Introduction
Welcome to the Healix Group Staff Healthcare Scheme guide.
Healix has chosen Healix Health Services Ltd. to manage this scheme. We're here to assess your medical needs and manage the care you may require.
The Healix Group Staff Healthcare Scheme is designed to cover the diagnosis and / or treatment of short-term medical conditions, as long as it is medically necessary.
Please note, the scheme does not cover all medical conditions. Certain conditions, items and treatments are excluded (see your exclusions and limitations for details).
All treatment, including consultations and diagnostics, must be authorised in advance. It's essential that you contact us before to confirm it's eligible for cover under the scheme.
Table of benefits
Your scheme benefits are outlined in the table below.
Please note, the below benefits are:
-
subject to an excess, and
-
subject to a total benefit limit per member, per scheme year of £100,000.
Benefit limits apply per member, per scheme year unless otherwise stated. Once a benefit limit is reached, no further cover will be provided within the scheme year specified below. Cover for continued consultations, diagnostics or treatment in the next scheme year will be subject to all healthcare scheme terms and conditions.
The scheme year will commence on the 1st April 2025 to 31st March 2026.
| Outpatient Diagnostics and Treatment | Level of cover | Benefit note |
Outpatient diagnostics and consultations with a specialist or practitioner following GP or specialist referral (self-referral available for specified cancer symptoms) |
Full cover | A |
Monitoring of a chronic condition |
Up to £1,000 per scheme year | B |
Neurodevelopmental disorder assessment |
Up to £2,000 per scheme lifetime | C |
Orthotics |
Up to £500 per scheme lifetime | D |
Outpatient treatment and surgical procedures |
Full cover | E |
Outpatient MRI, CT and PET scans following specialist referral |
Full cover | F |
| Inpatient and Day Case Treatment | ||
Specialist fees and hospital charges for inpatient and day case treatment |
Full cover | G |
Child accommodation - hospital |
Up to 20 days per scheme year | H |
| Therapies | ||
In-network outpatient physiotherapy (including self-referral) |
Full cover | I |
Out-of-network outpatient physiotherapy following GP referral |
Up to £250 per scheme year | J |
Out-of-network outpatient physiotherapy following specialist referral |
Full cover | K |
Outpatient complementary therapies |
Up to £200 per scheme year | L |
| Mental Health | ||
In-network outpatient mental health treatment (including self-referral) |
Full cover | M |
Out-of-network outpatient mental health treatment |
Up to £2,500 per scheme year | N |
Inpatient and day case mental health treatment |
Up to 28 days per scheme year | O |
Mental health treatment for eating disorders |
Up to £10,000 per scheme lifetime | P |
| Cancer Treatment | ||
Cancer treatment |
Full cover | Q |
Cancer additional services |
Full cover | R |
Mastectomy bras |
Up to £200 per scheme lifetime | S |
| Cash Benefits | ||
NHS cash benefit |
£200 each day or night | T |
NHS cash alternative |
Up to 25% of the costs to receive the procedure privately | U |
NHS cancer cash benefit |
£300 each day or night | V |
NHS cancer cash benefit for oral chemotherapy and targeted therapies |
£600 per month | W |
Baby cash benefit |
£100 per child | X |
| Additional Benefits | ||
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) Diagnostics following referral from our in-network experts (up to £500 per scheme year) |
Limited cover | Z |
Private ambulance charges |
Full cover | A2 |
Home healthcare |
Full cover | B2 |
Please note: the above benefits only apply when consultations, diagnostics or treatment take place in the UK unless specified otherwise.
Outpatient Diagnostics and Treatment
We will pay in full for:
- outpatient consultations with a specialist following GP referral
- outpatient consultations with a practitioner following GP or specialist referral. The practitioner must be registered with the correct governing body for their field, and meet our definition for a practitioner
- outpatient diagnostics following GP or specialist referral
Cover is subject to our reasonable and customary fees.
Outpatient Consultations with a Specialist on Self-Referral for Specified Cancer Symptoms
We will pay in full for self-referred* consultations and diagnostics for specified cancer symptoms.
Refer to the self-referred cancer benefits section for further information on symptoms that are eligible, and how to access this benefit.
If a diagnosis of cancer is made, cover for eligible treatment will be subject to any limits as outlined in your cancer treatment benefit.
*Cover for self-referral is subject to your scheme underwriting.
Back to topWe will pay up to £1,000 per scheme year for the below when required to monitor a chronic condition:
- outpatient follow up consultations with a specialist following GP referral
- outpatient diagnostics, treatment and therapies following GP or specialist referral
Once this benefit limit has been reached the chronic condition rule applies, as outlined in your exclusions and limitations.
Please note, this benefit includes mental health treatment for mental health conditions.
Back to topWe will pay up to £2,000 per scheme lifetime for the assessment of neurodevelopmental disorders, following GP or specialist referral. The assessment must be carried out by a specialist or educational psychologist that we recognise for benefit purposes.
You must have our confirmation before any assessment is carried out, and we will need full clinical details from your GP or specialist before we can confirm cover.
Once a diagnosis has been confirmed, there will be no further cover for any additional assessments, consultations, diagnostics or neurodevelopmental disorder treatments.
Please note, this benefit is not subject to your scheme underwriting.
Back to topWe will pay up to £500 per scheme lifetime towards medically necessary orthotics, when these are recommended by a GP, practitioner, physiotherapist or specialist.
Back to topWe will pay in full for hospital charges and specialist fees for outpatient treatment, surgical procedures and drugs and dressings used during an outpatient appointment.
Cover is subject to our reasonable and customary fees.
Back to topWe will pay in full for MRI, CT and PET scans following specialist referral.
Back to topSpecialist Fees
We will pay specialist fees in full for inpatient and day case treatment. Cover is subject to our reasonable and customary fees.
Hospital Charges
We will pay hospital charges in full for the following:
- accommodation and nursing care for inpatient or day case treatment
- operating theatre and recovery room
- prescribed medicines and dressings, for use whilst an inpatient or for day case treatment
- eligible surgical appliances - for example, a knee brace following ligament surgery
- prosthesis or device which is inserted during eligible surgery
- pathology, radiology, diagnostics, MRI, CT and PET scans
- physiotherapy received during inpatient or day case treatment
- intensive care
- short-term dialysis when needed temporarily for sudden kidney failure resulting from an eligible condition or treatment
- skin and corneal grafts
We will pay up to 20 days per scheme year for reasonable hospital costs for two children to stay with a parent or legal guardian if the parent or guardian has been admitted to hospital as an inpatient.
We will only pay the cost if:
- it is the child's parent or legal guardian who is admitted to hospital, and
- the treatment the parent r legal guardian receives is covered by the scheme.
We will pay in full for outpatient physiotherapy following GP, specialist or self-referral* when provided by our physiotherapy network provider.
You also have access to a digital triage service via the Member Zone. This service is not subject to your excess, your scheme underwriting, or any benefit limits (if applicable) when accessed through our digital pathway provider.
Refer to the musculoskeletal pathway section for further information.
*Cover for self-referral is subject to your scheme underwriting.
Back to topWe will pay up to £250 per scheme year for outpatient physiotherapy following GP referral, when taken outside of our physiotherapy network. The physiotherapist must be recognised by us for benefit purposes.
Please note, you also have access to a digital triage service via the Member Zone. This service is not subject to your excess, your scheme underwriting, or any benefit limits (if applicable) when accessed through our digital pathway provider. Refer to the musculoskeletal pathway section for further information.
Back to topWe will pay in full for for outpatient physiotherapy following specialist referral, when taken outside of our physiotherapy network. The physiotherapist must be recognised by us for benefit purposes.
Please note, you also have access to a digital triage service via the Member Zone. This service is not subject to your excess, your scheme underwriting, or any benefit limits (if applicable) when accessed through our digital pathway provider. Refer to the musculoskeletal pathway section for further information.
Back to topWe will pay up to £200 per scheme year for chiropractic, osteopathy and acupuncture sessions, following GP or specialist referral. The complementary practitioner must be recognised by us for benefit purposes.
Back to topWe will pay in full for outpatient consultations and mental health treatment for eligible mental health conditions following GP, specialist or self-referral*, when provided by our mental health network provider.
Please note, you also have access to a digital triage service via the Member Zone. This service is not subject to your excess, your scheme underwriting, or any benefit limits (if applicable) when accessed through our digital pathway provider.
Refer to the mental health pathway section for further information.
Please note, under 18s will require a referral letter from a GP or specialist.
*Cover for self-referral is subject to your scheme underwriting.
Back to topWe will pay up to £2,500 for outpatient consultations and mental health treatment for eligible mental health conditions following GP or specialist referral, when taken outside of our mental health network. The psychological therapist must be recognised by us for benefit purposes.
Please note, you also have access to a digital triage service via the Member Zone. This service is not subject to your excess, your scheme underwriting, or any benefit limits (if applicable) when accessed through our digital pathway provider. Refer to the mental health pathway section for further information.
Back to topWe will pay up to 28 days per scheme year for eligible inpatient and day case mental health treatment.
You must be under the direct care and supervision of a consultant psychiatrist, and receive authorisation from us in advance and in writing.
Where mental health treatment is for an addiction treatment programme, cover is limited to once per scheme lifetime.
Back to topWe will pay up to £10,000 per scheme lifetime towards eligible outpatient, inpatient and day case mental health treatment related to the diagnosis of an eating disorder. All treatment must be under the direct control and supervision of a consultant psychiatrist, and must be authorised by us in advance and in writing.
Please note, this benefit is not subject to your scheme underwriting.
Back to topWe will pay for cancer treatment as outlined in the cancer cover explained section.
For information on additional services available, refer to the cancer support explained section.
Back to topWe will pay in full for external prosthesis, wigs, scalp cooling 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.
Back to topWe will pay up to £200 per scheme lifetime for the cost of mastectomy bras required following eligible cancer treatment.
This benefit is available on a pay and claim basis only.
Back to topIn the event that you are admitted to an NHS hospital, or you elect to receive free treatment through the NHS, we will pay a cash benefit of £200 per day or night, following inpatient or day case treatment.
This benefit will only apply to claims for inpatient or day case treatment that would otherwise have been eligible for benefit under the scheme.
Back to topIn the event that you require an elective surgical procedure, and you choose to receive this treatment free of charge on the NHS, we may pay you a cash lump sum. Please contact us to check if your procedure will qualify for this benefit.
Back to topIn the event that you elect to receive cancer treatment through the NHS, we will pay a cancer cash benefit of £300 per day or night following inpatient or day case treatment, or outpatient radiotherapy.
This benefit will only apply to claims for inpatient or day case treatment, or outpatient radiotherapy that would otherwise have been eligible for benefit under the scheme.
Back to topIn the event that you elect to receive oral chemotherapy or targeted therapies via the NHS as an outpatient, we will pay a cancer cash benefit of £600 per month.
Back to topWe will pay a cash benefit of £100 per baby / child following birth or adoption, where either one or both parents are members of the scheme. This benefit can only be claimed once per baby / child, even if both parents are covered under the scheme.
This benefit is subject to a 12 month waiting period from the date you joined the scheme.
Back to topWe will pay up to £10,000 per scheme lifetime for gender dysphoria, as outlined in the gender dysphoria explained section.
Please note this benefit is not subject to your scheme underwriting.
Back to topRemote Advice Service with Our In-Network Experts
We will pay for up to 4 remote advice appointments per scheme year with our in-network experts, following self-referral. This service can be used to discuss any health concern including conditions that are normally excluded from cover such as the menopause, andropause, sexual health concerns, fertility or contraception advice.
Diagnostics Following In-Network Expert Referral
We will pay up to £500 per scheme year for diagnostics that are recommended following a remote advice appointment with our in-network experts.
Refer to the women’s or men’s health services section for further information on how to access these benefits.
Once either benefit limit has been reached, the scheme rules will apply as outlined in your exclusions and limitations section.
Please note, additional cover may be available outside of these limits for eligible claims, please contact us for further information.
Back to topWe will pay in full for transport by a private ambulance to and / or from a hospital when ordered for medical reasons.
Back to topWe will pay in full for home nursing charges with a registered nurse when recommended by a specialist and where it is:
-
medically necessary and without it you would have to receive treatment as an inpatient or day case admission, and
-
needed for medical reasons (i.e. not social or domestic reasons), and
-
under the direct supervision of a specialist
Mental health treatment delivered at home or in the community is not covered by the scheme.
Back to topCancer cover explained
We understand that a cancer diagnosis can be life-changing. That’s why we've included a specific section within the scheme to help you understand the level of cancer treatment cover available.
The scheme provides benefits for eligible outpatient, day case, and inpatient cancer treatment. To ensure you always receive the highest quality care, we work with centres of excellence for cancer treatment. If you are diagnosed with cancer, we may ask you to transfer to one of these centres, which could be in either the private or NHS sector.
If you choose to receive free eligible inpatient, day case or outpatient cancer treatment at an NHS centre, you may be eligible for the NHS cancer cash benefit, as outlined in your table of benefits.
Our experienced claims team are here to guide you through your cancer treatment and provide information on your available options.
The table below offers a summary of the cancer cover provided. Please read it alongside your table of benefits for full details.
| Summary of cancer benefits | What’s covered | What’s not covered |
| Where will I be covered to have cancer treatment? |
You will be covered in full for eligible cancer treatment:
|
You will not be covered for:
|
| What diagnostics will I be covered for? |
You will be covered in full for:
|
You will not be covered for any diagnostics that are:
|
| Will I be covered for surgery? |
You will be covered in full for:
|
You will not be covered for surgery that is:
|
|
Will I be covered for preventative diagnostics and treatment? |
You will be covered for prophylactic (preventative) surgery if:
For example, we will pay for a mastectomy to a healthy breast in the event that you have been diagnosed with cancer in the other breast and your specialist indicates that prophylactic surgery is medically necessary and will be carried at the same time as surgery to the diseased breast. You must have our written agreement before you have diagnostics or treatment and we will need full clinical details from your specialist before we can give our decision. |
You will not be covered for any preventative diagnostics or treatment, including:
|
|
What cancer drugs will I be covered for? |
You will be covered in full for:
|
You will not be covered for:
|
| Will I be covered for radiotherapy? |
You will be covered in full for radiotherapy, including when given for pain relief. |
You will not be covered for radiotherapy that is:
|
| Will I be covered for end of life care? |
|
You will not be covered for:
|
|
What cover will be available for routine monitoring when |
You will be covered for follow-up tests and specialist consultations to monitor you once you have completed cancer treatment. No time limits are placed on follow up tests and consultations as long as these are medically necessary and your specialist confirms this in writing. |
|
|
What other benefits and services are available? |
You will be covered for:
Please note, these are subject to any limits as outlined in your table of benefits. |
You will not be covered for:
|
|
Are there any other supportive benefits available? |
You also have access to a comprehensive support platform delivered by Perci Health to provide you with additional support for the psychological, physical and practical impacts of cancer when it is needed most. For further information please see the cancer support explained section. |
|
Cancer support explained
We understand that a cancer diagnosis can be a life-changing event, and we're committed to supporting you through every step. That’s why we've partnered with Perci Health to provide additional support for the psychological, physical and practical impacts of cancer.
Perci Health is here to support you, no matter how cancer has affected your life:
-
are you currently undergoing cancer treatment?
-
do you need extra support after completing your cancer treatment?
-
are you caring for a loved one with cancer?
Whatever your situation, Perci Health can provide a personalised care plan, a dedicated cancer nurse and access to caring experts across more than 20 different types of support, including:
| Recovery and rehabilitation | Symptom management | Support for carers |
|
|
|
This service is available at no extra cost - it won't count towards any benefit limits, nor is it subject to your scheme underwriting or any excess.
Please note, this benefit is available to members aged 18 and over.
For further information and access to this service, visit the Member Zone.
Gender dysphoria explained
We understand that gender dysphoria can cause distress for individuals who do not identify with the gender assigned at birth. That’s why we've included a specific section in the scheme to help you understand the level of cover available.
The table below provides a summary of the cover for gender dysphoria. Please read it alongside your table of benefits.
Cover is available for members aged 18 and over, with a benefit limit of £10,000 per scheme lifetime.
For further help and support, please contact us.
| Summary of benefits | What’s covered | What’s not covered |
| Where will I be covered? |
You will be covered within the benefit limit for:
|
You will not be covered for any outpatient consultations, diagnostics and therapies:
|
| What will I be covered for? |
You will be covered within the benefit limit for:
|
You will not be covered for:
|
| What other benefits and services are available? |
You will be covered within the benefit limit for:
|
You will not be covered for:
|
Second medical opinion
If you would like to receive a second medical opinion to feel confident with your specialist's recommendations, please contact us to discuss pre-authorisation. Our experienced claims team is here to guide and support you through the process.
Second opinions will be arranged with a specialist who is an expert in their field and is recognised for providing such consultations.
Please note, without written authorisation, we cannot cover any recommended or resulting diagnostics or treatment from a second opinion.
Virtual GP
As part of your scheme, you have access to a virtual GP service called YourHealth247, provided by Teladoc Health.
You can register for this service via the Member Zone, or directly through their portal at:
http://www.yourhealth247.co.uk/
The portal is the fastest and easiest way to sign up and book your consultations. If you cannot access the portal, you can also call YourHealth247 on 0204 586 5324.
To register, you will need your access code which is as follows: HEALIX23
If YourHealth247 make an onward referral, we can accept this in place of a referral from your NHS GP, provided that their recommendation is eligible for cover. Contact us to confirm eligibility.
Onward referrals are subject to your scheme underwriting, any personal exclusions and scheme exclusions and limitations. If additional information about your medical history is needed, we may require your consent to contact your NHS GP.
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide.
Prosthesis, Prostheses
Acute condition
Annual renewal date
Scheme Benefit, Scheme Benefits
Biological therapies
Cancer
Chronic condition
- requires ongoing or long-term monitoring through consultations, examinations, check-ups and / or tests
- needs ongoing or long-term control or relief of symptoms
- requires rehabilitation or for you to be specially trained to cope with it
- continues indefinitely
- has no known cure, or
- comes back or is likely to come back. <
Complementary practitioner
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council)
Day case
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Emergency
Employer
End of life care
Gender Dysphoria
General Practitioner, GP
High dependency unit, Intensive care
High-risk activities
Home healthcare
Hospital, Hospitals
- Private hospital - an independent hospital which can provide acute medical, surgical or psychiatric care. It must be registered under The Registered Homes Act (1984) and approved by the Healthcare Commission or any future law. It may also include a private bed in an NHS hospital.
Inpatient
Intensive care unit
Medically necessary
- in accordance with professional standards of medical practice in the United Kingdom
- clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
- required for reasons other than the comfort or convenience of the patient or specialist
- provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition
- provided only for an appropriate duration of time
- no more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results <
Mental health condition
Outpatient
Physiotherapist
Pre-existing condition
- you have received medication, advice or treatment, or
- you have experienced symptoms whether the condition was diagnosed or not <
Private ambulance
Psychological therapist
-
a psychologist who is:
-
Registered with the Health and Care Professions Council (HCPC);
-
Registered with the British Psychological Society (BPS) as a chartered Psychologist
-
a therapist who is:
-
An accredited member of the British Association of Counselling and Psychotherapy (BACP); or
-
An Accredited Member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP); or
-
An Accredited Member of Scotland’s Professional Body for Counselling and Psychotherapy (COSCA); or
-
A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)
Registered nurse
Related condition
Specialist, Specialist's
- a medical practitioner with full current registration with the General Medical Council or
-
a dentist with full current registration with the General Dental Council
and
-
a specialist in the treatment you are referred for (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
Practitioner
- an occupational therapist
- an orthoptist
- a podiatrist
- a speech and language therapist
- a dietician
- a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number. <
Treatment, Treatments
Trust Deed
Trustee, Trustees
United Kingdom
Waiting Period
You, Your, You're, You've, You'll
Pandemic
Epidemic
Diagnostic, Diagnostics
Member Zone
Member, Members
Scheme lifetime
Scheme, The Scheme
Supportive Therapies
Neurodevelopmental disorder, Neurodevelopmental disorders
We, Us, Our, We're, We've, We'll
Mental health treatment
Benefits
Main member, Main members
Fertility treatment, Fertility treatments
Cancer treatment
Neurodevelopmental disorder treatment, Neurodevelopmental disorder treatments
Emergency treatment
Addiction treatment programme
Treatment date
Experimental treatment
- the harmful effects are outweighed by the beneficial effects
- they are likely to lead to the same or better outcomes than available alternatives
- they are based on established medical practice in the United Kingdom <
Private hospital, Private hospitals
NHS hospital, NHS hospitals
Emergency repatriation
Women's health services
At Healix, we understand the importance of quick access to healthcare. That's why we've made accessing women’s health services as easy and seamless as possible. If you're experiencing a women’s health concern, you can consult with a GP who has additional training in women’s health through the virtual GP service. For more information on how to access this, visit the virtual GP section.
Alternatively, you can contact us and our experienced claims team will guide you to the most appropriate services, including access to remote advice from a our in-network experts.
Most women’s health conditions are covered through your table of benefits, however, some conditions may not be covered by the scheme. To address this, we've introduced additional women’s health benefits to provide extra cover where needed. Our experienced claims team can advise whether your condition and / or health concern is eligible for cover under these additional benefits.
The table below outlines the available services and how to access them through the scheme.
| Women’s health concern | How to access support |
|
If you need advice regarding any general women’s health query, including, but not limited to, menopause symptoms or contraception advice. |
You can access YourHealth247 through the portal to speak with a GP directly without needing to contact us. All GPs can offer advice on common concerns, but if you prefer, you can request a consultation with a GP who specialises in women’s health. Additionally, you can self-refer by contacting us, without the need for a GP referral. Our experienced claims team will guide you to the most appropriate service for your needs. This may include remote consultations and diagnostics with one of our in-network experts (where appropriate). Cover is provided up to the limits specified in your table of benefits. Once the benefit limit is reached, the scheme rules, as outlined in your exclusions and limitations, will apply. |
|
If you are concerned about a breast abnormality, for example a lump. |
Contact us to speak with our experienced claims team, who can support you and direct you to the most appropriate specialist without the need to see your GP first. Cover is provided as outlined in your table of benefits. More information about early signs of cancers and self-referral can be found here. |
|
If your GP has referred you to a specialist gynaecologist, for example, for unusual bleeding. |
Contact us to speak with our experienced claims team, who can assist in opening a new claim and directing you to the most suitable specialist. Cover is provided as outlined in your table of benefits. |
|
If you are experiencing complications of pregnancy. |
Contact us to speak with our experienced claims team, who can advise if cover is available for you. Cover is provided for specific pregnancy complications only, as outlined in your exclusions and limitations. |
|
If you require physiotherapy for a pelvic problem such as stress incontinence. |
Contact us to speak with our experienced claims team, who will arrange a telephone-based assessment with a senior physiotherapist to determine the most appropriate pathway for you, without the need to see your GP first. Cover is provided through your physiotherapy benefit, as outlined in your table of benefits. |
Men's health services
At Healix, we understand the importance of quick access to healthcare. That's why we've made accessing men's health services as easy and seamless as possible. If you're experiencing a men's health concern, you can consult with a GP who has additional training in men's health through the virtual GP service. For more information on how to access this, visit the virtual GP section.
Alternatively, you can contact us and our experienced claims team will guide you to the most appropriate services, including access to remote advice from a our in-network experts.
Most men's health conditions are covered through your table of benefits, however, some conditions may not be covered by the scheme. To address this, we've introduced additional men's health benefits to provide extra cover where needed. Our experienced claims team can advise whether your condition and / or health concern are eligible for cover under these additional benefits.
The table below outlines the available services and how to access them through the scheme.
| Men’s health concern | How to access support |
|
If you need advice regarding any general men’s health query, including urinary symptoms, sexual health and fertility advice. |
You can access YourHealth247 through the portal to speak with a GP directly without needing to contact us. All GPs can offer advice on common concerns, but if you prefer, you can request a consultation with a GP who specialises in men's health. Additionally, you can self-refer by contacting us, without the need for a GP referral. Our experienced claims team will guide you to the most appropriate service for your needs. This may include remote consultations and diagnostics with one of our in-network experts (where appropriate). Cover is provided up to the limits specified in your table of benefits. Once the benefit limit is reached, the scheme rules, as outlined in your exclusions and limitations, will apply. |
|
If you are concerned about early signs of prostate or testicular cancer. |
Contact us to speak with our experienced claims team, who can support you and direct you to the most appropriate specialist without the need to see your GP first. Cover is provided as outlined in your table of benefits. More information about early signs of cancers and self-referral can be found here. |
|
If your GP has referred you to a specialist. |
Contact us to speak with our experienced claims team, who can assist in opening a new claim and directing you to the most suitable specialist. Cover is provided as outlined in your table of benefits. |
|
For physiotherapy for a pelvic problem such as stress incontinence. |
Contact us to speak with our experienced claims team, who will arrange a telephone-based assessment with a senior physiotherapist to determine the most appropriate pathway for you, without the need to see your GP first. Cover is provided through your physiotherapy benefit, as outlined in your table of benefits. |
Self-referred cancer benefits
Experiencing symptoms that may be associated with cancer can be worrying, but it's important to remember that these symptoms don’t always indicate cancer. We are here to offer prompt support if you experience any symptoms that could potentially be related to cancer.
If you have any of the symptoms listed below, contact us to self-refer for a consultation and diagnostics. There is no need to see your GP these benefits, ensuring no delays in reaching a diagnosis.
Our experienced claims team will guide you through one of our clinical pathways with in-network providers.
| Type of cancer | Signs and symptoms to watch out for |
|
Breast cancer |
|
|
Bowel cancer |
|
|
Prostate cancer |
Raised PSA level as specified below:
|
|
Testicular cancer |
|
|
Skin cancer |
Any of the following changes to a mole or lesion on the skin:
|
Please remember that these 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. Our experienced claims team will be there to guide you and provide information on options available to you.
As with all healthcare benefits, it’s essential that you contact us before receiving any consultations, diagnostics or treatment to confirm this is eligible and to avoid incurring any unexpected costs. For further advice, or to open a new claim, contact us to speak with our experienced claims team.
Musculoskeletal health pathway
Musculoskeletal conditions affect the muscles, bones and joints, and are increasingly common as we age. These conditions can cause pain and discomfort causing impact to daily activities, however, early diagnosis and intervention can help ease symptoms and speed up recovery.
With this in mind, we've designed the Healix musculoskeletal pathway to provide timely and effective support.
How to make a claim
If you experience bone or joint pain, you can quickly access our digital physiotherapy triage service. Simply log into the Member Zone or the My Healix app, where you'll be directed to start your online journey. This service is available to all members over the age of 16.
Access the Member Zone
Click here to access the Member Zone using your individual member number
This digital service is designed to assess your needs and guide you toward the best course of recovery.
Where self-managed care is appropriate, you will gain immediate access to a tailored exercise program, with in-app access to a clinician when required.
If face-to-face physiotherapy is recommended, you will be guided to physiotherapy with one of our network providers. These sessions will not be subject to an excess, your scheme underwriting, or any benefit limits when accessed through our digital pathway provider, however, all other healthcare scheme terms and conditions will apply.
Telephone assessment
If you are unable to access the Member Zone, contact us to arrange a telephone-based clinical assessment. Our experienced claims team will take your details and arrange an initial telephone consultation with a physiotherapist at a convenient time for you, who will then recommend the most appropriate pathway.
The telephone-based clinical assessment will not be subject to an excess, but this will be applied to face-to-face physiotherapy if required. All other healthcare scheme terms and conditions will apply.
Mental health pathway
The importance of mental health and wellbeing is increasingly recognised in today’s busy world. Acknowledging feelings of stress, anxiety or other mental health challenges and seeking help are essential first steps towards developing coping strategies and reaching recovery.
If you're experiencing stress, anxiety, depression or any other mental health issues, the scheme provides several support options outlined below.
How to make a claim
Members are able to access a digital emotional wellness triage and receive immediate advice via the Member Zone. This service is designed to provide an initial assessment of your mental health needs and direct you to the most appropriate mental health treatment pathway. This service is available for everyone over the age of 16.
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 |
|
|
If face-to-face mental health treatment is recommended, you will be directed into an initial episode of mental health treatment with our network provider. This will not be not be subject to an excess, your scheme underwriting, or any benefit limits.
Should additional sessions be needed beyond the initial episode, all healthcare scheme terms and conditions will apply.
Telephone assessment
If you are unable to access the Member Zone, you can contact us for support and advice. There is no need to see your GP or obtain a referral letter unless you are under the age of 18*.
Our experienced claims team will take your details and arrange an initial telephone consultation with a senior psychological therapist at a convenient time for you. This consultation will allow you to discuss your concerns and determine the most suitable mental health treatment pathway, which may include:
- face-to-face cognitive behavioural therapy (CBT)
- guided online CBT
- counselling
- referral onwards to see a psychiatrist
Healix will pre-authorise your assessment and mental health treatment (within benefit limits where applicable) and settle all invoices directly.
The telephone-based clinical assessment will not be subject to an excess, but this will be applied to face-to-face mental health treatment if required. All other healthcare scheme terms and conditions will apply.
*Under 18s will require a referral letter from a GP or specialist.
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide.
Prosthesis, Prostheses
Acute condition
Annual renewal date
Scheme Benefit, Scheme Benefits
Biological therapies
Cancer
Chronic condition
- requires ongoing or long-term monitoring through consultations, examinations, check-ups and / or tests
- needs ongoing or long-term control or relief of symptoms
- requires rehabilitation or for you to be specially trained to cope with it
- continues indefinitely
- has no known cure, or
- comes back or is likely to come back. <
Complementary practitioner
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council)
Day case
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Emergency
Employer
End of life care
Gender Dysphoria
General Practitioner, GP
High dependency unit, Intensive care
High-risk activities
Home healthcare
Hospital, Hospitals
- Private hospital - an independent hospital which can provide acute medical, surgical or psychiatric care. It must be registered under The Registered Homes Act (1984) and approved by the Healthcare Commission or any future law. It may also include a private bed in an NHS hospital.
Inpatient
Intensive care unit
Medically necessary
- in accordance with professional standards of medical practice in the United Kingdom
- clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
- required for reasons other than the comfort or convenience of the patient or specialist
- provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition
- provided only for an appropriate duration of time
- no more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results <
Mental health condition
Outpatient
Physiotherapist
Pre-existing condition
- you have received medication, advice or treatment, or
- you have experienced symptoms whether the condition was diagnosed or not <
Private ambulance
Psychological therapist
-
a psychologist who is:
-
Registered with the Health and Care Professions Council (HCPC);
-
Registered with the British Psychological Society (BPS) as a chartered Psychologist
-
a therapist who is:
-
An accredited member of the British Association of Counselling and Psychotherapy (BACP); or
-
An Accredited Member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP); or
-
An Accredited Member of Scotland’s Professional Body for Counselling and Psychotherapy (COSCA); or
-
A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)
Registered nurse
Related condition
Specialist, Specialist's
- a medical practitioner with full current registration with the General Medical Council or
-
a dentist with full current registration with the General Dental Council
and
-
a specialist in the treatment you are referred for (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
Practitioner
- an occupational therapist
- an orthoptist
- a podiatrist
- a speech and language therapist
- a dietician
- a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number. <
Treatment, Treatments
Trust Deed
Trustee, Trustees
United Kingdom
Waiting Period
You, Your, You're, You've, You'll
Pandemic
Epidemic
Diagnostic, Diagnostics
Member Zone
Member, Members
Scheme lifetime
Scheme, The Scheme
Supportive Therapies
Neurodevelopmental disorder, Neurodevelopmental disorders
We, Us, Our, We're, We've, We'll
Mental health treatment
Benefits
Main member, Main members
Fertility treatment, Fertility treatments
Cancer treatment
Neurodevelopmental disorder treatment, Neurodevelopmental disorder treatments
Emergency treatment
Addiction treatment programme
Treatment date
Experimental treatment
- the harmful effects are outweighed by the beneficial effects
- they are likely to lead to the same or better outcomes than available alternatives
- they are based on established medical practice in the United Kingdom <
Private hospital, Private hospitals
NHS hospital, NHS hospitals
Emergency repatriation
Making a claim
You can register your claim easily, just contact us to check if your condition or referral is eligible under the terms and conditions of the scheme.
When opening a new claim, we may request a copy of your GP referral letter to allow us to accurately assess your claim.
It's essential that you contact us before receiving any consultations, diagnostics and treatment to confirm it's eligible.
Contact the claims team:
StaffPlan@healix.com
Monday-Friday 08.00-18.00 (Excl. bank holidays)
We will confirm:
- whether your proposed treatment (including consultations, diagnostics and therapies) is eligible for cover under the scheme.
- whether the costs will be covered.
- any benefit limits or excess that may apply to your claim.
To assist you, we have provided a helpful how to claim summary.
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
Access the 'Physiotherapy Assessment' tile via the Member Zone
Contact us to register a new claim
Access the 'Emotional Wellness Assessment' tile via the Member Zone
If you cannot access the Member Zone, contact us and we will assess your symptoms and help organise the most effective treatment
We will advise on cover available, and authorise eligible treatment
If you cannot access the Member Zone, contact us and we will assess your symptoms and help organise the most effective treatment
If appropriate, we will arrange a physiotherapy referral within 24 hours, through a Healix physiotherapy network provider
If appropriate, we will arrange a referral through a Healix mental health network provider
If further treatment is required, please contact us again
If further treatment is required, please contact us again
If further treatment is required, please contact us again
Your scheme underwriting
Fixed Moratorium Underwriting
The scheme is designed to cover new medical conditions that arise after you join. We will not cover treatment (including consultations, diagnostics and therapies) of a pre-existing condition, which means any medical condition for which you:
- have sought advice, or
- have received medication, or
- have received treatment (including consultations, diagnostics or therapies), or
- have had symptoms (whether the condition was diagnosed or not), or
- were (to the best of your knowledge) aware existed in the five years before joining the scheme
Pre-existing conditions may become eligible for cover after one year, provided that during this time you have not received medication, treatment (including consultations, diagnostics or therapies), had symptoms, or sought advice for that condition.
If a pre-existing condition does become eligible for cover, this cover is subject to the terms and conditions of the scheme. Refer to your exclusions and limitations for further information.
Your excess
Per scheme year excess
All members are liable for an excess of £100, payable once per scheme year if you make an eligible claim.
The excess will be applied to the first eligible authorisation issued to you each scheme year, regardless of when the last excess payment was made. This applies whether the authorisation is for the same condition, a related condition, or for an entirely new condition.
To ensure clarity, contact us before receiving any treatment (including consultations, diagnostics or therapies) to confirm when the excess will apply.
Please note, the excess will be deducted directly from your salary and you will be advised of this in advance. Healix HR department will be advised when the first invoice arrives for settlement, and that an excess deduction needs to be made at the next available payroll run.
Hospital cover
Restricted network
The scheme covers most hospitals throughout the UK. However, there are some hospitals where treatment (including consultations, diagnostics and treatment) is excluded from cover.
Below is a list of hospitals not covered under the scheme:
- All HCA Hospitals
- The Cromwell
- The London Clinic
If you have any queries about this list, or your chosen hospital or clinic, contact us.
Please note, our reasonable and customary fees will apply to specialist services.
It is important that before receiving any consultations, diagnostics or treatment, you contact us to confirm it's eligible for cover and the hospital, clinic or specialist are covered under the scheme.
Reasonable and customary fees
We apply a schedule of reasonable and customary (R&C) fees for specialist services. These fees are aligned with the common codes and principles set out by the Clinical Classification and Schedule Development (CCSD) group. Our fee levels are carefully reviewed, based on what the majority of specialists charge for medical and surgical services, and are validated by our clinical support team, and panel of specialist advisors.
If you choose a specialist who charges above our fee schedule, you have the option to either pay the difference yourself or we can help identify an alternative specialist who charges within the approved free schedule.
Refer to our fee schedule or contact us for further information.
What happens in an emergency?
Most private hospitals are not equipped for emergency admissions. In the event of an emergency you should:
- call for an NHS ambulance
- visit the accident and emergency (A&E) department at your local NHS hospital
If you wish to be transferred to a private hospital after receiving emergency care, contact us to discuss your options. We will confirm if your proposed treatment is eligible under the scheme.
What is not covered :
- emergency treatment costs at a private walk-in centre, A&E department, or clinic
- costs for intensive care or a high dependency unit if transferred to a private hospital specifically for this care
- transfer costs to a private hospital to receive treatment in an intensive care or high dependency unit
Exclusions and limitations
The following conditions and items are not eligible for cover under your scheme. If you have any queries, please contact us.
We do not cover any consultations, diagnostics or treatment to relieve symptoms commonly associated with, or caused by, ageing, puberty or other natural physiological causes.
Exception: we cover remote consultations and diagnostics with our in-network experts in women’s or men's health, as outlined in your table of benefits.
We do not cover any consultations, diagnostics or treatment required for alcohol, solvent or drug abuse, or any treatment arising from such abuse or addiction. This includes mental health treatment.
Exception: we cover one addiction treatment programme per scheme lifetime under the inpatient mental health benefit, as outlined in your table of benefits.
We do not cover any consultations, diagnostics or treatment to desensitise or neutralise any allergic condition or disorder.
We do not cover the supply or fitting of any appliances, physical aids or devices including but not limited to; hearing aids, spectacles, contact lenses, external prostheses and orthotics, unless it falls within our definition of a surgical appliance. Any consultations relating to these are also not covered.
Exception: we cover medically necessary orthotics as outlined in your table of benefits.
We do not cover artificial life maintenance (including mechanical ventilation) where this will not or is not expected to result in your recovery or restore you to your previous state of health.
We do not cover any consultations, diagnostics or treatment relating to:
- birth control
- sterilisation and / or reversal, or
- termination of pregnancy
Exception: we cover remote consultations and diagnostics with our in-network experts in women’s or men's health, as outlined in your table of benefits.
We do not cover any consultations, diagnostics or treatment related to chronic conditions that require ongoing care. A chronic condition is defined as a medical condition with at least one of the following characteristics:
- requires ongoing or long-term monitoring through consultations, examinations, check-ups and / or tests
- needs ongoing or long-term control or relief of symptoms
- requires rehabilitation or for you to be specially trained to cope with it
- continues indefinitely
- has no known cure, or
- comes back or is likely to come back.
This will apply to all medical conditions, whether or not a diagnosis has been made.
Exception: we cover eligible treatment (including consultations, diagnostics and therapies) arising out of a chronic condition, or treatment of acute symptoms of a chronic condition that flare-up. Such treatment will only be covered if it is likely to lead quickly to a complete recovery, or to you being fully restored to your previous state of health without you having to this long-term. For example, we pay for treatment following a heart attack which is the result of chronic heart disease. This exception does not apply to mental health conditions.
In some cases, it may not be immediately clear that the disease, illness or injury being treated is a chronic condition. In such situations, even if we have previously paid for treatment, we are not obliged to cover the ongoing costs of continuing, or similar, treatment.
This exclusion does not apply to cancer treatment.
Exception: we cover consultations, diagnostics and treatment of chronic conditions as outlined in your table of benefits.
We do not cover any consultations, diagnostics or treatment which arise from, or are related to any exclusion listed in this scheme guide.
Furthermore, treatment arising from or related to treatment that is not covered by the scheme will not be eligible for cover.
We do cover any consultations, diagnostics or treatment for medical conditions caused by or contributed to by nuclear, radioactive, biological or chemical contamination, or any of the following:
- wars (whether declared or not)
- act of foreign enemies
- riots
- revolutions
- invasions
- civil wars
- rebellions
- insurrections
- overthrowing of a legally constituted government
- explosions of war weapons
- terrorist acts, or
- military activity
Furthermore, consultations, diagnostics or treatment of any medical condition received while you are carrying out army, naval or air services duties will not be covered.
We do not cover consultations, diagnostics or treatment if it is primarily used for any of the following purposes:
- convalescence or rehabilitation (including therapy)
- general nursing care for domestic and / or social reasons
Exception: we cover up to 21 days of inpatient, day case or outpatient rehabilitation following eligible treatment when this is aimed at restoring health or mobility with the goal of returning you to independent living. Rehabilitation must be recommended by a specialist, be an integral part of eligible treatment and take place within 12 months of you being deemed medically fit by your specialist to begin.
We do not cover any consultations, diagnostics or treatment where the aim is to change your appearance, even when required for psychological reasons.
Treatment is not covered where:
- the intention, whether directly or indirectly, is the reduction or removal of healthy, surplus or fat tissue - for example, weight reduction surgery / treatment
- the aim is to aesthetically enhance the appearance of the face or body where no functional condition is present - for example, botox, fillers or asymptomatic rhinoplasty
Exception: we cover medically necessary treatment to restore your appearance in the following circumstances:
- where it results from an eligible underlying disease
- following eligible treatment (including cancer treatment)
- where the condition is causing a functional problem
Please note, we use clinical guidance as a benchmark to assess eligibility for cover under these exceptions. All requests for cover must be submitted in writing along with supporting medical information.
We do not cover consultations, diagnostics or treatment for or arising from deafness caused by a congenital abnormality, maturing or ageing.
Exception: we cover consultations, diagnostics and treatment for hearing impairment or deafness that arises as a result of an acute condition diagnosed within the previous 12 months. For example, glue ear or perforated eardrum.
We do not cover any consultations, diagnostics or treatment when relating to dental or oral conditions.
Exception: we cover eligible treatment related to the following specified oral surgical operations only, when treatment is carried out by a specialist:
- surgical removal of a complicated, buried, infected or impacted tooth root
- apicectomy or removal of the tip of a tooth’s root
- enucleation of a cyst of the jaw (removing a cyst from the jaw bone)
- surgical drainage of a fascial space abscess
- reimplantation of a natural tooth that has been knocked out or dislodged in an accident
- treatment of facial and mandibular fractures
We do not cover any consultations, diagnostics or treatment for or associated with dialysis.
Exception: we may cover dialysis that is required in the short-term following a complication of eligible treatment.
We do not cover drugs and dressings provided or prescribed for take home use.
Exception: we may cover outpatient drugs and dressings when required as part of eligible cancer treatment. Refer to the cancer cover explained section for further information.
We do not cover any costs for:
- emergency treatment in a private walk-in centre, accident and emergency department or clinic
- an emergency admission into a hospital
- treatment in an intensive care or high dependency unit if you have been transferred specifically to receive this care
- transferring to a private facility specifically to receive treatment in an intensive care or high dependency unit
We do not cover any treatment required to relieve symptoms at the end stage of a disease.
We do not cover any diagnostics or treatment (including medication) which, in our reasonable opinion, are experimental or not yet approved by the National Institute for Health and Care Excellence (NICE), are being researched or lack sufficient evidence to conclude that:
- the harmful effects are outweighed by the beneficial effects
- they are likely to lead to the same or better outcomes than available alternatives
- they are based on established medical practice in the United Kingdom
Examples of the criteria we use for considering a treatment as experimental include:
- the treatment is still undergoing clinical trials and / or has yet to undergo a phase III clinical trial for the indication in question
- the treatment does not have approval from the relevant government body
- the treatment does not conform to usual clinical practice in the view of the majority of medical practitioners in the relevant field
- the treatment is being used in a way other than that previously studied or that for which it has been granted approval by the relevant government body
- the treatment is rarely used, novel or unknown, and there is a lack of authoritative evidence of safety and efficacy
Furthermore, we do not cover any treatment required for complications arising or resulting from experimental treatment that you receive, or for any subsequent treatment you may need as a result of you undergoing any experimental treatment.
We do not cover any consultations, diagnostics or treatment to correct your eyesight due to long or short sightedness, including but not limited to; laser eye surgery, spectacles or contact lenses.
Exception: we cover eligible treatment to the eye resulting from an acute condition or injury.
We do not cover any consultations, diagnostics or treatment relating to:
- fertility investigations
- fertility treatment
- assisted reproduction, surrogacy, harvesting of donor eggs or donor insemination
- sperm collection and storage
- complications following any of the above
Exception: we cover remote consultations and diagnostics with our in-network experts in women’s or men's health, as outlined in your table of benefits.
We do not cover any consultations, diagnostics or treatment for, arising from or relating to gender dysphoria.
Exception: we cover gender dysphoria as outlined in your table of benefits. Refer to the gender dysphoria explained section for further information.
We do not cover any GP consultations or visits. Charges for the completion of claim forms or referral letters are also not covered, unless we have requested these specifically to assess your claim.
Exception: we cover virtual GP consultations as outlined in the virtual GP section.
We do not cover any consultations, diagnostics or treatment directly or indirectly related to participation in hazardous or high-risk activities.
We do not cover any holistic or alternative medicine or therapies - for example, yoga, massage, spas and health resorts.
We do not cover any consultations, diagnostics or treatment resulting from:
- you carrying out an illegal act
- a road accident where you were not wearing a seat belt (as required by law)
We do not cover any consultations, diagnostics or treatment (following diagnosis) of adult or childhood neurodevelopmental disorders.
We do not cover any consultations, diagnostics or treatment for the purpose of weight loss, this includes when required as a result of obesity.
We do not cover consultations, diagnostics and treatment outside the United Kingdom including evacuation or repatriation.
We do not cover any consultations, diagnostics or treatment for or arising from pandemic and / or epidemic disease.
We do not cover any personal comfort and convenience items or services, including but not limited to; travel expenses, television, WIFI, telephone costs, newspapers and guest meals.
We do not cover any consultations, diagnostics or treatment related to pregnancy or childbirth, other than as listed in the exception below.
Exception: we cover eligible treatment related to the following specified obstetric procedures / treatment:
- pelvic girdle pain in pregnancy
- miscarriage or when the foetus has died and remains with the placenta in the womb
- still birth
- hydatidiform mole (abnormal cell growth in the womb)
- ectopic pregnancy (foetus growing outside the womb)
- diastasis recti or rectus abdominis (splitting of the abdominal muscles during pregnancy)
- post-partum haemorrhage (heavy bleeding in the hours and days immediately after childbirth)
- retained placental membrane (afterbirth left in the womb after the delivery of the baby)
- eligible mental health treatment for postnatal depression as outlined in the outpatient mental health treatment benefit in your table of benefits
- medically essential caesarean section where this is an inevitable consequence of a complication to the current pregnancy
- complications following any of the above conditions
- flare-up of non-pregnancy-related medical conditions that have been made worse by pregnancy.
We will require full clinical details from your specialist to assess cover and eligibility.
In the event that the newborn requires immediate treatment as a result of an eligible caesarean section, this should be administered by the NHS free of charge. If the newborn is not entitled to NHS care and is not accepted as a dependant on the scheme, we will cover treatment for up to 7 days following the birth, to allow you time to make alternative arrangements. In cases where they are accepted as a member of the scheme, they will only be entitled to benefits outlined in the table of benefits and will be subject to the exclusions and limitations listed within the scheme.
We do not cover treatment required as a consequence of injury sustained whist training for, or participating in, sport for which you receive payment or sponsorship (other than travel costs).
We do not cover any form of genetic testing or screening, health screening, health checks or preventative treatment, procedures or medical services where no disease is present.
We do not cover consultations, diagnostics or treatment that is:
- recommended because of a genetic predisposition towards developing a medical condition
- recommended because of a family history of a medical condition
Exception: we may cover preventative cancer treatment. Refer to the cancer cover explained section for further information.
We do not cover any consultations, diagnostics or treatment for sexual dysfunction, sexually transmitted infections or sexual problems, whatever the cause.
Exception: we cover remote consultations and diagnostics with our in-network experts in women’s or men's health, as outlined in your table of benefits.
We do not cover any consultations, diagnostics or treatment for or relating to any speech disorder such as stammering.
Exception: we may cover short-term speech therapy for an acute condition immediately following eligible treatment. The speech therapy must be recommended by your treating specialist.
We do not cover any consultations, diagnostics or treatment required by a mother / birth parent or child as a result of a surrogate pregnancy.
Please note, if the child is accepted as a member of the scheme, they will only be entitled to benefits outlined in the table of benefits and will be subject to the exclusions and limitations listed within the scheme.
We do not cover any transplants, adoptive cell transfer, gene therapies and / or any complications related to, or resulting from these. This includes but is not limited; to CAR T cell therapy, Tumour Infiltrating Lymphocyte therapy and stem cell / bone marrow treatments.
We also do not cover consultations, diagnostics or treatment relating to:
- donor costs
- harvesting
- storage
- administration
- and / or any complications / treatment arising from any of the above
Exception: we will cover recipient costs for skin or corneal grafts. We will require full clinical details from your specialist to asses cover and eligibility.
We do not cover any consultations, diagnostics or treatment when they are carried out by:
- a provider who we do not recognise as being qualified and / or registered to provide the treatment you need, or to treat the medical condition you have
- sports therapists, massage therapists, or anyone who does not meet our definition of a practitioner or complementary practitioner
- you, your spouse, parents or children
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide.
Prosthesis, Prostheses
Acute condition
Annual renewal date
Scheme Benefit, Scheme Benefits
Biological therapies
Cancer
Chronic condition
- requires ongoing or long-term monitoring through consultations, examinations, check-ups and / or tests
- needs ongoing or long-term control or relief of symptoms
- requires rehabilitation or for you to be specially trained to cope with it
- continues indefinitely
- has no known cure, or
- comes back or is likely to come back. <
Complementary practitioner
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council)
Day case
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Emergency
Employer
End of life care
Gender Dysphoria
General Practitioner, GP
High dependency unit, Intensive care
High-risk activities
Home healthcare
Hospital, Hospitals
- Private hospital - an independent hospital which can provide acute medical, surgical or psychiatric care. It must be registered under The Registered Homes Act (1984) and approved by the Healthcare Commission or any future law. It may also include a private bed in an NHS hospital.
Inpatient
Intensive care unit
Medically necessary
- in accordance with professional standards of medical practice in the United Kingdom
- clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
- required for reasons other than the comfort or convenience of the patient or specialist
- provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition
- provided only for an appropriate duration of time
- no more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results <
Mental health condition
Outpatient
Physiotherapist
Pre-existing condition
- you have received medication, advice or treatment, or
- you have experienced symptoms whether the condition was diagnosed or not <
Private ambulance
Psychological therapist
-
a psychologist who is:
-
Registered with the Health and Care Professions Council (HCPC);
-
Registered with the British Psychological Society (BPS) as a chartered Psychologist
-
a therapist who is:
-
An accredited member of the British Association of Counselling and Psychotherapy (BACP); or
-
An Accredited Member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP); or
-
An Accredited Member of Scotland’s Professional Body for Counselling and Psychotherapy (COSCA); or
-
A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)
Registered nurse
Related condition
Specialist, Specialist's
- a medical practitioner with full current registration with the General Medical Council or
-
a dentist with full current registration with the General Dental Council
and
-
a specialist in the treatment you are referred for (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
Practitioner
- an occupational therapist
- an orthoptist
- a podiatrist
- a speech and language therapist
- a dietician
- a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number. <
Treatment, Treatments
Trust Deed
Trustee, Trustees
United Kingdom
Waiting Period
You, Your, You're, You've, You'll
Pandemic
Epidemic
Diagnostic, Diagnostics
Member Zone
Member, Members
Scheme lifetime
Scheme, The Scheme
Supportive Therapies
Neurodevelopmental disorder, Neurodevelopmental disorders
We, Us, Our, We're, We've, We'll
Mental health treatment
Benefits
Main member, Main members
Fertility treatment, Fertility treatments
Cancer treatment
Neurodevelopmental disorder treatment, Neurodevelopmental disorder treatments
Emergency treatment
Addiction treatment programme
Treatment date
Experimental treatment
- the harmful effects are outweighed by the beneficial effects
- they are likely to lead to the same or better outcomes than available alternatives
- they are based on established medical practice in the United Kingdom <
Private hospital, Private hospitals
NHS hospital, NHS hospitals
Emergency repatriation
End of cover
Cover for the member will end if:
-
their employment with Healix has come to an end for any reason
-
they no longer live full-time in the United Kingdom
-
they pass away
-
for any reason they or Healix ask us to end cover
- they have given us misleading information, have kept something from us, or have broken the conditions of this scheme
Continuation option
As Healix only provides corporate group schemes, we are unable to continue your cover as an individual if you leave the Healix Group Staff Healthcare Scheme.
We understand the importance of your healthcare and choosing a new provider may be daunting. We work closely with two providers to offer you the best choice possible to take your healthcare forward.
What is a continuation option?
A continuation option allows members who resign or retire from an employer that provides workplace healthcare benefits, to take out their own cover. You might be eligible to take over the benefits previously paid for by the employer, however it’s not always guaranteed that any ongoing claims will be covered.
National Friendly
Who are NF?
A Friendly Society that helps its customers meet their health protection needs by offering you cover through private medical insurance policies.
How do I contact them?
Call 0333 014 6244, (8am-6pm Monday to Friday). Quote HEALIX and the team will be able to obtain the best possible terms for your transition.
What do they cover?
My Private Medical Insurance policy is a flexible product that offers cover for everyone up to age 85. You can choose between guided outpatient only cover all the way through to unlimited inpatient cover.
To find out more about National Friendly visit here.
Usay Compare
Who are Usay?
The largest individual health insurance intermediary and are experts at finding the best cover for you.
How do I contact them?
Call 01285 864670 and quote HEALIX.
What do they cover?
Usay Compare will get to know your unique individual requirements, do all the hard work comparing prices and policies for you; then advise on the best and most cost-effective quote.
To find out more about Usay Compare, fill in this online form.
These terms are offered to you as a previous member of the scheme and are available for a limited time only, usually no more than 30 days from the date of leaving. It is therefore important that you act quickly to maintain continuity of cover.
Healix Health Services Ltd is an introducer appointed representative of both National Friendly and Usay Business Ltd, who are authorised and regulated by the Financial Conduct Authority. Calls may be recorded or monitored for quality control.
How to make a complaint
It is always our intention to provide a first class standard of service, however, we recognise that on occasion, your requirements may not have been met.
Should you have any cause for complaint, you should contact us.
How your complaint will be handled
Stage 1
You will receive written acknowledgement of your complaint within five business days of receipt. This will include the name and job title of the individual handling the complaint.
Stage 2
Within four weeks of receiving your complaint, you will receive either:
-
a final response, or
-
a holding response, explaining why we are not yet in a position to resolve the complaint and indicating when we will be making further contact (this will be within eight weeks from receiving the complaint)
Stage 3
If you have not received a final response within four weeks, by the end of eight weeks after receipt of the complaint, you will receive either:
-
a final response, or
-
a response explaining why we are still not in a position to provide a final response and explaining when we believe we will be able to do so
If we are unable to provide a final response, due to the delay which has now occurred, you may refer your complaint to the Trustees.
If, during stage 2 or 3, we issue our final response but you remain dissatisfied, you may refer your complaint to the Trustees. To do this, please set out your reasons fully in writing to the HR Director, asking for referral to the trustees for further consideration.
How to claim reimbursement
How to claim for cash benefits
If you have received treatment free of charge on the NHS, you may be eligible to reimbursement of cash benefits as outlined in your table of benefits.
These benefits will only be eligible if the treatment received would otherwise have been covered under the scheme.
Please note, only one cash benefit reimbursement can be claimed per admission.
In order to claim these benefits, you must register your claim via the Member Zone.
You will need to provide the following information for a claim to be processed:
- a copy of your NHS discharge paperwork which should confirm the following information:
- date of admission and discharge from the NHS hospital
- name and date of birth of the person admitted
- summary of the reason for admission and the treatment received
- bank details for the reimbursement to be made to:
- account holder’s name
- sort code
- account number
How to claim baby cash benefit
Following the birth or adoption of a baby or child, you may be eligible for a cash benefit as outlined in your table of benefits.
Please note, this benefit can only be claimed once per baby or child, even if both parents are covered under the scheme.
In order to claim these benefits, you must register your claim via the Member Zone.
You will need to provide the following information for a claim to be processed:
- a copy of the full birth or adoption certificate
- bank details for the reimbursement to be made to:
- account holder’s name
- sort code
- account number
How to claim reimbursement of medical expenses
If you have paid your treating provider directly for eligible treatment (including consultations, diagnostics and therapies), you can claim reimbursement for these costs as long as it is eligible for cover as outlined in your table of benefits.
In order to claim these benefits, you must register your claim via the Member Zone.
You will need to provide the following information for a claim to be processed:
- an itemised receipt confirming the following information:
- your treatment date
- details of the treatment (including consultations, diagnostics and therapies) received
- amount paid
- bank details for the reimbursement to be made to
- account holder’s name
- sort code
- account number
Important to note:
Once the claim has been confirmed as eligible, reimbursement will be arranged via direct bank transfer.
All reimbursement claims (including cash benefits) must be submitted within six months of your treatment date / birth or adoption date.
Additional information can be found in the payment of invoices section.
Payment of invoices
It's essential that all treatment (including consultations, diagnostics and therapies) is pre-authorised. This allows us issue a pre-authorisation your treating provider confirming cover under the scheme. This authorisation is subject to any benefit limits outlined in your table of benefits and our reasonable and customary fees.
If pre-authorisation has been issued, we will settle the invoice (up to applicable limits) directly with your specialist, therapist or hospital. You are responsible for making sure we have all the information we need to pay your claims.
In some circumstances it may be necessary for you to pay for pre-authorised treatment yourself, and request a reimbursement from us for the cost. In these cases please submit a copy of your receipt via the Member Zone, along with your bank account details, and we will arrange reimbursement via direct bank transfer. All reimbursement claims (including cash benefits) must be submitted within six months of your treatment date.
We will not pay for claims if:
- the invoice or reimbursement claim (including cash benefits) is not submitted within six months of your treatment date
- the treatment (including consultations, diagnostics and therapies) takes place after you have left the scheme
- you break any terms and conditions of your membership
- you incur a fee for non-attendance or late cancellations.
Requests for additional information
We may ask you to provide information to help us assess your claim. For example we may ask you for one or more of the following:
-
medical reports and other information about the condition / treatment (including consultations, diagnostics and therapies) you are claiming for. If we request a medical report from your specialist, and they charge for providing this, we will pay the cost
-
original accounts and invoices in connection with your claim
-
an independent medical examination or second opinion with an alternative specialist, and the results of this. We will pay for the cost of any independent medical examination or second opinion we require and we will authorise this in writing, in advance
-
results of any second opinions provided by alternative specialist you have independently sought. On such occasions, we may also request our own, independent, second opinion from an expert in that field. We will pay the costs of any second opinion we request, this includes the cost of the consultation and any diagnostics undertaken as a result of that consultation
We will liaise with you and your specialist throughout your claim, and will request medical information when we deem this to be necessary for assessment of your claim. You will be asked for your consent before we do this.
Throughout your claim, we will make you aware of the options that are available to you. If your specialist recommends treatment (including further consultations, diagnostics and therapies), you should contact us as soon as possible to be sure this is eligible for cover.
Our experienced claims team will assess the level of cover available to you within the terms and conditions of the scheme. In some instances it may be necessary to refer your claim to our specialist nurses, along with our panel of independent specialist advisors, who will advise on the level of cover available.
Duplicate cover
You must tell us if you are able to make a claim for the cost of any of your treatment (including consultations, diagnostics and therapies) from anyone else, either another healthcare scheme or under an insurance policy. For example, if you received an injury that was caused by someone else, such as a road traffic accident, and you are not at fault, the scheme will only pay a share of the total costs as appropriate.
If benefits are claimed for when the injury or medical condition was caused by a third party, the scheme shall, at its own expense, have the right to pursue such claims in any way considered appropriate in your name. You must co-operate with all reasonable requests in this respect, and advise us of any amount you recover directly from the third party.
Healix privacy notice
If you would like to know more about how Healix store and process your personal data, please find our Privacy Notice here.
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide.
Prosthesis, Prostheses
Acute condition
Annual renewal date
Scheme Benefit, Scheme Benefits
Biological therapies
Cancer
Chronic condition
- requires ongoing or long-term monitoring through consultations, examinations, check-ups and / or tests
- needs ongoing or long-term control or relief of symptoms
- requires rehabilitation or for you to be specially trained to cope with it
- continues indefinitely
- has no known cure, or
- comes back or is likely to come back. <
Complementary practitioner
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council)
Day case
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Emergency
Employer
End of life care
Gender Dysphoria
General Practitioner, GP
High dependency unit, Intensive care
High-risk activities
Home healthcare
Hospital, Hospitals
- Private hospital - an independent hospital which can provide acute medical, surgical or psychiatric care. It must be registered under The Registered Homes Act (1984) and approved by the Healthcare Commission or any future law. It may also include a private bed in an NHS hospital.
Inpatient
Intensive care unit
Medically necessary
- in accordance with professional standards of medical practice in the United Kingdom
- clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
- required for reasons other than the comfort or convenience of the patient or specialist
- provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition
- provided only for an appropriate duration of time
- no more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results <
Mental health condition
Outpatient
Physiotherapist
Pre-existing condition
- you have received medication, advice or treatment, or
- you have experienced symptoms whether the condition was diagnosed or not <
Private ambulance
Psychological therapist
-
a psychologist who is:
-
Registered with the Health and Care Professions Council (HCPC);
-
Registered with the British Psychological Society (BPS) as a chartered Psychologist
-
a therapist who is:
-
An accredited member of the British Association of Counselling and Psychotherapy (BACP); or
-
An Accredited Member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP); or
-
An Accredited Member of Scotland’s Professional Body for Counselling and Psychotherapy (COSCA); or
-
A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)
Registered nurse
Related condition
Specialist, Specialist's
- a medical practitioner with full current registration with the General Medical Council or
-
a dentist with full current registration with the General Dental Council
and
-
a specialist in the treatment you are referred for (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
Practitioner
- an occupational therapist
- an orthoptist
- a podiatrist
- a speech and language therapist
- a dietician
- a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number. <
Treatment, Treatments
Trust Deed
Trustee, Trustees
United Kingdom
Waiting Period
You, Your, You're, You've, You'll
Pandemic
Epidemic
Diagnostic, Diagnostics
Member Zone
Member, Members
Scheme lifetime
Scheme, The Scheme
Supportive Therapies
Neurodevelopmental disorder, Neurodevelopmental disorders
We, Us, Our, We're, We've, We'll
Mental health treatment
Benefits
Main member, Main members
Fertility treatment, Fertility treatments
Cancer treatment
Neurodevelopmental disorder treatment, Neurodevelopmental disorder treatments
Emergency treatment
Addiction treatment programme
Treatment date
Experimental treatment
- the harmful effects are outweighed by the beneficial effects
- they are likely to lead to the same or better outcomes than available alternatives
- they are based on established medical practice in the United Kingdom <
Private hospital, Private hospitals
NHS hospital, NHS hospitals
Emergency repatriation
The Healix Team
Our experienced claims team are available to advise and help you, and can be contacted via the below:
Healix Group Staff Healthcare Scheme
PO Box 124,
Esher,
KT10 1FR
Our operating hours are: Monday-Friday 08.00-18.00 (Excl. bank holidays)
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide.
Prosthesis, Prostheses
Acute condition
Annual renewal date
Scheme Benefit, Scheme Benefits
Biological therapies
Cancer
Chronic condition
- requires ongoing or long-term monitoring through consultations, examinations, check-ups and / or tests
- needs ongoing or long-term control or relief of symptoms
- requires rehabilitation or for you to be specially trained to cope with it
- continues indefinitely
- has no known cure, or
- comes back or is likely to come back. <
Complementary practitioner
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council)
Day case
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Emergency
Employer
End of life care
Gender Dysphoria
General Practitioner, GP
High dependency unit, Intensive care
High-risk activities
Home healthcare
Hospital, Hospitals
- Private hospital - an independent hospital which can provide acute medical, surgical or psychiatric care. It must be registered under The Registered Homes Act (1984) and approved by the Healthcare Commission or any future law. It may also include a private bed in an NHS hospital.
Inpatient
Intensive care unit
Medically necessary
- in accordance with professional standards of medical practice in the United Kingdom
- clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
- required for reasons other than the comfort or convenience of the patient or specialist
- provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition
- provided only for an appropriate duration of time
- no more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results <
Mental health condition
Outpatient
Physiotherapist
Pre-existing condition
- you have received medication, advice or treatment, or
- you have experienced symptoms whether the condition was diagnosed or not <
Private ambulance
Psychological therapist
-
a psychologist who is:
-
Registered with the Health and Care Professions Council (HCPC);
-
Registered with the British Psychological Society (BPS) as a chartered Psychologist
-
a therapist who is:
-
An accredited member of the British Association of Counselling and Psychotherapy (BACP); or
-
An Accredited Member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP); or
-
An Accredited Member of Scotland’s Professional Body for Counselling and Psychotherapy (COSCA); or
-
A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)
Registered nurse
Related condition
Specialist, Specialist's
- a medical practitioner with full current registration with the General Medical Council or
-
a dentist with full current registration with the General Dental Council
and
-
a specialist in the treatment you are referred for (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
Practitioner
- an occupational therapist
- an orthoptist
- a podiatrist
- a speech and language therapist
- a dietician
- a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number. <
Treatment, Treatments
Trust Deed
Trustee, Trustees
United Kingdom
Waiting Period
You, Your, You're, You've, You'll
Pandemic
Epidemic
Diagnostic, Diagnostics
Member Zone
Member, Members
Scheme lifetime
Scheme, The Scheme
Supportive Therapies
Neurodevelopmental disorder, Neurodevelopmental disorders
We, Us, Our, We're, We've, We'll
Mental health treatment
Benefits
Main member, Main members
Fertility treatment, Fertility treatments
Cancer treatment
Neurodevelopmental disorder treatment, Neurodevelopmental disorder treatments
Emergency treatment
Addiction treatment programme
Treatment date
Experimental treatment
- the harmful effects are outweighed by the beneficial effects
- they are likely to lead to the same or better outcomes than available alternatives
- they are based on established medical practice in the United Kingdom <
Private hospital, Private hospitals
NHS hospital, NHS hospitals
Emergency repatriation
Scheme Year 2025
The below changes will come into effect for the new scheme year from 1st April 2025.
Scheme Year 2024
The below changes will come into effect for the new scheme year from 1st April 2024.
Scheme Year 2023
The below changes will come into effect for the new scheme year from 1st April 2023.
| New Benefit | Benefit Limit | Benefit Note |
|
Digital Triage |
Please refer to Member Zone for further information |
Please refer to Musculoskeletal health pathway and Mental health pathway. |
|
Neurodevelopmental Disorder Assessment |
Up to £2,000 per scheme lifetime |
We will pay up to £2,000 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. |
| Exclusion Updates | Previous Wording | Updated Wording |
|
Congenital conditions |
We do not pay for treatment for conditions which were diagnosed or evident at birth. |
Removed |
|
Developmental problems, behavioural problems and learning difficulties |
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. |
Neurodevelopmental disorders We do not pay for treatment, following diagnosis, of adult or childhood neurodevelopmental disorders |
|
Temporary relief of symptoms |
We do not pay for treatment intended to provide temporary relief of symptoms or for the ongoing management of a condition. |
Removed |
|
Treatment for which others may be responsible |
We do not pay for any expenses which you have claimed or can claim from any other insurance or source. If another insurer provides cover, we will negotiate with them to make sure both companies pay their share of the claim. You must tell us in writing as soon as possible about any claim or right of legal action, against any other person that arises from the claim under this policy. You must keep us fully informed of any developments. If we ask you, you must take all steps to include the amount of benefit you are claiming from us under this policy in your claim against the other person. We can take over and defend or settle any claim or prosecute any claim, in your name for our own benefit. We will decide how to carry out any proceedings and settlement. |
Removed |
|
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 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. |
Scheme Year 2022
The below changes will come into effect for the new scheme year from 1st April 2022
| New Benefit | Benefit Limit | Benefit Note |
|
Practitioner, physiotherapist 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, physiotherapist or specialist. |
|
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. The physiotherapist must still be recognised by us for benefit purposes. |
|
Mastectomy bras |
£200 per scheme lifetime |
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. |
| Benefit changes | Previous Limit | New limit |
|
Women's health benefit |
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. |
Remote advice service with our in-network specialist gynaecologists or men's health specialists We will pay for up to 4 remote advice appointments per scheme year with our in-network specialist gynaecologists or men’s health specialists on self-referral. This service can be used to discuss any health concern including conditions that are normally excluded for cover such as the menopause, andropause, sexual health concerns, fertility or contraception advice.
Diagnostic tests and investigations following referral from our in-network gynaecologists or men's health specialists We will pay up to £500 per scheme year for diagnostic tests or investigations that are recommended following a remote advice appointment with our in-network specialist gynaecologists or men’s health specialists. Remote consultations and diagnostic tests and investigations will be covered up to the limits described above only. Once the benefit limits have been reached the scheme rules will apply as detailed in your exclusions and limitations. Please note: additional cover may be available outside of the above limits for eligible claims, please contact the claims helpline for further information. Please refer to the women's or men's health services page for further information on how to access these benefits |
|
Outpatient consultations with a specialist on self-referral for breast cancer symptoms |
We will pay in full for self-referred consultations and investigations for breast 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. |
Outpatient consultations and diagnostic tests with a specialist on self-referral for breast, bowel, testicular or prostate cancer symptoms We will pay within your overall outpatient limit for self-referred consultations and investigations for breast, bowel or prostate cancer symptoms. Please refer to the self-referred cancer benefits page for further information on how to access this benefit. If a diagnosis of cancer is made, cover for eligible treatment will be subject to any limits as detailed in your cancer treatment benefit. |
|
Outpatient mental heath treatment
|
We will pay up to £1,500 per scheme year outpatient consultations 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. |
We will pay up to £2,500 per scheme year outpatient consultations 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. |
|
COVID-19 NHS 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 following inpatient or daycase treatment for a maximum of 30 days per scheme year. This benefit will only apply to claims for daycase or inpatient treatment of COVID-19 and/or immediate 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 following inpatient or daycase treatment for a maximum of 30 days per scheme year. This benefit will only apply to claims for daycase or inpatient treatment of COVID-19 and/or immediate complications arising from this condition. |
|
Cancer Additional services |
We will pay in full for the cost of external prosthesis, wigs 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.
|
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. |
| Exclusion changes | Previous exclusion wording | New exclusion wording |
|
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, crutches, walking sticks, external prostheses and orthotics etc) which do not fall within our definition of a surgical appliance. Any consultations relating to these are also not covered. |
We do not pay for 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. |
|
Dialysis |
We do not pay for treatment for or associated with dialysis haemodialysis, (meaning the removal of waste matter from your blood by passing it through a kidney machine or dialyser). We do not pay for treatment for or associated with peritoneal dialysis (meaning the removal of waste matter from your blood by introducing fluid into your abdomen which acts as a filter). Exception: We will pay for eligible treatment for short-term dialysis when needed temporarily for sudden kidney failure resulting from an eligible condition or treatment. |
We do not pay for treatment for or associated with dialysis, unless it is required as a complication in the short term following eligible treatment. |
|
GP consultations / visits |
We do not pay for GP consultations. This includes any charges for the completion of claim forms or referral letters, unless we have requested these specifically to assess your claim. |
We do not pay for 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. |
|
Pandemic / epidemic |
new exclusion |
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. |
|
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.
|
Removed |
Scheme Year 2021
The below changes will come into effect for the new scheme year from 1st April 2021
| New Benefit | Benefit Limit | Benefit Note |
|
Remote consultations with our in-network specialist gynaecologists for women’s health concerns |
4 remote consultations per scheme year, via our in-network specialist gynaecologists |
You can contact our virtual GP, TrustDoc24, directly on 0345 319 4129 at any time to arrange a remote consultation with a GP with additional training in women’s health. Alternatively contact our helpline and speak with the nursing team, and if appropriate we may be able to arrange a remote consultation directly with our in-network gynaecologist. Please contact us to discuss this. Please note: remote consultations with our in-network gynaecologist will be limited to 4 per scheme year. If further consultations are required, these will be subject to the general terms and conditions of the scheme. There is no limit placed on remote consultations with our virtual GP. Please refer to the women’s health services page for further information on how to access this benefit. |
|
Diagnostic tests and investigations in relation to women’s health concerns |
Up to £500 per scheme year |
We will pay up to £500 per scheme year for diagnostic tests or investigations that are recommended following a remote consultation with our in-network specialist gynaecologists. Please refer to the women’s health services page for further information on how to access this benefit. |
Scheme Year 2020
The below changes will come into effect following the scheme renewal on 1st April 2020
| Benefit Name | Previous Benefit Wording | New Benefit Wording |
|
Outpatient consultations with a practitioner |
We will pay up to a maximum of £350 per scheme year for outpatient podiatry, speech and language therapy or dietary services when carried out by approved therapists. You must be referred by your GP or specialist, and have approval from us in writing, in advance of you receiving the treatment. |
We will pay in full for: Outpatient consultations with a specialist following GP referral Outpatient diagnostics and investigations following GP or specialist referral Outpatient treatment following specialist referral. Cover is subject to our reasonable and customary guidelines Outpatient treatment with a practitioner following GP or specialist referral |
|
Outpatient mental health |
We will pay up to £1,500 per scheme year for outpatient consultations for eligible mental health conditions following GP referral. If your referral is to a Psychological Therapist we will arrange a telephone-based clinical assessment with a Senior Therapist from our mental health network provider who will help organise the most effective treatment for you. This could include face to face therapy, guided self-management or specialist referral. Where treatment with a Psychological Therapist occurs outside our network provider it must be delivered under the direct supervision of a Consultant Psychiatrist. |
We will pay up to £1,500 per scheme year for outpatient consultations for eligible mental health conditions following GP or self-referral. If you self-refer or your referral is to a Psychological Therapist we will arrange a telephone-based clinical assessment with a Senior Therapist from our mental health network provider who will help organise the most effective treatment for you. This could include face to face therapy, guided self-management or specialist referral. Where treatment with a Psychological Therapist occurs outside our network provider it must be delivered under the direct supervision of a Consultant Psychiatrist. |
|
Home nursing after eligible private inpatient treatment
|
We will pay up to 13 weeks per scheme year for home nursing charges for registered nurses if recommended by a specialist and where treatment is:
We will need full clinical details before we give our authorisation and you must have our written agreement before treatment starts. Home nursing provided by a community mental health team is not covered by the scheme. |
Home healthcare We will pay in full for home nursing charges for registered nurses when recommended by a specialist and where treatment is:
We will need full clinical details before we give our authorisation and you must have our written agreement before treatment starts. Home nursing provided by a community Mental Health nurse is not covered by the scheme. |
| New Benefit Name | Benefit Limit | Benefit Note |
|
Cancer outpatient therapies & Cancer alternative therapies |
Combined limit of £1,000 per scheme year |
We will pay a combined limit of £1,000 per scheme year for cancer outpatient therapies and cancer alternative therapies. Cancer outpatient therapies Cancer alternative therapies Benefits will be paid to you on receipt of the necessary documents, which must be submitted within six months of your treatment date. These benefits are available when recommended by your specialist and required as a direct result of eligible cancer treatment. Treatment must be taken with a physiotherapist, complementary practitioner or practitioner we recognise for benefit purposes. For more details on how to access these benefits, please call on 0208 481 7718. |
|
Cancer outpatient mental health treatment |
£1,000 per scheme year |
We will pay up to £1,000 per scheme year for outpatient mental health treatment. Mental health treatment must be with a psychological therapist or psychiatrist for this to be eligible for cover. This benefit is available when recommended by your specialist and required as a direct result of eligible cancer treatment. Treatment must be taken with a psychological therapist we recognise for benefit purposes. For more details on how to access this benefit, please call on 0208 481 7718. |
|
Cancer additional services |
Full Cover |
We will pay in full for the cost of external prosthesis, wigs and medical tattooing for reconstructive purposes only. For wigs and medical tattooing, this benefit is available on a pay and claim basis only. Benefits will be paid to you on receipt of the necessary documents, which must be submitted within six months of your treatment date. This benefit is available when recommended by your specialist and required as a direct result of eligible cancer treatment. For more details on how to access this benefit, please call on 0208 481 7718. |
| Exclusion Title | Previous Exclusion Wording | New Exclusion Wording |
|
Transplant exclusion |
We do not pay for any transplants and/or complications related to, or resulting from transplants.
Exception: we will pay for recipient costs for skin or corneal grafts when eligible for benefit. |
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.
Exception: we will pay for recipient costs for skin or corneal grafts when eligible for benefit. |
|
Congenital exclusion |
We do not pay for treatment for conditions, including genetic conditions, which you have had from birth, whether or not these were diagnosed or evident at birth. Exception: we will pay for emergency operations carried out within 14 days of birth |
We do not pay for treatment for conditions which were diagnosed or evident at birth. |
|
Cosmetic surgery exclusion |
We do not pay for any form of plastic or reconstructive surgery, or scar revision, even when required for psychological reasons. We will not pay for breast enlargement or reduction or any treatment or procedure to change the shape or appearance of your breast(s) whether or not it is required for medical or psychological reasons, for example backache or enlarged breasts in males. We do not pay for any treatment, including surgery:
Exception: We will pay for post-traumatic or post-surgical reconstruction to restore function or appearance if it is medically necessary as a direct result of you having an accident or because of other surgery or cancer, which itself would have been covered under the scheme. We will pay for breast reduction/augmentation in a healthy breast if the primary purpose is to improve symmetry following surgery for cancer in the contralateral breast. |
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:
Exception: We will pay for medically necessary treatment to restore your appearance in the following circumstances:
Please note: we use NHS guidance as a benchmark for deciding whether requests for treatment are eligible for cover. All requests for cover must be submitted in writing with supporting medical information |
|
Chronic exclusion |
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:
Please note: this will apply to all medical conditions, whether or not a diagnosis has been made. We will pay for eligible acute conditions related to a chronic condition (this does not apply to mental health conditions). For example, we pay for a heart bypass following a heart attack arising out of chronic heart disease. However, many chronic conditions are of a relapsing and remitting nature, requiring management of recurrent episodes where symptoms deteriorate - e.g. multiple sclerosis, Crohn’s disease, long-term depressive illness, psoriasis etc. The relapses are part of the normal illness course and therefore cannot be classed as acute complications of the disease and are not eligible for benefit. Please note: in some cases it might not be clear at the time of treatment that the condition being treated is chronic. We may not pay the ongoing costs of continuing, or similar treatment even where we have previously paid for this type of or similar treatment. As we expect an acute condition to resolve completely within three months, we would begin to consider any condition lasting longer than this as chronic. |
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
Please note: this will apply to all medical conditions, whether or not a diagnosis has been made. 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. |
|
Removal of the following exclusions |
AIDS/HIV Alcohol abuse, substance abuse and addiction Self-inflicted illness or injury Telephone consultations Vaccinations Varicose veins of the leg
|
|
Scheme Year 2019
The new scheme year renews on the 1st April 2019. There will be no changes made to the scheme for this year.
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide.
Prosthesis, Prostheses
Acute condition
Annual renewal date
Scheme Benefit, Scheme Benefits
Biological therapies
Cancer
Chronic condition
- requires ongoing or long-term monitoring through consultations, examinations, check-ups and / or tests
- needs ongoing or long-term control or relief of symptoms
- requires rehabilitation or for you to be specially trained to cope with it
- continues indefinitely
- has no known cure, or
- comes back or is likely to come back. <
Complementary practitioner
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council)
Day case
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Emergency
Employer
End of life care
Gender Dysphoria
General Practitioner, GP
High dependency unit, Intensive care
High-risk activities
Home healthcare
Hospital, Hospitals
- Private hospital - an independent hospital which can provide acute medical, surgical or psychiatric care. It must be registered under The Registered Homes Act (1984) and approved by the Healthcare Commission or any future law. It may also include a private bed in an NHS hospital.
Inpatient
Intensive care unit
Medically necessary
- in accordance with professional standards of medical practice in the United Kingdom
- clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
- required for reasons other than the comfort or convenience of the patient or specialist
- provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition
- provided only for an appropriate duration of time
- no more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results <
Mental health condition
Outpatient
Physiotherapist
Pre-existing condition
- you have received medication, advice or treatment, or
- you have experienced symptoms whether the condition was diagnosed or not <
Private ambulance
Psychological therapist
-
a psychologist who is:
-
Registered with the Health and Care Professions Council (HCPC);
-
Registered with the British Psychological Society (BPS) as a chartered Psychologist
-
a therapist who is:
-
An accredited member of the British Association of Counselling and Psychotherapy (BACP); or
-
An Accredited Member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP); or
-
An Accredited Member of Scotland’s Professional Body for Counselling and Psychotherapy (COSCA); or
-
A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP)
Registered nurse
Related condition
Specialist, Specialist's
- a medical practitioner with full current registration with the General Medical Council or
-
a dentist with full current registration with the General Dental Council
and
-
a specialist in the treatment you are referred for (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
Practitioner
- an occupational therapist
- an orthoptist
- a podiatrist
- a speech and language therapist
- a dietician
- a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number. <
Treatment, Treatments
Trust Deed
Trustee, Trustees
United Kingdom
Waiting Period
You, Your, You're, You've, You'll
Pandemic
Epidemic
Diagnostic, Diagnostics
Member Zone
Member, Members
Scheme lifetime
Scheme, The Scheme
Supportive Therapies
Neurodevelopmental disorder, Neurodevelopmental disorders
We, Us, Our, We're, We've, We'll
Mental health treatment
Benefits
Main member, Main members
Fertility treatment, Fertility treatments
Cancer treatment
Neurodevelopmental disorder treatment, Neurodevelopmental disorder treatments
Emergency treatment
Addiction treatment programme
Treatment date
Experimental treatment
- the harmful effects are outweighed by the beneficial effects
- they are likely to lead to the same or better outcomes than available alternatives
- they are based on established medical practice in the United Kingdom <