Terms and conditions of your health insurance.€¦ · double check any of the details of your...

Terms and conditions of your health insurance.

POLICY SUMMARY AND POLICY DOCUMENT

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Contents.

page

Your policy summary 3

Your policy document 7

1. Cover and benefits in detail 14

2. Underwriting 20

3. Exclusions 22

4. Policy terms and conditions, general conditions, policy administration 25

5. Complaints 35

6. Law and interpretation 36

7. Currency 36

8. Glossary of definitions 36

How to contact us 44

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Your policy summary.

This policy summary highlights the benefits of yourPruHealth private health insurance.

Please read your policy document for full terms and conditions.

What is PruHealth private health insurance?n It is an insurance plan underwritten

by PruHealth that aims to cover the cost of private medical treatment for acute conditions for UK residents. You must be aged 18 or over to have a PruHealth policy.

n Your policy with us is for a 12 month period.

What benefits does this plan offer me?n With our Vitality programme everyone

can benefit from a healthy lifestyle. If you eat well, take a bit of exercise andmaintain an all round healthy lifestyle youcould receive a reward when you renew.

n At policy renewal, PruHealth willallocate a no claims discount per policybased on claims made during the policyyear. The full twelve months of thepolicy year will be reviewed. Where lateclaims are received and not taken intoaccount these will be added into the

following renewal calculation. Claimsmade by any member(s) on the policywill be taken into account.

n The no claims discount will be increasedby 5% for each year the member doesnot claim to a maximum of 35%. It willdecrease by 10% if a claim is made in the policy year.

n A Vitality renewal reward will also becalculated based on a member’s attainedVitality status in the policy year. TheVitality renewal reward will be based ona combination of the member’s Vitalitystatus and the monthly premium paid inthe policy period.

n Prices with our Vitality partners mayincrease during the year. For our fixedprice Vitality benefits no price shallexceed the amount equal to thechange in the Consumer Price Index(since our last price increase) againstthe Bronze price. For our percentagediscount Vitality benefits, the amountmay vary during the year if that retailerchanges its standard price (please seesection 1.16ii of your policy documentfor full details).

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What does each plan cover?We have four different types of cover. You’llbe able to check which one you chose byreading your membership certificate.

The Comprehensive plan covers:n All eligible hospital fees, including

specialist fees, plus greater levels ofoutpatient care and higher cover limits

n All eligible outpatient costs

n A wider range of additional benefitssuch as complementary and alternativetherapies.

The Select plan covers:n All eligible hospital fees, including

specialist fees, plus greater levels ofoutpatient care

n Option of £0 or £250 excess

The Core plan covers:n All eligible hospital fees, including

specialist fees

n Limited outpatient costs following anddirectly related to a hospital stay

n Option of £0 or £250 excess.

The Value plan covers:n All eligible hospital fees and limited

outpatient costs. The member will needto contribute a pre-set amount per benefitin the form of a fixed co-payment.

Please read the ‘Summary of PruHealth plansand benefits’ section in your policy documentfor full details on what your plan covers. Thisincludes details on our full cancer cover.

What our plans do not cover:

As with many private health insuranceplans, there are some standard treatmentsand conditions that we don’t cover. Theseare as follows:

n Any regular monitoring or treatment ofchronic conditions. Examples of chronicconditions include diabetes, HIV/AIDSand allergies

n Any treatment received outside the UKn Emergency treatment or visits to

your GPn Preventative treatment

(and regular checks)n Pregnancy and childbirthn Self-inflicted injuriesn Cosmetic treatmentn Organ transplantsn Medication and dressings

(except when administered during hospital admissions)

n Fertility, infertility and menopause-related treatment

n Experimental, unproven or unregisteredtreatment or practices

n Treatment related to developmentalproblems, learning difficulties, ordelayed speech disorders

n Dentistryn Refractive eye surgery and optometryn Treatment for obesity

n Deafness

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If you selected ‘moratorium underwriting’,any conditions that you have been affectedby in the five years before the start of yourcover will not be covered in the first twoyears of your policy. Please read the'Underwriting' section in your policydocument for full details.

Depending on the plan you have selectedthere may be times when you are requiredto contribute towards the treatment youreceive through an excess or co-payment,or where your treatment cost exceeds thePruHealth fee maximum. Please see yourmembership certificate for details of anyexcess or co-payments that may apply.

Out of hospital list co-payment

An out of hospital list co-payment appliesfor services outside of a member’s selectedhospital list. For an inpatient admissionoutside of the member’s selected hospitallist a 40% co-payment will apply to thehospital charges. For a diagnostic scanoutside of the member’s selected hospitallist a 40% co-payment will apply to thehospital tariff. Under the Value plan therewill be no cover for outpatient diagnosticscans outside of the member’s selectedhospital list.

How do I claim?We hope you don’t need to claim but ifyou do we’ve made the process as simpleas possible.

n Step 1: Visit your GP. If you needmedical treatment, the first thing to do isto visit your GP. If they refer you fortreatment, tell them you have cover withPruHealth and ask for the following:

– Full details of your condition/injury,diagnosis and intended treatment

– Full name and address of thespecialist and the hospital/clinicyou've been referred to.

n Step 2: Give us a call on 0845 125 1911.

Once you've got all the details, call ourdedicated Claims Team for yourauthorisation number – jot this downand keep it safe for your trip to thespecialist. If you have treatment withoutit, it could mean you won't be covered.

It's worth remembering that you mightbe asked to give details of yourcondition over the phone, so you maywant to make the call in private. Todouble check any of the details of yourcover, log on the Member Zone atpruhealth.co.uk/member and clickon `My cover'.

You may be able to receive anauthorisation number online. Please log onto the Member Zone atpruhealth.co.uk/member to find out.

n Step 3: Book your appointment.You can now book your appointmentwith the specialist and start yourtreatment. When you go, make sure youtake the authorisation number we gaveyou. If you need further visits, ask for aprocedure code and description of thetreatment or investigation. Always speakto our Claims Team to make sure you'recovered for further treatment.

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n Step 4: Settling the bill. In mostcases, bills will be sent direct to us. If you do get a bill, simply forward it onto us at PruHealth Customer Services, Stirling FK9 4UE. If you make a paymentyourself, send us the bill with proof ofpayment and we'll pay you back.

Can I change my mind?You have 30 days from the start date of yourcover, or from when you received yourpolicy documentation, whichever is later, tocancel your policy and receive a full refund.If you have any claims larger than yourpremium we will collect the difference andany outstanding claims will be cancelled.You will not receive a refund for any Vitalityactivities used or points earned. Cool offprovisions for any gym membership willdepend on the terms and conditions of therelevant gym.

What if I need to complain?We hope that you never need to complain,but if you do, you can write to us at:

PruHealth Customer Services,Stirling FK9 4UE.

Copies of our Complaint HandlingProcedures are also available at thisaddress. Or you can call us on 0800 096 6322.

If you are not satisfied with our reply youcan take your complaint to:

The Financial Ombudsman Service,South Quay Plaza,183 Marsh Wall,London E14 9SR.

www.fsa.gov.uk/register or by contacting the FSA directly on 0845 606 1234.

This is a free service. Using it will not affect your legal rights.

Compensation You may have a right to compensation ifwe or another authority decide that you’vebought a plan in which the informationprovided by PruHealth was incorrect ormisleading and resulted in financial loss.Please contact our Customer Services office for more information.

If PruHealth is unable to meet its financialobligations in full you may be entitled to helpfrom the Financial Services CompensationScheme. Further information is availablefrom the Financial Services CompensationScheme. Telephone 020 7892 7300 or visit the website at www.fscs.org.uk

How to contact us

OnlineVia our Member Zone atpruhealth.co.uk/memberand send us a secure message

By postPruHealth Customer ServicesStirling FK9 4UE

By phone

0845 125 1911

Please note that PruHealth can only giveinformation on PruHealth products.

Your policy document.

About this document

This document reflects the Terms and Conditions of the policy as agreed betweenPruHealth and the policyholder.

Please refer to this document in conjunction with your membership certificate for full details of cover and exclusions that may apply.

Words in italics in this document are defined terms which have a specific meaning.You should check their meaning in the glossary at the back of this document.

About PruHealth

PruHealth was launched in October 2004 and is a joint venture between Prudentialand Discovery Holdings, the South African health insurance leader. PruHealth’smodel for private medical insurance is based on a successful concept in South Africa.

About Prudential UK and Discovery Holdings

Established in 1848, today Prudential plc is a leading international financial servicescompany with some 21 million customers, policyholders and unit holders and some23,000 employees worldwide. Discovery Holdings was founded in 1992 as aspecialist health insurance company in South Africa. It is now one of the marketleaders in healthcare and life insurance in South Africa.

For more information visit www.prudential.co.uk and www.discovery.co.za

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Overall winner ofthe best CustomerExperience league

table for 2008

Best PMIProvider 2007 & 2008

Best IndividualPMI Provider 2006, 2007

& 2008

Health InsuranceCompany of the Year

2006 & 2007

Best Individual PMIProvider 2006, 2007 & 2008

Best Group PMI Provider 2007

Important regulatory information

PruHealth is the trading name of both Prudential Health Limited and PrudentialHealth Services Limited. Prudential Health Limited, registration number 5051253, is an insurer that underwrites the insurance products. Prudential Health ServicesLimited, registration number 5933141, is an insurance intermediary with FSAauthorisation to mediate insurance business. Our registered offices are at LaurencePountney Hill, London EC4R 0HH. Both Prudential Health Limited and PrudentialHealth Services Limited are authorised and regulated by the Financial ServicesAuthority (FSA). You can check our authorisation on the FSA’s Register by visitingthe FSA’s website:

www.fsa.gov.uk/register or by contacting the FSA directly on 0845 606 1234.

The products we offer

Prudential Health Services Limited only offers products underwritten by PrudentialHealth Limited. Prudential Health Services Limited can offer other insuranceproducts from a specific range of insurers. If you wish to see this list of insurers andinsurance products, it is available on request.

Statement of demands and needs

This policy is designed to meet the demands of people who wish to ensure theirhealth needs are met quickly.

We aim to offer increased choice and access to high quality facilities. Our productswill also reward you if you make an effort to lead a healthy lifestyle. To ensure youare completely confident that our products will meet your personal demands andneeds, we would advise that you read the information we give you both before andimmediately after we have completed a sale with you.

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Data Protection

PruHealth, our group of companies and our business associates, service providersand agents will use your information, together with other information, foradministration, customer services, marketing and profiling your purchasingpreferences and fraud prevention. We will only pass your information to them forthese purposes.

We will also pass your information to any legal or regulatory body such as theFinancial Ombudsman or the Financial Services Authority if we are required to do so.

If you have appointed a broker in relation to this policy, we may also need to passcertain information of yours to that broker.

Please rest assured that we will always maintain the greatest care in the transfer ofthis information to the parties noted and act in accordance with the most up-to-datedata protection legislation to ensure your confidentiality is not breached in any way.

For the above purposes it will be necessary to transfer your information to countriesthat provide a different level of data protection from the UK. We have contracts inplace to ensure your information is protected in accordance with UK law.

You have a right to obtain a copy of your personal information (for which we maycharge a fee) and to have any inaccuracies corrected by writing to:

PruHealth c/o The Privacy ManagerInformation Risk and Privacy TeamPrudential Assurance Company Ltd, 3 Sheldon Square,London, W2 6PR.

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Overview

This is the policy wording and benefitdescription for the PruHealth privatehealth insurance (PMI) taken out by thepolicyholder.

PruHealth expects that this policy willenable the member to protect andenhance their wellbeing and that of theirdependant members in times of bothillness and health. It is intended tocomplement rather than replace NHSservices provided in the UK.

Any examples contained in this policywording are for illustrative purposesonly and do not reflect the totality of the circumstances covered by therelevant clause.

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Your PruHealth policy terms and conditions.

Contacting us

For more information or furtherclarification on the benefits, cover,exclusions and the rules included in thispolicy you can contact us as follows:

Online

Via our Member Zone atpruhealth.co.uk/member and send us a secure message

By post

PruHealth Customer ServicesStirling FK9 4UE

By phone

0845 125 1911

Or contact your adviser.

How we will communicate with you

We will use a member’s email address asthe primary form of contact regarding this policy and our Vitality programme.Please note we generally do not sendpaper copies of our policy documentationor Vitality information to you unlessexplicitly requested. All policydocumentation can be found by loggingin to our secure online Member Zone atpruhealth.co.uk/member.

Summary of PruHealth plans and benefits

'Covered' in the summary of benefits means we will pay for treatment athospitals on your selected hospital list, where charges are within thePruHealth fee maxima for the services provided.

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Comprehensive Select Core Value

INPATIENT CARE

Hospital charges Covered Covered Covered Covered3

Specialistconsultant fees

Covered Covered Covered Covered3

Diagnostic tests Covered Covered Covered Covered3

Radio- andchemotherapy Covered Covered Covered Covered

Psychiatrictreatment

Combinedpsychiatric limit of £20,000 perpolicy year


None None

OUTPATIENT CARE

Specialistconsultations

Covered Combined limit of£750 per policyyear1

Combined limit of£600 per policyyear1,2

Combined limit of£600 per policyyear1,4

Diagnostic scans:MRI, CT, and PETscans

Covered Covered Covered Covered4

Diagnostic tests:other

Covered Covered Combined limit of £600 per policy year1

Combined limit of £600 per policy year1,5

Physiotherapy Covered Combined limit of £750 per policy year1



Chiropractic andosteopathy

Limit of £800 perpolicy year

Combined limit of £750 per policy year1



Radio- andchemotherapy Covered Covered Covered Covered

Psychiatrictreatment


Sub limit of £750 to an overall combinedpsychiatric limit of £7000 perpolicy year

None None

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Comprehensive Select Core Value

OTHER BENEFITS

Complementaryand alternativetherapies

Limit of £600 perpolicy year

None None None

Childbirth cashbenefit £100 per child £100 per child £100 per child £100 per child

Home nursing Covered £3,000 limit perpolicy year

£3,000 limit perpolicy year

£3,000 limit perpolicy year

Private ambulance Covered £60 per trip £60 per trip £60 per trip

Parentalaccommodation

Yes (for childrenof 12 or under, 1 parent)




NHS hospital cashbenefit

£100 per day(overall annuallimit of £2000)




EXCESS

Option of £0,£100, £250, £500or £1000

Option of £0 or£250

Option of £0 or£250

No excessavailable

VITALITYBENEFITS

Full Vitalitybenefits




1 The combined limit means that claims for specialist consultations, diagnostic tests, physiotherapy,chiropractic and osteopathy all aggregate to one limit for each member on the policy.

2 Cover is restricted to treatment following and directly related to an eligible hospital admission. We consider treatment which falls within a maximum of six months of the eligible hospital admission tobe directly related to the original admission. Generally any treatment after six months would not beconsidered to be directly related to the original hospital admission.

3 A co-payment of £100 applies per inpatient admission within selected hospital list.4 A co-payment of £50 applies per interaction.5 A co-payment of £20 applies per interaction.

Notes:

n Specialist/consultant fees: includes surgeons’, anaesthetists' and physicians' fees whilst as aninpatient or day case patient

n Diagnostic scans include CT, MRI and PET scans. These must be following consultant referral onlyand also within the member’s selected hospital list. A co-payment of 40% of the tariff will apply forscans undertaken outside of member’s selected hospital list.

n Other diagnostic tests include pathology, X-rays and physiological tests such as an ECG.n Physiotherapy, chiropractic and osteopathy. Cover will only apply up to the number of

authorised sessions.

1. Cover and benefits in detail

We will only pay for the treatments andservices as expressly laid out in theschedule on page 12, subject to theconditions of cover, definitions andexclusions detailed later in this policydocument and laid out in themembership certificate. We will not pay for any other treatments or servicesunless we expressly agree to do so inwriting. Please read the summary ofbenefits in conjunction with ‘Conditionsof cover’ and ‘Exclusions’ set out overthe page. Cover is available only topermanent residents of the UK and is for treatment in the UK, Channel Islandsand the Isle of Man.

PruHealth will cover fees charged byconsultants who hold or have held anNHS post or equivalent and areregistered as a specialist with theGeneral Medical Council. Othertherapists must be registered withappropriate regulatory bodies. If theproposed provider charges outside thePruHealth fee maximum the membermay be expected to pay the difference.This will be specified at the claimauthorisation stage.

1.0 Hospital lists and co-payments

The selected hospital list where themember can be treated is specified inthe membership certificate and isavailable on our website. PruHealthhospital lists may change from time to time and we recommend that themember check the most up-to-dateversion on our Member Zone beforetheir treatment commences.

Our hospital lists are made up of someof UK’s leading private hospital groups.The member's selected hospital list willbe able to provide most services whichare available within their purchasedbenefits. If the member has anyproblems finding a service they need inthe selected hospital list, they shouldcontact us and we will help to locate afacility and/or consultants who providethat service. In certain circumstancesthis may mean they will need to travel toobtain the service within the selectedhospital list and avoid a co-payment.

If the member goes to a hospital not ontheir selected hospital list they will beliable to contribute up to 40% of thehospital charges relating to theirtreatment.

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1.1 Benefit limits

Any benefit limits stated apply for eachperson covered under the policy. Theselimits also apply to the total of claimsover the policy year.

Where a combined limit applies it meansthat the cost of any treatment paid forout of those benefits accumulatestowards the overall limit. There may besub-limits within the overall combinedlimit and the member should check thesummary of benefits in this documentfor further detail.

1.2 Excesses

Excesses apply per person coveredunder the policy. Excesses relate to thetotal amount of claims over a policy yearfor an individual, not to each claimevent. Please note that after everyrenewal a new excess will apply to each person covered.

1.3 Value plan co-payments

A co-payment is a set value a membermust contribute towards treatmentspecified in the summary on page 12,for services provided within themember’s chosen hospital list. Co-payments apply per member perclaim event covered under the policyand applies each time they see orreceive treatment from their medicalprovider. The co-payment amount willvary for different treatment types.

The co-payment will be deducted fromthe PruHealth fee maximum or the tariff that we will pay in relation to thetreatment in question.

1.4 Out of hospital list co-payment

An out of hospital list co-paymentapplies for services outside of amember’s selected hospital list. For aninpatient admission outside of themember’s selected hospital list a 40%co-payment will apply to the hospitalcharges. For a diagnostic scan outside of the member’s selected hospital list a 40% co-payment will apply to thehospital tariff. Under the value planthere will be no cover for the outpatientdiagnostic scans outside of themember’s selected hospital list.

1.5 PruHealth fee maximum

If the proposed treatment cost is abovethe PruHealth fee maximum for thattreatment, the member will have tocontribute the difference between thisamount and the claimed amount.Alternatively, the member can choose to have treatment with a differentpractitioner who charges within the PruHealth fee maximum for that treatment.

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1.6 Intensive and high dependency care

Critical care

We will pay for critical care where it ispart of the expected post-operativemanagement of the member and wherethe intention is to treat a disease, illnessor injury which is likely to respondquickly to treatment.

We will pay for unexpected care in aprivate hospital providing the followingconditions are met:

n It follows an elective, non-emergency admission;

n It is provided in a dedicated criticalcare area; and

n It is the most appropriate setting for such treatment

We do not pay for unexpected criticalcare in an NHS hospital under anycircumstances. We do not pay for anylevel of critical care which is notmedically necessary for the conditionbeing treated.

1.7 Psychiatric care

PruHealth will actively managepsychiatric treatment in order to achievethe best outcome for the member on acase by case basis. Please note that dueto the nature of psychiatric illness it maybe that over the course of treatment, thecondition will be deemed to be chronic(see Exclusions: chronic conditions).

The overall psychiatric treatment limitapplies for both inpatient and outpatienttreatment or services and includes bothaccommodation and treatment costs.The outpatient sub-limit is for outpatienttreatment or services and accumulatesto the overall psychiatric limit.

1.8 Rehabilitation

Cover is available for rehabilitation,which is treatment intended to restorehealth or mobility or return the memberto independent living, following a strokeor injury. The rehabilitation must beintegral to eligible inpatient treatment,should start no more than 2 monthsafter initial diagnosis or date of injuryand will normally be covered for 30 daysonly and will be managed within ourguidelines for chronic conditions. To beeligible a specialist should make thereferral to a rehabilitation unit.

1.9 Complementary and alternativetherapies

Where covered, this category includesmedical and healthcare systems andpractices that are not presentlyconsidered to be part of conventionalmedicine. To be eligible for cover, these therapies must be used fortreatment of an acute conditionfollowing referral by a GP or specialist.All practitioners must have adequateexperience and indemnity insuranceand must be registered with theappropriate authority and be a member

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of a speciality organisation. Our list ofcriteria for entry for all providers isavailable on request and on the MemberZone. Treatment for pre-existingconditions or chronic conditions is notcovered, nor are associated medicinesand products.

1.10 Childbirth cash benefit

This is payable on the birth of a child toa member who has been covered by apolicy for at least nine months prior tothe birth. In order to claim the benefitthe member must provide PruHealthwith a copy of the birth certificate andrequest the payment of benefit withinsix months of the birth.

1.11 Nursing at home

In order to claim the nursing at homebenefit, such treatment must:

n immediately follow a period ofinpatient treatment for a medicalcondition covered by the policy;

n be for treatment that wouldotherwise be provided in hospital as an inpatient;

n be undertaken by a trained nurse;and

n be recommended by and carried out under the supervision of themember’s specialist.

1.12 Private ambulance

Use of an ambulance is covered forprivate transfers between hospitals,whether NHS or private. This use islimited to paid services provided byindependent companies or the NHS. It is limited to medically necessarytransfers where there is a reasonablemedical need for the action to be taken.Transfers for non-medical reasons willnot be covered.

1.13 Parental accommodationbenefit

This benefit is paid to enable one parentto stay in the same hospital as their child(up to and including 12 year olds) whenthe child is admitted as an inpatient to aprivate hospital or an NHS private wardwithin an NHS Private Patient Unit (PPU).

Paediatric conditions are mainly treatedin NHS hospitals, though some privatehospitals still provide treatment. If thechild covered under the policy goes toan NHS hospital for treatment, the childis eligible for the NHS hospital cashbenefit as described in the clause below.

1.14 NHS hospital cash benefit

This benefit applies only to NHS daycases or stays in a general NHS ward,not an NHS PPU. The NHS hospital cashbenefit is paid out only for conditionsthat PruHealth would have covered if treated privately under the policy.Consequently, this benefit wouldn’t be

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available for a visit to Accident andEmergency (A&E) as A&E treatment isnot covered by PruHealth. Any standardor personal exclusions still apply (referto Section 3).

If the member is admitted to an NHShospital for an acute event and is eligiblefor transfer to a private hospital, they willbe eligible for the cash benefit if theychose not to move to a private facility.

If the member does choose to claim thecash benefit, this will be recorded as aclaim in the normal way and will affect thecalculation of the reward payable to themember on renewal (see Section 4.10b).The member, or their representative,must call PruHealth to requestauthorisation for the claim in accordancewith the normal procedure (see Section4.9b) and submit to PruHealth the NHSdischarge form as evidence of theirtreatment or hospital stay.

1.15 Cancer benefit

PruHealth will pay for treatment for allstages of cancer, for both cure andpalliative care, subject to our generalterms and conditions. Radiotherapy andchemotherapy are fully covered on allplans, subject to authorisation. Thereare no financial limits on inpatient andoutpatient cancer treatment on any planand a donation is available for hospicecare. Where an annual outpatient

benefit limit applies, consultations anddiagnostic tests directly related tocancer treatment will be fully funded.

We will evaluate therapy not yetconsidered by NICE on a case by casebasis using all currently availableevidence from properly controlledmature phase III clinical trials and maypay for the use of a new, licensed anti-cancer drug, or new use for a drug witha licensed indication where there iscredible scientific evidence to supportits use. Chemotherapy, radiotherapyand surgery for the treatment of cancerwill be covered provided it followsguidance issued by the National Institute for Health and ClinicalExcellence (NICE).

Appropriate bone marrow or stem celltransplants are also covered.

No time limits are placed on treatmentand follow up care for cancer providedcover is continuous and while you areeligible for benefits. Rules coveringchronic conditions do not apply to cancer.

A donation is available for hospice care.

PruHealth will not pay for complementaryand alternative therapies as the primarytreatment for cancer as part of the cancerbenefit. However, we will pay forcomplementary and alternative therapyas part of the Complementary andAlternative Therapies benefit. (Seesection 1.9).

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1.16 Vitality

This is our dynamic programme in whichmembers can engage in a wide selectionof health-promoting activities and beawarded points which move themthrough different statuses, each ofwhich has a published threshold basedon the number of adults on the policy.While higher statuses entitle membersto higher value rewards, all membershave the opportunity to participate in an evolving range of offers. Theprogramme promotes members’ healthand reduces the likelihood of their needto make a claim on the policy.

i) Vitality status

There are 4 statuses, Bronze, Silver,Gold and Platinum. A member's Vitalitystatus is determined by the recordedefforts that the member makes withVitality during a policy year. On renewalof the policy, a member maintains theirVitality status based on the pointsearned during the year until the nextpolicy renewal or until the memberimproves it.

Every member starts at Bronze levelwhen the policy commences.

Vitality status can go down followingrenewal if the number of Vitality pointsrequired to maintain the status is notachieved.

Vitality status can change midwaythrough the policy year as new adultdependants are added or removed.

ii) Vitality commitment

The Vitality programme evolves to giveour members the advantage of newopportunities and technologies as theyarise. It grows from our relationship withthird party providers and depends onthe range of services they offer. Weactively revise the ways in which pointscan be earned and rewarded.

Specifically, we may change themethodology for awarding points or eligible activities in the Vitalityprogramme and the Vitality status the member may achieve as a result. We may also change our Vitalitypartners from time to time and theincentives we offer. There may beinstances where other aspects of theVitality programme, such as particularbenefits, may be significantly enhanced,changed or withdrawn.

The revisions may occur if our Vitalitypartners offer additional services orbecome unable to maintain their levelsof service to us, or where we add newVitality partners to the programme.Vitality revisions may also be required toprevent the fraudulent use of benefits.Revisions may be required as a result of other factors beyond our control.

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Vitality benefits are calculated in one of two ways: as a fixed price, or as apercentage discount by reference to the standard retail rate.

We reserve the right to increase the costof fixed price Vitality benefits during thepolicy year. If we do need to increasethese prices, we will increase them forall our members at the same time, toavoid any confusion. Such priceincreases, if made, will only occur onceduring a policy year and take effecteither on 1 January or 1 July. No suchprice increase shall exceed the amountequal to the change in the ConsumerPrice Index (since our last price increasefor that benefit) as calculated against theBronze price (or the price paid by allmembers if there is no difference inprice according to Vitality status). For example, if the Bronze price (orstandard price, if applicable) for aparticular benefit is £100, and CPIincreases 3%, the maximum priceincrease for any vitality status shall be£3. Therefore, if the Platinum price forthat particular benefit is £10, the mostthe Platinum member would pay is £13.

The cost of Vitality benefits calculated asa percentage discount to a retailer’sstandard price may vary during the yearif that retailer changes its standard price.For example, the discount on a Bootshealth screen is 50%. The currentstandard price is £40, so the cost to

members is currently £20. If Boots wereto reduce the standard price to £30, thecost to members would be £15. If thestandard price was increased to £50, thecost to members would be £25.

Any changes to the Vitality programme,including the prices of fixed price Vitalitybenefits, will be communicated to you atleast 42 days before the changes takeeffect, unless this is made impossible byfactors outside our control. If thepolicyholder is unsatisfied with thechanges they may cancel the policy inaccordance with the cancellationprovisions in section 4.8 below. Memberswill still be subject to the notice period ofany relevant Vitality partner, and to anyapplicable terms and conditions relevantto that Vitality partner.

For the avoidance of doubt, please notethat this clause refers to changes to theVitality programme made within thepolicy year and does not preventPruHealth from applying changes andprice increases at renewal following theexpiry of a policy year.

2. Underwriting

2.1 Full Medical Underwriting

Under “full medical underwriting” amember will have made a declarationregarding their medical history. Pre-existing conditions will be identifiedfrom that declaration and exclusions

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applied to the policy. The member canrequest that these exclusions arereviewed at renewal.These may beremoved at the underwriters' discretion.

PruHealth may request furtherinformation when a claim is being made to establish any relationship to a pre-existing condition and/or to check that the condition was disclosedon the medical declaration. It is theresponsibility of the member to discloseany pre-existing conditions to PruHealthupon joining the policy and failure to doso may result in personal exclusionsbeing applied and claims being declinedor any sums already paid out on themember’s behalf being recovered byPruHealth. If the member has anydoubts about such disclosure theyshould call our Customer Services Team on 0800 092 7333.

2.2 Moratorium Underwriting

Under “moratorium underwriting”,conditions which existed up to fiveyears before the date of the start ofcover will not be explicitly identified but may be excluded from cover for two years from the date of commencement.

We will exclude cover for treatmentfor any medical condition or relatedcondition which the member or theircovered dependants have hadsymptoms of, whether diagnosed ornot, been aware of or sought advice onor received medical treatment for in thefive years before the start of cover

PruHealth will in most cases requestfurther information when a claim isbeing made to establish whether thecondition is pre-existing and therebyexcluded by the moratorium clause.

2.3 Switch/CPME Underwriting

Where this option is selected, only pre-existing conditions excluded by theprevious provider’s policy will beexcluded from cover. PruHealth mayrequest further information when aclaim is being made to establish anyrelationship to a pre-existing conditionand/or to check eligibility of the transferagainst the declaration signed.

Complications or increased treatmentcosts as a result of an excluded pre-existing condition will not be covered.

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3. Exclusions

The following conditions and healthcareservices are not covered by PruHealthunder this policy. In addition, anyconsultations, complications orsubsequent treatment related to theseexclusions are also not covered.

3.1 Accident and Emergency care

This includes all immediate care untilstabilisation has been achieved.

3.2 Chronic conditions

Any day-to-day monitoring and therapyof chronic conditions is excluded fromcover. This includes consultations byany healthcare professionals,medication, investigations (blood tests,radiology) etc. Examples of chronicconditions include diabetes and asthma.

However, acute complications related tochronic conditions will be coveredsubject to the member’s policy unless aspecific exclusion relating to thatcondition has been applied.

Consultations leading up to thediagnosis of a chronic condition will becovered. Many chronic illnesses are of arelapsing and remitting nature e.g.multiple sclerosis. The relapses are partof the normal illness course andtherefore cannot be classed as acutecomplications of the disease.

3.3 Complications of any treatmentnot approved by PruHealth

This relates to unproven orunregistered treatment or treatmentreceived whilst overseas. This alsorefers to increased treatment costsincurred for a disease, illness or injurywhich is ineligible for cover or forwhich cover has been excluded.

3.4 Cosmetic treatment

Any treatment primarily for cosmeticreasons or resulting from previouscosmetic treatment is excluded, even ifthe request is psychologicallymotivated. Breast reduction oraugmentation operations are excluded,whether or not for back pain. Treatmentwhich involves the removal of healthytissue or the removal of surplus or fattissue is also excluded.

Exceptions to this exclusion:Post-traumatic or post-surgicalreconstruction to restore function orappearance is included if performedwithin 12 months of major injury orprimary surgery.

We will pay for the initial reconstructivesurgery to restore function andappearance following cancer treatment.Any subsequent related treatment willonly be covered if it is intended to curean acute medical condition.

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3.5 Deafness

We will not cover for any treatment fordeafness that arises as a result of anycongenital abnormality, maturity orageing. We will only pay for treatmentfor deafness that arises as a result of anacute medical condition.

3.6 Dentistry

This includes any general conservativedental procedures, e.g. simpleextractions, restorations, root canaltreatment, implants, crowns, veneers,bridges and dentures includingperiodontal or orthodontic treatment areexcluded. Minor enamel, dentine andincisal edge fractures restored throughconservative means are also not covered.

Surgical procedures performed by aconsultant oral or maxillofacial surgeonwill be assessed for eligibility whentreating an acute medical condition for example:

n re-implantation of the member’sown teeth following trauma;

n elective reduction of facial andmandibular fractures followingrecent trauma;

n surgical removal of impacted teeth,buried teeth and complicated buriedroots;

n surgical drainage of a fascial space(tracking) abscess;

n removal of cysts of the jaw; and

n apicectomy.

We do not cover:

n orthognathic surgery for functional(eating and speech) or aestheticreasons; or

n procedures to prepare fororthodontics or prosthetic surgery.

3.7 Experimental, unproven orunregistered treatment or practices

This includes those that are notconsidered to be established UKmedical practice or for which there isinsufficient evidence of safety oreffectiveness e.g. not having beenreviewed and approved for general usein the NHS by the National Institute forHealth and Clinical Excellence (NICE).Experimental treatment may beconsidered for cover if it is conducted in a properly controlled clinical trial.

3.8 Fertility and hormone-relatedtreatment

Assisted reproductive therapy and othertreatments related to infertility andsterilisation are excluded.

Treatment of physiological or naturalchanges as a result of ageing e.g.menopause or puberty and hormonereplacement therapy is also excluded.

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3.9 Frail care

This refers to, for example, carereceived in convalescence and nursinghomes, respite care, and domesticsupport that does not require a trainedpractitioner.

3.10 Gender re-assignmentoperations or any related medicalor surgical treatment

3.11 General practitionerconsultations or visits

3.12 Healthcare services related to:

n Alcohol, drug or solvent abuse

n Wilfully self-inflicted illness or injury;including treatment related toattempted suicide

n Injuries sustained duringparticipation in professional or semi-professional sports

n Injuries sustained in a road trafficaccident where a seat belt has notbeen worn

n Injuries sustained duringparticipation in a wilful violation ofthe law

n Injuries sustained during war,terrorist activity, riot, civilcommotion, rebellion or insurrection

n Any exclusion. This includes anyconsultations and other servicesrelated to these exclusions.

3.13 Medication and dressings

Except when administered for useduring hospital admissions, medicines or outpatient dressings provided orprescribed to take home are notcovered.

3.14 Organ transplants

3.15 Overseas treatment

All treatment provided outside the UK is excluded.

3.16 Pregnancy and childbirth

Treatment directly or indirectly arisingfrom or required as a result ofpregnancy, childbirth or infertility is notcovered except for ectopic pregnancy,hydatidiform mole, post partumhaemorrhage, miscarriage, retainedplacenta or stillbirth.

3.17 Preventative treatment (and regular checks)

This includes sight tests, regularmonitoring of, for example, cholesterollevels, and screening for early detectionof diseases such as diabetes, cancer etc.The removal of healthy tissue forprevention of disease is excluded as isgenetic testing of any type.

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3.18 Refractive eye surgery and optometry

This is surgical treatment to correct longor short sightedness, astigmatism, orany other refractive error, includingaccommodating lenses followingcataract surgery.

3.19 Retention of disposable anddurable medical devices andequipment

The cost of medical devices andequipment is not covered. Examples ofexclusions are bandages and dressings,unless part of inpatient and day casetreatment, wheelchairs, crutches,glasses and contact lenses, externalprostheses, orthotics and hearing aids.

Consultations related to these are notcovered.

3.20 Routine check-ups

Visits to a doctor where there is nospecific medical complaint are excludedfrom cover e.g. visits to get prescriptions,blood pressure checks etc.

3.21 Treatment for obesity

We do not pay for treatment for obesity,including surgery for obesity.

3.22 Treatment related todevelopmental problems, learningdifficulties, or delayed speechdisorders

For example, dyslexia, Attention DeficitHyperactivity Disorder (ADHD), etc.

4. Policy terms and conditions, general conditions,policy administration

4.1 Compliance with policy terms

PruHealth’s liability under this policy willbe conditional upon the policyholderand each insured member complyingwith its terms and conditions and nothaving misled PruHealth bymisstatement or concealment, eitherknowingly or unknowingly.

4.2 Policy duration

The policy will run for one year from thestart date of cover until the renewal dateand is therefore a one year contract (thisis defined as the “policy year”).

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4.3 Cooling off

The member has 30 days in which tochange their mind.

They should notify PruHealth withinthose 30 days that they do not wanttheir cover to continue. The 30 daysstarts from the later of the following:

a) the start date of the cover of thepolicy; or

b) receipt of the policy documentation

Please contact PruHealth customerservices on 0800 434 6510

During this period, a full refund of anypremiums paid less any claims isavailable. Any excess of claims madeover premiums paid will be recoverableby PruHealth from the policyholder andany outstanding claims will becancelled. There will be no refund inrespect of any Vitality activities or pointsearned under a cancelled policy.

Cooling off provisions for any gymmembership or other PruHealth Vitalitypartner depends on the terms andconditions of the Vitality partner.

During the policy year

4.4 Amounts due to PruHealth

This includes, but is not limited to healthinsurance and Vitality benefit premiumsand policy excesses owed by thepolicyholder or member. Premiumsinclude any Insurance Premium Tax(IPT) that is payable on the coverprovided, as well as other taxes, leviesor charges that may be introducedwhich are payable by law.

Settlement is required within 30 days ofthe date payment is due in order forcover to be maintained. Failure to settlewithin 30 days will result in a temporaryhold being placed on the policy with theauthorisation and payment of all claimsbeing suspended.

PruHealth reserves the right to cancelthe policy after 30 days of payment notbeing received. PruHealth reserves theright to use a debt collection agency forthe collection of any unpaid amounts.

If the member cancels the policy underthe terms of section 4.8 of this policydocument, they should be aware thatpremiums are billed in arrears and theymay therefore be liable for furtherpremiums.

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4.5 Change of risk

Standard premium rate changes willtake effect at the end of each policyyear. PruHealth reserves the right toapply plan and premium changes duringthe policy year when the following haveoccurred:

n addition or removal of a dependantor partner;

n correction of an error that producesa change in the premium billed e.g.correction in date of birth; or

n any other material changes in theinformation or membership given aspart of the application for coverunder this policy (note, this excludesunderwriting information).

4.6 Membership additions,withdrawals or other changes

Dependants or partners can be added tothe policy throughout the policy year onthe same underwriting terms as thepolicyholder. If they cannot satisfy theeligibility for that underwriting type theywill be asked to select anotherunderwriting option. PruHealth willallow a maximum of 8 children to beadded to the policy.

Should changes be made to the policywith an effective date prior to therequested date the policyholder will be

liable for the outstanding amount fromthe effective date which will be includedin the subsequent bill.

New dependants or partners will beentitled to the full amounts of benefitlimits regardless of the time of year theyjoined. They can then participate inVitality activities and earn Vitality pointsup to the renewal of the policy. Newadult dependants or partners will alterthe Vitality status thresholds.

Dependants or partners can bewithdrawn from the policy throughoutthe policy year. PruHealth must benotified no less than 30 days in advanceof the termination.

Any member who leaves the policybefore the end of the policy year will notbe entitled to any pro rata share ofbenefits they may have earned duringthat policy year in respect of low claimsor Vitality status. All of a member’sVitality benefits will cease when theircover ceases subject to the noticeperiod of the relevant Vitality partner.All Vitality points earned by the memberwill be removed from the policy andthresholds will be adjusted accordingly.

To make changes to your policycontact Customer Service Team on 0800 092 7333.

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4.7 Changes during the year

There will be no change in premiumsduring the policy year unless promptedby a change covered in section 4.5 or4.6 above.

Subject to the above, PruHealth mayvary the other terms and conditions ofthe policy during the policy year.PruHealth shall notify the policyholder inwriting identifying any variations in theterms and conditions at least 28 daysbefore the variations take effect. If thepolicyholder does not wish to accept thevariations, the member can cancel thepolicy within the 28 days without anyfurther liability to PruHealth.

Members may still be subject to thenotice period of any relevant Vitalitypartner. Please note that alterations toterms and conditions relating to Vitalitypartners, or charges due from membersto access a particular Vitality benefit, donot form part of the policy terms andconditions and so do not fall under thescope of this term.

4.8 Cancellation

a) Rights to cancel

n (i) The policyholder is free to cancelthe policy during the term bygiving notice in accordance withthe terms of this section.

n (ii) PruHealth may only cancel thepolicy during the term if thepolicyholder fails, as detailed in this section, to meet their obligations.

b) How to cancel

n (i) The policy may be cancelled witheffect from the end of any policymonth (the “Cancellation Point”).For example, if you joinedPruHealth on the 15th of anymonth, your policy month willend on the 14th of the followingmonth and the monthsthereafter. Please note that the15th of the month is only anexample and you will need tocheck the date you joinedPruHealth to calculate the end of your policy month.

n (ii) To cancel, the policyholdermust contact PruHealthCustomer Services on 0800 434 6510. This must bebefore their chosen CancellationPoint. Therefore, if they joinedPruHealth on 15th January, theywould need to call PruHealth no later than the 14th of anymonth in order for thecancellation to be effective at theend their policy month. If theyfail to cancel by the end of theirpolicy month (for example if they called on 15th of thatmonth), they would be liable to pay a further monthlypremium and the policy wouldbe effective until the 14th of the following month.

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n (iii) The policyholder shall remainliable for any premium paymentsdue in respect of all cover in the periods prior to theCancellation Point.

n (iv) The policyholderwill remain liable for all payments due under the policy until they instructPruHealth directly (either bytelephone or by writing) to cancelin accordance with this section, or until PruHealth itself cancelsthe policy as outlined below.

n (v) The policyholder cannot cancelthe policy by instructing theirbank to cancel any applicabledirect debit, or by otherwisefailing to pay any sum due, or by failing to observe any of the termsand conditions of this policy.

c) Effect of cancellation

n (i) The policywill end on theCancellation Date. For theavoidance of doubt, themembership of all memberswillend with the policy, including themembership of the policyholder’sdependants.

n (ii) PruHealth shall not make anypayment for treatment which isprovided after the CancellationPoint, irrespective of whether ithas been previously authorised.Nevertheless, prior to theCancellation Date claims maycontinue to be authorised and

treatment provided and paid for, regardless of whether thepolicyholder has already givennotice to cancel the policy.

d) When PruHealth may cancel

n (i) PruHealth reserves the right tocancel the policy if thepolicyholder fails to pay any duesum on its payment date. Exceptas provided in paragraph 4.8(d)(ii) & (iii), PruHealth will first givethe policyholder notice that thepolicy is suspended for onemonth until the next paymentdate. During such a periodPruHealth reserves the right tomake no authorisations orpayments under the policy. If,after that second payment date,any sums remain due, PruHealthwill cancel the suspended policy,and reserves the right to recoverany outstanding sums (which, forthe avoidance of doubt, shall notinclude any additional premiumin respect of the suspendedmonth). Nevertheless, if anyoutstanding sums are paid on or before that second paymentdate, PruHealth may, at itsdiscretion, reinstate thesuspended policy.

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n (ii) If the policyholder instructs itsbank to cancel their direct debits,once PruHealth has receivednotice of the direct debitcancellation from the bank,PruHealth will cancel the policyat the end of the policyholder’snext policy month (“theCancellation Point”). PruHealthreserves the right to recover anyunpaid premiums up until theCancellation Point.

n (iii) PruHealth may immediatelycancel this policy or terminate aninsured person’s cover or subjectthe cover to different terms (withretrospective effect whereappropriate) if the policyholderor a member has at any time:

n misled PruHealth bymisstatement orconcealment, whether or notdone knowingly;

n agreed to, assisted orconcealed any attempt by athird party to defraudPruHealth; or

n otherwise failed to observethe terms and conditions withPruHealth.

4.9 Claims

The procedure for members to follow inmaking a claim is laid out in section 4.9b:

a) Referral

The memberwill need to be referred by a general practitioner (GP) for aspecialist consultation or otheroutpatient treatment, except fordiagnostic scans where they need to be referred by a specialist, for thattreatment or consultation to be covered.They will need to be referred by aspecialist for admission to hospital inorder for treatment at that hospital to be covered.

b) Authorisation

The member must call PruHealth or go online for authorisation before any treatment including consultations,outpatient, day case or inpatienttreatment to check:

n That the intended treatment datefalls within the member's period of cover;

n That the member is eligible for cover for the treatment (diagnosisand treatment details will beclinically assessed);

n Whether any pre-existing conditionsor other exclusions apply. PruHealthmay request medical informationfrom a GP/specialist to confirm thehistory and status of the condition aspart of the authorisation process;

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n That the specialist or therapist isrecognised by PruHealth or that theconditions specified in Section 1 are satisfied;

n That the specialist’s fees are covered by the member's plan, if the specialist’s fee are higher than PruHealth’s fee maxima, the member will be responsible for the difference; and

n That the costs of the facility to which the member is to be admitted,e.g. a hospital or day clinic, are fullycovered. All authorisation requestsare reviewed against PruHealth’sclinical protocols.

The member should have to hand:

n the details of their condition andintended treatment;

n their GP contact details; and

n the details of the relevant specialistor therapist i.e. full name, phonenumber, number and postcode.

For hospital admissions, the member willbe given an authorisation number andtarget length of stay, which the hospitalwill require.

Where the member pays fees orcharges, claims for reimbursementshould be submitted within 6 months ofthe treatment date to be eligible.

Where the member does not obtainauthorisation from PruHealth beforebeing treated, they may be liable to payall or part of the costs of treatment.

We are not always able to confirm at thetime of authorisations whether or nottotal benefit limits have been exceeded.It is therefore possible that other claimssubmitted by a member will havecaused their benefit limits to beexceeded. In such circumstances, anytreatment costs over and above thebenefit limits will not be covered.

c) Third party claims

The membermust, without delay, givePruHealth written notification of anyclaim or right of action against any thirdparty for any circumstances which gaverise to the claim under this policy, forexample, if a member claims fortreatment following a car accident wherethe third party may have been at fault. If the member decides to pursue a thirdparty for damages, the membermustcontinue to keep PruHealth fullyinformed in writing and take all stepsPruHealth reasonably requires in makinga claim against the third party, which mayinclude recovery of PruHealth’s outlay.

If the member fails to inform PruHealthof a third party claim, and makes arecovery (which includes any settlementmade) without including PruHealth’soutlay, PruHealth reserves the right torecover its outlay and any sums due fromthe member.

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PruHealth shall be entitled to initiateproceedings in a member’s name forrecovery of its outlay or any sums dueunder this policy. PruHealth shall havefull discretion in the conduct of any such proceedings and in the settlementof any such claim.

d) Prevention of fraud

If any claim under this policy is in anyrespect fraudulent or unfounded, allbenefit paid or due in respect of thatclaim will be forfeited and recoverable.Failure to disclose material informationcould result in the policy being cancelled.PruHealth also reserves the right to takeappropriate legal action and/or refer thematter to the police to seek criminalprosecution. Information relating to suchmatters may be disclosed to others with a view to preventing fraudulent orimproper claims.

4.10 Renewal

a) Plan, premium changes

a) Except for the changes listed insection 4.5, plan and premium changeswill take effect only at the end of thepolicy year. Plan changes may besubject to underwriting requirements.

b) PruHealth reserves the right todecline a plan upgrade based on theclaims experience of the policyholder ora dependant or partner in respect of therisk of the policy.

c) PruHealth will automatically renewthe policy unless there has beenfraudulent activity or the policyholderor policy dependants have misledPruHealth in any way. PruHealth will not decline renewal based on claimsexperience alone. Where a plan isdiscontinued, PruHealth will move themember to the closest availablealternative.

b) Policy renewal

At the end of the policy year PruHealthmay elect to offer to the policyholderrenewal of the policy, possibly onaltered terms to those in force, forexample with different cover offered ordifferent premiums charged based onage, medical inflation and claimsexperience. PruHealth will send out arenewal notice detailing the terms ofrenewal at least one month before theend of the policy year. In the unlikelyevent that the policyholder does notreceive these terms at least one monthbefore the end of the policy year theyshould notify customer services orcontact their adviser.

Acceptance by the policyholder of therenewal terms made available in thisway to the policyholders and memberswill be assumed unless PruHealth isinformed otherwise by the policyholder.

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At policy renewal, PruHealth willallocate a no claims discount per policybased on claims made during the policyyear. The full twelve months of thepolicy year will be reviewed. Where lateclaims are received and not taken intoaccount these will be added into thefollowing renewal calculation. Claimsmade by any member(s) on the policywill be taken into account.

Any claims made with an openauthorisation for a date within the policyyear will be deemed to be a claim andbe included for that policy year. The noclaims discount will be increased by 5%for each year the member does notclaim to a maximum of 35%. It willdecrease by 10% if a claim is made in the policy year.

The Vitality renewal reward will also becalculated based on a policy’s attainedVitality status in the policy year. TheVitality status will be based on Vitalitypoints earned during the policy year.The Vitality renewal reward will bebased on a combination of the Vitalitystatus and the monthly premium paid inthe policy period.

Should the policy premium havechanged over the policy year an averagewill be calculated.

The Vitality renewal reward can be paid as a tax-free cash lump sum or as a discount off the new policy yearpremium. The cash lump sum is payableonly after renewal.

The member will need to selectbetween a premium discount or a cashlump sum. Selection must be madewithin the given selection period and bythe time this closes. If no selection ismade the reward will fall away. Thesimplest way of making a selection willbe via our secure online facility.

The member has 30 days after theirrenewal date in which to change theirmind. They should notify PruHealthwithin those 30 days that they do notwant their cover to continue.

During this period, if any claims are paidin respect of treatment during thisperiod, the memberwill be liable fortheir full premium up to the end of theirpolicymonth. The memberwill only beable to withdraw at the start of the nextpolicymonth. There will be no refund inrespect of any Vitality activities or Vitalitypoints earned under a cancelled policy.

4.11 Other insurance

If there is any other insurance coveringany of the same benefits insured underthis policy, the policyholder mustdisclose this to PruHealth and PruHealthshall not be liable to pay or contributemore than PruHealth’s proportionateshare between the insuring parties.

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4.12 Liability for treatment

Our liability under this policy is limitedto the liability to pay for treatment orservices in respect of claims qualifyingfor cover under this policy, inaccordance with the ‘Conditions ofcover’ and the ‘Exclusions’ set outabove. The choice of provider of thetreatment or services (“provider”) is theresponsibility of the member claimingunder this policy. We make norepresentations or recommendations toany member regarding the availabilityand standard of any treatment orservices offered or provided to themember by any provider.

We will not be held liable to anymember for any loss, harm or damage ofany description resulting from lack ofavailability or from a defect in the qualityof any treatment or service offered orprovided by such provider. This policyrepresents the whole and onlyagreement between the policyholderand PruHealth relating to the provisionof PMI cover. Treatment authorisedwhile the policy is active and takes place after termination of the policy willnot be covered.

Any advice, conversations, e-mails,leaflets, letters or similar communicationsreceived by the policyholder or anymember in relation to the cover do notform part of this policy. This is withoutprejudice to our rights in respect ofdeclarations made by the policyholder ormember in their completed applicationform for this policy.

PruHealth makes use of Vitality partnersto offer services and activities relating tothe Vitality programme. While thesecompanies are carefully selected,PruHealth cannot be held liable for anyloss or harm resulting to the memberarising from any act or omission on thepart of a Vitality partner, or as a result ofusing any service or product providedby a Vitality partner.

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5. Complaints

5.1 Making a complaint

We hope the member never needs tocomplain, but if they do, they mustplease write to us at:


If we cannot settle their complaint theymay be entitled to refer it to theFinancial Ombudsman Service.

5.2 Our complaints process

We want to deal with concerns fairly,effectively and promptly. However,some complaints are more complex than others and may take some time toinvestigate. We will keep the memberinformed of the progress made toresolve the complaint.

If we have not resolved a member’scomplaint within 8 weeks of receiving itwe will send the member a letterexplaining why the complaint has notbeen resolved and confirming when wewill make contact again. We will also sendthe member details of their right to referthe complaint to the FinancialOmbudsman Service, if eligible to do this.

Our complaints process is available on request, by contacting us on 0800 096 6322.

5.3 Escalation of complaints

If a member is not satisfied withPruHealth’s response they may then beeligible to take their complaint to theFinancial Ombudsman Service bycontacting them at:

The Financial Ombudsman ServiceSouth Quay PlazaMarsh WallLondon E14 9SR

Telephone: 0845 080 1800

Email: [email protected]

Website: www.financial-ombudsman.org.uk

5.4 Compensation

The policyholder or a member may have a right to compensation ifPruHealth or another authority decidesthat the policyholder has bought a planin which the information provided byPruHealth was incorrect or misleadingand resulted in financial loss.

Please contact PruHealth’s CustomerServices office for more information.

If PruHealth is unable to meet itsfinancial obligations in full thepolicyholder or the members may be entitled to help from the FinancialServices Compensation Scheme. The limit applicable for an eligibleclaimant is 90% of the claim.

Further information is available bycontacting them at:

Financial Services CompensationScheme

7th floor, Lloyds Chambers Portsoken Street London E1 8BN

Telephone: 020 7892 7300 or 0800 678 1100

Email: [email protected]

Website: www.fscs.org.uk

6. Law and interpretation

6.1 This policy will be governed by and construed in accordance with thelaws of England and Wales and will be subject to the exclusive jurisdictionof the English Courts.

6.2 The schedule and paragraphheadings are for convenience only and do not form part of the policy itselfnor do they affect its construction.

6.3 A person who is not party to this contract has no right under theContracts (Rights of Third Parties) Act 1999 to enforce any terms of thispolicy. In addition to the policyholder,members covered by the policy areconsidered to be parties to this policy.

7. Currency

Every payment to PruHealth or byPruHealth under this policy shall bepayable in the lawful currency of theUnited Kingdom.

8. Glossary of definitions

Words and phrases printed in italics inthis policy document have the meaningsset out below. The following arestandard definitions of common PMIterms and some specific to PruHealth:

8.1 Acute condition

A disease, illness or injury that is likely to respond quickly to treatment whichaims to return you to the state of healththey were in immediately beforesuffering the disease, illness or injury, or which leads to their recovery. Weconsider that an acute condition wouldresolve within three months or less.

Treatment of an acute condition shouldbe intended to deal with the underlyingcondition rather than provide temporaryrelief of symptoms.

8.2 Admission

The interval between the time a memberenters a hospital ward as a day case orfor an overnight stay until the time theyare discharged. This does not include an admission to an Accident andEmergency department/ward nor an outpatient attendance.

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8.3 Cancer

A malignant tumour, tissues or cells,characterised by the uncontrolledgrowth and spread of malignant cellsand invasion of tissue.

8.4 Chronic condition

A disease, illness or injury, which has at least one of the followingcharacteristics:

a) Continues indefinitely and has noknown cure;

b) It comes back or is likely to comeback;

c) It is permanent;

d) Means the member needs to berehabilitated or specially trained tocope with it; or

e) Needs long-term monitoring,consultations, checkups,examinations or tests.

8.5 Children

a) The term “children” incorporatesbiological and adopted children as wellas children under guardianship. Themain criterion is that they are financiallydependent on the principal membertaking out the policy

b) Children can remain on the policyuntil the age of 21 years, or 24 years if in full time education.

8.6 Complementary therapy

Complementary disciplines are thosewhich usually, if not invariably,complement conventional medicaltreatment, whilst alternative disciplinesare those which purport to offerdiagnostic and therapeutic alternativesto conventional medicine.

8.7 Combined limits

Claims for specialist consultations,diagnostic tests, chiropractors,osteopaths and physiotherapists allaggregate to one limit, for each memberof the family.

8.8 Critical care

Any care given in an Intensive CareUnit, Intensive Therapy Unit, CoronaryCare Unit, High Dependency Unit,Paediatric Intensive Care Unit, NeonatalIntensive Care Unit, Special Care BabyUnit or similar level of care is consideredto be critical care.

8.9 Day case treatment

Treatment which means the memberhas to be admitted to hospital or a daycase unit because they need a period of clinically supervised recovery but do not have to stay overnight.

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8.10 Diagnostic tests

Investigations, such as x-rays or bloodtests, to find or to help find the cause ofyour symptoms.

8.11 Ectopic pregnancy

An abnormal pregnancy where thefertilised egg attaches itself outside thecavity of the uterus.

8.12 Eligible treatment

Treatment of an acute condition togetherwith the products and equipment usedas part of the treatment that:

n is consistent with generally acceptedstandards of medical practice andrepresentative of best practices inthe medical profession in the UK;

n is clinically appropriate in terms oftype, frequency, extent duration andthe facility or location where theservices are provided; and

n is demonstrated through scientificevidence to be effective inimproving health outcomes.

8.13 Excess

The amount of money a member mustcontribute towards any treatment theyhave in a policy year.

8.14 Family membership

A family membership covers two adultmembers or more.

8.15 General NHS ward

This is a ward within an NHS hospitalwhere there is generally no charge forthe bed.

8.16 Hospital charges

The portion of total fees paid byPruHealth for a member’s treatment(whether inpatient or outpatient) thatrelates to costs incurred by the hospital.This includes, but is not limited to,accommodation, meals, drugs andsurgical dressings, nursing care,operating costs, eligible intensive andhigh dependency care, physiotherapyand any prosthesis used during anoperation.

8.17 Hydatidiform mole

A tumour in the placenta that occurs inearly pregnancy.

8.18 Inpatient

A patient who is admitted to hospitaland who occupies a bed overnight orlonger, for medical reasons.

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8.19 Interaction

A visit by a member to their healthcareprovider

8.20 Member

Refers to the people including thepolicyholder who are covered underthe policy. It may also include thepartner and any dependant memberswho are covered.

8.21 Miscarriage

Loss of a pregnancy under 24 weeks’gestation.

8.22 Nurse

A qualified nurse who is on the registerof the Nursing and Midwifery Council(NMC) and holds a valid NMC personalidentification number.

8.23 Outpatient

A patient who attends a hospital,consulting room, or outpatient clinic and is not admitted as a day patient or an inpatient.

8.24 Out of hospital list co-payment

Where treatment is received outside of the designated hospital list, a percentage co-payment may apply to the hospital charges.

8.25 Palliative care

Holistic therapy aimed to relieve or reduce the symptoms of those with advanced cancer but not toproduce a cure.

8.26 Participation in professional or semi-professional sports

Taking part (including part-timeparticipation) in a sporting activityas a means of livelihood or for directfinancial gain.

8.27 PMI

Refers to private medical insurance

8.28 Policy

The PruHealth contract of insurance to provide PMI cover for members, as detailed in this document.

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8.29 Policyholder

Refers to the person taking out this policy.

8.30 Post partum haemorrhage

Loss of over 500ml of blood from thegenital tract within 24 hours of delivery.

8.31 PPU

Private patients unit. These can beseparate wings or wards within an NHS hospital.

8.32 Pre-existing condition

Either a diagnosed condition or anundiagnosed symptom or collection of symptoms that the member isexperiencing or has experienced orbeen treated for within the previous 5 years. Ongoing follow-upconsultations or advice sought forconditions are classed as treatment.

8.33 PruHealth fee maximum

The PruHealth fee maximumdefines the upper limit of the range of fees expected by PruHealth for any treatment provided byhealthcare provider.

8.34 Related medical condition

Any symptom, disease, illness or injury,which reasonable medical opinionconsiders to be associated with anothersymptom, disease, illness or injury.

8.35 Retained placenta

Part or all of the placenta (afterbirth)remains in the womb during the thirdstage of labour.

8.36 Single membership

A single membership covers one adultmember.

8.37 Stillbirth

Delivery of a child which has not shownany signs of life after the 24th week ofpregnancy.

8.38 Tariff

The charges negotiated by PruHealthand the healthcare provider in relationto their healthcare services provided.

8.39 Therapists

These include physiotherapists,chiropractors, osteopaths,acupuncturists, homeopaths, podiatristsand other practitioners as may beagreed by PruHealth.

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8.40 Treatment

Surgical or medical services (includingdiagnostic tests), that is needed todiagnose, relieve or cure a disease,illness or injury.

8.41 UK

United Kingdom (excluding the ChannelIslands and Isle of Man).

8.42 We, us, our

Refers to PruHealth

41

42

Your notes.

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Your notes.

PruHealth is a trading name of Prudential Health Limited and Prudential Health Services Limited which are registeredin England and Wales. Registered office at Laurence Pountney Hill, London EC4R 0HH. Registered numbers 5051253and 5933141 respectively. Prudential Health Limited and Prudential Health Services Limited are authorised andregulated by the Financial Services Authority.

BOOTS POLICY DOCUMENT & SUMMARY PRUHM19225 03/2010


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