appliances, physical aids or devices (including but not limited to hearing aids, spectacles, contact lenses, external prostheses and orthotics etc) which do not fall within our definition of a surgical appliance. Any consultations relating to these are also not covered.

WORDING FOR SCHEMES WITH ORTHOTICS BENEFIT: We do not pay for the supply or fitting of appliances, physical aids or devices (including but not limited to hearing aids, spectacles, contact lenses, external prostheses and orthotics etc) which do not fall within our definition of a surgical appliance other than as listed in your table of benefits. Any consultations relating to these are also not covered.

Birth control & contraception

We do not pay for:

birth control
sterilisation and/or reversal
termination of pregnancy

Chronic conditions

We do not pay for treatment of chronic conditions. By this we mean any medical condition which has at least one of the following characteristics:

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

Please note: this will apply to all medical conditions, whether or not a diagnosis has been made.

Exception: We will pay for eligible treatment arising out of a chronic condition, or for treatment of acute symptoms of a chronic condition that flare up. However, we only pay if the treatment is likely to lead quickly to a complete recovery or to you being fully restored to your previous state of health, without you having to receive prolonged treatment. For example, we pay for treatment following a heart attack arising out of chronic heart disease. This exception does not apply to treatment of a mental health condition.

Please note: in some cases it might not be clear, at the time of treatment, that the disease, illness or injury being treated is a chronic condition. We are not obliged to pay the ongoing costs of continuing, or similar, treatment. This is the case even where we have previously paid for this type of or similar treatment.

Please note this exclusion does not apply to the treatment of cancer.

Complications from excluded/restricted conditions or treatment

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

Contamination, wars, riots and terrorist acts

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

Convalescence, rehabilitation and general nursing care

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

Exception: We will pay up to 28 days of inpatient, daycase and/or outpatient rehabilitation treatment which is intended to restore health or mobility with the aim of returning you to independent living. The rehabilitation must be referred by a specialist and be an integral part of eligible treatment. Treatment must take place within 12 months of you having been deemed medically fit to commence rehabilitation by your specialist.

Cosmetic treatment

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

We do not pay for any treatment, including surgery:

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

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

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

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

Dangerous or high risk activities

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

Dental or oral treatment

We do not pay for any dental or oral treatment other than as listed in the exception below.

Exception: We will pay for eligible treatment related only to the following specified oral surgical operations when carried out by a specialist:

surgically remove a complicated, buried, infected or impacted tooth root
apicectomy or removal of the tip of a tooth’s root
enucleation of a cyst of the jaw (removing a cyst from the jaw bone)
surgical drainage of a fascial space (tracking) abscess
putting a natural tooth back into a jaw bone after it is knocked out or dislodged in an accident
treatment of facial and mandibular fractures.

Dialysis

We do not pay for treatment for or associated with dialysis, unless it is required as a complication in the short term following eligible treatment.

Drugs and dressings for outpatient or take-home use

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

Emergency treatment in the UK

We do not pay for:

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

End of life care (terminal care)

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

Experimental drugs and treatment

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

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

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

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

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

Eyesight correction

We do not pay for treatment to correct your eyesight due to long or short vision, including but not limited to, laser eye surgery, spectacles or contact lenses.

Exception: We will pay for eligible treatment to the eye resulting from an acute condition or injury.

Fertility treatment

We do not pay for:

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

Gender dysphoria

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

General practitioner consultations

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

Holistic and alternative medicine

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

Illegal activity

We do not pay for:

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

Neurodevelopmental disorders

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

FOR SCHEMES WITH ASSESSMENT BENEFIT:

We do not pay for any treatment (following diagnosis) of adult or childhood neurodevelopmental disorders

Obesity

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

Overseas treatment

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

Pandemic and/or epidemic disease

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

Personal comfort and convenience items

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

Pregnancy and childbirth

We do not pay for any treatment related to pregnancy or childbirth, other than as listed in the exception below:

Exception: We will pay for the following eligible specified obstetric procedures / treatment:

pelvic girdle pain in pregnancy
miscarriage or when the foetus has died and remains with the placenta in the womb
still birth
hydatidiform mole (abnormal cell growth in the womb)
ectopic pregnancy (foetus growing outside the womb)
diastasis recti or Rectus Abdominis (splitting of the abdominal muscles during pregnancy)
post-partum haemorrhage (heavy bleeding in the hours and days immediately after childbirth)
retained placental membrane (afterbirth left in the womb after the delivery of the baby)
eligible mental health treatment for post-natal depression subject to the conditions and limitations set out in the mental health benefit.
medically essential caesarean section where this is an inevitable consequence of a complication to the current pregnancy.
complications following any of the above conditions.
flare up of a non-pregnancy related medical condition that has been made worse by pregnancy.

We will require full clinical details from your specialist before we can give our decision on cover.

In the event that the newborn requires immediate treatment as a result of an eligible caesarean section, this should be administered by the NHS free of charge. If the newborn is not entitled to NHS care and is not accepted as a dependant on the scheme we will pay for treatment for up to 7 days following the birth, to allow you time to make alternative arrangements. In cases where they are accepted as a member of the scheme they will only be entitled to benefits outlined in the benefits table and will be subject to the exclusions listed within the scheme.

Screening and preventative treatment

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

We do not pay for treatment;

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

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

Sexual dysfunction

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

Sleep disorders

We do not pay for treatment for or arising from sleep disorders. This includes but is not limited to: sleep apnoea, snoring, insomnia, sleep walking, narcolepsy, and night terrors.

Speech disorders

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

Surrogacy

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

Transplants and adoptive cell transfer therapies

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

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

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

Unrecognised providers

We do not pay for treatment carried out by a provider who we do not recognise as being qualified and/or registered to provide the type of treatment you need or for treating the medical condition you have.

We do not pay for treatment with sports therapists, massage therapists, or anyone who does not meet our definition of a practitioner or complementary practitioner.

We do not pay for any treatment carried out by 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.

Partners

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

Active treatment

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

Neurodevelopmental disorders

Acute condition

Annual renewal date

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

Benefit

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

Benefits

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

Biological therapies

Cancer

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

Chronic condition

Please refer to the chronic conditions exclusion.

Complementary practitioner

Daycase

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

Dependant

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

-a member’s unmarried dependent children

Dependants

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

-a member’s unmarried dependent children

Dialysis

The removal of waste matter from the blood by either:

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

Disorder

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

Emergency

Employer

- ABC who is named as your employer

End of life care

Gender Dysphoria

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

Gender Incongruence

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

General Practitioner

- a registered medical practitioner in general practice.

GP

- a registered medical practitioner in general practice

High dependency unit

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

High risk activities

Home healthcare

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

Hospital

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

Inpatient

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

Intensive care unit

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

Medical condition

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

Medically necessary

– treatment that is considered to be:

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

Members

- an employee covered under the scheme.

Mental health condition

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

Outpatient

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

Palliative care

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

Partner

- a member’s 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.

Prosthesis

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

Psychological therapist

we recognise the following as psychological therapists.

a psychologist who is:

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

a therapist who is:

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

Registered nurse

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

Related condition

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

Specialist

- we consider a specialist to be:

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

and

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

Start date

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

Surgical appliance

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

The Scheme

- The ABC Healthcare Scheme

Practitioner

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

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.

We, Us, Our

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

You, Your

- the eligible member and their dependants, if eligible.

Pandemic

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

Epidemic

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

Member Zone

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

Member

- an employee covered under the scheme.

Scheme lifetime

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

Scheme

- your employer's Corporate Healthcare scheme, of which you are a member

End of cover

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

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

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

Cover for dependants will end in the following situations:

Your partner's cover will end:

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

Your dependant child’s cover will end:

after they have turned 24. They will be removed from cover on the next annual renewal date following their 24^th birthday.
if they get married, then they will no longer be considered a dependant for the purposes of this scheme.
if they no longer live full time in the United Kingdom

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

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

Continuation option

As Healix Health only provides corporate group schemes, we are unable to continue your cover as an individual if you leave the 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 provide you with the best choice possible to take your healthcare forward.

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

National Friendly

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

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

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

To find out more about National Friendly visit here.

Usay Compare

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

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

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

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

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

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

How to make a complaint

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

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

How your complaint will be handled

Stage 1

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

Stage 2

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

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

Stage 3

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

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

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

How to claim reimbursement

How to claim for cash benefits

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

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

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

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

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

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

How to claim baby cash benefit

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

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

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

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

How to claim reimbursement of medical expenses

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

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

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

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

Please note:

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

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

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

Payment of invoices

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

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

We will not pay for claims:

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

FAQs

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

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

Requests for additional information

We may ask you to provide information to help us assess your claim. For example we may ask you for one or more of the following:

Medical reports and other information about the treatment for which you are claiming. If we request a medical report from your specialist and they charge for providing this we will pay the cost.
Original accounts and invoices in connection with your claim.
Obtain results of an independent medical examination or second opinion for which we may ask you to make an appointment with a with a specialist. We will pay for the cost of any independent medical examination or second opinion we require and we will authorise this in writing, in advance.
Provide results of any second opinion you have independently sought under the care of another specialist. On such occasions we may additionally request our own, independent, second opinion from an expert in that field to assess eligibility of cover. We will pay the costs of any second opinion we organise on your behalf, this includes the cost of the consultation and any tests undertaken as a result of that consultation.

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

Throughout your claim we will make you aware of the options that are available to you. If your medical specialist recommends treatment, you should contact the claims helpline as soon as possible to be sure that continued treatment is covered.

Our team of case managers will assess the level of cover available to you for planned treatment within the terms and conditions of the scheme. In some instances it may be necessary to refer your claim to our specialist nurses, along with our panel of independent specialist advisors, who will advise on the level of cover available for the recommended treatment.

Duplicate cover

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

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

Healix privacy notice

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

Section 9: Glossary

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

Partners

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

Active treatment

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

Neurodevelopmental disorders

Acute condition

Annual renewal date

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

Benefit

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

Benefits

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

Biological therapies

Cancer

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

Chronic condition

Please refer to the chronic conditions exclusion.

Complementary practitioner

Daycase

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

Dependant

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

-a member’s unmarried dependent children

Dependants

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

-a member’s unmarried dependent children

Dialysis

The removal of waste matter from the blood by either:

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

Disorder

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

Emergency

Employer

- ABC who is named as your employer

End of life care

Gender Dysphoria

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

Gender Incongruence

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

General Practitioner

- a registered medical practitioner in general practice.

GP

- a registered medical practitioner in general practice

High dependency unit

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

High risk activities

Home healthcare

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

Hospital

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

Inpatient

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

Intensive care unit

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

Medical condition

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

Medically necessary

– treatment that is considered to be:

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

Members

- an employee covered under the scheme.

Mental health condition

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

Outpatient

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

Palliative care

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

Partner

- a member’s 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.

Prosthesis

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

Psychological therapist

we recognise the following as psychological therapists.

a psychologist who is:

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

a therapist who is:

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

Registered nurse

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

Related condition

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

Specialist

- we consider a specialist to be:

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

and

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

Start date

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

Surgical appliance

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

The Scheme

- The ABC Healthcare Scheme

Practitioner

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

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.

We, Us, Our

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

You, Your

- the eligible member and their dependants, if eligible.

Pandemic

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

Epidemic

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

Member Zone

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

Member

- an employee covered under the scheme.

Scheme lifetime

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

Scheme

- your employer's Corporate Healthcare scheme, of which you are a member

Contact Us

The Healix Team

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

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

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

Any correspondence should be sent to the following address:

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.

Partners

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

Active treatment

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

Neurodevelopmental disorders

Acute condition

Annual renewal date

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

Benefit

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

Benefits

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

Biological therapies

Cancer

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

Chronic condition

Please refer to the chronic conditions exclusion.

Complementary practitioner

Daycase

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

Dependant

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

-a member’s unmarried dependent children

Dependants

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

-a member’s unmarried dependent children

Dialysis

The removal of waste matter from the blood by either:

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

Disorder

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

Emergency

Employer

- ABC who is named as your employer

End of life care

Gender Dysphoria

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

Gender Incongruence

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

General Practitioner

- a registered medical practitioner in general practice.

GP

- a registered medical practitioner in general practice

High dependency unit

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

High risk activities

Home healthcare

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

Hospital

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

Inpatient

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

Intensive care unit

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

Medical condition

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

Medically necessary

– treatment that is considered to be:

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

Members

- an employee covered under the scheme.

Mental health condition

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

Outpatient

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

Palliative care

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

Partner

- a member’s 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.

Prosthesis

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

Psychological therapist

we recognise the following as psychological therapists.

a psychologist who is:

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

a therapist who is:

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

Registered nurse

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

Related condition

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

Specialist

- we consider a specialist to be:

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

and

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

Start date

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

Surgical appliance

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

The Scheme

- The ABC Healthcare Scheme

Practitioner

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

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.

We, Us, Our

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

You, Your

- the eligible member and their dependants, if eligible.

Pandemic

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

Epidemic

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

Member Zone

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

Member

- an employee covered under the scheme.

Scheme lifetime

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

Scheme

- your employer's Corporate Healthcare scheme, of which you are a member

Scheme Year 2023

The below changes will come into effect following the scheme renewal on 1st April 2024.

New Benefits	Benefit Limit	Benefit Wording
Out of network physiotherapy on specialist referral	Full cover	We will pay in full for out of network outpatient physiotherapy when this is referred by a specialist.
lf referral for breast, bowel or prostate cancer symptoms	Full cover	We will pay in full for self-referred* consultations and investigations for breast, bowel or prostate cancer symptoms. If a diagnosis of cancer is made, cover for eligible treatment will be subject to any limits as detailed in your cancer treatment benefit. *Please note, cover for self-referral is subject to the medical underwriting on your scheme.
Outpatient consultations with a practitioner	Full cover	We will pay in full for consultations with a dietician, nurse, orthoptist, podiatrist or speech therapist following specialist referral. The practitioner must be registered with the correct governing body for their field, and meet our definition for a practitioner.
Practitioner or specialist recommended orthotics	£500 per scheme lifetime	We will pay up to £500 per scheme lifetime towards medically necessary orthotics, when these are recommended by a practitioner or specialist.
NHS cancer cash benefit for oral chemotherapy and targeted therapies	£600 per month	In the event that you elect to receive oral chemotherapy or targeted therapies via the NHS as an outpatient, we will pay an NHS cancer cash benefit of £600 per month whilst you receive such treatment.
Cancer outpatient therapies Cancer alternative therapies (£250 limit within the £1,000 limit per scheme year)	Combined limit of £1,000 per scheme year	We will pay up to a total limit of £1,000 per scheme year for the following therapies, when required as a direct result of eligible cancer treatment. Cancer outpatient therapies on GP, specialist or self-referral We will pay up to the benefit limit for physiotherapy, osteopathy, chiropractic treatment, manual lymphatic drainage and dietician services. Treatment must be taken with a physiotherapist, practitioner or complementary practitioner that we recognise for benefit purposes. Cancer alternative therapies on GP, specialist or self-referral We will reimburse up to £250 on a pay and claim basis within the above combined limit of £1,000 per scheme year for acupuncture, reflexology and aromatherapy.
Cancer additional services	Full cover	We will pay in full for the cost of external prosthesis, wigs, scalp cooling treatment and medical tattooing (for reconstructive purposes only) when recommended by your specialist, and required as a direct result of eligible cancer treatment. For wigs and medical tattooing, this benefit is available on a pay and claim basis only.
Mastectomy bras	Up to £200 per lifetime of the scheme	We will reimburse up to £200 per lifetime for the cost of mastectomy bras required following eligible cancer treatment. This benefit is available on a pay and claim basis only.
Disorders of the eye	Full cover for specified treatment	We will pay for eligible acute treatment of the following conditions: cataracts detached retina surgical correction of a squint drooping eyelids (ptosis) – we will only provide benefit for ptosis (drooping eyelids), if your optometrist identifies visual impairment and you are referred by your general practitioner or optician to a consultant ophthalmologist wet aged related macular degeneration, where we will pay for a short course of treatment following initial diagnosis
Remote advice service with our in-network specialist gynaecologists (up to 4 consultations per scheme year) Diagnostic tests and investigations following referral from our in-network remote gynaecologists (up to £500 per scheme year)	Limited cover	Remote advice service with our in-network specialist gynaecologists We will pay for up to 4 remote advice appointments per scheme year with our in-network specialist gynaecologists on self-referral. This service can be used to discuss any women’s health concern including conditions that are normally excluded for cover such as the menopause or for contraception/fertility advice. Diagnostic tests and investigations following referral from our in-network gynaecologists We will pay up to £500 per scheme year for diagnostic tests or investigations that are recommended following a remote advice appointment with our in-network specialist gynaecologists. Remote consultations and diagnostic tests and investigations will be covered up to the limits described above only. Once the benefit limits have been reached the scheme rules will apply as detailed in your exclusions and limitations. Please note: additional cover may be available outside of the above limits for eligible claims, please contact the claims helpline for further information. Please refer to the women's health services page for further information on how to access these benefits.
Outpatient consultations and diagnostics required as a result of long COVID Outpatient, daycase and inpatient treatment required as a result of long COVID Outpatient mental health treatment required as a result of long COVID (upto £1,500 per scheme year) Outpatient physiotherapy treatment required as a result of long COVID (up to £500 per scheme year) Outpatient complementary therapies required as a result of long COVID (up to £250 per scheme year)	Combined overall limit of £5,000 per scheme year (up to £15,000 per lifetime)	The below benefits will be paid for when treatment is required as a result of COVID-19 (commonly referred to as 'long COVID'). The benefits have a combined limit of £5,000 per scheme year up to a maximum of £15,000 per lifetime. Outpatient consultations and diagnostics We will pay up in full for: Outpatient consultations with a specialist following GP referral Outpatient diagnostics and investigations following GP or specialist referral Outpatient treatment following specialist referral Cover is subject to our reasonable and customary fees. Outpatient, daycase and inpatient treatment We will pay for hospital and specialist fees, for outpatient, daycase and inpatient treatment. Please note cover is not available for acute treatment of COVID-19, including treatment in an intensive care unit, high dependency unit, acute ward setting or NHS hospital. Outpatient mental health treatment We will pay up to £1,500 per scheme year, for outpatient consultations for eligible mental health conditions, following GP or self-referral, when treatment is required as a result of long COVID. If your referral is to a psychological therapist we will arrange a telephone based clinical assessment with a senior psychological therapist from our mental health network provider, who will help organise the most effective treatment for you. This could include face to face therapy, guided self-management or specialist referral. Where treatment with a psychological therapist occurs outside our network provider, it must be delivered under the direct supervision of a consultant psychiatrist. Outpatient physiotherapy We will pay up to £500 per scheme year for outpatient physiotherapy following GP or self-referral, when treatment is required as a result of long COVID. If this is a self-referral, we will arrange a telephone based clinical assessment with a senior physiotherapist, who will help organise the most effective treatment for you. This could include face to face physiotherapy, guided self-management or specialist referral. The telephone based clinical assessment will not be subject to any excess, if one applies, however it will be applied to subsequent treatment should this be required. We will continue to monitor your progress by liaising with your treatment provider and authorise additional treatment where necessary and eligible. If treatment takes place outside our physiotherapy network, the physiotherapist must still be recognised by us for benefit purposes. Outpatient complementary therapies We will pay up to £250 per scheme year for chiropractic treatment, osteopathy and acupuncture, following GP or specialist referral, when treatment is required as a result of long COVID. You must be referred to a complementary practitioner we have recognised for benefit purpose.
Benefit Changes	Previous Wording	New Wording
Mental health treatment	Outpatient mental health treatment following GP or specialist referral Outpatient mental health therapies following GP, specialist or self-referral (self-referral via Healix network provider only) We will pay up to £2,500 per scheme year for outpatient consultations and therapy, for eligible mental health conditions following GP or self-referral. If your referral is to a psychological therapist we will arrange a telephone-based clinical assessment with a senior psychological therapist from our mental health network provider who will help organise the most effective treatment for you. This could include face to face therapy, guided self-management or specialist referral. Where treatment with a psychological therapist occurs outside our network provider it must be delivered under the direct supervision of a consultant psychiatrist. Please refer to the mental health pathway for further information. Please note, cover for self-referral is subject to the medical underwriting on your scheme.	In network outpatient mental health treatment We will pay in full for outpatient consultations for eligible mental health conditions following GP, specialist or self-referral, when treatment is provided by our mental health network provider. We will arrange a telephone-based clinical assessment with a senior psychological therapist from our mental health network provider, who will help organise the most effective treatment for you. This could include face to face therapy, guided self-management or specialist referral. Please refer to the mental health pathway for further information. Please note, cover for self-referral is subject to the medical underwriting on your scheme and Under 18’s will require a referral letter from their own GP. Out of network mental health treatment* We will pay up to £2,500 per scheme year for outpatient consultations for eligible mental health conditions following GP or specialist referral, when treatment is taken outside of our mental health network. Treatment with a psychological therapist must be under the direct supervision of a consultant psychiatrist, and they must still be recognised by us for benefit purposes. Cover is subject to our reasonable and customary fees.
Inpatient and daycase mental health treatment	We will pay up to a maximum of 28 days per scheme year for eligible inpatient and daycase mental health treatment. All treatment must be under the direct control and supervision of a consultant psychiatrist, and must be authorised by us in advance and in writing.	We will pay up to a maximum of 28 days per scheme year for eligible inpatient and daycase mental health treatment. All treatment must be under the direct control and supervision of a consultant psychiatrist, and must be authorised by us in advance and in writing. Where treatment is for an addiction treatment programme, cover is limited to once per scheme lifetime.
NHS cash benefit	NHS cash benefit for inpatient treatment In the event that you are admitted to an NHS hospital, or you elect to receive free treatment through the NHS we will pay an NHS Cash Benefit of £250 per night up to a maximum of £2,500. This benefit will only apply to claims for daycase or inpatient treatment that would otherwise have been eligible for benefit under your scheme. NHS cash benefit following daycase treatment In the event that you are admitted to an NHS hospital, or you elect to receive free treatment through the NHS we will pay an NHS Cash Benefit of £125 per day up to a maximum of £500 for daycase treatment. This benefit will only apply to claims for daycase or inpatient treatment that would otherwise have been eligible for benefit under your scheme.	NHS cash benefit In the event that you are admitted to an NHS hospital, or you elect to receive free treatment through the NHS, we will pay an NHS cash benefit of £250 per night or day, for inpatient or daycase treatment. This benefit will only apply to claims for daycase or inpatient treatment that would otherwise have been eligible for benefit under your scheme.
NHS cancer cash benefit	In the event that you elect to receive free cancer treatment through the NHS, we will pay an NHS Cancer Cash Benefit of £100 per night or day following eligible inpatient or daycase treatment, or outpatient radiotherapy treatment up to a maximum of £10,000 per scheme year.	In the event that you elect to receive free cancer treatment through the NHS, we will pay an NHS cancer cash benefit of £300 per night or day following eligible inpatient or daycase treatment, or outpatient radiotherapy treatment. This benefit will only apply to claims for daycase or inpatient treatment that would otherwise have been eligible for benefit under your scheme.
COVID-19 Cash Benefit	In the event that you are admitted to hospital and receive free NHS funded treatment we will pay an NHS cash benefit of £300 per day or night for inpatient or daycase treatment. This benefit will only apply to claims for daycase or inpatient treatment of COVID-19 and/or complications arising from this condition.	In the event that you are admitted to hospital and receive free NHS funded treatment, we will pay an NHS cash benefit of £150 per day or night, up to a maximum of 30 days per scheme year, following inpatient or daycase treatment. This benefit will only apply to claims for daycase or inpatient treatment of COVID-19 and/or immediate complications arising from this condition.
Pregnancy complications	We will pay for the following specified obstetric procedures / treatment: ectopic pregnancy miscarriage missed abortion stillbirth post partum haemorrhage retained placental membrane hydatidiform mole.	Pregnancy and childbirth We will pay for the following specified obstetric procedures / treatment: pelvic girdle pain in pregnancy miscarriage or when the foetus has died and remains with the placenta in the womb stillbirth hydatidiform mole (abnormal cell growth in the womb) ectopic pregnancy (foetus growing outside the womb) Diastasis recti or Rectus Abdominis (splitting of the abdominal muscles during pregnancy) post-partum haemorrhage (heavy bleeding in the hours and days immediately after childbirth) retained placental membrane (afterbirth left in the womb after the delivery of the baby) eligible mental health treatment for post-natal depression (subject to the conditions and limitations set out in the mental health benefit) medically essential caesarean section where this is an inevitable consequence of a complication to the current pregnancy (see caesarean section benefit for eligibility criteria and benefit limits) complications following any of the above conditions flare up of a non-pregnancy related medical condition that has been made worse by pregnancy. We will require full clinical details from your specialist before we can give our decision on cover. In the event that the newborn requires immediate treatment as a result of an eligible caesarean section, this should be administered by the NHS free of charge. If the newborn is not entitled to NHS care and is not accepted as a dependant on the scheme we will pay for treatment for up to 7 days following the birth, to allow you time to make alternative arrangements. In cases where they are accepted as a member of the scheme they will only be entitled to benefits outlined in the benefits table and will be subject to the exclusions listed within the scheme.
Exclusion Changes	Previous Wording	New Wording
AIDS/HIV	We do not pay for treatment which is in any way linked to Human Immunodeficiency Virus (HIV) or AIDS infection or any related illness.	Exclusion removed.
Cosmetic treatment	We do not pay for any form of plastic or reconstructive surgery, or scar revision, even when required for psychological reasons other than as outlined in your table of benefits. We do not pay for any treatment, including surgery: which is for or involves the removal of healthy tissue (i.e. tissue which is not diseased), surplus or fat tissue where the intention of treatment, whether directly or indirectly, is the reduction or removal of surplus or fat tissue. We do not pay for any treatment for dermatochalasis (baggy eyes), ptosis (drooping) of the eyelid and/or brow. Exception: We will pay for the initial treatment to restore function or appearance if it is medically necessary as a direct result of you having an accident or because of other surgery or cancer, which itself would have been covered under the scheme. Any subsequent related treatment will only be covered if it is intended to cure an acute condition. Cover is subject to written authorisation before receiving the treatment.	We do not pay for any treatment to change your appearance even when required for psychological reasons. We do not pay for any treatment, including surgery: where the intention of treatment, whether directly or indirectly, is the reduction or removal of healthy, surplus or fat tissue (for example, weight reduction surgery / treatment) unless specified in your lifestyle surgery benefits where the aim is to aesthetically enhance the appearance of the face or body where no functional condition is present (for example, botox, fillers or asymptomatic rhinoplasty). Exception: we will pay for medically necessary treatment to restore your appearance in the following circumstances: where it results from an eligible underlying disease process following eligible treatment (including cancer treatment) where the condition is causing a functional problem. Please note: we use NHS guidance as a benchmark for deciding whether the exceptions above are eligible for cover. All requests for cover must be submitted in writing with supporting medical information.
Dialysis	We do not pay for treatment for or associated with dialysis.	We do not pay for treatment for or associated with dialysis, unless it is required as a complication in the short term following eligible treatment.
Pandemic and/or epidemic disease		We do not pay for treatment for or arising from pandemic and / or epidemic disease. Please note: you may be able to claim NHS COVID Cash Benefit, if this is detailed in your table of benefits and you will be covered for treatment of Long COVID as detailed in your COVID-19 cover explained.
Sleep disorders	We do not pay for treatment for or arising from sleep disorders. This includes but is not limited to: sleep apnoea, snoring, insomnia, sleep walking, narcolepsy, and night terrors.	Exclusion removed.

Scheme Year 2024

The below changes will come into effect following the scheme renewal on 1st April 2024.

New Benefits	Benefit Limit	Benefit Wording
Out of network physiotherapy on specialist referral	Full cover	We will pay in full for out of network outpatient physiotherapy when this is referred by a specialist.
lf referral for breast, bowel or prostate cancer symptoms	Full cover	We will pay in full for self-referred* consultations and investigations for breast, bowel or prostate cancer symptoms. If a diagnosis of cancer is made, cover for eligible treatment will be subject to any limits as detailed in your cancer treatment benefit. *Please note, cover for self-referral is subject to the medical underwriting on your scheme.
Outpatient consultations with a practitioner	Full cover	We will pay in full for consultations with a dietician, nurse, orthoptist, podiatrist or speech therapist following specialist referral. The practitioner must be registered with the correct governing body for their field, and meet our definition for a practitioner.
Practitioner or specialist recommended orthotics	£500 per scheme lifetime	We will pay up to £500 per scheme lifetime towards medically necessary orthotics, when these are recommended by a practitioner or specialist.
NHS cancer cash benefit for oral chemotherapy and targeted therapies	£600 per month	In the event that you elect to receive oral chemotherapy or targeted therapies via the NHS as an outpatient, we will pay an NHS cancer cash benefit of £600 per month whilst you receive such treatment.
Cancer outpatient therapies Cancer alternative therapies (£250 limit within the £1,000 limit per scheme year)	Combined limit of £1,000 per scheme year	We will pay up to a total limit of £1,000 per scheme year for the following therapies, when required as a direct result of eligible cancer treatment. Cancer outpatient therapies on GP, specialist or self-referral We will pay up to the benefit limit for physiotherapy, osteopathy, chiropractic treatment, manual lymphatic drainage and dietician services. Treatment must be taken with a physiotherapist, practitioner or complementary practitioner that we recognise for benefit purposes. Cancer alternative therapies on GP, specialist or self-referral We will reimburse up to £250 on a pay and claim basis within the above combined limit of £1,000 per scheme year for acupuncture, reflexology and aromatherapy.
Cancer additional services	Full cover	We will pay in full for the cost of external prosthesis, wigs, scalp cooling treatment and medical tattooing (for reconstructive purposes only) when recommended by your specialist, and required as a direct result of eligible cancer treatment. For wigs and medical tattooing, this benefit is available on a pay and claim basis only.
Mastectomy bras	Up to £200 per lifetime of the scheme	We will reimburse up to £200 per lifetime for the cost of mastectomy bras required following eligible cancer treatment. This benefit is available on a pay and claim basis only.
Disorders of the eye	Full cover for specified treatment	We will pay for eligible acute treatment of the following conditions: cataracts detached retina surgical correction of a squint drooping eyelids (ptosis) – we will only provide benefit for ptosis (drooping eyelids), if your optometrist identifies visual impairment and you are referred by your general practitioner or optician to a consultant ophthalmologist wet aged related macular degeneration, where we will pay for a short course of treatment following initial diagnosis
Remote advice service with our in-network specialist gynaecologists (up to 4 consultations per scheme year) Diagnostic tests and investigations following referral from our in-network remote gynaecologists (up to £500 per scheme year)	Limited cover	Remote advice service with our in-network specialist gynaecologists We will pay for up to 4 remote advice appointments per scheme year with our in-network specialist gynaecologists on self-referral. This service can be used to discuss any women’s health concern including conditions that are normally excluded for cover such as the menopause or for contraception/fertility advice. Diagnostic tests and investigations following referral from our in-network gynaecologists We will pay up to £500 per scheme year for diagnostic tests or investigations that are recommended following a remote advice appointment with our in-network specialist gynaecologists. Remote consultations and diagnostic tests and investigations will be covered up to the limits described above only. Once the benefit limits have been reached the scheme rules will apply as detailed in your exclusions and limitations. Please note: additional cover may be available outside of the above limits for eligible claims, please contact the claims helpline for further information. Please refer to the women's health services page for further information on how to access these benefits.
Outpatient consultations and diagnostics required as a result of long COVID Outpatient, daycase and inpatient treatment required as a result of long COVID Outpatient mental health treatment required as a result of long COVID (upto £1,500 per scheme year) Outpatient physiotherapy treatment required as a result of long COVID (up to £500 per scheme year) Outpatient complementary therapies required as a result of long COVID (up to £250 per scheme year)	Combined overall limit of £5,000 per scheme year (up to £15,000 per lifetime)	The below benefits will be paid for when treatment is required as a result of COVID-19 (commonly referred to as 'long COVID'). The benefits have a combined limit of £5,000 per scheme year up to a maximum of £15,000 per lifetime. Outpatient consultations and diagnostics We will pay up in full for: Outpatient consultations with a specialist following GP referral Outpatient diagnostics and investigations following GP or specialist referral Outpatient treatment following specialist referral Cover is subject to our reasonable and customary fees. Outpatient, daycase and inpatient treatment We will pay for hospital and specialist fees, for outpatient, daycase and inpatient treatment. Please note cover is not available for acute treatment of COVID-19, including treatment in an intensive care unit, high dependency unit, acute ward setting or NHS hospital. Outpatient mental health treatment We will pay up to £1,500 per scheme year, for outpatient consultations for eligible mental health conditions, following GP or self-referral, when treatment is required as a result of long COVID. If your referral is to a psychological therapist we will arrange a telephone based clinical assessment with a senior psychological therapist from our mental health network provider, who will help organise the most effective treatment for you. This could include face to face therapy, guided self-management or specialist referral. Where treatment with a psychological therapist occurs outside our network provider, it must be delivered under the direct supervision of a consultant psychiatrist. Outpatient physiotherapy We will pay up to £500 per scheme year for outpatient physiotherapy following GP or self-referral, when treatment is required as a result of long COVID. If this is a self-referral, we will arrange a telephone based clinical assessment with a senior physiotherapist, who will help organise the most effective treatment for you. This could include face to face physiotherapy, guided self-management or specialist referral. The telephone based clinical assessment will not be subject to any excess, if one applies, however it will be applied to subsequent treatment should this be required. We will continue to monitor your progress by liaising with your treatment provider and authorise additional treatment where necessary and eligible. If treatment takes place outside our physiotherapy network, the physiotherapist must still be recognised by us for benefit purposes. Outpatient complementary therapies We will pay up to £250 per scheme year for chiropractic treatment, osteopathy and acupuncture, following GP or specialist referral, when treatment is required as a result of long COVID. You must be referred to a complementary practitioner we have recognised for benefit purpose.
Benefit Changes	Previous Wording	New Wording
Mental health treatment	Outpatient mental health treatment following GP or specialist referral Outpatient mental health therapies following GP, specialist or self-referral (self-referral via Healix network provider only) We will pay up to £2,500 per scheme year for outpatient consultations and therapy, for eligible mental health conditions following GP or self-referral. If your referral is to a psychological therapist we will arrange a telephone-based clinical assessment with a senior psychological therapist from our mental health network provider who will help organise the most effective treatment for you. This could include face to face therapy, guided self-management or specialist referral. Where treatment with a psychological therapist occurs outside our network provider it must be delivered under the direct supervision of a consultant psychiatrist. Please refer to the mental health pathway for further information. Please note, cover for self-referral is subject to the medical underwriting on your scheme.	In network outpatient mental health treatment We will pay in full for outpatient consultations for eligible mental health conditions following GP, specialist or self-referral, when treatment is provided by our mental health network provider. We will arrange a telephone-based clinical assessment with a senior psychological therapist from our mental health network provider, who will help organise the most effective treatment for you. This could include face to face therapy, guided self-management or specialist referral. Please refer to the mental health pathway for further information. Please note, cover for self-referral is subject to the medical underwriting on your scheme and Under 18’s will require a referral letter from their own GP. Out of network mental health treatment* We will pay up to £2,500 per scheme year for outpatient consultations for eligible mental health conditions following GP or specialist referral, when treatment is taken outside of our mental health network. Treatment with a psychological therapist must be under the direct supervision of a consultant psychiatrist, and they must still be recognised by us for benefit purposes. Cover is subject to our reasonable and customary fees.
Inpatient and daycase mental health treatment	We will pay up to a maximum of 28 days per scheme year for eligible inpatient and daycase mental health treatment. All treatment must be under the direct control and supervision of a consultant psychiatrist, and must be authorised by us in advance and in writing.	We will pay up to a maximum of 28 days per scheme year for eligible inpatient and daycase mental health treatment. All treatment must be under the direct control and supervision of a consultant psychiatrist, and must be authorised by us in advance and in writing. Where treatment is for an addiction treatment programme, cover is limited to once per scheme lifetime.
NHS cash benefit	NHS cash benefit for inpatient treatment In the event that you are admitted to an NHS hospital, or you elect to receive free treatment through the NHS we will pay an NHS Cash Benefit of £250 per night up to a maximum of £2,500. This benefit will only apply to claims for daycase or inpatient treatment that would otherwise have been eligible for benefit under your scheme. NHS cash benefit following daycase treatment In the event that you are admitted to an NHS hospital, or you elect to receive free treatment through the NHS we will pay an NHS Cash Benefit of £125 per day up to a maximum of £500 for daycase treatment. This benefit will only apply to claims for daycase or inpatient treatment that would otherwise have been eligible for benefit under your scheme.	NHS cash benefit In the event that you are admitted to an NHS hospital, or you elect to receive free treatment through the NHS, we will pay an NHS cash benefit of £250 per night or day, for inpatient or daycase treatment. This benefit will only apply to claims for daycase or inpatient treatment that would otherwise have been eligible for benefit under your scheme.
NHS cancer cash benefit	In the event that you elect to receive free cancer treatment through the NHS, we will pay an NHS Cancer Cash Benefit of £100 per night or day following eligible inpatient or daycase treatment, or outpatient radiotherapy treatment up to a maximum of £10,000 per scheme year.	In the event that you elect to receive free cancer treatment through the NHS, we will pay an NHS cancer cash benefit of £300 per night or day following eligible inpatient or daycase treatment, or outpatient radiotherapy treatment. This benefit will only apply to claims for daycase or inpatient treatment that would otherwise have been eligible for benefit under your scheme.
COVID-19 Cash Benefit	In the event that you are admitted to hospital and receive free NHS funded treatment we will pay an NHS cash benefit of £300 per day or night for inpatient or daycase treatment. This benefit will only apply to claims for daycase or inpatient treatment of COVID-19 and/or complications arising from this condition.	In the event that you are admitted to hospital and receive free NHS funded treatment, we will pay an NHS cash benefit of £150 per day or night, up to a maximum of 30 days per scheme year, following inpatient or daycase treatment. This benefit will only apply to claims for daycase or inpatient treatment of COVID-19 and/or immediate complications arising from this condition.
Pregnancy complications	We will pay for the following specified obstetric procedures / treatment: ectopic pregnancy miscarriage missed abortion stillbirth post partum haemorrhage retained placental membrane hydatidiform mole.	Pregnancy and childbirth We will pay for the following specified obstetric procedures / treatment: pelvic girdle pain in pregnancy miscarriage or when the foetus has died and remains with the placenta in the womb stillbirth hydatidiform mole (abnormal cell growth in the womb) ectopic pregnancy (foetus growing outside the womb) Diastasis recti or Rectus Abdominis (splitting of the abdominal muscles during pregnancy) post-partum haemorrhage (heavy bleeding in the hours and days immediately after childbirth) retained placental membrane (afterbirth left in the womb after the delivery of the baby) eligible mental health treatment for post-natal depression (subject to the conditions and limitations set out in the mental health benefit) medically essential caesarean section where this is an inevitable consequence of a complication to the current pregnancy (see caesarean section benefit for eligibility criteria and benefit limits) complications following any of the above conditions flare up of a non-pregnancy related medical condition that has been made worse by pregnancy. We will require full clinical details from your specialist before we can give our decision on cover. In the event that the newborn requires immediate treatment as a result of an eligible caesarean section, this should be administered by the NHS free of charge. If the newborn is not entitled to NHS care and is not accepted as a dependant on the scheme we will pay for treatment for up to 7 days following the birth, to allow you time to make alternative arrangements. In cases where they are accepted as a member of the scheme they will only be entitled to benefits outlined in the benefits table and will be subject to the exclusions listed within the scheme.
Exclusion Changes	Previous Wording	New Wording
AIDS/HIV	We do not pay for treatment which is in any way linked to Human Immunodeficiency Virus (HIV) or AIDS infection or any related illness.	Exclusion removed.
Cosmetic treatment	We do not pay for any form of plastic or reconstructive surgery, or scar revision, even when required for psychological reasons other than as outlined in your table of benefits. We do not pay for any treatment, including surgery: which is for or involves the removal of healthy tissue (i.e. tissue which is not diseased), surplus or fat tissue where the intention of treatment, whether directly or indirectly, is the reduction or removal of surplus or fat tissue. We do not pay for any treatment for dermatochalasis (baggy eyes), ptosis (drooping) of the eyelid and/or brow. Exception: We will pay for the initial treatment to restore function or appearance if it is medically necessary as a direct result of you having an accident or because of other surgery or cancer, which itself would have been covered under the scheme. Any subsequent related treatment will only be covered if it is intended to cure an acute condition. Cover is subject to written authorisation before receiving the treatment.	We do not pay for any treatment to change your appearance even when required for psychological reasons. We do not pay for any treatment, including surgery: where the intention of treatment, whether directly or indirectly, is the reduction or removal of healthy, surplus or fat tissue (for example, weight reduction surgery / treatment) unless specified in your lifestyle surgery benefits where the aim is to aesthetically enhance the appearance of the face or body where no functional condition is present (for example, botox, fillers or asymptomatic rhinoplasty). Exception: we will pay for medically necessary treatment to restore your appearance in the following circumstances: where it results from an eligible underlying disease process following eligible treatment (including cancer treatment) where the condition is causing a functional problem. Please note: we use NHS guidance as a benchmark for deciding whether the exceptions above are eligible for cover. All requests for cover must be submitted in writing with supporting medical information.
Dialysis	We do not pay for treatment for or associated with dialysis.	We do not pay for treatment for or associated with dialysis, unless it is required as a complication in the short term following eligible treatment.
Pandemic and/or epidemic disease		We do not pay for treatment for or arising from pandemic and / or epidemic disease. Please note: you may be able to claim NHS COVID Cash Benefit, if this is detailed in your table of benefits and you will be covered for treatment of Long COVID as detailed in your COVID-19 cover explained.
Sleep disorders	We do not pay for treatment for or arising from sleep disorders. This includes but is not limited to: sleep apnoea, snoring, insomnia, sleep walking, narcolepsy, and night terrors.	Exclusion removed.

Scheme Year 2025

The below changes will come into effect following the scheme renewal on 1st April 2025.

Benefit Changes	Previous Wording	New Wording
Mental health treatment	Out of network outpatient mental health treatment We will pay up to £1500 for outpatient consultations for eligible mental health conditions following GP or specialist referral when taken out of the Healix network provider. Where treatment with a psychological therapist occurs outside our network provider it must be delivered under the direct supervision of a consultant psychiatrist.	Out of network outpatient mental health treatment We will pay up to £1,500 for outpatient consultations for eligible mental health conditions following GP or specialist referral when taken outside of the Healix network provider. Where treatment with a psychological therapist occurs outside our network provider the psychological therapist must be recognised by us for benefit purposes.

Section 9: Glossary

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

Partners

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

Active treatment

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

Neurodevelopmental disorders

Acute condition

Annual renewal date

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

Benefit

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

Benefits

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

Biological therapies

Cancer

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

Chronic condition

Please refer to the chronic conditions exclusion.

Complementary practitioner

Daycase

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

Dependant

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

-a member’s unmarried dependent children

Dependants

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

-a member’s unmarried dependent children

Dialysis

The removal of waste matter from the blood by either:

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

Disorder

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

Emergency

Employer

- ABC who is named as your employer

End of life care

Gender Dysphoria

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

Gender Incongruence

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

General Practitioner

- a registered medical practitioner in general practice.

GP

- a registered medical practitioner in general practice

High dependency unit

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

High risk activities

Home healthcare

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

Hospital

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

Inpatient

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

Intensive care unit

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

Medical condition

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

Medically necessary

– treatment that is considered to be:

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

Members

- an employee covered under the scheme.

Mental health condition

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

Outpatient

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

Palliative care

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

Partner

- a member’s 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.

Prosthesis

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Psychological therapist

we recognise the following as psychological therapists.

a psychologist who is:

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

a therapist who is:

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

Registered nurse

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

Related condition

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

Specialist

- we consider a specialist to be:

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

and

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

Start date

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

Surgical appliance

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

The Scheme

- The ABC Healthcare Scheme

Practitioner

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

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.

We, Us, Our

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

You, Your

- the eligible member and their dependants, if eligible.

Pandemic

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

Epidemic

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

Member Zone

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

Member

- an employee covered under the scheme.

Scheme lifetime

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

Scheme

- your employer's Corporate Healthcare scheme, of which you are a member