Convergys Emea 2018 Handbook

Convergys Emea Ltd
Healthcare insurance plan

Advance Membership handbook
December 2018
Welcome to your membership Personal Advisory team
Welcome to your membership of AXA PPP healthcare. 0800 051 8019
Monday to Friday 8am to 8pm and Saturday 9am to 5pm
I know there’s a lot in this handbook, but we want to make
sure you’ve got all the information you need. For queries or claims pre-authorisation including Working Body and
Stronger Minds. Remember a GP referral may not be needed for
These are exciting times in health and medicine. The human some conditions.
race has never seen such a pace of new discoveries and
developments, and it’s pretty likely the speed of things will To contact us by Next Generation Text on any of the numbers listed
only increase. in this handbook just prefix the number listed with 18001.
In an ideal world, we’d cover all proven treatment for all health Overseas emergency control centre
conditions, all of the time, no matter how they’ve come to
affect you. But no health insurance – or health service for that +44(0) 1892 513 999
matter – in the world could ever do that. So, we cover the vast
majority of the thousands of claims we get every week, while Health information
still keeping your health insurance affordable. Unfortunately, it axappphealthcare.co.uk/health
often takes more words to explain the detail of what’s not
Access to our on-line health centres
covered than to simply tell you all that is, but there’s nothing to
hide so we tell you everything. Leaving your employer
Everyone here – all of our nurses, doctors, health experts, Stay covered with the same personal medical underwriting
phone advisers, claims handlers, technicians… everyone –
Call us on 0800 028 2915
wants you to enjoy the best possible health and healthcare.
I wish you the best of health.
Keith Gibbs Wellbeing Services
Chief Executive, AXA PPP healthcare Please visit your Wellbeing Hub for all the details of your
Wellbeing services.
We may record and/or monitor calls for quality assurance, training and
as a record of our conversation.
Contents
If you’re leaving your company
Stay covered with the same personal medical underwriting 1 > Quick start guide to your membership
If you’re leaving employment you will find transferring to an Your benefits
AXA PPP healthcare personal plan is quick, easy and trouble free. The main things we don’t cover
Contact us as soon as you know you will be leaving your company scheme
by phoning 0800 028 2915, you won’t need to fill in any forms or have any 2 > Making a claim and using your Advance services
kind of medical examination – we’ll arrange everything over the phone.
For the vast majority of existing AXA PPP healthcare members, we can 3 > How your membership works
cover you for existing medical conditions with no additional medical
underwriting, when leaving employment and are transferring to a plan with
comparable benefits and restrictions. 4 > Your cover for specific conditions, treatment, tests
To ensure you retain this special benefit it is important you call us on and costs
0800 028 2915 as soon as you know you will be leaving. You may find it
Includes full details of your cancer cover
difficult to get continued cover for any existing or previous medical
conditions at a later date. We will also try to get in touch with you as soon as
we know you are leaving your employment to let you know more about your 5 > Managing your membership
options.
6 > Legal information
7 > Glossary
Advance membership handbook Page 3

1 Quick start
This section explains the basics of the cover your company has
chosen. It also tells you some of the key things that are not
covered too.
guide to your Reading this will help you to understand the benefits available.
The tables in this guide give you an outline of your cover. For full
details of your cover, please read the rest of your handbook too.
membership To make the handbook easier for you to use, we’ve added in
links to all contents pages and anywhere we mention another
section for more information. To go to a particular section from a
contents page, simply click on the title of the section you need.
Sections referenced for more information through the rest of the
handbook are underlined so you know if you click on the
underlined area, you’ll go straight to that section
1.1 > Your benefits

1.2 > The main things we don’t cover
Words and phrases in bold type

Some of the words and phrases we use have a specific meaning.
For example, when we talk about treatment.
We’ve highlighted these words in bold. You can find their meanings in the
glossary section of your handbook.
You and your

When we use you and your, we mean the lead member and any
family members covered by the plan.
We, us and our

When we use we, us and our, we mean AXA PPP healthcare.
Page 4
1 Quick start guide to your membership
1.1 > Your benefits

This section shows you the cover your membership gives you.
Please make sure you call us before each stage of your treatment so we can let you know
the extent of your cover.
If you don’t contact us before receiving treatment or you don’t have treatment with a
provider we have helped you choose, we won’t make any payment for the treatment you
receive. This would mean you would have to pay for the whole cost of that treatment.
If you’re an in-patient or day-patient

Private hospital and day-patient unit fees Paid in full Including fees for in-patient or day-patient:
>> For more information see Section 3 - ‘Paying the  accommodation
places w here you’re treated’  diagnostic tests
 using the operating theatre
 nursing care
 drugs
 dressings
 radiotherapy and chemotherapy
 physiotherapy
 surgical appliances that the specialist uses during
surgery.
Hospital accommodation for one parent while a Paid in full Covers the cost of one parent staying in hospital with a
child is in hospital child. The child must be covered by your membership
and having treatment covered by it.
Hotel accommodation for one parent while a child is Up to £100 a night up to £500 a year Covers towards the costs for one parent to stay near to
in hospital the private hospital where a child is having treatment.
The child must be covered by the membership and
having treatment covered by it. We will not take any
excess off this cash payment.
Specialist fees No yearly limit Includes fees for:
>> For more information see Section 3-‘Paying the  surgeons
specialists and practitioners that treat you’  anaesthetists
 physicians.

If you’re an out-patient
Access to Working Body: For muscle, bone and joint pain – No GP referral needed - Call us on 0800 051 8019
Surgery No yearly limit
CT, MRI or PET scans Paid in full
>> For more information see Section 3 -‘Paying the
specialists and practitioners that treat you’
Specialist consultations No yearly limit Practitioners are nurses, dieticians, orthoptists,
speech therapists, psychotherapists or psychologists.
Diagnostic tests when your specialist refers you
Practitioner fees when your specialist refers you
>> For more information see Section 3 -‘Paying the
specialists and practitioners that treat you’
Fees for out-patient treatment by physiotherapists, No yearly limit on fees up to a combined overall maximum We call physiotherapists, osteopaths and chiropractors
acupuncturists, homeopaths, osteopaths or of 10 sessions in a year when your GP refers you or you therapists.
chiropractors have therapist treatment through our Working Body team

Mental Health
Private hospital and Paid in full Including fees for:
day-patient unit fees for mental health treatment • accommodation
>> For more information see Section 3 - ‘Paying the • diagnostic tests
places w here you’re treated’ • drugs.
Specialist fees for mental health treatment No yearly limit
Mental Health - If you’re an out-patient

Access to Stronger Minds: For any mental health concerns – No GP referral needed - Call us on 0800 051 8019
Counselling sessions through Stronger Minds Sessions with a counsellor when this is directed by, and This could be face to face, email or telephone
arranged through, the Stronger Minds service counselling.
The type and amount of counselling will be arranged
as clinically appropriate by the Stronger Minds service.
Only counselling arranged through Stronger Minds is
covered by your plan.
Over 18s only.
Counselling is not subject to the excess, or other
monetary benefit limits.
Specialist consultations for mental health No yearly limit
treatment
Mental health treatment by psychologists and No yearly limit
psychotherapists
>> For more information see Section 4 – Mental Health

Additional benefits
Nurse to give you chemotherapy or antibiotics by Paid in full We will pay for treatment:
intravenous drip at home  at home
 somewhere else that is appropriate.
We will pay for a nurse to give you chemotherapy or
antibiotics by intravenous drip. This is so long as:
 we have agreed the treatment beforehand and
 you would otherwise need to be admitted for in-
patient or day-patient treatment and
 the nurse is working under the supervision of a
specialist and
 the treatment is provided through a healthcare
services supplier that we have a contract with for this
kind of service.
Cash payment when you have free treatment £50 per night up to £5,000 each year We pay this when:
under the NHS  you are admitted for in-patient treatment before
midnight
 we would have covered your treatment if you had
had it privately.
We will not take your excess off this cash payment.
You can also receive this cash payment if you have
treatment in an NHS Intensive Therapy or Intensive
Care unit, whether it follows private treatment or not.
Oral surgery Paid in full So long as your dentist refers you, we will pay for:
 reinserting your own teeth after a trauma
 surgical removal of impacted teeth, buried teeth and
complicated buried roots
 removal of cysts in the jaw (sometimes called
enucleation).
Ambulance transport Paid in full If you are having private in-patient or day-patient
treatment and it is medically necessary to use a road
ambulance to transport you to another medical facility.

Additional benefits
Overseas evacuation and repatriation Paid in full Our evacuation or repatriation service is available to
move you to another hospital which has the necessary
medical facilities either in the country where you are
taken ill or in another nearby country (evacuation) or
bringing you back to the United Kingdom
(repatriation).
Immediate emergency in-patient treatment Paid in full up to £40,000 a year
received while travelling abroad which relates to an
evacuation or repatriation we have arranged for you
External prostheses Up to £5,000 for the lifetime of your membership We will pay this benefit towards the cost of providing
an external prosthesis.We will not take your excess
off this cash payment.
>> For details, see Section 4 – External prostheses
and appliances
Excess information
Excess per member per year £125 Excesses do not apply to:
 Overseas evacuation and repatriation service
 NHS cash benefit
 Day-patient and out-patient radiotherapy and
chemotherapy cash benefit
 Parent hotel accommodation
 Counselling arranged through Stronger Minds
 External prostheses
Cancer cover and care

For details, see Section 4 - Cancer.

1.2 > The main things we don’t cover

Like all health insurance plans, there are a few things that are not covered. We’ve listed the
most significant things here, but please also see the detail later in your handbook.
Does my membership mean I don’t need to use the NHS?

No. Your insurance is not designed to cover every situation. It is designed to add to, not
replace, the NHS. There are some conditions and treatments that the NHS is best at
handling – emergencies are a good example.
Your plan does not cover For more information Notes

Routine pregnancy and childbirth >> For details, see Section 4 – ‘Pregnancy and childbirth’ or
call us on 0800 051 8019
Treatment of ongoing, recurrent and long-term >> For details, see Section 3 - ‘How your membership w orks
conditions (chronic conditions) w ith conditions that last a long time or come back’

> Muscle, bone and joint conditions
Working Body
> Mental health concerns

Stronger Minds
> Claiming for other conditions

Cover for treatment, tests and diagnoses
> Expert Help

Health at Hand
Health information
Dedicated nurses
Find out more at your Wellbeing Hub

2 Making a claim and For more information on all the services and offers available to
you with your membership, head to your Wellbeing Hub.
Please call us on 0800 051 8019 if you don’t have your login
using your Advance details to hand or have any queries about the hub.
services
Page 11
2 Making a claim and using your Advance services
Working Body Stronger Minds

for muscle, bone and joint conditions for mental health concerns
0800 051 8019 0800 051 8019
Working Body makes it easy for you to get expert
Stronger Minds provides prompt access to mental healthcare
physiotherapy services fast.
and support.
You don’t even need to get a referral from your GP first.
You don’t even need to get a referral from your GP first.
Call us on 0800 051 8019 - As soon as you develop a problem
Call us on 0800 051 8019 - If you experience stress, anxiety
you can call your Personal Advisory team to check your cover
or any mental health concerns, call your Personal Advisory
and arrange a clinical needs assessment with a
team to check your cover. They’ll pass you straight through to
physiotherapist over the phone.
the Stronger Minds team to speak to a trained counsellor or
Assessments available 8am to 6pm, Monday to Friday psychologist.
Initial clinical needs assessment - During the phone call the Initial clinical needs assessment - One of the team will talk
physiotherapist will listen to your concerns and take you things through, make an initial assessment and then direct you
through an initial assessment. to the treatment that’s right for you.
After the assessment After the assessment
The physiotherapist will recommend treatment, which could The counsellor or psychologist will recommend treatment,
be one of three options: which could include:
 Self-management – we’ll provide you with easy to follow  Counselling – Face to face, by email or over the telephone.
guidance on how best to manage your condition.  Treatment with a psychologist – we’ll put you in touch with
 Treatment with a physiotherapist, osteopath or chiropractor a selected provider.
– we’ll put you in touch with a selected provider.  Referral on to a specialist – we can arrange for you to see
 Referral on to a specialist – we can arrange for you to see a private specialist.
a private specialist through our Fast Track Appointments  Self Help.
service.
Only counselling arranged through Stronger Minds is covered by your plan.
Members under the age of 18 will need a GP referral for these types of
conditions as the ‘Working Body’ service is not available to them. Over 18s only.

Making a claim for all other conditions

0800 051 8019
1 Ask your GP for an open referral
If your GP says you need specialist treatment, tell them you want to go private and ask for an
‘open referral’.
With an open referral your GP advises the type of specialist you need treatment from but
Fast Track Appointment service
doesn’t name a particular specialist. Our Fast Track Appointments will then help you find a Whenever you need treatment, our team will support
suitable specialist and make a convenient appointment for you. Occasionally the NHS will be you by helping you choose a selected provider to treat
best placed to provide care locally (for example specialist paediatric (children’s) care at a NHS you and will usually be able to arrange an
centre of excellence). When this is the case we will talk to you about your NHS options as well. appointment with them through our Fast Track
2 Call us before you see the specialist Appointments.
Call us as soon as you’ve seen your GP.
What if your GP refers you to a named
You need to call us before booking a consultation so we can find a specialist for you. We can
only pay for treatment with providers that we have helped you find. If you have treatment with a
specialist?
provider that we haven’t helped you choose, you will have to pay the costs in full. Simply give us a call and we’ll help from there.
Please help us by having the open referral information from your GP to hand when you call.
Occasionally, if we don’t have enough information to choose a specialist, we may ask for
Second opinion service
additional information from your GP and/or a copy of the open referral letter. If you would like a second opinion from another
3 We’ll check your cover and let you know what happens next specialist, please call us and we can discuss the
options with you.
We’ll check the treatment is covered by your plan, help you find a suitable specialist and offer
to make the appointment for you.
In all cases we may record and/or monitor calls for quality
To book the appointment, we’ll need to share some personal information with the specialist
assurance, training and as a record of our conversation
including medical information. In some circumstances, you may prefer to make the appointment
yourself.
We may ask you to provide more information, for example from your GP or specialist. You, your
GP or your specialist must provide us with the information we ask for by the date that we ask for
it or you may not be covered for your claim.
If you need further treatment, please call us first.

Expert Help
Have you ever wished a friend or someone in your family was a medical expert? You’d be
able to talk to them whenever you liked and they’d have time to listen, reassure and explain
in words you understand.
Being there to help with your health questions is just what our Expert Help services are here
for. Our medical teams including nurses and a wide variety of healthcare professionals can
answer the questions you might often wish you could ask.
Our Expert Help services do not diagnose or prescribe, and are not designed to replace your
GP. Any information you share with us is confidential and will not be shared with other parts
of our business, like our claims department.
Support from our Dedicated Nurse

Health at Hand Health information you can trust
Services
Call 0800 003 004 Personal support after diagnosis of a
axappphealthcare.co.uk/health
with your health queries – any time heart condition or cancer
Our medical team is ready to help – day or Our online Health Centres bring together the Our members have access to our Dedicated
night – whether you want to talk about a latest information from our own experts, Nurse Service, 24/7, 365 days a year. If you
specific health worry, medication and specialist organisations and NHS resources. are diagnosed with a heart condition or
treatment or simply need a little guidance You can also put your own questions to our cancer, our dedicated nurses will be there for
and reassurance. panel of experts at our regular live online you and your family.
Open 24 hours a day, 365 days a year discussions. Dedicated Heart Nurse
Midwife and pharmacist services: Alternatively you can e-mail your question 0800 2182 303
Monday to Friday 8am to 8pm through our Ask the Expert online panel and
an appropriate medical professional will Dedicated Cancer Nurse
Saturday 8am to 4pm
Sundays 8am to 12pm. respond to you. 0800 1114 811
> Nurses > Extensive panel, including doctors,
psychologists, nurses, physiotherapists and
> Counsellors dieticians
> Midwives
> Pharmacists
Page 14
3.1 > How we pay claims
3.2 > Looking at who should provide treatment
3.3 > Eligible treatment
3.4 > Our cover for treatment and surgery
3.5 > How your membership works with pre-existing

conditions and symptoms of them
3.6 > How your membership works with conditions

that last a long time or come back (chronic
conditions)
3.7 > Paying the specialists and practitioners that

treat you
3 How your 3.8 > Paying the places where you’re treated
membership works 3.9 > General restrictions
Please read all of your handbook

For full details of how your membership works, please read the rest of your
handbook too.
Page 15
3 How your membership works
When you call us, we’ll explain if your treatment is covered and normally you
Any questions? won’t need to fill in any forms.
If you’re unsure how something works, just call 0800 051 8019 and we’ll be Usually, this all happens very quickly. However, sometimes we need more
very glad to explain. It’s often quicker and easier than working it out from the detailed medical information, including access to your medical records.
handbook alone.
What does ‘more detailed’ mean?
3.1 > How we pay claims We may need more detailed information in any of the following ways:
We normally settle any bills directly with the specialist or the hospital where We may need your GP or specialist to send us more details about your
you’ve had your treatment. If your treatment is not covered for any reason, we medical condition. Your GP may charge you for providing this information.
will let you know. This charge is not covered by your plan.
We may also ask you to give us consent to access your medical records.
How do you pay my medical bills?
In some cases, we may also ask you to complete additional forms. We wi ll need
Specialists and hospitals normally send their bills to us, so we can pay them you to complete these forms as soon as possible, but no later than six months
directly. after your treatment starts (unless there is a good reason why this is not
For more details, see Section 3 - ‘Paying the specialists and practitioners w ho treat possible).
you’.
Very rarely, we may have to ask a specialist to advise us on the medical facts or
examine you. In these cases, we will pay for the specialist to do this and will
Do I need to tell the place where I have my treatment that I am an AXA take your personal circumstances into account when choosing the specialist.
PPP healthcare member?
Yes, you must tell the place where you have your treatment that you are an What happens if I don’t want to give the information you’ve asked for?
AXA PPP healthcare member. This will mean that the fees charged for your If you do not give us the information we ask for, or do not consent to our
treatment are those we have agreed with the hospital or centre. accessing your medical records when we ask, we will not be able to assess
your claim and so will not be able to pay it. We may also ask you to pay back
What happens if I’ve paid the bills myself already or if I receive a bill? any money that we have previously paid to do with this medical condition.
If you paid your medical bills yourself and your treatment is covered, we will
refund you the costs, minus any excess. Please send the original receipts from
What if my treatment isn’t covered?
the specialist or hospital to AXA PPP healthcare, Phillips House, Crescent
Road, Tunbridge Wells, Kent TN1 2PL. If your membership doesn’t cover your treatment, we’ll explain this and also tell
you about what we can do to support you through your NHS treatment.
If you receive a bill, please call us and w e’ll explain w hat to do next.
What should I do if I need further treatment? What if I want to see a specific specialist?
If you need further treatment, please call us first to confirm your cover. You always need to ask your GP for an open referral. That’s a referral that
doesn’t name a specialist. With an open referral, you’ll have a choice of
specialist and we can make your appointment for you. This will also mean we
The information we may need when you make a claim can check that we cover that specialist’s fees.

Where can I find more information about the quality and cost of private ‘Eligible treatment’ is treatment of a disease, illness or injury where that
treatment:
treatment?
 Is of an acute condition (for details see 3.6).
You can find independent information about the quality and cost of private
treatment available from doctors and hospitals from the Private Healthcare  Is conventional treatment (for details see 3.4).
Information Network: www.phin.org.uk  Is not preventative.
 Does not cost more than an equivalent treatment that is at least as likely to
deliver a similar therapeutic or diagnostic outcome.
What happens if I need emergency treatment in the UK?
 Is not provided or used primarily for the convenience or financial or other
In an emergency, please call for an NHS ambulance or go to a hospital A&E advantage of you or your specialist or other health professional.
department. Most private hospitals are not set up for emergency treatment.
Treatment needs to meet all of these requirements. There are some exceptions
If you need further treatment after your emergency treatment, please call us, which will be described in the relevant sections of this handbook. For example
as we may be able to cover this. there are times when we do cover treatment of chronic conditions or
If you have free treatment on the NHS that would have been covered by the unproven treatment. You will find more details of when that is the case in
plan, we will pay you a cash payment. This includes treatment in an NHS sections 3.6 and 3.4.
Intensive Therapy or Intensive Care Unit. If we are in doubt about whether each of these requirements will be met we may
For information on emergencies abroad, please see Section 4 – ‘Evacuation and need to seek a second medical opinion or identify an alternative specialist to
repatriation’. offer a second opinion and examine you to confirm that your treatment meets
the definition of eligible treatment. In these cases we will pay for the specialist
to do this.
3.2 > Looking at who should provide treatment
Your membership does not cover prim ary care services such as any service
that could be provided by GPs, dentists and opticians. This includes drugs and 3.4 > Our cover for treatment and surgery
treatment.
We cover treatment and surgery that is conventional treatment.
When diagnostic tests are routinely required as part of your referral to a
specialist we may arrange these for you. We do this to help assist the
What do you mean by conventional treatment?
specialist to quickly and effectively diagnose or identify what treatment may be
required. We define conventional treatment as treatment that:
 is established as best medical practice and is practised widely within the UK;
and
3.3 > Eligible treatment  is clinically appropriate in terms of necessity, type, frequency, extent, duration
Your membership covers ‘eligible treatment’. and the facility or location where the treatment is provided; and has either
You will need to read all sections of this handbook to understand whether  been shown to be effective for your medical condition through substantive
treatment is eligible treatment. peer reviewed clinical evidence in published authoritative medical journals; or
 been approved by NICE (The National Institute for Health and Care
Excellence) as a treatment which may be used in routine practice.

Are there any additional requirements for drug treatments? Are there restrictions on what you pay for unproven treatment?
If the treatment is a drug, the drug must be: The amount we pay for unproven treatment will depend on how much it costs
 licensed for use by the European Medicines Agency or the Medicines and and how much we would pay if you have conventional treatment for your
Healthcare products Regulatory Agency; and medical condition instead.
 used according to that licence.  If the unproven treatment costs less than the equivalent conventional
treatment we will pay the cost of the unproven treatment.
 If the unproven treatment costs more than the equivalent conventional
Are there any additional requirements for surgical treatments?
treatment we will pay up to the cost we would have paid for the equivalent
If the treatment is a surgical procedure it must also be listed conventional treatment. We will pay up to the amount we would have paid a
and identified in our schedule of procedures and fees. specialist and hospital in the Directory of Hospitals. To understand what
» You can find our schedule at axappphealthcare.co.uk/fees or call us on 0800 the equivalent conventional treatment is, we will look at the treatment other
051 8019 and we’ll send you a copy patients with the same medical condition and prognosis would be given.
Do I need to let you know if I want unproven treatment?
What happens if my specialist says I need treatment that is not Yes, if you would like an unproven treatment, you or your specialist must
contact us at least 10 working days before you book that treatment. This is so
conventional treatment?
we can:
We know our members may wish to have access to emerging treatments as they  obtain full details of the treatment
become available. So, we will consider covering the following treatment when it’s
carried out by a specialist:  support you with additional information and questions for your specialist,
before you have treatment
 surgery not listed and identified in the schedule of procedures and fees; and
 agree what costs (if any) we will meet, see important points below. All
 other treatments and diagnostic tests which are not conventional unproven treatment must be agreed by us in writing, so you are clear before
treatments. undergoing treatment of any shortfall you may have to pay to the hospital
In this handbook we refer to this treatment as unproven treatment. and /or the specialist.
The cover for unproven treatment is more restrictive than for conventional Will there be any restrictions on my cover after I have had unproven
treatments.
treatment?
Unproven treatment must: Yes there will. We will not pay for further treatment for your medical condition
 be authorised by us before it takes place after you have undergone unproven treatment, including complications or
 take place in the UK other medical conditions associated with the unproven treatment.
 be agreed by us as a suitable equivalent to conventional treatment.
If there is no suitable equivalent conventional treatment, there won’t be any » To check whether we will agree to cover a treatment, please call us on 0800
cover for the unproven treatment. 051 8019 before you book your treatment.

3.5 > How your membership works with pre-existing conditions Acute conditions
and symptoms of them An acute condition is a disease, illness or injury that is likely to respond quickly
to treatment that aims to return you to the state of health you were in
Your company plan covers treatment of conditions that you were aware of or
already had when you joined. immediately before suffering the disease, illness or injury, or that leads to your
full recovery.
What if you didn’t tell us about a condition, symptom or treatment you

Chronic conditions
knew about when we asked?
A chronic condition is a disease, illness or injury that has one or more of the
Whatever underwriting style your company has chosen, we may have asked following characteristics:
you some medical questions before agreeing cover for you or your family
members. If we did, we worked out your terms based on your answers. So, if  it needs ongoing or long-term monitoring through consultations, examinations,
you did not answer accurately, even if this was by accident, we may not cover check-ups or tests
treatment for the condition.  it needs ongoing or long-term control or relief of symptoms
This means we will not cover treatment or any conditions that you should have  it requires your rehabilitation, or for you to be specially trained to cope with it
told us about when we asked, but that you either did not tell us about at all, or  it continues indefinitely
that you did not tell us the full extent of. This includes:  it has no known cure
 any pre-existing or previous condition, whether you had treatment for them or
 it comes back or is likely to come back.
not
 any previous medical condition that recurs
Does my membership cover me for conditions that last a long time or
 any previous medical condition that you should reasonably have known come back (chronic conditions)?
about, even if you did not speak to a doctor.
Like most health insurance, your membership is designed to cover unexpected
Whenever you claim, we may ask your GP, specialist or practitioner for more illness and conditions that respond quickly to treatment (acute conditions).
information to confirm whether we can cover your claim.
Because we do not cover ongoing, recurring long-term treatment for chronic
If we need to look at your medical history, we will need some time to do this conditions, this means we will not cover:
before we can confirm whether we can cover your claim.
 monitoring of a medical condition
 any treatment that only offers temporary relief of your symptoms, rather than
3.6 > How your membership works with conditions that last a long dealing with the underlying condition
time or come back (chronic conditions)  routine follow up consultations.
However, please see the notes on treatment for cancer and heart conditions
What are acute conditions and chronic conditions? as there are some exceptions to these rules.
Like most health insurers we use the Association of British Insurer’s definitions
for these: What happens if a condition I have is a chronic condition?
If your condition is chronic, there will be a limit to how long we cover your
treatment. If we are not able to continue to cover your treatment, we will tell
you beforehand so you can decide whether to start paying for the treatment
yourself, or to transfer to the NHS.

How does this affect my cover for cancer treatment? 3.7 > Paying the specialist, practitioners
We treat cancer treatment in a different way to other long-term conditions and and therapists that treat you
cover more long-term treatment.
There is a full explanation of how w e cover cancer treatm ent in Section 4 Does my plan cover the full fees charged by specialists?
When you receive treatment we have agreed cover for from a provider we have
How does this affect my cover for treatment of heart conditions? helped you choose, we can pay the treatment charges in full.
If you have any of the following surgery on your heart, we will carry on paying
for long-term monitoring, consultations, check-ups and examinations related to Who will be paid under the benefit for practitioners?
the surgery. We will continue to pay for this while you are still a member and We will pay for the out-patient treatment you need with a practitioner. By
have out-patient cover. practitioners we mean a:
 coronary artery bypass  nurse
 cardiac valve surgery  dietician
 implanting a pace maker or defibrillator  orthoptist
 coronary angioplasty.  speech therapist
We will not pay for routine checks that a GP would normally carry out, such as  psychologist
anticoagulation, lipid monitoring or blood pressure monitoring.  psychotherapist.
We will pay so long as your treatment is with a practitioner we have chosen
What other treatment is covered for chronic conditions?
for you and your specialist refers you and is directing your treatment.
There are particular situations where we can cover treatment for chronic
conditions.
Who will be paid under the benefit for therapists?
 The initial investigations to diagnose your condition.
We will pay out-patient treatment fees for any of the following we recognise so
 Treatment for a few months so that your specialist can start your treatment. long as your treatment is covered and is with a therapist we or the Working
If your condition flares up or you develop complications, we will cover short-term Body team have helped you choose:
in-patient treatment to take your condition back to its controlled state.  physiotherapists
 osteopaths
Are there any conditions that are always regarded as chronic?
 chiropractors.
Yes. Some conditions are likely to always need ongoing treatment or are likely If our Working Body team or your GP refers you for the treatment, you are
to recur. This is particularly the case if the condition is likely to get worse over covered for the sessions you need up to an overall maximum of 10 sessions in
time. An example is Crohn’s disease (inflammatory bowel disease).
a year. If your specialist refers you, we may agree to more sessions.
If you have one of these conditions, we will contact you to tell you when we will
If you choose to use a therapist that we do not help you to choose, we will not
stop cover for treatment of the condition. We will contact you so that you can
pay for your treatment.
then decide whether to start paying for the treatment yourself, or to transfer to
the NHS.
More information about how w e cover treatm ent for chronic conditions , including
some examples of how our cover w orks is available from your Wellbeing Hub

Acupuncturists and homeopaths  physiotherapy

We will pay out-patient treatment fees for acupuncturists and homeopaths  surgical appliances that the specialist uses during surgery.
that we help you to choose so long as your treatment is covered and your GP For more about how w e pay for treatm ent, please also see ‘Paying the specialists
or specialist refers you. and practitioners that treat you’
Who will be paid for mental health treatment? What you must tell the place where you have your treatment?
We will pay for covered in-patient or day-patient psychiatric treatment, You must tell the place where you have your treatment that you are an
including specialist fees. If you need to go into hospital for in-patient or day- AXA PPP healthcare member. This will help to ensure that the fees charged for
patient treatment of a psychiatric condition, the hospital will contact us to your treatment are those we have agreed with the hospital or centre.
check your cover before you go in.
We will pay for out-patient treatment by any of the following: What happens if you use a hospital or scanning centre that we have not
 mental health specialist (psychiatrist) helped you to choose?
 a psychologist or psychotherapist, so long as a specialist oversees your If you have in-patient or day-patient treatment at a hospital, day-patient unit
treatment or you have been referred through Stronger Minds. or use a scanning centre that we have not helped you choose, you will not be
covered and you will need to settle all the costs yourself. This could be a
We will pay for counselling arranged by the Stronger Minds team. These
significant amount.
payments will be made direct to the provider.
Where can I have out-patient treatment?

3.8 > Paying the places where you’re treated We will pay fees at an out-patient facility in full so long as we have an
agreement with the provider that covers out-patient treatment. We will pay
Where can I have treatment? these so long as your treatment is covered by your membership, and a
If your treatment is covered by your membership, we will pay your hospital fees specialist we have chosen for you is overseeing it.
in full. This is so long as a specialist we have helped you choose is overseeing We do not pay for out-patient drugs or dressings.
your treatment, and you use one of the following :
If we don’t have an agreement with that provider, we will not pay any of their
 a hospital fees. Please always check with us beforehand to make sure we have an
 a day-patient unit arrangement with them.
 a scanning centre (for CT, MRI or PET scans).
What about intensive care?
In-patient and day-patient hospital fees include costs for things like:
 accommodation If you have private intensive care treatment in a private hospital or in an NHS
Intensive Therapy or Intensive Care unit, we will pay for this so long as:
 diagnostic tests
 it immediately follows private treatment that was covered by your
 using the operating theatre membership
 nursing care  you or your next of kin have asked for you to have the intensive care
 drugs treatment privately.
 dressings
 radiotherapy and chemotherapy

What about treatment on the NHS?

If you have free treatment on the NHS that would have been covered by your
membership, we will pay you a cash payment. This includes treatment in an
NHS Intensive Therapy or Intensive Care unit.
Does the plan cover payment for treatment anywhere else?

We only pay for treatment at the places listed. For example, we do not pay
anything for treatment at a health hydro, spa, nature cure clinic or any similar
place, even if it is registered as a hospital.
3.9 > General restrictions
High charges
We will not pay if any of the following charge a significant amount more than
they usually do, unless we have agreed this beforehand:
 a specialist
 a physiotherapist
 an osteopath
 a chiropractor.
Consultations within 10 days of treatment

We will not pay any separate fee that your specialist makes for consultations
within 10 days of carrying out surgery.
Treatment and referrals by family members

We will not pay for drugs or treatment if:
 the person referring you is a member of your family
 the person who treats you is a member of your family.

There are particular rules for how we cover some
conditions, treatments, tests and costs. This section
explains what these are.
You should read this section alongside the other sections
of this handbook as the other rules of cover will also
apply, for example our rules about chronic conditions
and who we pay.
Any questions?
If you’re unsure how something works, just call 0800 051 8019 and we’ll be
very glad to explain. It’s often quicker and easier than working it out from the
handbook alone.
4 Your cover
for specific conditions,
treatment,
tests and costs
Page 23
4 Your cover for specific conditions, treatment and costs
4.1 > Cancer 4.18 > Learning and developmental disorders
4.2 > Bariatric Surgery 4.19 > Longsightedness, short sightedness and
astigmatism
4.3 > Breast reduction
4.20 > Mechanicalheart pumps (Ventricular Assist
4.4 > Chiropody and foot care
Devices (VAD) and artificial hearts)
4.5 > Consequences of previous treatment, medical or
4.21 > Mental Health
surgical intervention or body modification
4.22 > Natural ageing
4.6 > Contraception
4.23 > Nuclear, biological or chemical contamination
4.7 > Cosmetic surgery
and war
4.8 > Criminal activity
4.24 > Organ or tissue donation
4.9 > Drugs and dressings
4.25 > Pregnancy and childbirth
4.10 > Evacuation and repatriation
4.26 > Reconstructive surgery
4.11 > External prostheses or appliances
4.27 > Rehabilitation
4.12 > Fat removal
4.28 > Self-inflicted injury and suicide
4.13 > Gender re-assignment or gender confirmation
4.29 > Sexual dysfunction
4.14 > Genetic tests, preventative treatment and
4.30 > Social, domestic and other costs unrelated to
screening tests
treatment
4.15 > GP and primary care services
4.31 > Sports related treatment
4.16 > Infertility and assisted reproduction
4.32 > Sterilisation
4.17 > Kidney dialysis
4.33 > Teeth and dental conditions

If you are diagnosed w ith cancer – please call us on 0800 051 8019 so w e can
4.34 > Treatment abroad
explain how w e can support you
4.35 > Treatment that is not medically necessary If you have day-patient or out-patient radiotherapy or chemotherapy on the
NHS, and your plan would have covered that treatment, we will make a cash
payment of £50 a day up to £5,000 per year.
4.36 > Varicose Veins
We will also make a cash payment for in-patient treatment on the NHS (as
well as out-patient and day-patient radiotherapy or chemotherapy). Please
4.37 > Warts see the details in your benefits table.
4.38 > Weight loss treatment

Do the rules about chronic or recurring conditions apply to cancer?
We don’t apply our rules about chronic or recurring conditions to cancer.
Please carefully read all of this section to find out how we cover treatment for
cancer.
4.1 > Cancer
Due to the nature of cancer, we cover it a little differently to other conditions. Comparing our cancer cover
This section explains the differences. If a specific aspect of your cover is not
mentioned here, the standard cover described elsewhere in your handbook To help make our cancer cover clearer, the following information is in a format
applies. that the Association of British Insurers (ABI) recommend.
About your cover for cancer treatment

We will cover investigations into cancer and treatment to cancer cells.
Experienced and dedicated nurses and case managers

Our registered nurses and case managers provide support over the phone and
have years of experience of supporting cancer patients and their families. When
you call, we’ll put you in touch with a nurse or case manager who will then
support you throughout your treatment.
Your nurse or case manager will be happy to speak to your specialist or doctor
directly if you need them to check any details. They can also give you guidance
on what to expect during treatment and how to talk about your illness to friends
and family.

Place of treatment Am I covered?

Private hospitals, day-patient units or scanning centres Yes
Chemotherapy by intravenous drip at home Yes
Diagnostic Am I covered?
Whether you’re an in-patient, day-patient, or out-patient

Surgery as shown below under ‘Surgery’ Yes
CT, MRI and PET scans Yes
Genetic testing proven to help choose the best chemotherapy Yes
Genetic testing to work out whether you have a genetic risk of developing cancer No
Specialist fees for the specialist treating your cancer when you are an in-patient or Yes
day-patient.
Diagnostic tests as an in-patient or day-patient Yes
If you’re an out-patient
Specialist consultations with the specialist treating your cancer when you are an out- Yes
patient
Diagnostic tests as an out-patient when ordered by the specialist treating your Yes
cancer
Surgery Am I covered?
Whether you’re an in-patient, day-patient or out-patient

Surgery for the treatment or diagnosis of cancer, so long as that treatment has been Yes
shown to be effective
See Section 7 - ‘Glossary’ for how w e define surgery
See Section 3 - ‘Our cover for treatm ent and surgery’ for more about effective treatm ent

Preventative Am I covered?
Preventative treatment, such as: No
 screening when you do not have symptom(s) of cancer. For example, if you had a
screen that showed you have a genetic risk of breast cancer, we would not cover the
screening or any treatment to reduce the chances of developing breast cancer in
future
 vaccines to prevent cancer developing or coming back– such as vaccinations to
prevent cervical cancer
Drug Therapy Am I covered?
Out-patient drugs or other drugs that a GP could prescribe or could be bought over the No – Please call us about these drugs. We don’t cover them, but we can he lp you
counter. This includes drugs or prescriptions you are given to take home if you have apply to get these paid for by the NHS. Call us on 0800 051 8019 and we can talk
had in-patient, day-patient or out-patient treatment you through this.
Drug treatment to kill cancer cells – including: Yes
 biological therapies, such as Herceptin or Avastin We will cover these drugs for 1 year or the period of the license, whichever is
 chemotherapy shorter.
We will cover if:
 they have been licensed by the European Medicines Agency or the Medicines
and Healthcare products Regulatory Agency, and
 they are used according to their license, and
 they have been shown to be effective.
Because drug licenses change, this means that the drugs we cover will change
from time to time.
Please call us once you know your treatment plan.
Clinical drug trials No

Drug Therapy Am I covered?
Other Drugs Yes. They are covered for a period of three months so long as you have them at
We cover: the same time as you are having chemotherapy or biological therapy to kill
 Bone-strengthening drugs such as bisphosphonates or Denosumab cancer cells covered by the plan.
 Hormone therapy that is given by injection (for example goserelin, also known as
Zoladex)
Antivirals, antibiotics, antifungals, anti-sickness and anticoagulant drugs Yes, while you are having chemotherapy that is covered by the plan.
Drugs for treating conditions secondary to cancer such as erythropoietin (EPO) Yes, while you are having chemotherapy that is covered by the plan.
Radiotherapy Am I covered?
Radiotherapy, including when it is used to relieve pain Yes
Palliative and end of life care Am I covered?
Care to relieve pain or other symptoms rather than cure the cancer We will provide cover and support throughout your cancer treatment even if it
becomes incurable. We cover radiotherapy, chemotherapy and surgery (such as
draining fluid or inserting a stent) to relieve pain.
Monitoring Am I covered?
Follow ups – cover for follow up consultations and reviews for cancer Yes, for a period of ten years so long as you are still a member and have a plan
that covers this.
Routine monitoring or checks that a GP or someone else in a GP surgery (or other No
primary care setting) could carry out
Follow up procedures that are for monitoring rather than treatment. Yes, for a period of ten years so long as you are still a member and have a plan
Some cancer patients need procedures to check whether cancer is still present or has that covers this.
returned. For example, these could include colonoscopies to check the bowel or
cystoscopies to check the bladder.

Limits What limits are there?
Time limits on cancer treatment There are some time limits for drug treatments given for prolonged periods as
Your membership covers you while you are having treatment to kill cancer cells described in the ‘Drug therapy’ and ‘Monitoring’ sections of this table.
Money limits on cancer treatment No specific limits – the same rules apply to your cancer treatment as for any
other treatment.
Other benefits Am I covered?
Stem cell or bone marrow treatment Yes

This includes paying reasonable costs to a live donor to donate bone marrow or stem
cells.
It does not include any related administration costs. For example, we will not cover
transport costs or the cost of finding a donor.
See Section 4 - ‘Organ and tissue donation’ for more details

4.2 > Bariatric Surgery 4.8 > Criminal activity

We do not cover any fees for any kind of bariatric surgery, regardless of why We do not cover treatment you need as a result of your active involvement in
the surgery is needed. This includes fitting a gastric band, creating a gastric criminal activity.
sleeve, or other similar treatment.
See also Weight loss treatment 4.9 > Drugs and Dressings
We don’t cover drugs, dressings or prescriptions that:
 you are given to take home after you have had in-patient, day-patient or
4.3 > Breast reduction out-patient treatment
We do not cover either male or female breast reduction.  could be prescribed by a GP or bought without a prescription
 are taken or administered when you attend a hospital, consulting room or
4.4 > Chiropody and foot care clinic for out-patient treatment.
We will not cover any general chiropody or foot care, even if a surgical podiatrist There are some exceptions for drugs given for cancer treatment.
provides it. This includes things like gait analysis and orthotics. >> There is a full explanation of how w e cover cancer treatment in Section 4 of this
handbook
4.5 > Consequences of previous treatment, medical or surgical

intervention or body modification 4.10 > Evacuation and repatriation
If you had treatment, medical or surgical intervention or body modification
previously that would not be covered by your membership, we do not cover What assistance is available to me if I fall ill overseas?
further treatment or increased treatment costs that are: There is very limited cover on the plan for treatment you have outside the
 a result of the treatment, medical or surgical intervention or body modification United Kingdom. We strongly advise you to take out travel ins urance when
you had previously, or travelling abroad.
 connected with the treatment, medical or surgical intervention or body If you fall ill abroad you do have access to an overseas medical assistance line.
modification you had previously. This service is provided by an international assistance company on our behalf.
The overseas medical assistance line is manned around the clock to provide
help and assistance in any part of the world. They will normally give immediate
4.6 > Contraception advice and can arrange to put you in touch with an English-speaking doctor.
That doctor will help arrange treatment locally or, if you have already started
We do not cover contraception or any consequence of using contraception.
treatment, will ensure that existing arrangement is satisfactory. Call the
emergency control centre on +44 (0) 1892 513 999 to alert the international
4.7 > Cosmetic surgery assistance company who can help you. Please note that in this situation any
costs for treatment would not be covered by the plan.
We do not cover:
This plan also provides an emergency evacuation or repatriation service
 Cosmetic treatment or cosmetic surgery.
should you be injured or become ill suddenly, and need immediate emergency
 Treatment that is connected to previous cosmetic treatment or cosmetic in-patient treatment. The exclusions in the other sections of this handbook
surgery. don’t apply to the evacuation or repatriation service but will apply to any
See also Reconstructive surgery treatment on return home to the UK.

If you need the evacuation or repatriation service , contact the emergency control The overseas evacuation and repatriation service will not be available
centre on +44 (0) 1892 513 999 so that immediate help or advice can be given ov er
for:
the phone.
 Any medical condition that does not prevent you from continuing to travel or
Arrangements may then be made for an appointed doctor to see you. If the work and which does not need immediate emergency in-patient treatment.
appointed doctor establishes that the hospitals locally are inadequate, or the
 Any costs incurred which arise from or are directly or indirectly caused by a
appropriate treatment is not available locally, then they will arrange to move
deliberately self-inflicted injury, suicide or attempt at suicide.
you or bring you back to the UK.
 Any costs incurred which arise from, or are in any way connected with,
If the appointed doctor thinks there is a medical need, then the evacuation or
alcohol abuse, drug abuse or substance abuse.
repatriation will include medical supervision. The rules relating to evacuation
and repatriation can be found below.  Any costs incurred as a result of engaging in or training for any sport for
which you receive a salary or monetary reimbursement, including grants or
sponsorship (unless you receive travel costs only).
What will the evacuation and repatriation service provide?
 Treatment of injuries sustained from base jumping, cliff diving, flying in an
The overseas evacuation and repatriation service is available to provide the unlicensed aircraft or as a learner, martial arts, free climbing, mountaineering
following services when the arrangements are made by us: with or without ropes, scuba diving to a depth of more than 10 metres,
Transferring you by air ambulance, regular airline or any other method of trekking to a height of over 2,500 metres, bungee jumping, canyoning, hang -
transport we consider appropriate. We will decide the method of transport and gliding, paragliding or microlighting, parachuting, potholing, skiing off piste or
the date and time. any other winter sports activity carried out off piste.
 Cover for the reasonable and necessary transport and additional  Moving you from a ship, oil-rig platform or similar off-shore location.
accommodation costs for another person, who m ust be 18 or over, to  Any costs that we don’t approve beforehand or costs incurred where we
accompany you if you are under 18 (or in other cases where we believe that haven’t been told about the accident or illness for which you need the
your medical condition makes it appropriate) while you are being moved. overseas evacuation and repatriation service within 30 days of it
 Cover for the reasonable additional travelling expenses and accommodation happening (unless this was not reasonably possible).
costs, incurred in returning to the UK any family members covered by an  Treatment costs other than for the necessary treatment administered by the
AXA PPP healthcare plan who are accompanying you on the overseas international assistance company appointed by us whilst they are moving you
journey. and immediate emergency in-patient treatment received whilst travelling
 Bringing your body back to a port or airport in the UK if you die abroad except abroad when it immediately precedes or immediately follows an evacuation or
if you die as a direct result of a deliberately self-inflicted injury or suicide repatriation we have arranged for you.
attempt.  Any unused portion of your travel ticket, and that of any accompanying
We will also pay for immediate emergency in-patient treatment received while person, will immediately become our property and you must give it to us.
travelling abroad, immediately before or immediately after an evacuation or  Any costs incurred as a result of nuclear, biological or chemical
repatriation we have arranged for you. contamination; war (whether declared or not); act of foreign enemy; invasion;
civil war; riot; rebellion; insurrection; revolution; overthrow of a legally
What is not covered? constituted government; explosions of war weapons or any event similar to
those listed.
Evacuation or repatriation service if you have travelled outside the UK to get
treatment (whether or not that was the only reason) or travelled against
medical advice (including the published advice of the Chief Medical Officer of
the Department of Health of England).

 Any costs incurred when you are on a leisure trip and you are travelling to a We do not cover the costs for the purchase or hire of appliances, such as
country or area that the UK Foreign and Commonwealth Office lists as a crutches, joint supports and braces, mechanical walking aids and contact
place which they either advise against: lenses.
 all travel to; or How to claim
 all travel on holiday or non-essential business. If you want to claim this benefit, you should call us on 0800 051 8019 and we
will explain what to do next. Please remember to ask the provider of your
We will not be liable in respect of the overseas evacuation and external prosthesis for full receipts as we cannot pay claims without a receipt.
repatriation service for:
 Any failure to provide the overseas evacuation and repatriation service or 4.12 > Fat removal
for any delays in providing it, unless the failure or delay is caused by our
negligence (including that of the international assistance company we have We do not cover the removal of fat or surplus tissue, such as abdominoplasty
appointed to act for us), or of agents appointed by either party. (tummy tuck), whether the removal is needed for medical or psychological
reasons.
 Failure or delay in providing the overseas evacuation or repatriation
service if; See also Weight loss treatment
i) by law the overseas evacuation or repatriation service cannot
be provided in the country which it is needed; or
4.13 > Gender re-assignment or gender confirmation
ii) the failure or delay is caused by any reason beyond our control
We do not cover gender re-assignment or gender confirmation treatment or
including, but not limited to, strikes and flight conditions.
anything connected with them in any way, such as:
 Injury or death caused while you are being moved unless it is caused by our
 gender re-assignment operations or other surgical treatment
negligence or the negligence of anyone acting on our behalf.
 psychotherapy or similar services
 any other treatment.
4.11 > External prostheses or appliances
4.14 > Genetic tests, preventative treatment and screening tests
We will pay up to £5,000 towards the cost of an external prosthesis needed
following an accident or surgery for a medical condition. Health insurance is designed to cover problems that you’re experiencing at the
moment, so it generally doesn’t cover preventative treatment or screening tests
We will do this so long as: including genetic tests.
 you had a medically documented accident or medical condition
What is not covered for genetic tests, preventative treatment and
that has led to the need for the prosthesis; and screening?
 all claims are made within 12 months of the amputation or
We do not pay for:
removal of the body part.
 preventative treatment
We will only pay this benefit once, regardless of how long you remain a member
of AXA PPP healthcare.  routine preventative examinations and check-ups
 genetic screening tests to check whether:
What is not covered?
 you have a medical condition when you have no symptoms
We do not cover replacement of teeth or hair, including wigs or hair transplants.

 you have a genetic risk of developing a medical condition in the 4.17 > Kidney dialysis
future
We do cover kidney dialysis, but only in some situations.
 there is a genetic risk of you passing on a medical condition.
 genetic tests to identify a medical condition where the result of the test isn’t What is covered for kidney dialysis?
proven to change the course of treatment. This might be because the course
of treatment for your symptoms will be the same regardless of what medical We will cover kidney dialysis for up to six weeks if you are being prepared for
condition has caused them kidney transplant. However, we will not cover regular or long-term kidney
dialysis if you have chronic kidney failure.
 any other preventative treatment or screening tests to see whether you have
a medical condition if you do not have any symptoms See also Organ or tissue donation
 vaccinations.
What is covered for genetic tests? 4.18 > Learning and developmental disorders
We will pay for genetic testing when it is proven to help choose the best course We do not cover any treatment, investigations, assessment or grading to do
of drug treatment for your medical condition. This means that it must be with:
recommended in the drug licence for a specific targeted therapy, such as HER2  speech delay
testing for the use of Herceptin for breast cancer.
 learning disorders
Please call us before you have any genetic tests to confirm that we will cover
them. Your specialist might want to do a variety of tests and they might not all  educational problems
be covered. The cost to you might be significant if the tests aren’t covered  behavioural problems
under your plan.  physical development
If you’re unsure w hether your treatm ent is preventative or not, please call us on  psychological development.
0800 051 8019 before going ahead w ith the treatm ent.
Some examples of the conditions we do not cover are the following (please call
if you would like to know if a condition is covered):
4.15 > GP and primary care services  dyslexia
We do not cover primary care services or treatment that would normally be  dyspraxia
carried out in a primary care setting. This includes any fees for services that a  autistic spectrum disorder
GP, dentist or optician could normally carry out.  attention deficit hyperactivity disorder (ADHD)
 speech and language problems, including speech therapy needed because of
another medical condition.
4.16 > Infertility and assisted reproduction
We do not cover investigation or treatment of infertility and assisted
reproduction or treatment designed to increase fertility. This includes: 4.19 > Long sightedness, short sightedness and astigmatism
 treatment to prevent future miscarriage We do not cover any treatment to correct long sightedness, short sightedness
 investigations into miscarriage or astigmatism.
 assisted reproduction
 anything that happens, or any treatment you need, as a result of these
treatments or investigations.

4.20 > Mechanical heart pumps (Ventricular Assist Devices (VAD) 4.22 > Natural ageing
and artificial hearts) We do not pay for treatment of symptoms generally associated with the natural
process of ageing. This includes treatment for the symptoms of puberty and
There is no cover for the provision or implantation of a mechanical heart pump. menopause.
There is also no cover for the long-term monitoring, consultations, check-ups,
scans and examinations related to the implantation or the device.
4.23 > Nuclear, biological or chemical contamination and war risks
4.21 > Mental health We do not cover treatment you need as a result of nuclear, biological or
chemical contamination. We do not cover treatment you need as a result of war
We will cover your treatment for psychiatric illness up to the levels shown in (declared or not), an act of a foreign enemy, invasion, civil war, riot, rebe llion,
your benefits table. The Stronger Minds service can help provide access to
insurrection, revolution, overthrow of a legally constituted government,
treatment for all mental health concerns (available for over 18s).
explosions of war weapons, or any similar event.
Your cover includes:
We do cover treatment due to a terrorist act so long as the act does not cause
 counselling provided through the Stronger Minds service (for over 18s) nuclear, biological or chemical contamination.
 out-patient treatment
 in-patient and day-patient treatment in hospital paid in full
4.24 > Organ or tissue donation
What happens if I need to go into hospital for a psychiatric condition? If you plan to donate an organ or tissue as a live donor, or receive an organ or
tissue from a live donor, please call us so that we can tell you what support we
If you need to go into hospital for in-patient or day-patient treatment of a offer.
psychiatric condition, the hospital will contact us to check your cover before you
go in. If your treatment is covered, we will agree to pay the hospital for an initial
period of time in hospital. The hospital will tell you how long this period is. What we don’t cover
We do not pay for:
What if my condition goes on for a long time?  the cost of collecting donor organs or tissue
Our normal rules on chronic conditions apply to mental health problems. So if  any related administration costs – for example, the cost of searching for a
your condition becomes chronic, unfortunately we may no longer be able to donor
cover your treatment. If this happens, we will contact you beforehand so that  any costs towards organ or tissue donation that’s not done in line with the
you can decide whether to start paying for the treatment yourself, or to transfer appropriate regulatory guidelines.
to the NHS.
For more details, see ‘How your membership w orks w ith conditions that last a long
time or come back’
4.25 > Pregnancy and childbirth
As pregnancy and childbirth are not medical conditions and because the NHS
What is not covered? provides for them, our cover is limited.
We do not cover any treatment connected in any way to: We don’t cover the normal checks or other interventions, such as monitoring
and screening, which you will have during pregnancy and birth. H owever, if you
 an injury you inflicted on yourself deliberately develop a medical condition while pregnant or giving birth, we may cover it.
 a suicide attempt.

What is covered during pregnancy and childbirth? What is not covered?

We will cover the additional costs for treatment of medical conditions that We do not cover treatment that is connected to previous reconstructive or
arise during pregnancy or childbirth. For example: cosmetic surgery.
 ectopic pregnancy (pregnancy where the embryo or foetus grows outside the See also Cosmetic Surgery
womb)
 hydatidiform mole (abnormal cell growth in the womb)
4.27 > Rehabilitation
 retained placenta (afterbirth retained in the womb)
We do cover in-patient rehabilitation for a short period, but there are some
 placenta praevia
limits to our cover.
 eclampsia (a coma or seizure during pregnancy and following pre eclampsia)
 diabetes What is covered for rehabilitation?
 post partum haemorrhage (heavy bleeding in the hours and days immediately We will cover in-patient rehabilitation for up to 28 days, so long as:
after childbirth)
 It is part of treatment that is covered by your membership
 miscarriage requiring immediate surgical treatment.
 a specialist in rehabilitation is overseeing your treatment
Because our cover for pregnancy and childbirth is limited, please call us on 0800
 the treatment can’t be carried out as a day-patient or out-patient, or in
051 8019 to check w hat you are covered for before starting any private treatm ent
another suitable location
 we have agreed the costs before you s tart rehabilitation.
4.26 > Reconstructive surgery If you need rehabilitation, please call us on 0800 051 8019, as we will need to
We do cover reconstructive surgery, but only in certain situations. confirm that we recognise the hospital or unit where you are having the
rehabilitation.
What is covered? If you have severe central nervous system damage following external trauma or
accident, we will extend this cover to up to 180 days of in-patient rehabilitation.
We will cover your first reconstructive surgery following a medically
documented accident or surgery for a medical condition.
We will do this so long as: 4.28 > Self-inflicted injury and suicide
 we agree the method and cost of the treatment in writing beforehand. We do not cover treatment you need as a direct or indirect result of a
In the case of breast cancer the first reconstructive surgery means: deliberately self-inflicted injury or a suicide attempt.
 one planned surgery to reconstruct the diseased breast
 one further planned surgery to the other breast, when it has not been 4.29 > Sexual dysfunction
operated on, to improve symmetry
We do not cover treatment for sexual dysfunction or anything related to sexual
 nipple tattooing, up to 2 sessions.
dysfunction.
Please call us on 0800 051 8019 before agreeing to reconstructive surgery so w e

can tell you if you are covered.

4.30 > Social, domestic and other costs unrelated to treatment 4.34 > Treatment abroad
We do not cover the costs that you pay for social or domestic reasons, such as There is very limited cover on the plan for treatment you have outside the
home help costs. We do not cover the costs that you pay for any reasons that United Kingdom. We strongly advise you to take out travel insurance when
are not directly to do with treatment such as travel to or from the place you are travelling abroad.
being treated. We will only pay for immediate emergency in-patient treatment received while
travelling abroad, immediately before or immediately after an evacuation or
repatriation we have arranged for you up to the amount shown in your benefits
4.31 > Sports related treatment table.
We do not cover treatment you need as a result of training for or taking part in Please see Evacuation and repatriation for further details
any sport for which you:
 are paid
 receive a grant or sponsorship (we don’t count travel costs in this); or 4.35 > Treatment that is not medically necessary
 are competing for prize money. Like most health insurers, we only cover treatment that is medically necessary.
We do not cover treatment that is not medically necessary, or that can be
considered a personal choice.
4.32 > Sterilisation
We do not cover: 4.36 > Varicose Veins
 sterilisation
We do cover treatment of varicose veins, but only in certain circumstances.
 any consequence of being sterilised
What is covered?
 reversal of sterilisation
We will cover one surgical procedure per leg to treat varicose veins, for the
 any consequence of a reversal of sterilisation.
lifetime of your membership with us. This may be foam injection
(sclerotherapy), ablation or other surgery.
4.33 > Teeth and dental conditions We will cover one follow up consultation with your specialist and one simple
injection sclerotherapy per leg to treat residual or remaining veins when it is
The plan does not cover treating dental problems or any routine dental care.
carried out in the 6 months after you’ve had the main surgical procedure.
This also means we will not pay any fees for dental specialists, such as
orthodontists, periodontists, endodontists or prosthodontists. What’s not covered?
We will cover the following types of oral surgery when you are referred for We do not cover more than one surgical procedure per leg, regardless of how
treatment by a dentist: long you stay a member with us.
 reinserting your own teeth after an injury There is no cover for the treatment of recurrent varicose veins under your plan.
 removing impacted teeth, buried teeth and complicated buried roots >>Please see ‘How your membership works with conditions that last a long time
 removal of cysts in the jaw (sometimes called enucleation). or come back (chronic conditions )’
There is no cover for the treatment of thread veins or superficial veins.

4.37 > Warts

We do not cover treatment of skin warts.
4.38 > Weight loss treatment

We do not cover treatment for weight loss.
What is not covered?
We do not cover any fees for any kind of bariatric surgery, regardless of why
the surgery is needed. This includes fitting a gastric band, creating a gastric
sleeve, or other similar treatment.

5.1 > Adding a family member
5.2 > Paying income tax on your subscription
5.3 > Leaving your employer
5.4 > Making a complaint
5.5 > Paying your excess
5 Managing your
membership
Page 38
5 Managing your membership
5.1 > Adding a family member or baby 5.3 > Leaving your employer
Whether you can add family members, including babies, to your cover will Call us on 0800 028 2915 when you know you’re leaving.
depend on the agreement we have with your employer. Depending on your
agreement with your employer, there may be restrictions on when you can add If you leave the employer that provides this plan, it’s quick and easy to transfer
family members. to a personal plan.
Please call us or speak to your Human Resources Departm ent for details. When you transfer to a personal plan with similar cover we can usually continue
to cover any existing medical conditions without the need for medical
Who you can add underwriting – so you won’t have to fill in any form or have a medical
examination.
You can normally add:
Call us as soon as you know you’re leaving as you may find it difficult to get
 Your partner. You must either be married, in a civil partnership or living
continued cover for any existing or previous medical conditions later.
together permanently in a similar relationship.
We’ll also try to get in touch with you when we know that you’re leaving your
 Any of your children or your partner’s children. Children can stay on the plan employer.
up to the age of 25 when they will come off the plan at the renewal date
following their birthday.
5.4 > Making a complaint
Babies born after fertility treatment, or following assisted reproduction, Your cover is provided under our company agreement with your company.
or who you have adopted However, we do give all members full access to the complaint resolution
You can add a baby born after fertility treatment, or following assisted process.
reproduction (such as IVF), or who you’ve adopted, to your membership. As Our aim is to make sure you’re always happy with your membership. If things
with most health insurance, our cover for treatment has a few limits in these do go wrong, it’s important to us that we put things right as quickly as possible.
situations.
If a baby is born after fertility treatment, or following assisted reproduction, or if Making a complaint
you have adopted a baby: If you want to make a complaint, you can call us or write to us using the contact
 We may ask for more details of the baby’s medical history. details below.
 We will not cover any treatment in a Special Care Baby Unit or paediatric To help us resolve your complaint, please give us the following details:
intensive care.  your name and membership number
We count fertility treatment as taking any prescription or non-prescription drug  a contact telephone number
or other treatment to increase fertility.
 the details of your complaint
 any relevant information that we may not have already seen.
5.2 > Paying income tax on your subscription Please call us on 0800 051 8019.
You will have to pay income tax on the subscription paid by your employer. Or write to:
AXA PPP healthcare, Phillips House, Crescent Road, Tunbridge Wells, Kent
TN1 2PL

5 Managing your membership
Answering your complaint If your claim is for a treatment that has a limit we will apply the limit before we
take the excess off.
We’ll respond to your complaint as quickly as we can.
If we can’t get back to you straight away, we’ll contact you within five working Even if your treatment costs less than your excess, please tell us about it so
days to explain the next steps. we can make sure we take this into account if you claim again that year.
We always aim to resolve things within eight weeks from when you first told us Your excess applies per member covered by the plan.
about your concerns. If it looks like it will take us longer than this, we will let you We only take the £125 excess off once per member each year. So even if you
know the reasons for the delay and regularly keep you up to date with our claim several times we will only take the excess off once. It doesn’t matter if you
progress claim several times for the same medical condition or for several medical
conditions.
The Financial Ombudsman Service
It also applies for each membership year. This means that if you incur costs
You may be entitled to refer your complaint to the Financial Ombudsman during this membership year, we will take the excess off what we pay for your
Service. The ombudsman service can liaise with us directly about your claim. If you then incur more costs in the next membership year, even if it’s for
complaint and if we can’t respond fully to a complaint within eight weeks, or if the same condition, we will take the excess off that claim.
you’re unhappy with our final response, you can ask the Financial Ombudsman
Service for an independent review. If your claim goes over your renewal, we’ll take the excess off the amount we
The Financial Ombudsman Service pay for your claim before renewal, then we’ll take the excess off the amount we
Exchange Tower pay for your claim after your renewal.
Harbour Exchange Square If you have any questions about how your excess works, please call us on 0800
London 051 8019.
E14 9SR
Phone: 0300 123 9 123 or 0800 023 4567 (These numbers may not be
available from outside the UK – so from abroad please call
+44 20 7964 0500)
Email: [email protected]
Website: financial-ombudsman.org.uk
Your legal rights

None of the information in this section affects your legal rights.
5.5 > Paying your excess

You have an excess on your membership of £125 per member each year. Here
is how the excess works:
We will take your excess off the amount covered by the plan for the first claim
for each person in each membership year.

6.1 > Rights and responsibilities
6.2 > Our authorisation and regulation details
6.3 > The Financial Services Compensation Scheme

(FSCS)
6.4 > Your personal information
6.5 > What to do if somebody else is responsible for

part of the cost of your claim
6.6 > What to do if your claim relates to an injury or

medical condition that was caused by or
contributed to by another person
6 Legal
Information
Page 41
6 Legal information
6.1 > Rights and responsibilities Subrogated rights

This section sets out the rights and responsibilities you, your employer and we We, or any person or company that we nominate, have subrogated rights of
have to each other. recovery of the lead member or any family members in the event of a claim.
This means that we will assume the rights of the lead member or any family
members to recover any amount they are entitled to that we have already
The plan
covered under this plan.
The cover is provided under an agreement with your company who selects the
level of benefits included. For example, we may recover amounts from someone who caused injury or
illness, or from another insurer or state healthcare provider.
The plan is for one year unless your company has advised you otherwise.
The lead member must provide us with all documents, including medical
Only those people listed in the company agreement can be members of this records, and any reasonable assistance we may need to exercise these
plan. subrogated rights.
All cover ends when the lead member stops working for the company or if the The lead member must not do anything to prejudice these subrogated rights.
company’s group membership ends.
We reserve the right to deduct from any claims payment otherwise due to you
We will pay for covered costs incurred during a period for which the subscription an amount that will be recovered from a third party or state healthcare provider.
has been paid.
We will confirm the date that the plan starts and ends, who is covered, and any What happens if you break the terms of the plan?
special terms that apply.
If you break any terms of the plan that we reasonably consider to be
Your membership certificate is proof of your cover under the plan. fundamental, we may do one or more of the following:
 refuse to pay any of your claims;
Renewal  recover from you any loss caused by the break;
At the end of each plan year, we will contact the company to tell them the  refuse to renew your membership to the plan;
terms the plan will continue on if the plan is still available. We will renew the
 impose different terms to your cover on the plan;
plan on the new terms unless the company asks us to make changes or tells
us they wish to cancel. You will be bound by those terms.  end your membership of the plan and all cover immediately.
If you (or anyone acting on your behalf) claim knowing that the claim is false or
Providing us with information fraudulent, we can refuse to pay that claim and may declare your membership
of the plan void, as if it never existed. If we have already paid the claim we can
Whenever we ask you to give us information, you will make sure that all the
information you give us is sufficiently true, accurate and complete for us to be recover what we have paid from you.
able to work out the risk we are considering. If we later discover that it is not, we If we pay a claim and the claim is later found to be wholly or partly false or
can cancel your membership to the plan or apply different terms of cover in line fraudulent, we will be able to recover what we have paid from you.
with the terms we would have applied if the information had been presented to
us fairly.
Our right to refuse to add a family member

We can refuse to add a family member to the plan. We will tell the lead
member if we do this.

6 Legal information
International sanctions 6.2 > Our authorisation and regulation details

We will not do business with any individual or organisation that appears on an AXA PPP healthcare is authorised by the Prudential Regulation Authority and
economic sanctions list or is subject to similar restrictions from any other law or regulated by the Financial Conduct Authority (FCA) and the Prudential
regulation. This includes sanction lists, laws and regulations of the European Regulation Authority.
Union, United Kingdom, United States of America or under a United Nations
The FCA sets out regulations for the sale and administration of general
resolution. We will immediately end cover and stop paying claims on the plan if
insurance. We must follow these regulations when we deal with you.
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 Our financial services register number is 202947.
you have permission from a relevant authority to continue cover or subscription You can check details of our registration on the FCA website: fca.org.uk
payments under a plan. In this case, we can cancel your membership of the
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 6.3 > The Financial Services Compensation Scheme (FSCS)
list or subject to similar restrictions you must let us know within 7 days of finding
AXA PPP healthcare is a participant in the Financial Services Compensation
this out.
Scheme (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
What happens if the company agreement ends? contracts of insurance. It may do this by:
If the company agreement ends, you can apply to transfer to another plan.  providing financial assistance to the insurer
 transferring policies to another insurer
Legal rights  paying compensation.
Each family member may make individual claims under the plan, which may The Scheme was established under the Financial Services and Markets Act
be without the knowledge of the lead member in accordance with our approach 2000 and is administered by the Financial Services Compensation Scheme
to personal data. Only the company and we have legal rights under this plan. Limited. You can find more information about the scheme on the FSCS website:
No clause or term of this plan will be enforceable, by virtue of the Contract fscs.org.uk.
(Rights of Third Parties) Act 1999, by any other person, including the lead
member and any family member.
The lead member is liable for excesses and any shortfalls incurred by a family 6.4 > Your personal information
member under the plan. Here is a summary of the data privacy notice that you can find on our website
axappphealthcare.co.uk/privacynotice.
Law applying to the plan Please make sure that everyone covered by the plan reads this summary and
The law of England and Wales will apply to the plan. the full data privacy notice on our website. If you would like a copy of the full
notice, call us on 0800 051 8019 and we’ll send you one.
Language for your plan We want to reassure you we never sell personal member information to third
We will use English for all information and communications about the plan. 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.

6 Legal information
We get information about you and your family members who are covered by 6.6 > What to do if your claim relates to an injury or medical
the plan. This information can be provided by you, those family members, your
healthcare providers, your employer, your employer’s intermediary (if they have
condition that was caused or contributed to by another person
one) and third party suppliers of information, for example on-line shopping You must tell us as quickly as possible if you believe someone else or
surveys. something (i.e. a third party) contributed to or caused the need for your
treatment, such as a road traffic accident, an injury or potential clinical
We process your information mainly for managing your membership and claims,
negligence.
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 This does not change the benefits you can claim under your plan (your “Claim”)
processing because it helps us run our business, such as research, finding out and also means that you can potentially be repaid for any costs you paid
more about you, statistical analysis, for example to help us decide on premiums yourself, such as your excess or if you paid for private treatment that wasn’t
and marketing. covered by your plan. Where appropriate, we will pay our share of the Claim
and recover what we pay from the third party.
We may disclose your information to other people or organisations. For
example we’ll do this to: Where you bring a claim against a third party (a “Third Party Claim”), you (or
 manage your claims, e.g. to deal with your doctors; your representatives) must:
 manage the scheme with your employer or their intermediary;  include all amounts paid by us for treatment relating to your Third Party
 help us prevent and detect crime and medical malpractice by talking to Claim (our “Outlay’) against the third party;
other insurers and relevant agencies; and
 include interest on our Outlay at 8% p.a.;
 allow other AXA companies in the UK to contact you if you have
agreed.  keep us fully informed on the progress of your Third Party Claim and any
action against the third party or any pre-action matters;
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  agree any proposed reduction to our Outlay and interest with us prior to
your plan properly. settlement. If no such agreement has been sought we retain the right to
recover 100% of our Outlay and interest directly from you;
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  repay any recovery of our Outlay and interest from the third party directly to
marketing communications. You can also ask us for a copy of information we us within 21 days of settlement;
hold about you and ask us to correct information that is wrong.  provide us with details of any settlement in full.
If you want to ask to exercise any of your rights just call us on 0800 051 8019 or In the event you recover our Outlay and interest and do not repay us this
write to us. recovered amount in full we will be entitled to recover from you what you owe us
and your plan may be cancelled in accordance with ‘What happens if you break
the terms of your plan’.
6.5 > What to do if somebody else is responsible for part of the Even if you decide not to make a claim against a third party for the recovery of
cost of your claim damages we retain the right (at our own expense) to make a claim in your name
You must tell us if you are able to recover any part of your claim from any other against the third party for our Outlay and interest. You must co-operate with all
party. Other parties would include: reasonable requests in this respect.
 an insurer that you have another insurance policy with The rights and remedies in this clause are in addition to and not instead of
 a state healthcare system rights or remedies provided by law.
 a third party that has a legal responsibility or liability to pay. We will pay our If you have any questions please call 0800 051 8019 and ask for the Third Party
proper share of the claim. Recovery team.

7 Glossary Certain terms in this handbook have specific meanings. The
terms and their meanings are listed in this glossary.
Where we’ve highlighted these terms in bold they have a
specific meaning.
 The terms marked with this symbol have meanings that
are agreed by the Association of British Insurers.
These meanings are used by most medical insurers.
Page 45
7 Glossary
acupuncturist – a medical practitioner who specialises in acupuncture who is day-patient unit – a medical unit where day-patient treatment is carried out.
registered under the relevant Act or a practitioner of acupuncture who is a
member of the British Acupuncture Council (BAcC); and who, in all cases, diagnostic tests  – investigations, such as x-rays or blood tests, to find or to
meets our criteria for acupuncturist recognition for benefit purposes in their field help to find the cause of your symptoms.
of practice, and who we have told in writing that we currently recognise them as
an acupuncturist for benefit purposes in that field for the provision of out- evacuation or repatriation service – moving you to another hospital which
patient treatment only. has the necessary medical facilities either in the country where you are taken ill
The full criteria w e use w hen recognising m edical practitioners are available on or in another nearby country (evacuation) or bringing you back to the UK
request (repatriation). The service includes immediate emergency in-patient treatment
received while travelling abroad, when it immediately precedes or immedi ately
acute condition  – a disease, illness or injury that is likely to respond quickly follows an evacuation or repatriation we have arranged for you, and any
to treatment which aims to return you to the state of health you were in necessary treatment administered by the international assistance company
immediately before suffering the disease, illness or injury, or which leads to your appointed by us whilst they are moving you.
full recovery. external prosthesis - an artificial, removable replacement for a part of the
body.
appointed doctor – a medical practitioner chosen by us to advise us on your
medical condition and need for the evacuation or repatriation service. facility – a private hospital, or unit a centre we have chosen to provide you
with treatment.
cancer  – a malignant tumour, tissues or cells, characterised by the
Some facilities may have arrangements with other establishments to provide
uncontrolled growth and spread of malignant cells and invasion of tissue. treatment.
chronic condition  – a disease, illness or injury that has one or more of the family member – 1) the lead member’s current spouse or civil partner or any
following characteristics: person living permanently in a similar relationship with the lead member; and 2)
 it needs ongoing or long-term monitoring through consultations, examinations, any of their or the lead member’s children.
check-ups and/or tests
Children can stay on the plan up to the age of 25.
 it needs ongoing or long-term control or relief of symptoms
Children will come off the plan at the renewal date following their birthday.
 it requires your rehabilitation or for you to be specially trained to cope with it
 it continues indefinitely GP – a general practitioner on the General Medical Council (GMC) GP register.
 it has no known cure We will only accept referrals from your NHS GP practice unless your company
 it comes back or is likely to come back. provides access to an alternative GP service. In this case we will accept
referrals from the alternative GP service under your company’s arrangement.
company – the company that pays for the group membership that your plan is
part of.
day-patient  – a patient who is admitted to a hospital or day-patient unit

because they need a period of medically supervised recovery, but does not
occupy a bed overnight.

7 Glossary
homeopath – a medical practitioner with full registration under the Medical practitioner – a dietician, nurse, orthoptist, psychotherapist, psychologist or
Acts, who specialises in homeopathy who is registered under the relevant Act or speech therapist that we have recognised. We will pay for treatment by a
a practitioner of homeopathy who holds full membership of the Faculty of practitioner if both the following apply:
Homeopathy is registered with the Faculty of Homeopathy; and who, in all  a specialist refers you to them
cases, meets our criteria for homeopath recognition for benefit purposes in their
 the treatment is as an out-patient.
field of practice, and who we have told in writing that we currently recognise
them as a homeopath for benefit purposes in that field for the provision of out- If the treatment is as an in-patient or day-patient, that treatment will be
patient treatment only. included as part of your private hospital charges.
The full criteria w e use w hen recognising m edical practitioners are available on The full criteria w e use w hen recognising practitioners are available on request
request
private hospital – a hospital we have chosen to provide your treatment.
in-patient  – a patient who is admitted to hospital and who occupies a bed
overnight or longer, for medical reasons. scanning centre – a centre where out-patient CT (computerised tomography),
MRI (magnetic resonance imaging) and PET (positron emission tomography) is
lead member – the first person named on your membership certificate. carried out.
medical condition – any disease, illness or injury, including psychiatric illness. specialist – a medical practitioner who meets all of the following conditions:
 has specialist training in an area of medicine, such as training as a consultant
nurse  – a qualified nurse who is on the register of the Nursing and Midwifery surgeon, consultant anaesthetist, consultant physician or consultant
Council (NMC) and holds a valid NMC personal identification number. psychiatrist
 is fully registered under the Medical Acts
out-patient  – a patient who attends a hospital, consulting room, or out-patient
 is recognised by us as a specialist.
clinic and is not admitted as a day-patient or an in-patient.
The definition of a specialist who we recognise for out-patient treatment only
plan – the insurance contract between the company and us. The full terms of is widened to include those who meet all of the following conditions:
the plan are set out in the latest versions of:  specialise in musculoskeletal medicine, sports medicine, psychosexual
 the company agreement medicine or podiatric surgery
 any application form we ask you to fill in  is fully registered under the Medical Acts
 this handbook  is recognised by us as a specialist.
 your membership certificate and our letter of acceptance. The full criteria w e use w hen recognising specialists are available on request.
surgery/surgical procedure – an operation or other invasive surgical

intervention listed in the schedule of procedures and fees.
terrorist act – any act 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.

7 Glossary
therapist – a medical practitioner who meets all of the following conditions:

 is a practitioner in physiotherapy, osteopathy, chiropractic, treatment
 is fully registered under the relevant Acts
 is recognised by us as a therapist for out-patient treatment.
The full criteria w e use w hen recognising medical practitioners are available
on request.
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.
year – the 12 months from the plan start date or last renewal date. However,
the company agreement may amend the period of cover to something different.
If this happens, you should be informed by your company.

Claims and queries
including Working Body and Stronger Minds
0800 051 8019
If you’re leaving your employer

0800 028 2915
Your membership documents are available in other formats.
If you would like a Braille, large print or audio version, please contact us.
PB67767a/12.18 HCCM 42264 Digital
This private medical insurance plan is underwritten by AXA PPP healthcare Limited
AXA PPP healthcare Limited Registered Office: 5 Old Broad Street, London, EC2N 1AD, United Kingdom.
AXA PPP healthcare, Phillips House, Crescent Road, Tunbridge Wells, Kent TN1 2PL AXA PPP healthcare Limited.
Registered Office: 5 Old Broad Street, London, EC2N 1AD, United Kingdom. Registered in England No. 3148119 © AXA PPP healthcare 2018. AXA PPP healthcare is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct
Authority and the Prudential Regulation Authority. We may record and/or monitor calls for quality assurance, training and as a record of our conversation

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Convergys Emea Ltd

Healthcare insurance plan

Advance membership handbook Page 3

1.1 > Your benefits

Words and phrases in bold type

You and your

We, us and our

1.1 > Your benefits

If you’re an in-patient or day-patient

Advance membership handbook Page 5

Advance membership handbook Page 6

Mental Health - If you’re an out-patient

Advance membership handbook Page 7

Advance membership handbook Page 8

Cancer cover and care

Advance membership handbook Page 9

1.2 > The main things we don’t cover

Does my membership mean I don’t need to use the NHS?

Your plan does not cover For more information Notes

Advance membership handbook Page 10

> Mental health concerns

> Claiming for other conditions

> Expert Help

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Working Body Stronger Minds

Advance membership handbook Page 12

Making a claim for all other conditions

Advance membership handbook Page 13

Support from our Dedicated Nurse

3.2 > Looking at who should provide treatment

3.3 > Eligible treatment

3.4 > Our cover for treatment and surgery

3.5 > How your membership works with pre-existing

3.6 > How your membership works with conditions

3.7 > Paying the specialists and practitioners that

membership works 3.9 > General restrictions

Please read all of your handbook

Advance membership handbook Page 16

Advance membership handbook Page 17

Advance membership handbook Page 18

What if you didn’t tell us about a condition, symptom or treatment you

Advance membership handbook Page 19

Advance membership handbook Page 20

Acupuncturists and homeopaths  physiotherapy

Where can I have out-patient treatment?

Advance membership handbook Page 21

What about treatment on the NHS?

Does the plan cover payment for treatment anywhere else?

3.9 > General restrictions

Consultations within 10 days of treatment

Treatment and referrals by family members

Advance membership handbook Page 22

4.1 > Cancer 4.18 > Learning and developmental disorders

Advance membership handbook Page 24

4.38 > Weight loss treatment

About your cover for cancer treatment

Experienced and dedicated nurses and case managers

Advance membership handbook Page 25

Place of treatment Am I covered?