CashBack Gold, Silver, Bronze - AXA Health€¦ · per claim up to annual maximum: 50% 50% 50%...

Membership handbookApril 2019

healthcare

CashBack Gold, Silver,

Bronze

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Contacting us

While it is important that you read and understand the plan handbook, we understand that it is often easier to call us to obtain information – so we have a team of Personal Advisers to help you. You should always call them on 0345 605 0187 when you need treatment so we can help you to understand the extent of your cover before you incur any treatment costs.

Quick reference guide for important information

Personal Advisory Team 0345 605 0187 Our team of Personal Advisers is available to take your call in complete confidence. If you wish to discuss any aspect of your membership from adding a family member to increasing your level of cover, call the number above. Open Monday to Friday 8am to 6pm.

Health at Hand 0800 003 004 Confidential information service A team of healthcare professionals is available for health information and to answer your health related questions anytime – day or night, 365 days a year.

Want a higher level of cover? Take a look at the table on page 5 to see how much we would pay you as a member and what you could receive if you took out the higher level of cover.

We may record and/or monitor calls for quality assurance, training and as a record of our conversation.

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Contents

1 Your cover ........................................................................................................ 4 2 Benefits table ................................................................................................... 5 3 Your benefits explained ................................................................................. 11

1. Dental treatment ...................................................................................................................11 2. Dental accident .....................................................................................................................11 3. Optical benefit .......................................................................................................................12 4. Physiotherapy, osteopathy, chiropractic, acupuncture and homeopathy .........................13 5. Chiropody and podiatry ........................................................................................................13 6. Specialist consultation fees (including diagnostic tests) .....................................................13 7. Hearing aid ............................................................................................................................13 8. Specialist allergy testing .......................................................................................................13 9. Hospital in-patient ................................................................................................................13 10. Intensive care hospital in-patient .........................................................................................14 11. Childbirth benefit ..................................................................................................................14 12. Multiple births – twins ...........................................................................................................14 13. Multiple births – triplets ........................................................................................................14 14. Accidental death benefit .......................................................................................................14 15. Accidental loss of sight ..........................................................................................................15 16. Accidental loss of hearing .....................................................................................................15 17. Health assessment benefit ....................................................................................................15 18. Health at Hand ......................................................................................................................15

4 What this plan does not cover you for .......................................................... 17 5 Making a claim ............................................................................................... 18

1. What you need to do to make a claim ..................................................................................18 2. How we pay claims ................................................................................................................18

6 General information about your plan ........................................................... 20 1. Joining and adding family members ....................................................................................20 2. Premiums ..............................................................................................................................20 3. Sales ......................................................................................................................................21 4. Cancelling your plan .............................................................................................................21 5. General ..................................................................................................................................21

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7 Regulatory information ................................................................................. 23 1. Your personal information ....................................................................................................23 2. What regulatory protection do I have? .................................................................................23 3. Not happy with our service? .................................................................................................24

8 Definitions ...................................................................................................... 26

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1 Your cover

This summary contains a brief description of this health cash plan from AXA PPP healthcare.

It does not contain the full terms and conditions which can be found in this plan handbook and your schedule of membership.

This plan meets the demands and needs of someone seeking the cover set out in the following summary section and should be read alongside your membership statement which shows which cover level and plan options you have purchased.

Summary of the CashBackGold, Silver, Bronze plan The CashBack plan offers cover that gives you, as a resident of the UK, money back for a range of everyday healthcare bills in the UK, including those from dentists, opticians, physiotherapists, osteopaths, chiropractors, acupuncturists and homeopaths. In addition the plan provides cash benefits for childbirth, hospital in-patient stays of more than four consecutive nights, accidental loss of sight or hearing, and accidental death.

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2 Benefits table

The table on the following few pages shows the benefits available to you. For each benefit we will pay up to the maximum shown for your level of cover in each benefit year. The benefits are explained fully in this handbook. You must read this table in conjunction with the rest of your handbook.

CashBack benefits Gold, Silver, Bronze Benefit Bronze Silver Gold

Professional care cover 1. Dental

treatment. £45 £90 £135

Benefit payable per claim up to annual maximum:

50% 50% 50%

Qualifying period: Six months.* Six months.* Six months.*

Where can I find more information? Section 1 Dental treatment in the benefit rules. 2. Dental accident

(up to £2,500 cash back per incident up to a maximum of four incidents in a benefit year).

Up to £10,000 Up to £10,000 Up to £10,000


100% 100% 100%

Qualifying period: Immediate access. Immediate access. Immediate access.

Where can I find more information? Section 2 Dental accident in the benefit rules. 3. Optical benefit. £35 £70 £105


50% 50% 50%


Where can I find more information? Section 3 Optical benefit in the benefit rules.

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CashBack benefits Gold, Silver, Bronze Benefit Bronze Silver Gold 4. Physiotherapy,

osteopathy, chiropractic, acupuncture and homeopathy.

£130 £260 £390


50% 50% 50%


Where can I find more information? Section 4 Physiotherapy, osteopathy, chiropractic, acupuncture and homeopathy in the benefit rules.

5. Chiropody and podiatry.

£40 £80 £120


50% 50% 50%


Where can I find more information? Section 5 Chiropody and podiatry in the benefit rules. 6. Specialist

consultation fees (including diagnostic tests).

£75 £150 £225


50% 50% 50%


Where can I find more information? Section 6 Specialist consultation fees (including diagnostic tests) in the benefit rules.

7. Hearing aid. £35 £70 £105


50% 50% 50%

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Where can I find more information? Section 7 Hearing aid in the benefit rules. 8. Specialist allergy

testing. £35 £70 £105


50% 50% 50%


Where can I find more information? Section 8 Specialist allergy testing in the benefit rules.

Hospital care cover 9. Hospital in-

patient

(Up to 50 nights stay in a benefit year).

£77 per week (£11 per night).




100% 100% 100%


Where can I find more information? Section 9 Hospital in-patient in the benefit rules. 10. Intensive care

hospital in-patient

(Up to 7 nights stay in a benefit year).





100% 100% 100%

Qualifying

period: Six months.* Six months.* Six months.*

Where can I find more information? Section 10 Intensive care hospital in-patient in the benefit rules.

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Additional benefits 11. Childbirth

benefit. £110 per child. £220 per child. £330 per child.


100% 100% 100%

Qualifying period: 12 months. 12 months. 12 months.

Where can I find more information? Section 11 Childbirth benefit in the benefit rules. 12. Multiple births -

twins. £220 per child. £440 per child. £660 per child.


100% 100% 100%


Where can I find more information? Section 12 Multiple births - twins in the benefit rules. 13. Multiple births -

triplets. £330 per child. £660 per child. £990 per child.


100% 100% 100%


Where can I find more information? Section 15 Multiple births - triplets in the benefit rules. 14. Accidental death

benefit. £2,500 £5,000 £7,500


100% 100% 100%

Qualifying period: None. None. None.

Where can I find more information? Section 14 Accidental death benefit in the benefit rules.

15. Accidental loss of sight benefit.

£1,000 £2,000 £3,000

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100% 100% 100%


Where can I find more information? Section 15 Accidental loss of sight benefit in the benefit rules.

16. Accidental loss of hearing benefit.

£1,000 £2,000 £3,000


100% 100% 100%


Where can I find more information? Section 16 Accidental loss of hearing benefit in the benefit rules.

17. Health assessment benefit.

£75 £150 £225


50% 50% 50%


Where can I find more information? Section 17 Health assessment in the benefit rules.

18. 365 days a year/ 24 hour Health at Hand service and stress counselling line.

Freephone access. Freephone access. Freephone access.

Qualifying period: Immediate access. Immediate access. Immediate access.

Where can I find more information? Section 18 Health at Hand in the benefit rules. *In some cases we may have agreed a different qualifying period and this will be shown on your membership statement.

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What are the main exclusions and limitations of the CashBack Gold, Silver, Bronze plan? As with all insurance policies, general exclusions apply. The following is a summary of the main exclusions and limitations of the plan.

What are the main exclusions and limitations of cover? Where can I find more information?

The lead member must be 18 or over and below the age of 66 to join the scheme. Once you have joined, your plan may continue up to any age as long as you continue to live in the United Kingdom. If you take out dual membership, both the lead member and his/her partner must be under 66 at the time of joining. (In some circumstances, we may choose not to apply the age restrictions described above. Receipt of your schedule of membership will indicate we have waived the restriction).

The ‘Joining and adding family members’ section of this plan handbook.

We will not pay benefit until after the relevant qualifying period has passed. If you increase your cover, we will pay benefit at the existing rate for any medical condition arising during the new qualifying period.

The ‘What this plan does not cover you for’ section of the plan handbook.

Please see page 26 for an explanation of the words that appear in bold 11

3 Your benefits explained

What this plan covers you for These are the rules that apply in each benefit year before we will pay the benefits shown on the table of benefits . Please read the claims procedure before making a claim. We will not pay benefit for treatment or services provided outside the United Kingdom . We will not pay more than the amounts shown in the table of benefits.

We will not return your receipt unless you ask us to and send us a reply paid envelope.

1. Dental treatment

We will pay benefit if you have paid directly to a dentist or dental hygienist, who is registered with the General Dental Council, for treatment (including a check-up or new dentures). We will not pay benefit for any premiums you paid under a dental-care contract scheme.

2. Dental accident

We will pay benefit for the following costs of dental treatment up to £2,500 per dental accident that arises after your plan start date, subject to a maximum of four claims for each person covered on the plan each benefit year, up to a maximum of £10,000 each benefit year:

Benefit Amount payable Examination and report to include all necessary smoothing, polishing and vitality testing

Up to £26.50 per incident

X-rays Up to £19.50 per incident

Porcelain jacket crown Up to £220.00 per unit

Dentine bonded crown Up to £318.00 per unit

Metal bonded porcelain crown Up to £263.50 per unit

Post/core construction Up to £54.50 per tooth

Metal bonded porcelain bridgework – retainer Up to £263.50 per retainer

All metal bridgework – pontic Up to £185.50 per pontic

Laboratory constructed adhesive bridge – retainer

Up to £180.50 per retainer

Laboratory constructed adhesive bridge – pontic

Up to £189.00 per pontic

Laboratory constructed adhesive facing or veneer Up to £230.00 per unit

Root canal treatment – incisor Up to £105.50 per incisor

Root canal treatment – canine Up to £105.50 per canine

Root canal treatment – premolar Up to £128.00 per premolar

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Root canal treatment – molar Up to £180.50 per molar

Permanent acrylic denture Up to £301.00 per denture

Permanent metal denture Up to £378.50 per denture

Temporary denture following tooth loss (where required)


Laboratory made temporary bridge following tooth loss (where required)

Up to £84.50 up to three units

Laboratory made temporary bridge following tooth loss (additional units)

Up to £21.50 per unit

Emergency and other treatment following dental injury not otherwise specified


We will not pay benefit for:

(I) injury caused by foodstuffs (including foreign bodies therein) in the course of consumption;

(II) injury caused other than by direct extra oral impact.

(III) treatment that relates to damage or injury caused whilst participating in any contact sport when the appropriate mouth protection was not being worn.

(IV) any prescription charges or associated costs.

(V) mouthguards, gum shields or any dental appliances.

(VI) self-inflicted injuries.

(VII) costs which we consider are not necessarily incurred or which are charged in excess of the usual amount for that treatment.

(VIII) implants, cosmetic and orthodontic treatment.

(IX) damage to dentures, other than whilst being worn.

(X) reimbursement for travelling expenses or telephone calls in connection with any treatment.

(XI) extraction of wisdom teeth, other than those extracted in an emergency at the dentist’s

surgery.

(XII) damage caused by tooth brushing or other oral hygiene procedures.

(XIII) any treatment, care or repair to, or in connection with ‘tooth jewellery’; or

(XIV) treatments for normal wear and tear.

3. Optical benefit

We will pay benefit if you have paid an optician for eyesight tests or prescribed spectacles, lenses or contact lenses. This benefit does not cover contact lens check-ups or solutions, non-prescribed spectacles, spectacle repairs, new frames, replacements needed after accidental damage, or non-prescribed items you buy under an optical-care contract scheme. If you do buy items under an optical-


care contract and you want to claim from your plan, you must ask your optician to provide a receipt showing the cost of all items you have bought under the optical-care contract.

4. Physiotherapy, osteopathy, chiropractic, acupuncture and homeopathy

We will pay benefit if you have paid directly for physiotherapy, osteopathy, chiropractic, acupuncture and homeopathy treatment. The practitioners we recognise for benefit are:

A physiotherapist who is registered with the Health Professions Council (HPC).

An osteopath who is registered with the General Osteopathic Council (GOsC).

A chiropractor who is registered with the General Chiropractic Council (GCC).

An acupuncturist who is a member of the British Acupuncture Council.

A homeopath who holds full membership of the Faculty of Homeopathy.

We will not pay more than the maximum benefit in any one benefit year for all treatments received from the practitioners shown.

We will only pay the benefit for treatment of a medical condition. We will not pay benefit for diagnostic tests or consultations.

5. Chiropody and podiatry

We will pay benefit if you have paid directly for chiropody or podiatry treatment with a chiropodist or a podiatrist who is registered with the Health Professions Council.

6. Specialist consultation fees (including diagnostic tests)

We will pay benefit if you have paid a specialist directly for an out-patient consultation or for a diagnostic test that the specialist recommends. This benefit is only available if your general practitioner refers you for the consultation. We will not pay for examinations carried out for legal reports, or for insurance, employment and emigration reasons.

7. Hearing aid

We will pay benefit towards the cost of one, medically prescribed, hearing aid that you have paid for in any benefit year.

8. Specialist allergy testing

We will pay benefit towards the cost of allergy testing carried out by, or on referral from, a specialist. There is no benefit for treatment charges.

9. Hospital in-patient

We will pay benefit at the appropriate nightly rate for the period that you are in hospital for in-patient treatment only when the hospital stay has exceeded four consecutive nights. If you are in hospital for less than four consecutive nights then no benefit will be payable. In any event, we will not pay benefit for more than 50 nights of in-patient treatment in any one benefit year.

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10. Intensive care hospital in-patient

We will pay benefit at the appropriate nightly rate for the period you receive in-patient treatment in an intensive therapy unit of a hospital only when the hospital stay has exceeded four consecutive nights. If you are in hospital for less than four consecutive nights then no benefit will be payable. In any event, we will not pay benefit for more than seven nights of in-patient treatment in an intensive therapy unit in any one benefit year.

11. Childbirth benefit

We will pay benefit at the appropriate rate for each child. We will pay this benefit to one parent covered on this plan, providing they are named on the birth certificate. You must send an original or certified true copy of the full (not short) birth certificate for each child to support your claim. We will also pay benefit at the appropriate rate for each child under the age of one that you legally adopt. You must send us the legal adoption papers to support your claim. We will not pay benefit until we receive these.

12. Multiple births – twins

We will pay benefit at the appropriate rate for each child. We will pay this benefit to one parent covered on the plan providing they are named on the birth certificate. We will only pay one ‘childbirth’ benefit at the appropriate rate if the birth of twins is as a result of in-vitro fertilisation or assisted conception. You must send an original or certified true copy of the full (not short) birth certificate for each child to support your claim. We will also pay benefit at the appropriate rate for each child twin under the age of one that you legally adopt. You must send us the legal adoption papers to support your claim. We will not pay benefit until we receive these.

13. Multiple births – triplets

We will pay benefit at the appropriate rate for each child. We will pay this benefit to one parent covered on this plan, providing they are named on the birth certificate. We will only pay one ‘childbirth’ benefit at the appropriate rate if the birth of triplets is as a result of in-vitro fertilisation or assisted conception. We will not pay benefit for more than three children born at the same event. You must send an original or certified true copy of the full (not short) birth certificate for each child to support your claim. We will also pay benefit at the appropriate rate for each child triplet under the age of one that you legally adopt. You must send us the legal adoption papers to support your claim. We will not pay benefit until we receive these.

14. Accidental death benefit

We will pay this benefit if you have an accident after your plan start date, which results in your death solely and independently of any other cause and within 90 days of such accident. If you die, your personal representative should let us know as soon as possible. We will send that person a claim form and ask them for the original death certificate or a certified true copy together with Grant of Probate or Letters of Administration to support the claim.


15. Accidental loss of sight

We will pay this benefit if you have an accident after your plan start date, which results in the complete and irreversible loss of sight in one or both of your eyes solely and independently of any other cause and within 90 days of such accident. You must send us an ophthalmologist’s report to support your claim before we will pay this benefit.

16. Accidental loss of hearing

We will pay this benefit if you have an accident after your plan start date, which results in complete and irreversible loss of hearing in one or both of your ears solely and independently of any other cause and within 90 days of such accident. You must send us a report from the otolaryngologist (also known as an ENT specialist) to support your claim before we will pay this benefit.

17. Health assessment benefit

We will pay benefit for you to have a health assessment, which may include a consultation and physical examination by the screening doctor or nurse. It may cover skin, ears, eyes, throat, central nervous system, cardiovascular system, abdominal system, muscles, joints, spine, gait and testicular or breast examinations with instruction in self-examination. It will include a medical report detailing all test results and their meanings plus recommendations for improving and maintaining health. You can ask any questions you have about health matters. No information about your health or wellbeing will be sent to us – it is entirely confidential between you and the person carrying out the health assessment. We only require a certificate confirming that the assessment has been completed and the receipt for the amount paid. Your health assessment can be carried out by any Care Quality Commission (CQC) recognised provider. We will not pay this benefit if the health assessment is carried out by your general practitioner or if the health assessment takes place in a general practitioners’ surgery.

18. Health at Hand

24 hour medical support for you and your family

Through our telephone health information service, Health at Hand, you have access to a qualified and experienced team of healthcare professionals, 24 hours a day, 365 days a year.

Whether you are calling because you have late night worries about a child’s health, or you have some questions that you forgot to ask your GP, it’s likely that Health at Hand will be able to provide you with the help you need.

The team of nurses, pharmacists, counsellors and midwives is on hand to give you the benefit of their expertise. They can answer your questions and give you all the latest information on specific illnesses, treatments and medications as well as details of local and national organisations. They can also send you free fact sheets and leaflets on a wide range of medical issues, conditions and treatments, and will happily phone you back afterwards to discuss any further questions you may have from what you have read.

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Health at Hand – 0800 003 004 Health at Hand is available to you anytime – day or night, 365 days a year.

You can also email Health at Hand by going to our website: axappphealthcare.co.uk

If calling from outside the UK please dial +44 1892 772 578 – international call rates apply.

Please remember to have your membership number to hand before you call.

Please note: Health at Hand does not diagnose or prescribe and is not designed to take the place of your GP. However, it can provide you with valuable information to help put your mind at rest. As Health at Hand is a confidential service, any information you discuss is not shared with our team of Personal Advisers. If you wish to authorise treatment, enquire about a claim or have a membership query, our team of Personal Advisers will be happy to help you.


4 What this plan does not cover you for

1. We will not pay for treatment received before the relevant qualifying period has passed.

If you increase your cover, we will pay benefit at the existing rate for any medical condition arising during the new qualifying period.

2. We will not pay benefit if treatment is needed as a direct or indirect result or consequence of:

(I) engaging in or training for a sport for which you receive a salary or monetary reimbursement, including grants or sponsorship (unless you receive travel costs only).

(II) base jumping, cliff diving, flying in an unlicensed aircraft or as a learner, martial arts, free climbing, mountaineering with or without ropes, scuba diving to a depth of more than 10 metres, trekking to a height of over 2,500 metres, bungee jumping, canyoning, hang-gliding, paragliding or microlighting, parachuting, potholing, skiing off-piste or any other winter sports activity carried out off-piste.

(III) a deliberately self-inflicted injury or an attempt at suicide.

(IV) nuclear contamination, biological contamination or chemical contamination, war (whether declared or not), act of foreign enemy, invasion, civil war, riot, rebellion, insurrection, revolution, overthrow of a legally constituted government, explosions of war weapons or any event similar to one of those listed.

Please note: For clarity: We will pay benefit for treatment required as a result of a terrorist act providing that terrorist act does not result in nuclear, biological or chemical contamination.

3. You may not claim for more than one benefit in respect of the same treatment or hospital stay.

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5 Making a claim

Have your treatment and pay for it. Make sure you keep your receipts or hospital admission details.

Are you outside of the qualifying period for that benefit?

Yes No

Unfortunately you cannot make a claim for a benefit in the qualifying period.

Send us a completed claim form, along with your receipts.

Wait seven working days for your cheque, as long as we have all the necessary information. However, due

to their nature, claims such as accidental death, dental accident and accidental loss of sight/hearing may take longer.

1. What you need to do to make a claim

To make a claim you must send us a completed claim form.

You should make all claims for all benefit as soon as possible and not later than six months after the date of the accident (if you are claiming for the dental accident benefit, accidental death benefit, accidental loss of sight benefit, or accidental loss of hearing benefit or you receive treatment or leave hospital (for all other benefits) unless this was not reasonably possible.

You must also enclose your receipts for any treatment.

You must pay for your treatment before you make a claim.

If necessary, you must authorise us to receive any relevant medical information we need before we will pay a claim for benefit. The medical information we receive will remain confidential. If you require an additional claim form please contact us.

2. How we pay claims

2.1 We treat claims as arising in a benefit year according to:

the dates you are in hospital – for hospital in-patient and intensive care hospital treatment benefits;


the date of your baby’s birth or adoption – for childbirth and multiple birth benefits; the date of death – for accidental death benefit; and the date you receive treatment as shown on the receipt – for other claims.

2.2 We will pay benefits by cheque to your home address.

2.3 We will not refund any charges you have to pay for filling in a claim form, providing a medical certificate or report, or for appointments for treatment that you miss.

2.4 If you make a claim which is in any way dishonest:

we will not pay any benefits for that claim; and if we have already paid benefits for that claim before we discovered the dishonesty we can

recover those benefits from you; and we can take any of the actions listed in Section 6, paragraph 5.4.

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6 General information about your plan

1. Joining and adding family members

1.1 The lead member may apply to join the scheme if:

he/she is 18 or over and below the age of 66; and the lead member and the family members live in the United Kingdom.

Once you have joined, your plan may continue up to any age as long as you continue to live in the United Kingdom. If you take out dual membership, both the lead member and his/her partner must be under 66 at the time of joining (N.B In some circumstances we may choose not to apply the age restriction described above. Receipt of your schedule of membership will indicate we have waived the restriction).

1.2 If you want to join the scheme or if you have already joined and you want to increase or reduce your cover, you can contact us to do so. We will register you as a lead member from the date we receive your application. We may refuse to accept you as a lead member or to increase or reduce your cover. If you also arrange cover for your partner, you will still be registered as the lead member and your partner cannot have separate membership himself or herself. If you are single when you join the scheme, and you later get married, or live with a partner, and you wish to add them to your cover, contact us with your partner’s name and his or her date of birth. When we receive these details, we will change our records so that you have dual membership and can claim the relevant benefits for your partner, as long as the scheme’s qualifying period has ended.

If you want to register a child, contact us with the details of the child’s full name and date of birth. If a child does not have the same name as you, you must give us proof that he or she is your or your partner’s child.

2. Premiums

2.1 Your cover will commence from the date your completed acceptance form is received and will renew automatically for each month that you continue to pay the premiums or maintain a valid Direct Debit mandate for the payment of your premiums. You must make sure the premiums are kept up to date. If your premiums are not up to date, you will not be entitled to any benefit after the date that the premium became due. When you are more than six weeks behind with your premiums, your cover will end. We will not refund any premiums for periods for which you had cover.

2.2 Except if you change your cover, for each contract period, your premiums and plan terms are fixed, however for each new contract period, we may change:

the premiums you pay; the cover provided by the plan; and the condition of your cover.


If we change the premiums you pay, we will send one month’s notice to the lead member at your last known address. If we change the cover, we will write to the lead member to tell you about the changes.

3. Sales

3.1 When we sell our policies directly to customers we provide information to help customers make the right decisions for their needs but we do not offer a personal recommendation for any of our policies. You may also have bought your plan through an intermediary or broker, in which case they will inform you whether they offer a personal recommendation.

4. Cancelling your plan

4.1 The lead member may cancel this plan within 14 days of the renewal date (the cancellation period) by contacting us during the cancellation period. We will then return any premium paid for the plan providing no claims have been made on the plan in relation to the period of cover before the cancellation (being no more than 14 days’ cover). If you incur eligible claims costs within that period of cover we reserve the right to require the lead member to pay for the services we actually provided in connection with the plan to the extent permitted by law and any return of the premium is subject to this. If the lead member does not cancel the plan during the cancellation period the plan will continue on the terms described in this handbook for the remainder of the contract period .

5. General

5.1 You must give us written details of any changes of circumstances (for example a divorce) which may affect the benefits that you are entitled to.

5.2 We will tell you in writing the plan start date. We can refuse to give cover and will tell you if we do.

5.3 You may not have more than one plan.

5.4 If you break any terms of the plan which we reasonably consider to be fundamental or make, or attempt to make, a dishonest claim, we can:

refuse to make any payment; and end your plan and all cover under it immediately.

5.5 We reserve the right to discontinue the scheme. If we do so we will give you notice in writing three months before it takes effect.

5.6 We reserve the right to amend the terms of this plan during any contract period in order to take account of any changes to the legal or regulatory requirements which impact on our ability to provide the plan on the current terms.

5.7 We, or any person or company that we nominate, have subrogated rights of recovery of the policyholder or any family members in the event of a claim. This means that we will assume the rights of policyholders or any family members to recover any amount which they are

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entitled, for example from someone who caused your injury or illness, another insurer or a state healthcare system, and which we have already covered under this policy. The policyholder must provide us with all documents, including medical records, and provide any reasonable assistance we may need to enable us to exercise these subrogated rights and must not do anything to prejudice such rights at any time. We reserve the right to deduct from any claims payment otherwise due to you or an amount equivalent to the amount you could recover from a third party or state healthcare system.

5.8 We will not do business with any individual or organisation that appears on an economic sanctions list or is subject to similar restrictions from any other law or regulation. This includes sanction lists, laws and regulations of the European Union, United Kingdom, United States of America or under a United Nations resolution. We will immediately end cover and stop paying claims on your plan if you or a family member are directly or indirectly subject to economic sanctions, including sanctions against your country of residence. We will do this even if you have permission from a relevant authority to continue cover or premium payments under a plan. In this case, we can cancel your plan or remove a family member immediately without notice, but will then tell you if we do this. If you know that you or a family member are on a sanctions list or subject to similar restrictions you must let us know within 7 days of finding this out.

5.9 You and we are free to choose the law that applies to this plan. In the absence of an agreement to the contrary, the law of England and Wales will apply.

5.10 Only the lead member and we have legal rights under this plan and it is not intended that any clause of the term of this plan should be enforceable, by virtue of the contract (Rights of Third Parties) Act 1999, by any other person including any family member.

5.11 This plan is written in English and all other communication to you relating to this plan will also be in English.

5.12 You may wish to review your cover periodically to ensure that it continues to meet your requirements.


7 Regulatory information

1. Your personal information

Here is a summary of the data privacy notice that you can find on our website axappphealthcare.co.uk/privacynotice.

Please make sure that everyone covered by this plan reads this summary and the full data privacy notice on our website. If you would like a copy of the full notice call us on 0345 605 0187 and we’ll send you one.

We want to reassure you we never sell personal member information to third parties. We will only use your information in ways we are allowed to by law, which includes only collecting as much information as we need. We will get your consent to process information such as your medical information when it’s necessary to do so.

We get information about you and the family members who are covered by your plan from you, those family members, your healthcare providers, your employer (if you are on a company scheme), your insurance broker if you have one and third party suppliers of information, such as credit reference agencies.

We process your information mainly for managing your membership and claims, including investigating fraud. We also have a legal obligation to do things such as report suspected crime to law enforcement agencies. We also do some processing because it helps us run our business, such as research, finding out more about you, statistical analysis for example to help us decide on premiums and marketing.

We may disclose your information to other people or organisations. For example we’ll do this to:

manage your claims, e.g. to deal with your doctors or any reinsurers; manage your plan with your insurance broker; help us prevent and detect crime and medical malpractice by talking to other insurers and

relevant agencies; and allow other AXA companies in the UK to contact you if you have agreed.

Where our using your information relies on your consent you can withdraw your consent, but if you do we may not be able to process your claims or manage your plan properly.

In some cases you have the right to ask us to stop processing your information or tell us that you don’t want to receive certain information from us, such as marketing communications. You can also ask us for a copy of information we hold about you and ask us to correct information that is wrong.

If you want to ask to exercise any of your rights just call us on 0345 605 0187 or write to us.

2. What regulatory protection do I have?

AXA PPP healthcare is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority (FCA) and the Prudential Regulation Authority. The FCA have set out rules

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which regulate the sale and administration of general insurance, which we must follow when we deal with you. Our register number is 202947. This information can be checked from the FCA website: fca.org.uk

The Financial Services Compensation Scheme (FSCS)

We are also participants in the Financial Services Compensation Scheme established under the Financial Services and Markets Act 2000. The scheme is administered by the Financial Services Compensation Scheme Limited (FSCS). The scheme may act if it decides that an insurance company is in such serious financial difficulties that it may not be able to honour its contracts of insurance. The scheme may assist by providing financial assistance to the insurer concerned, by transferring policies to another insurer, or by paying compensation to eligible policyholders.

Further information about the operation of the scheme is available on the FSCS website: fscs.org.uk

3. Not happy with our service?

The most important thing for us is to help resolve your concerns as quickly and easily as possible. We’ll do all we can to resolve your complaint by the end of the next business day. However, if we can’t do this, we’ll contact you within five working days to acknowledge your complaint and explain the next steps. Letting us know when you’re unhappy with our service gives us the opportunity to put things right for you and improve our service for everybody.

This plan meets the demands and needs of someone seeking the cover set out in the following summary section and should be read alongside your membership statement which shows which cover level and plan options you have purchased.

No matter how you decide to communicate your concerns, we’ll listen. You can call us on 0345 605 0187, or write to us at:

AXA PPP healthcare

Phillips House

Crescent Road

Tunbridge Wells

Kent TN1 2PL

To help us resolve your complaint, we’ll need the following:

Your name and membership details A contact telephone number A description of your complaint Any relevant information relating to your complaint that we may not have already seen.

Financial Ombudsman Service We will generally issue our final response within eight weeks from when you originally contacted us. However, we will respond sooner than this, if we are able.

If it looks as though our review of your complaint will take longer than this, we will let you know the reasons for the delay and will keep you updated.


If we cannot respond fully to your complaint within eight weeks, or you are unhappy with our final response, you can refer your complaint to the Financial Ombudsman Service for an independent review. The Financial Ombudsman Service will only consider your complaint once we have issued a final response, or if eight weeks has passed since you first notified us of your complaint.

How to contact the Financial Ombudsman Service

The Financial Ombudsman Service Exchange Tower Harbour Exchange Square London E14 9SR

By telephone: 0300 123 9 123 or 0800 023 4567 Email: [email protected] Website: financial-ombudsman.org.uk

Online Dispute Resolution (ODR) If you bought your plan online, there is an Online Dispute Resolution (ODR) platform created by the EU Commission, which can help with resolving disputes.

You can enter a complaint about your policy onto the ODR, which will forward your complaint to the relevant Alternative Dispute Resolution (ADR) scheme. For insurance companies in the UK this is the Financial Ombudsman Service (FOS). You can contact the Financial Ombudsman Service directly using the contact details above. For more information about the ODR please visit http://ec.europa.eu/consumers/odr

None of these procedures affect your legal rights.

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8 Definitions

Throughout this handbook certain words and phrases appear in bold. Where these words appear they have a special medical or legal meaning. These meanings are set out below.

Additionally, when we refer to ‘you’ or ‘your’ throughout this document, we mean the lead member and any family members named on the lead member’s membership statement. When you see ‘we’, ‘us’ or ‘our’ we are referring to AXA PPP healthcare, who is the insurance company who underwrite this product.

accident – this is when you sustain bodily injury caused by accidental external violent and visible means or as a result of a recorded act of negligence.

benefit(s) – the benefit(s) that we will pay to you depending on your cover level. The table of benefits shows the maximum benefits you can receive.

benefit year – this is:

the 12 month period after you qualify for benefit, either after first becoming a member of the scheme or after you change your cover; and

every 12 month period after that for which we accept your premiums. claim – a claim for benefit under this plan.

contract period – each consecutive month from your plan start date and when your plan was last renewed.

day-patient treatment – treatment which, for medical reasons, means you have to go into a hospital or day-patient unit because you need a period of clinically supervised recovery but so not have to stay overnight.

day-patient unit – a centre in which day-patient treatment is carried out.

dental accident – a sudden and unexpected injury to the mouth, which causes damage to the teeth and/or gums, and results from a direct extra oral impact.

dentist – a dental surgeon who is currently registered with the General Dental Council.

diagnostic tests – investigations, such as x-rays or blood tests, to find or to help to find the cause of your symptoms.

family member – (1) the lead member’s current spouse or civil partner or any person (whether or not of the same sex) living permanently in a similar relationship with the lead member and (2) any of their or the lead member’s children, including adopted children, under 18 years of age, when the plan is taken out or when it is renewed.

hospital – any establishment which is licensed as a medical or surgical hospital in the country where it operates.

in-patient treatment – treatment which, for medical reasons, means you have to stay in hospital overnight or for longer.

lead member – the person named on the schedule of membership.

medical condition – any disease, illness or injury, including psychiatric illness.


out-patient treatment – treatment given at a hospital, consulting room or out-patient clinic where you do not go in for day-patient treatment or in-patient treatment.

plan – the insurance contract between you and us. Its full terms are set out in the current versions of the following documents as sent to you from time to time:

any application form we ask you to fill in these terms and the table of benefits setting out your cover your schedule of membership and our letter of acceptance.

plan start date – the date from which your membership begins as shown on your schedule of membership.

qualifying period – the period before you are entitled to most benefits. The qualifying period that applies to each benefit is shown on the table of benefits. We will not pay benefit if you receive any treatment during these qualifying periods. The qualifying period does not apply to the ‘hospital in-patient’ benefit after an accident, as long as we have received your first premium and registered your membership. If you increase your cover in order to receive higher benefits, you will only be entitled to existing benefits until the end of the new qualifying period.

receipt – the original receipt provided by the healthcare provider. All receipts for treatment must show the full name of the person who received the treatment. We will not accept receipts made out in joint names. The receipts should also fully describe the treatment received or the items paid for, the date of the treatment, the full cost and the date the account was paid. We will not accept till slips, credit card sales vouchers, photocopied or altered receipts.

schedule of membership – the document showing the plan start date and those covered by the plan.

scheme – the CashBack Gold, Silver, Bronze scheme.

specialist – a person, with a part-time or full-time NHS consultant appointment, who appears on the General Medical Council specialist register in the speciality for which they are offering treatment.

surgical procedure – an operation or other invasive surgical intervention.

terrorist act – any clandestine use of violence by an individual terrorist or a terrorist group to coerce or intimidate the civilian population to achieve a political, military, social or religious goal.

treatment – surgical or medical services (including diagnostic tests) that are needed to diagnose, relieve or cure a disease, illness or injury.

United Kingdom – Great Britain and Northern Ireland, including the Channel Islands and the Isle of Man.

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This private medical insurance plan is underwritten by AXA PPP healthcare Limited –

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