Your guide to Bupa Premier Network SECI Operatives Scheme. Effective from 1 September 2008

Transcription

1 Effective from 1 September 2008 Your guide to Bupa Premier Network SECI Operatives Scheme This is page 1 of 8 which should be read together in full. These pages are for the summary of your Bupa membership for the SECI Operatives Scheme from 1 September

2 SELECT Bupa helpline lines are open 9am to 5pm Monday to Friday. Welcome to Bupa Welcome to SECI Operatives Scheme s Bupa private medical insurance, which aims to fund medical treatment. SELECT together with Bupa, has carefully chosen this scheme to provide you with the reassurance and benefits of Bupa cover. This is page 2 of 8 which should be read together in full. These pages are for the summary of your Bupa membership for the SECI Operatives Scheme from 1 September

3 Summary of cover and benefits The type of treatment covered You are only covered for eligible treatment. By this we mean treatment of an acute condition together with the products and equipment used as part of the treatment that: are consistent with generally accepted standards of medical practice and representative of best practices in the medical profession in the UK are clinically appropriate in terms of type, frequency, extent, duration and the facility or location where the services are provided are demonstrated through scientific evidence to be effective in improving health outcomes, and are not provided or used primarily for the expediency of you or your consultant or other healthcare professional and the treatment, services or charges are not excluded under the terms and conditions of the agreement between SELECT and Bupa. Treatment must be on the initial referral of your GP. The consultant in overall charge of your treatment must be a Bupa recognised consultant. Bupa recognised practitioners and facilities Your cover depends on you using certain Bupa recognised medical practitioners and treatment facilities. Who you use can affect the level of benefits you are covered for. Also, they may only be recognised by us for certain types of treatment or levels of benefits. The type of treatment and/or level of benefit that we recognise them for can change from time to time. What is not covered There are certain medical conditions and treatments that you are not covered for. There are some exceptions to the exclusions. Further details are available from the helpline although you may need to contact SELECT for full details. The excluded medical conditions and treatments include: treatment for ageing, menopause and puberty; AIDS/ HIV; allergies; birth control, conception, sexual problems or sex changes; chronic conditions; complications from excluded conditions; treatment resulting from contamination, wars, riots or terrorist acts; convalescence care, rehabilitation or general nursing care; cosmetic, reconstructive or weight loss treatment; treatment for deafness or to correct eyesight; dental or oral treatment; dialysis; experimental drugs and treatment; HRT and bone densitometry; intensive care (other than routinely needed after private day-patient treatment or in patient treatment); learning difficulties, behavioural and developmental problems; pregnancy and childbirth; screening and preventive treatment; sleep problems and disorders; speech disorders; temporary relief of symptoms; out-patient drugs and dressings; physical aids and appliances; overseas emergency treatment and repatriation. This is page 3 of 8 which should be read together in full. These pages are for the summary of your Bupa membership for the SECI Operatives Scheme from 1 September

4 Summary of cover table for the SECI Operatives Scheme benefits maximum benefit available notes When you are not admitted to hospital out-patient consultations and treatment out-patient consultations with a consultant out-patient therapies and complementary medicine on GP or consultant referral hospital charges for out-patient tests and investigations on consultant referral up to a total of 750 each year - this limit includes 250 for complementary medicine treatment with a scheme recognised consultant with a scheme recognised therapist or complementary medicine practitioner (acupuncture, chiropractic, homoeopathy and osteopathy only) out-patient MRI, CT and PET scans on consultant referral paid in full in a scheme recognised imaging centre for the type of scan you need When you are admitted to hospital out-patient surgical operations, day-patient or in-patient treatment consultants fees for medical and surgical hospital treatment paid in full with a Bupa partnership consultant and in a partnership network hospital - benefit limits apply for Bupa recognised non-partnership consultants hospital charges for: accommodation, theatre charges, nursing care, drugs and surgical dressings, intensive care, diagnostic tests and MRI, CT and PET scans, therapies, prostheses and appliances parent accommodation paid in full in a partnership network hospital and for intensive care in a scheme recognised critical care unit; a list of the prostheses and appliances covered is available on request one parent only, accompanying a child under 12 who is a member of the scheme and receiving eligible in-patient treatment treatment at home discretionary benefit with a scheme recognised medical treatment provider - call the SELECT Bupa helpline for details This is page 4 of 8 which should be read together in full. These pages are for the summary of your Bupa membership for the SECI Operatives Scheme from 1 September

5 benefits Additional benefits private ambulance maximum benefit available 320 each year - maximum 80 any single trip notes when medically necessary and related to private eligible day-patient or in-patient treatment home nursing 600 each year when immediately following private eligible in-patient treatment NHS cash benefit 50 a night for 35 nights a year for NHS hospital in-patient treatment that would otherwise be covered under the scheme pregnancy cash benefit 75 when your pregnancy has reached 28 weeks We pay pregnancy cash benefit to female members who have been in continuous membership of the scheme for 10 months before their pregnancy started. We pay a pregnancy cash benefit of 75 when your pregnancy has reached 28 weeks. To claim this benefit please send us your claim form together with a medical certificate stating that your pregnancy has reached 28 weeks. Benefits for specific medical conditions cancer treatment as for other treatment set out in this table except for: out-patient consultations with a consultant out-patient therapies and complementary medicine on GP or consultant referral hospital charges for out-patient tests and investigations on consultant referral out-patient MRI, CT and PET scans on consultant referral hospital charges and consultants fees for bone marrow and stem cell transplants paid in full with a scheme recognised consultant with a scheme recognised therapist or complementary medicine practitioner (acupuncture, chiropractic, homoeopathy and osteopathy only) in a scheme recognised imaging centre for the type of scan you need with a Bupa partnership consultant and in a specialist treatment centre benefit limits apply for Bupa recognised non-partnership consultants consultant oncologists fees for chemotherapy and radiotherapy hospital charges for out-patient cancer drugs with a Bupa partnership consultant in a partnership network hospital or specialist treatment centre benefit limits apply for Bupa recognised non-partnership consultants in a partnership network hospital or specialist treatment centre psychiatric treatment discretionary benefit call the SELECT Bupa helpline for details Excess An excess of 150 applies each year to each person covered under the scheme. You are responsible for paying your excess. Call the SELECT Bupa helpline to confirm how the excess works and how it affects your benefits. This is page 5 of 8 which should be read together in full. These pages are for the summary of your Bupa membership for the SECI Operatives Scheme from 1 September

6 What to do if you need treatment Always call the SELECT Bupa helpline before arranging any consultations or treatment to check your cover and the benefits available to you. Also, should you have any queries about your treatment they can offer you the opportunity to speak to a nurse working in Bupa s care management team. SELECT Bupa helpline number: lines are open 9am to 5pm Monday to Friday. Once you have called the SELECT Bupa helpline and your Scheme Group Secretary has verified your membership, Bupa will then contact you directly to arrange your consultation or treatment. In order to facilitate the process, please have the answers to the following questions to hand: what condition are you suffering from? what treatment has been recommended? on what date will you receive the treatment? where will your proposed treatment take place? will you need to stay in hospital? If so, for how long? what is the name of the consultant or other healthcare practitioner? Bupa HealthLine As a Bupa member if you have any queries or questions about your health, call our confidential 24 hour Bupa HealthLine where our qualified nursing team have the time to listen and the skills to help, whatever your health question or concern. Call the Bupa HealthLine on * Calls may be recorded and to maintain the quality of our Bupa HealthLine service a nursing manager may monitor some calls always respecting the confidentiality of the call. * BT landline calls to 0845 numbers will cost no more than 3.95 pence per minute. Charges from other providers may vary and calls from mobiles usually cost more. This is page 6 of 8 which should be read together in full. These pages are for the summary of your Bupa membership for the SECI Operatives Scheme from 1 September

7 Steps to making a claim 1 If your GP refers you for a consultation or treatment Explain you are a Bupa member. If you need to see a consultant ask your GP to refer you to a Bupa recognised consultant who charges within Bupa benefit limits and who has admitting rights to a Bupa partnership network hospital. The rules and benefits explain about partnership consultants, non-partnership consultants and partnership network hospitals or you can call the SELECT Bupa helpline and we will explain. If you need to see a therapist or complementary medicine practitioner ask your GP to refer you to a Bupa recognised practitioner. The rules and benefits explain why this is important for you or you can call the SELECT Bupa helpline and we will explain. 2 Call the SELECT Bupa helpline , lines are open 9am to 5pm Monday to Friday When you call the SELECT Bupa helpline we will verify your membership and refer you to Bupa who will confirm whether: your consultant, therapist or complementary medicine practitioner is recognised by Bupa your proposed treatment is covered and the benefits available to you you need a claim form in some cases you may not need to complete a claim form and we will tell you about this when you call us. 3 When you see the consultant, therapist or complementary medicine practitioner Show them your membership details (see rule 1.1 The agreement between the sponsor and us in Your membership guide, or call the SELECT Bupa helpline and we will explain). 4a If your consultant recommends out-patient diagnostic tests or treatment Call the SELECT Bupa helpline and your details will be referred to Bupa who will confirm whether the tests and/or treatment are covered under your membership and the benefits available to you. 4b If your consultant recommends day-patient or in-patient treatment Call the SELECT Bupa helpline and your details will be referred to Bupa who will: confirm whether your treatment is covered and the benefits available to you help you choose a partnership network hospital in your area. 5 When you go into hospital Take your membership details with you. 6 When you leave hospital Settle any personal expenses such as newspapers, phone calls or guest meals. We will settle the medical and hospital bills covered under your membership. 7 If your consultant recommends home nursing or out-patient treatment after your hospital stay Call the SELECT Bupa helpline and your details will be referred to Bupa who will confirm your cover and the benefits available to you. This is page 7 of 8 which should be read together in full. These pages are for the summary of your Bupa membership for the SECI Operatives Scheme from 1 September

8 Important information Your cover is provided under an agreement between SELECT and Bupa Insurance Limited and is subject to the terms and conditions of that agreement. There is no contractual agreement between you and Bupa covering your membership. Only SELECT and Bupa have legal rights under the agreement, although we will allow anyone covered under the agreement access to our complaints process. These pages only contain a brief summary of the SECI Operatives Scheme Changes to the scheme may have been agreed between SELECT and Bupa under the agreement. If any changes do apply they could affect for example the amount and type of benefits payable and/or the exclusions set out in these summary pages. Also, the agreement is an annual one and the terms of your cover may change from time to time particularly at renewal. The SELECT Bupa helpline can provide further details, although you may need to contact SELECT for full details of the cover under the agreement. If you have cause for complaint The SELECT Bupa helpline is always the first number to call if you have a complaint. If they are unable to resolve the problem you can contact Bupa s Customer Relations Department: call ,* lines are open 8am - 5pm, Monday to Friday, or write to: Bupa, Anchorage Quay, Salford Quays M50 3XL. They will consider your complaint and can provide you with full details of our internal complaints process. It s very rare that we can t settle a complaint, but if this does happen, you may refer your complaint to the Financial Ombudsman Service: call or write to South Quay Plaza, 183 Marsh Wall, London E14 9SR. The Financial Services Compensation Scheme (FSCS) In the unlikely event that we cannot meet our financial obligations, you may be entitled to compensation from the Financial Services Compensation Scheme. This will depend on the type of business and the circumstances of your claim. The FSCS may arrange to transfer your policy to another insurer, provide a new policy or, where appropriate, provide compensation. The first 2,000 of any claim paid by the FSCS would be met in full and above this amount, 90 percent of the remainder will be met. Further information about compensation scheme arrangements is available from the FSCS on or on its website Bupa Data Protection Notice Confidentiality: The confidentiality of patient and member information is of paramount concern to the companies in the Bupa group. To this end, Bupa fully complies with Data Protection Legislation and Medical Confidentiality Guidelines. Bupa sometimes uses third parties to process data on its behalf. Such processing, which may be outside of the European Economic Area, is subject to contractual restrictions with regard to confidentiality and security in addition to the obligations imposed by the Data Protection Act. Medical Information: Medical information will be kept confidential. It will only be disclosed to those involved with your treatment or care, including your GP, or to their agents, and, if applicable, to any person or organisation who may be responsible for meeting your treatment expenses, or their agents. Member details: All membership documents and confirmation of how we have dealt with any claim you may make will be sent to the main member. Telephone calls: In the interest of continuously improving our service to members, your call may be recorded and may be monitored. Research: Anonymised or aggregated data may be used by Bupa, or disclosed to others, for research or statistical purposes. Fraud: Information may be disclosed to others with a view to preventing fraudulent or improper claims. Names and Addresses: Bupa does not make the names and addresses of members or patients available to other organisations. Keeping you informed: Bupa would, on occasion, like to keep you informed about the Bupa products and services which it considers may be of interest to you. Contact Address: If you have any Data Protection queries please write to the Bupa Group Information Protection Manager, at Bupa House, Bloomsbury Way, London WC1A 2BA or at DataProtection@Bupa.com. * BT landline calls to 0845 numbers will cost no more than 3.95 pence per minute. Charges from other providers may vary and calls from mobiles usually cost more. Calls may be recorded and may be monitored. Bupa Premier Network is provided by Bupa Insurance Limited. Registered in England and Wales No # Bupa Insurance Services Limited. Registered in England and Wales No # Registered Office Bupa House Bloomsbury Way London WC1A 2BA #Authorised and regulated by the Financial Services Authority Bupa Bupa and the heartbeat symbol are trade marks of The British United Provident Association Limited. This is page 8 of 8 which should be read together in full. These pages are for the summary of your Bupa membership for the SECI Operatives Scheme from 1 September SECI Operatives Scheme/PNNU/500N/CE/JAN05-L/ UNI