2236869 bby pmi membership guide

7/31/2019 2236869 BBY PMI Membership Guide

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Bup By you

Yi G id


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A i Gid

Welcome to your upa membershp gue.

At upa, we ow that surace ca be har to follow. hats why weve mae

ths gue as smple as possble. Youll f vual chapters that eal wth each

aspect of your Bupa By You cover, clug a step-by-step gue to mag a clam.

lease mae sure that you eep ths gue somewhere safe. Youll ee t whe you

come to clam.

if ay of the terms or laguage use leaves you cofuse ot worry. here s

a glossary o page 41 you ca refer to, where youll f clear eftos of wors

that are c the text. f course you ca always call the upa elple

o 0845 60 90 777 f you ee help to uersta your cover.

W d i knW W A i d ?

hs gue clues etals of all of the optos avalable wth Bupa By You, ot

all of whch wll be relevat to you. he precse etals of the vual cover

optos you have chose are lste your membershp certfcate. lease rea

ths membershp gue together wth your membershp certfcate, as together

they set out full etals of how your health surace wors.

W d iGid W k Wi Y i i i A?

Your certfcate explas the beefts avalable to you a also proves a seres

of otes that correspo to the relevat secto of the membershp gue (where

you wll f a more etale explaato of the beeft your vual polcy).

nA

Were always o ha to help.

or queres about your cover call our ecate elple o 0845 60 90 777.

or those wth hearg or speech ffcultes who use a textphoe, call us o

0845 606 6863. r wrte to us at upa, alfor Quays, achester, 50 3XL.

A ALLin

if you have ay questos or worres about your health, call our cofetal upa

ealthLe o 0845 601 3216. ur qualfe ursg team s o ha 24 hours

a ay, so whatever your health questo or cocer, they have the slls a

practcal, professoal experece to help.

alls may be recore a motore.

nnA A GLA n

2. Claiming p.9

2.1 ag a clam p.11

2.2 ow we wll eal wth your clam p.12

2.3 if you wat to wthraw a clam p.13

2.4 x-grata paymets p.14

2.5 if you have a excess p.14

3. Benefits: what ae cvee f p.15

rompt dagoss p.18

reatmet a are p.20

omprehesve p.22

A os p.29

Ba B y Effective fm 1 Jana 2012

4. What ae nt cvee f p.32

6. ptecting ata p.49

5. Glssa p.41

1. Hw membeshi wks p.3

1.1 he agreemet a your membershp ocumets p.4

1.2 aymet of beefts p.4

1.3 Whe your membershp starts, reews a es p.4

1.4 ag chages p.7

1.5 Geeral formato p.7

1.6 ag a complat p.8

TIP:

Cross-CheCk the

benefits listed in

your membership

CertifiCate with the

relevant paragraphs

in the guide to make

sur e t hat you have the

Cover that you want.

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he etals of your

Bupa By You cover are

ths membershp gue. i

ths frst secto youll f

explaatos of how your

beefts wll be pa, alog

wth formato o how

your polcy wors, how to

mae chages as well as

how to cacel or reew your

membershp.

As always, f theres aythg

that you ot uersta or

we ca help you wth, please

ot hestate to get touch.

1 . W Yi Wk

Important note please read this section before you read the rest of this

membership guide as it explains how this membership guide and your

membership certificate work together.

hs Bupa By You membershp gue a your cc

together set out full etals of your . hey shoul ot be rea as

separate ocumets.

if you have ravel a mergecy ecal over as part of your Bupa By You

c the etals of that cover are ot clue ths membershp gue.

You wll have a separate Bupa By You ravel a mergecy ecal over

membershp gue, whch explas those .

hs membershp gue s a geerc gue. it cotas the geeral membershp

terms that apply to all Bupa By You members. You may ot have all the cover

set out ths membershp gue. it s your cc that

shows the cover that s specfc to your . Ay elemets of cover ths

membershp gue that are ether:

o show your cc as ot covere or

o o ot appear your cc

you are ot covere for a you shoul therefore gore them whe reag

ths membershp gue. if you are covere, the beefts a the amouts pay

are show o your cc. Your cc coul

also show some chages to the terms of cover set out ths membershp gue

partcularly the further etals secto of your cc.

Whe reag ths membershp gue a your cc, t

s your cc whch s persoal to you. hs meas that f

your cc cotracts ths membershp gue t s your

cc that wll tae prorty.

Always call the helple f you are usure of your cover.

Ba B y: y les an benefits

hs membershp gue sets out the geeral terms a cotos of your

Bupa By You cover effectve from 1 Jauary 2012.

o or ayoe jog Bupa By You after the effectve from ate the membershp

gue apples from ther .

o or ayoe whose membershp of Bupa By You s reewe o or after the

effectve from ate t apples from ther .

Wors a phrases c ths membershp gue are efe terms

whch have a specfc meag. You shoul chec ther meag the glossary. lease

ote that Bupa By You s show throughout italics. hs s ot a efe term but s

italics to show that t s the offcal ame of the cover you have bought.

ou do find any

ms or phrases

t youre unsure

why not CheCk

glossary on

e 40.

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1.1 THE GrEEET d your EBErHp doCuET

The ageement between an s

i retur for payg subscrptos, agree to prove a

(f ay) wth cover uer the terms of our .

ly a b have legal rghts uer our , although wll stll allow

ayoe who s covere uermembershp complete access to our complats process

(see ag a complat secto 1.6).

The cments that make ageement

he followg ocumets together mae up the . hese ocumets must be rea

together as a whole, they shoul ot be rea as separate ocumets.

1.The Bupa By You embeshi Gie: ths sets out the geeral terms a cotos of

membershp (a ay exclusos) a all the elemets of cover that ca be prove

uer your Bupa By Youc.

2. y membeshi cetificate: ths shows the cover that you have chose, clug the

lmts that apply, ay varatos to the beefts, terms or cotos explae ths

membershp gue a whether a xc apples to your cover a f t oes the amout

a how t apples.

3.y alicatin f cve: ths clues ay quote request, applcatos for cover for

a (f ay) a the eclaratos that mae urg the applcato

process, clug the aswers prove omecal hstory a that of

(f ay).

4. Where or (f ay) have ravel a mergecy ecal over

clue ther , the Bupa By YouTavel an Emegenc eical Cve

embeshi Gie.

1.2 pyET o BEET

w oly pay for that you receve, or the that you are ettle to, whle

you are covere uer the a oly pay accorace wth the .

w also oly pay the that apple to you o the ate you receve your

or the ate that you became ettle to those a oly relato to you

receve the uk.

Whe you receve prvate mecal treatmet you have a cotract wth the provers of

your . You are resposble for the costs you cur havg prvate .

owever, f your s pay the costs that are covere uer

your . Ay costs, clug costs, that are ot covere uer your

are your sole resposblty.

i may cases have arragemets wth provers about how much they charge

members for a how pay them. or costs covere uer your

wll, most cases, pay the prover of your rect such as thec cor c. We wll wrte to tell the ma member how we have ealt

wth ay clam.

Please also see the section Claiming.

1.3 WHE your EBErHp TrT, rEEW d Ed

tating membeshi

ycover starts o .

y cover starts o ther . y a

() may ot be the same.

y ight t cancel

y may cacelmembershp for ay reaso by wrtg to wth 21 ays of recevg

the frst membershp certfcate se eachcofrmg cover. As log as

have ot mae ay clams wll refu all ofsubscrptos for thata ay

sums have pa for future years.

y may cacel ay of membershp for ay reaso by wrtg to wth

21 ays of recevg the frst membershp certfcate se eachcofrmg ther

cover. As log as o clams have bee mae respect of ther cover wll refu all

subscrptos pa respect of that cover for thata ay sums pa

respect of that for future years.

renewing membeshi

os a aual oe a your membershp must be reewe eacho your

, subject to the ag chages secto.

Your membershp wll reew automatcally as log as cotue to pay

subscrptos a ay other charges uless:

o ece to e your membershp

o ece to e the Bupa By You scheme; or

o f your cover s arrage by a , o ot agree tomembershp or

the membershp of ay of reewg.

if ece to e thec or fcover s arrage by a a o

ot agree tomembershp or the membershp of reewg, wll

wrte to let ow at least 28 ays before .

Hw membeshi can en

y ca emembershp or the membershp of ay of at ay tme.

if wat to emembershp or that of must wrte to .

ifmembershp es the membershp of all wll also e.

ymembershp a that of wll automatcally e f:

o o ot reew your membershp

o o ot paysubscrptos or ay other paymet you have to mae respect

of the cover, o or before the ate they are ue

o stop lvg the uk( must form f stop lvg the uk)

o e; or

o ece to e thec.

y membershp wll automatcally e f:

o membershp es

o o ot reew ther membershp

o that stops lvg the uk( must tell f ay stops lvg

the uk)

o that es; or

o ece to e thec.

i ato, f your have the ealth xpeses over A o that cover wll e

automatcally:

o fmembershp es

o whe that reaches 18 years of age (or 21 years of age f they are full tme

eucato)

o f that s 18 years of age or over a ceases to be full tme eucato

( must tell f ths happes)

o f that stops lvg ataress ( must tell f ths happes).

ifmembershp of thec s base o you beg ether:

o employe by the ; or

o a member of the

a the has agree wth thatmembershp a that of

wll e f:

o cease to be employe by the ; or

o cease to be a member of the

as applcable, wll emembershp of thec at the e of the moth whch

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are avse or eterme that are o loger employe by, or a member of, that

.

y shoul callhelple to cofrm f yourc s arrage by a .

w ca e a persos membershp f there s reasoable evece that or they msle

or attempte to o so. y ths mea, gvg false formato or eepg ecessary

formato from , ether tetoally or carelessly, whch may fluece whe ecg:

o whether or ot wll prove cover for them

o whether have to pay ay clam

Jining anthe Ba scheme

if ece to close the scheme, or f your cover s arrage by a a

o ot agree tomembershp beg reewe, may offer the opportuty to

jo aother b health surace scheme o the bass of the terms a cotos of the

ew scheme that offer. if are a a trasfer wth oe

moth wll ot a ayc c tomembershp or that of ay of

, f they are , uer the ew scheme other tha those

that apply uer ths scheme.

if your membershp es for ay other reaso, or ot offer you a opportuty to jo

aother b health surace scheme o the bass explae above, you may apply to jo

aother b health surace scheme. You may oly o ths as log as your membershp

t e because you msle or attempte to mslea . w wll coser your applcato

at sole screto.

paing sbscitins an the chages

y must pay subscrptos to avace for a throughout

membershp. he amout must pay ametho of paymet are show o

paymet scheule.

ifcover s arrage by a a have agree wth your

thatsubscrptos are collecte by them a pa to obehalf (eg by payroll

eucto) the wll pay obehalf.

refn f sbscitins if membeshi ens

ifmembershp es for ay reaso wll refu ay subscrptos have pa

whch relate to a pero aftercover es.

if membershp es for ay reaso wll refu ay subscrptos

have pa respect of that whch relate to a pero after ther cover es.

Lw claims bns

i calculatg the subscrptos payable ext wll apply a low clams bous to

core health surace subscrptos base upo the value of the clams pa for a

by urg the 12-moth pero preceg calculato. if o

ot pay ay clams wth the calculato pero wll receve a bous to reuce ay

subscrpto ajustmet that s otherwse apple tosubscrptos. if pay a clam

for a , wll receve a crease ato to ay subscrpto

ajustmet that s otherwse apple.

As calculatesubscrptos pror to , wll assess all elgble

clams pa by for a :

o the frst 10 moths offrst, a

o for subsequet, moths 11 a 12 of the prevousplus moths 1 to 10 of

the curret.

lease ote that clams a may mae relato to ay of the

followg o ot cout as clams the assessmet of the low clams bous to be

apple tosubscrptos:

o A os (beefts A1 to A4)

o tess chec (beeft d3.1)

o n cash beeft (beefts 5.5 a 10); a

o ravel a mergecy ecal over.

1.4 G CHGE

Changes we can make

w ca chage the terms a cotos of the membershp at .

hese chages coul affect:

o how calculate subscrptos, the amout have to pay, how ofte pay them

a the metho of paymet (the cost of subscrptos has typcally rse hgher tha

the retal prce ex (i) over the same pero, but ths oes ot mea that they wll

crease by the same rate the future), a

o the amout a type of cover prove uer thec.

ifcover s arrage by a , at may also chage or

wthraw the amout of ay scout or preferetal rates.

w ca, at ay tme, chage the amout have to pay respect of isurace

remum ax (i) or ay other taxes, leves or charges that may be trouce a whch

are payable respect of your cover f there s a chage the rate of i or f ay such

taxes, leves or charges are trouce.

w wll ot a ayc c to someoes cover for mecal cotos that

starte after ther prove they gave all the formato ase for before

ther .

if o mae ay chages to the terms a cotos ofmembershp wll wrte to

tell at least 28 ays before the chage taes effect.

ifcover s arrage by a , may mae chages to the terms a

cotos ofmembershp o a f o ot accept ay of the

chages ca emembershp ether:

o wth 28 ays of the ate o whch the chage taes effect; or

o wth 28 ays of us tellg about the chage

whchever s later, a f o emembershp wth the 28 ays wll treat the

chages as ot havg bee mae.

Changes can make

At ca apply to:

o a, remove or chage a xc

o chage ay of the Bupa By You optos have chose.

w wll coserapplcato at sole screto. if apply to crease cover

uer thec may as to agree toc c before accept

applcato. hese chages may also affect the subscrptos have to pay.

othe aties

no other perso s allowe to mae or cofrm ay chages to your membershp or your

o behalf or ece ot to eforce ay of rghts. qually, o chage to your

membershp or your wll be val uless t s specfcally agree betwee the

a a cofrme wrtg.

1.5 GEErL orTo

Change f aess

yshoul call or wrte to tell fchagearess. ifo ot cotact to tell us

have chagearess a paysubscrptos by rect ebt,membershp

of thec wll automatcally e oext f caot cotact.

Cesnence an cments

All correspoece a membershp ocumets are set to the .

Whe se ocumets to , caot retur orgal ocumets to you. owever,

wll se copes f you as to o so at the tme you gve the ocumets. Letters

betwee us must be set wth the postage costs pa before postg. We ca each assume

that the letter wll be receve three ays after postg.

licable law

he s govere by glsh law.

TIP:

if youre unsure

if any Changes

aff eCt you r

Cover, Just give us

a C all and we ll

be happy to advise.

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1.6 G CopLT

if somethg has goe wrog, wat to o everythg ca to put t rght. eres a

smple proceure to esure your cocers are ealt wth as qucly a effectvely as

possble. if you have ay complats the helple s always the frst umber to call. y ca

f the helple umber a other cotact etals at the frot of ths gue. or members

wth specal ees offer a choce of ralle, large prt or auo for correspoece.

lease let ow whch you woul prefer.

if have ot bee able to resolve the problem a you wsh to tae your complat

further, you ca cotact ustomer elatos departmet. lease call: 0845 606 6739,

calls may be recore a may be motore.

r wrte to: upa, alfor Quays, achester, 50 3XL.

r cotact us va our webste at: www.ba.c.k/membes/membe-feeback

its very rare that cat settle a complat, but f ths oes happe, you may refer your

complat to the acal mbusma ervce. You ca wrte to them at: outh Quay

laza, 183 arsh Wall, Loo 14 9 or call them o 0800 023 4567. lease let us ow

f you wat a full copy of our complats proceure.

noe of these proceures affect your legal rghts.

The inancial evices Cmensatin cheme (C)

i the ulely evet that caot meet our facal oblgatos, you may be ettle to

compesato from the acal ervces ompesato cheme. hs wll epe o the

type of busess a the crcumstaces of your clam. he may arrage to trasfer your

polcy to aother surer, prove a ew polcy or, where approprate, prove compesato.

urther formato about compesato scheme arragemets s avalable from the

o 0800 678 1100 or 020 7741 4100 or o ts webste www.fscs.g.k

At a tme of ll health ths

secto wll prove ey

formato you wll ee

to clam.

Weve clue a smplestep-by-step gue to the

clams process, whch you

ca refer to for formato

o gettg a referral from

your G a how to chec

your treatmet costs wll

be covere.

2 . LAiinG

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TEp-By-TEp GudE To G CL

1. Visit Gpo he process starts wth a vst to your G.

Your G wll avse you f you ee to see a cosultat or he althcare professoal.

2. sk f a efeal letteo if you ee to see a cosultat, your G wll prove you wth a referral letter

whch wll etal the type of specalst your G woul le you to see.

o We recomme that you as for a ope referral letter whch wll etal the care

your G woul le you to have, but wll ot be aresse to a specfc cosultat,

hosptal or healthcare professoal. A ope referral letter ees to clue

your Gs assessmet of your symptoms, the boy area affecte a mecal

specalty requre.

o y obtag a ope referral we ca offer you greater flexblty a a choce of

cosultats, as well as help you to mae sure you avo ay extra costs (some

cosultats charge fees whch are outse our beeft lmts a f they o, you

may ee to pay some of the fees). Youll f a smple ope referral form for

your G to complete your membershp pac a atoal copes ca be

owloae from www.ba.c.k/en-efeal

o You ca of course as your G to suggest a sutable perso for you to see a

mae a ote of t separately to as us about. if your G oes wat to prove you

wth a referral to a specfc cosultat mae sure you cofrm wth us that they

charge wth our lmts to avo beg lable for ay uforesee costs.

3. Call so As soo as you have see your G, please call us so that we ca scuss your

optos a expla whch cosultats a healthcare professoals are covere

uer your upa membershp. We wll let you ow what you ee to o ext a

se you ay e cessary pre-treatmet forms you may ee to complete.

4. Get a e-athisatin nmbeo Whe we have cofrme that your treatmet s covere, we wll scuss your

clam wth you a ssue you a pre-authorsato umber. You ca the cotact

your cosultat or healthcare prover to arrage a appotmet.

o We recomme you gve your pre-authorsato umber to the cosultat or

healthcare professoal you see so that the voce for ay treatmet costs ca be

set to us rectly.

if for ay reaso you are set the voce, smply se t o to:

lams departmet, upa, alfor Quays, 50 3XL

ce we have mae our paymet, we wll se you a summary of your clam a

treatmet etals. lease ote that paymet may tae a umber of wees epeg

o how qucly voces are submtte to us.

CL CHECLT WHT youLL EEd To E CL

o help us to mae the clams process as smple a swft as possble, please have the

followg formato close to ha whe you call to mae a clam:

o Your upa membershp umber

o he coto you are sufferg from

o detals of whe your symptoms frst bega

o detals of whe you frst cosulte your G about your coto

o detals of the treatmet that has bee recommee

o date(s) o whch you are to receve treatmet

o he ame of the cosultat or other healthcare professoal volve

o detals of where your propose treatmet wll tae place

o Your expecte legth of stay hosptal (f applcable).

2.1 G CL

2.1.1 Claims the than cash benefitw recomme that you always cotact before arragg or recevg ay .

hs s the oly way that ca cofrm the that are avalable to you before you

cur ay costs for your . Ay costs you cur that are ot covere uer your

are your resposblty.

newitten membes

Wth full mecal uerwrtg, your mecal hstory s prove whe you jo thec.

w the revew your formato a ece what cover ca offer you. Ay -x

c (a cotos relate to t) wll be exclue a lste as a c c

o your cc. w ca, some cases, revew yourc c

future f you as us to.

Whe you call wll:

o cofrm whether your propose , mecal prover or treatmet faclty wll

be elgble uer your

o the level of avalable to you; a

o f you wsh to mae a clam, tell you whether you wll ee to complete a clam form.

f nt nee t cmlete a claim fm, wll treat your call to as your clam oce

are otfe that you have receve your . i most cases wll be otfe thatyou have receve your by your cor the prover of your .

f nee t cmlete a claim fm, you wll ee to retur the fully complete clam

form to as soo as possble a ay evet wth sx moths of recevg the

for whch you are clamg uless ths was ot reasoably possble.

matim membes

Wth moratorum uerwrtg, you are ase to prove etals about your mecal hstory

f you mae a clam a ot whe you jo the c.

over s automatcally exclue for two years from the start of yourc for ay

cotos whch you:

o ha symptoms of

o receve mecato for

o ha for; or

o receve avce about

the fve years before your .

over s also exclue for ay matim cnitin uless you o ot:

o have symptoms of

o receve mecato for; or

o receve avce about

the coto for a cotuous pero of two years.

Whe you joe thec you agree you woul ot be covere for ay c. ach tme you mae a clam you must prove us wth formato so ca

cofrm whether your propose s covere uer.

Whe you call us wll se you a pre-treatmet form to complete gvg etals of the

hstory of the mecal coto you are clamg for, clug formato that you wll

ee to as your gpor cfor. Your gpor cmay charge you a fee for

provg a report whch o ot pay. ach clam you mae urgmembershp wll

be assesse o ths formato a ay further formato as you to prove to us at

the tmeou clam. ce receve all the formato as you for wll:

o cofrm whether your propose , mecal prover or treatmet faclty wll be

elgble uer your

o the level of avalable to you; a

o f you wsh to mae a clam, tell you whether you wll ee to complete a clam form.

f nt nee t cmlete a claim fm, wll treat your submsso of your

pre-treatmet form to as your clam oce are otfe that you have receve your

. i most cases wll be otfe that you have receve by your

cor c c.

TIP:

before you make

a C lai m p lea se

refer to the Claims

CheCklist opposite

to ensure you have

all the inf orm atio n

youll need.

if possible,

always have

your membership

CertifiCate to hand

when you Call.

1 1


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f nee t cmlete a claim fm you wll ee to retur the fully complete clam

form to as soo as possble a ay evet wth sx moths of recevg the

for whch you are clamg uless ths was ot reasoably possble.

remembe: he value of the clams you mae ca affect the level of your subscrptos for

the followg year. ee also the Low claims bonus secto How your membership works

or call us for more formato.

2.1.2 Claims f cash benefits

all the helple to chec your . w wll cofrm your a tell you whether

you ee to complete a clam form. You must se ether:

o your complete clam form f you ee to complete oe please ote that for n

cash beeft you wll ee to tae your clam form wth you to the hosptal a as

them to complete the hosptal sectos; or

o f you o ot ee a clam form, a coverg letter gvg your ame, aress a

membershp umber

together wth your orgal ocumets for example scharge otes, voces a recepts.

2.1.3 Teatment neee becase f smene elses falt

Whe you clam for you ee because of a jury or mecal coto that was

cause by or was the fault of someoe else (a thr party), for example, a jury suffere

a roa accet whch you are a vctm, all of the followg cotos apply whe you

mae such a clam:

o you agree you are resposble for the paymet of ay costs whch may ultmately be

recovere from the thr party

o you must otfy as soo as possble that your was eee as a result of

a thr party. You ca otfy ether by wrtg to or completg the approprate

secto o your clam form. You must prove wth ay further etals that

reasoably as you for

o you must tae ay reasoable steps as of you to recover from the thr party the

cost of the pa for by a clam terest f you are ettle to o so

o you (or your solctor) must eep fully forme wrtg of the progress a

outcome of your clam

o f you recover the cost of ay pa for by , you must repay the amout a

ay terest to .

2.1.4 othe insance cve

if you have other surace cover for the cost of the or servces that you are

clamg from you must prove wth full etals of that other surace polcy as

soo as possble. You must o ths ether by wrtg to or by completg the approprate

secto o your clam form. i whch case wll oly pay share of the cost of the

for whch you are clamg.

2.2 HoW WE WLL dEL WTH your CL

2.2.1 Geneal infmatin

w oly pay for that you receve, or the that you are ettle

to, whle you are covere uer the a oly pay accorace wth the

. w also oly pay the that apple to you o the ate you receve your

or the ate that you became ettle to those .

xcept for n cash beeft a the acer Assst A o (f applcable), oly pay

elgble costs a expeses actually curre by you for you receve. w o ot

have to pay a clam f you brea ay terms a cotos of your membershp. less

tell you otherwse, your clam form a proof to support your clam must be set to .

2.2.2 pviing s with infmatin

You wll ee to prove wth formato to help assess your clam f mae a reasoable

request for you to o so. or example, may as you for oe or more of the followg:

o mecal reports a other formato about the for whch you are clamg

o the results of ay epeet mecal examato whch may as you to uergo

at expese

o orgal accouts a voces coecto wth your clam (clug ay relate to

costs covere by your xc f ay). w caot accept photocopes of

accouts or voces or orgals that have ha alteratos mae to them

if you o ot prove wth ay formato reasoably as you for wll be uable

to assess your clam.

obtaining meical ets fm Gp : Whe you ee to request a mecal report from

your gp, we ca o ths o your behalf wth your coset.

We will alwas ask f cnsent befe eqesting a et fm Gp n

behalf an we will ask f cnsent n the telehne when we exlain t the nee

f the et. You ca choose from three courses of acto:

o You ca gve your coset wthout asg to see the octors report before t s set

to . he octor wll se the report rectly to .

if you gve your coset to obtag a report wthout catg that you wsh to

see t, you ca chage your m by cotactg your octor before the report s set

to . i whch case you wll have the opportuty to see the report a as the octor

to chage the report or a your commets before t s set to , or wthhol your

coset for ts release.

o You ca gve your coset, but as to see ay report before t s set to , whch

case you wll have 21 ays, after otfy you that have requeste a report from

the octor, to cotact your octor to mae arragemets to see the report.

if you fal to cotact the octor wth 21 ays, wll request they se the report

rect to . if however you cotact your octor wth a vew to seeg the report,

you must gve the octor wrtte coset before they ca release t to .

You may as your octor to chage the report f you th t s msleag. if your

octor refuses, you ca sst o ag your ow commet to the report before

t s set to .

o You ca wthhol your coset, but f you o, please bear m that may be

uable to progress wth your clam.

Whether or ot you cate that you wsh to see the report before t s set, you have

the rght to as your octor to let you see a copy, prove that you as them wth

sx moths of the report havg bee supple to .

Your octor s ettle to wthhol some or all of the formato cotae the

report f (a) they feel that t may be harmful to you (b) t woul cate ther tetos

respect of you or (c) woul reveal the etty of aother perso wthout ther

coset (other tha that of a health professoal relato to your care).

w may mae a cotrbuto to the costs of ay report that have requeste o your

behalf, ths wll be cofrme at pot of telephoe coset. if o mae a cotrbuto,you wll be lable for ay amout above ths.

2.2.3 Hw we a claim

Claims the than cash benefits: for costs covere uer your wll,

most cases, pay the prover of your rect such as the c c

or cor whchever other perso or faclty s ettle to receve the paymet.

therwse wll pay the .

w wll wrte to tell the how have ealt wth ay clam.

Claims f cash benefits: pay clams by cheque to, or by rect paymet to the

ba accout of, the .

2.3 you WT To WTHdrW CL

if, for ay reaso, you wsh to wthraw your clam for the costs of you have

receve, you shoul call the helple to tell as soo as possble. You wll be uable to

wthraw your clam f have alreay pa your clam.

if you o wthraw your clam you wll be resposble for payg the costs of that .1 3


9/27

2.4 E-GrT pyET

if agree to pay for the costs of to whch you are ot ettle uer your

, .e. a ex-grata paymet, ths paymet wll stll cout towars ay maxmum

amout wll pay uer your . ag these paymets oes ot oblge to mae

them the future.

2.5 you HVE ECE

y may have agree wth that a xc shall apply to your .

he cc shows f oe oes apply a f so:

o the amout

o who t apples to

o what type of t s apple to; a

o the pero for whch the xc wll apply

ome further etals of how a xc wors are set out below a shoul be rea together

wth your cc. if you are usure whether a xc oes apply to you

please refer to your cc or cotact the helple.

2.5.1 Hw an excess wks

avg a xc meas that you have to pay part of ay costs that woulotherwse be pa by up to the amout of your xc. y elgble costs

mea costs that woul have bee payable uer your f you ha ot ha a xc.

if your xc apples eacht starts at the begg of each eve f

s ogog. o, your xc coul apply twce to a sgle course of f

your begs oea cotues to the ext.

w wll wrte to the to tell them who you shoul pay the xc to, for

example, your c, or c c. he xc must be pa rect

to them ot to b. w wll also wrte to tell the the amout of the xc

that remas (f ay).

You shoul always mae a clam for elgble costs eve f wll ot pay the clam

because of your xc. therwse the amout wll ot be coute towars yourxc a

you may lose out shoul you ee to clam aga.

2.5.2 Hw the excess alies t benefits

less we say otherwse your membeshi cetificate:

o apply the xc toclams the orer whch process those clams

o whe you clam for elgble costs uer a that has a beeft lmt your

xc amout wll cout towars your total beeft lmt for that

o the xc oes ot apply to n cash beeft or to the Health Expenses Cover, Dental

Cover, Complementary Therapies Cover and Cancer Assist Add ons or to the Fitness

check within Fit and Active Cover.

3 . ni :WA YA d

lease tae a loo at your

membershp certfcate

for a lst of the specfc

beefts of your chose

Bupa By You polcy. Ay

elemets of cover that you

see escrbe ths gue

that are ot lste o your

certfcate or are show

as ot covere, are ot

clue your surace.

Youll see that cover s

ve to three core

optos: rompt dagoss,

reatmet a are, a

omprehesve. here are

also sectos ecate

to the we varety of a

os that are avalable wth

Bupa By You.

if you have purchase ay

a os o top of your

core health surace,

you wll f mportat

formato about these

wth ths secto.

15


10/27

This sectin exlains chages a f an the imact f bth the

te f nee an chsen meical actitines an/ teatment

facilit t be eligible ne .

oTE o BEET

he followg otes apply equally to all the beefts a shoul be rea together wth

those beefts.

restictins an/ limitatins t benefits

Your cover may be lmte or restrcte through oe or more of the followg:

o beeft lmts these may be lmts o:

the amouts wll pay a/or restrctos o the cover you have uer your

. Your cc shows the beeft lmts a/or restrctos

that apply to your ; or

the maxmum amouts wll pay towars the costs of your , whch

apply partcularly whe you use a c cthat s ot wth your c

access or a cwho s ot a

o a xc ths s explae secto 2.5 the secto Claiming. Your

cc shows f a xc apples to your . if oe oes apply, your beeft

lmts show your cc wll be subject to your xc

o f you are a , apply to certa

beefts a certa exceptos as set out ths membershp gue. Your

cc shows f apply to your a f so how log your

are

o exclusos apply to your cover: the geeral exclusos are set out the secto What

you are not covered for. ome exclusos also apply ths secto a there may also

be exclusos your cc.

Being efee f teatment an Ba ecgnise meical actitines

an ecgnise facilities

Your must follow a tal referral by a gpafter you have see the gp perso.

owever, for -or -prove by a csuch

referral s ot requre the case of a mecal emergecy.

You are oly covere for . lease see the glossary se cto for what

mea by . Your cover for costs epes o you usg

certa b recogse mecal a other health practtoers a c c.

lease ote:

o the mecal practtoers, other healthcare professoals a c c you

use ca affect the level of pay you

o the level of beefts pay you epes upo whether the c cyou use

s wth your c cc

o certa mecal practtoers, other healthcare professoals a cc

that recogse may oly be recogse by for certa types of or

treatg certa mecal cotos or certa levels of

o the mecal practtoers, other healthcare professoals a c c that

recogse a the type of mecal coto a/or type of a/or level

of that recogse them for ca chage from tme to tme.

y teatment csts ae nl cvee when:

o the perso who has overall resposblty for your s a c. if the

perso who has overall resposblty for your s ot a cthe oe

of your costs are covere the oly excepto to ths s where a gprefers

you for -by a

(f applcable), or c c(f applcable)

o the mecal practtoer or other healthcare professoal a the c c

are recogse by for treatg the mecal coto you have a for provg the

type of you ee. i ato, the level of beefts pay epes upo

whether the c cyou use s wth your c cc.

mtant: Always call before arragg ay to chec your a

whether your chose mecal practtoer or other healthcare professoal or c

cs recogse by for both treatg the mecal coto you have a for

provg the type of you ee a the c cs wth your

ccc. Ay costs cur that are ot covere uer your

are your resposblty.

using a nn-ecgnise facilit

Whe you cotact wll chec your cover a help you to f a sutable alteratve

b recogse treatmet faclty. owever, f, for mecal reasos, your propose

-or -caot tae place a c c

may agree to your beg carre out a treatmet faclty that s ot a

c c. w ee full clcal etals from your cbefore ca gve

ecso. if o agree, pay beefts for the as f the treatmet faclty

ha bee a c c.

reasnable an cstma chages

w oly pay charges that are reasoable a customary. hs meas that

the amout you are charge by mecal practtoers, other healthcare professoals a/or

treatmet facltes a what you are charge for have to be le wth what the majorty of

our other members are charge for smlar or servces.

17


11/27

propT dGo

Getting iagnse

You are oly covere for ths beeft f your cc shows t s covere.

Benefit pd1 Cnsltatins an iagnsis

w o ot pay ay c fees, fees,

fees or c c for or relato to the agoss of ay c.

w o ot pay ay fees or fees for or

relato to the agoss of ay sease, lless or jury.

w o ot pay ay c c or c fees for ay for a sease,

lless or jury whch has bee .

Benefit pd1.1 ot-atient cnsltatins

w pay c fees for -cosultatos to eable the agoss of your sease,

lless or jury as - a you are referre for the cosultato by your gp

or c.

Benefit pd1.2 diagnstic tests/eligible sgical eatins

Whe requeste by your gpor cfor the agoss of your sease, lless or jury

pay c c (clug the charge for terpretato of the results) for c

a/or c for the agoss of your sease, lless or jury

receve as -, -or -. w

pay c fees for c uertae for the agoss of your

sease, lless or jury.

Please also see Exclusion 13, Diagnostic tests that include treatment provided at the same

time in the section What you are not covered for.

he followg sectos expla the type of c c pay relato to c

a c uertae for the agoss of your sease, lless or jury.

Benefit pd1.2.1 ccmmatin

w pay for your accommoato costs clug your ow meals a refreshmets whle

are recevg c or a c for the agoss of your

sease, lless or jury as -or -.

w o ot pay for persoal tems such as telephoe calls, ewspapers, guest meals a

refreshmets or persoal laury.

w o ot pay c c for accommoato f:

o the charge s for a overght stay for c or a elgble surgcal operato

for the agoss of your sease, lless or jury that woul ormally be carre out as

-or -

o the charge s for use of a be forc or a c for

the agoss of your sease, lless or jury that woul ormally be carre out as

-

o the accommoato s prmarly use for ay purpose other tha recevg c

or c for the agoss of your sease, lless or jury.

Benefit pd1.2.2 paent accmmatin

w pay for each ght a paret ees to stay the faclty wth ther chl. w oly pay for

oe paret each ght. hs beeft apples to the chls cover a ay charges are payable

from the chls . he chl must be:

o a member uer the

o uer 16 years of age; a

o havg c or a c for the agoss of ther

sease, lless or jury as -.

Benefit pd1.2.3 Theate chages, nsing cae, gs an

sgical essings

w pay for use of the operatg theatre a for ursg care, rugs a surgcal ressgs

whe eee as a essetal part of c or c

uertae for the agoss of your sease, lless or jury, whch you receve as

- , - or - .

w o ot pay for extra ursg servces ato to those that the cwoul usually

prove as part of ormal patet care wthout mag ay extra charge.

w o ot pay for rugs a surgcal ressgs use for c receve as

-or for you to use after your stay the faclty.

lease also see xcluso 15, Drugs and dressings for out-patient or take-home use and

complementary and alternative products in the section What you are not covered for.

(i, a scas are ot pa uer ths beeft see beeft d1.3.)

Benefit pd1.3 ot-atient r, CT an pET scans

Whe requeste by yourcto eable the ofyour condition pay

c c (clug the charge for terpretato of the results), for:

o i scas (magetc resoace magg)

o scas (compute tomography)

o scas (postro emsso tomography)

receve as - .

Getting teate

Benefit pd2 Cance Cve

You are oly covere for Cancer Coverf your cc shows t s covere.

if you are covere for Cancer Cover, pay for of cco the same bass

as set out beeft 5 a also beefts 2.4, 3, 4 a 7 to 9 for cc.

Benefit pd3 ctive Cve/it an ctive Cve

You are oly covere for etherActive Coveror Fit and Active Coverf your

cc shows t s covere. You shoul call to f out f your coto s a c,

j c.

if you are covere for ether Active Coveror Fit and Active Cover, pay for

you requre after your c,j c has bee a

that s for or relate to the c,j c. w o ot pay for

ay that s ot relate to a c,j c.

if you are covere for ether Active Coveror Fit and Active Cover, pay for for

c,j c o the same bass as set out beefts 2, 3, 4 a 7

to 10 for cc.

Benefit pd3.1 itness checkYou are oly covere for a ccf your cc shows t s covere.

if are covere for a cc wll pay for oe ccto be uertae at a

b h a C for a (f ay) each.

A ccs ot approprate for people wth certa mecal cotos or who are

curretly tag partcular mecatos. You shoul cotact us before boog a

ccto cofrm that you are able to uergo t. We ca prove formato about those

people who shoul ot uergo a cc.

19


12/27

TrETET d CrE

Getting iagnse

Benefit TC1 can an test cve

You are oly covere for Scan and Test Coverf your cc shows t s covere.

w o ot pay ay c fees, fees or

fees for ay -cosultatos.

w o ot pay ay c fees, fees,

fees or c c for or relato to the agoss of ay c.

Benefit TC1.1 diagnstic tests/eligible sgical eatins



a/or c uertae for the agoss of your sease, lless

or jury, whch are receve as - , -or -

. w pay c fees for cuertae for the

agoss of your sease, lless or jury.

he followg sectos expla the type of c c pay relato to ca c uertae for the agoss of your sease, lless or jury.

Benefit TC1.1.1 ccmmatin


are recevg c or a c for the agoss of your





o the charge s for a overght stay for c or a c


-or -



-


or a c for the agoss of your sease, lless or jury

Benefit TC1.1.2 Theate chages, nsing cae, gs an

sgical essings



uertae for the of your coto, whch you receve as - ,-or -.

w o ot pay for extra ursg servces ato to those that the faclty woul usually


w o ot pay for rugs a surgcal ressgs use for c receve as


lease also see Exclusion 15, Drugs and dressings for out-patient or take-home use and


(ut-patet i, a scas are ot pa uer ths beeft see beeft 1.2.)

Benefit TC1.2 ot-atient r, CT an pET scans

Whe requeste by your cto eable the of your coto pay

c c (clug the charge for terpretato of the results), for:




receve as - .

Getting teate

Benefit TC2 Teatment f acte cnitin


w o ot pay ay before your cc has bee uer ths

beeft. w oly pay relato to you requre after your cc

has bee that s for or relate to that cc.

w pay o the bass set out 2, 3, 4 a 6 to 10 for

that s requre after your cc has bee a s for or relate to that

cc.

Benefit TC2.1 Teatment f cance


if you are covere for ths beeft, pay for of cco the bass set

out beeft 5 a also beefts 2.4, 3, 4 a 7 to 9.

21


13/27

CoprEHEVE

Benefit C1 Cnsltatins an iagnsis


Benefit C1.1 ot-atient cnsltatins

w pay c fees for -cosultatos that are to eable the agoss

of your sease, lless or jury as -a you are referre for the

cosultato by your gpor c.

Benefit C1.2 diagnstic tests/eligible sgical eatins



a/or c for the agoss of your sease, lless or jury

receve as -, -or -. w

pay c fees for c uertae for the agoss of your

sease, lless or jury.

he followg sectos expla the type of c c pay relato to c

a c uertae for the agoss of your sease, lless or jury.

Benefit C1.2.1 ccmmatin


are recevg c or c for the agoss of your





o the charge s for a overght stay for c or a c


-or -



-


or c for the agoss of your sease, lless or jury

Benefit C1.2.2 paent accmmatin

w pay for each ght a paret ees to stay the cwth ther chl. w oly pay for

oe paret each ght. hs beeft apples to the chls cover a ay c are payable

from the chls . he chl must be:

o a member uer the o uer 16 years of age; a

o havg c or a c for the agoss of ther

sease, lless or jury as -

Benefit C1.2.3 Theate chages, nsing cae, gs

an sgical essings



uertae for the agoss of your sease, lless or jury, whch you receve as

- , -or -.



w o ot pay for rugs a surgcal ressgs use for c as part of





Benefit C1.3 ot-atient r, CT an pET scans

Whe requeste by your cto eable the agoss of your sease, lless or jury

pay c c (clug the charge for terpretato of the results), for:




receve as -.

Getting teate

ot-atient teatment

Benefit C2 ot-atient cnsltatins an teatment


Benefit C2.1 ot-atient cnsltatins

w pay c fees for -cosultatos that are to assess your c

c whe carre out as - a you are referre for the


Benefit C2.2 ot-atient theaies an chages elate

t t-atient teatment

ot-atient theaies

w pay fees for -of your c c whe you are

referre for the bygpor c.

if your crefers you to a mecal or health practtoer who s ot a

may pay the charges as f the practtoer were a f all of the followg apply:

o your crefers you to the practtoer before the -taes

place a remas overall charge of your care; a

o the practtoer has apple for b recogto a have ot wrtte to say

he/she s ot recogse by b

Chages elate t t-atient teatment

w pay c c for - whch s relate to a s a tegral part

of your - . w treat these charges as fallg uer ths beeft 2.2.

Benefit C2.3 diagnstic tests

Whe requeste by your gpor cto help eterme or assess your c

c as part of - pay c c (clug the charge for

terpretato of the results) for c.


Benefit C2.4 ot-atient r, CT an pET scans

Whe requeste by your cto help eterme or assess your cc

as part of - pay c c (clug the charge for

terpretato of the results), for:




Being teate in hsital

Benefit C3 Cnsltants fees f sgical an

meical hsital teatment


23


14/27

Benefit C3.1 gens an anaesthetists

w pay csurgeos fees a caaesthetsts fees for

c o your c c.

Benefit C3.2 phsicians

w pay cphyscas fees for -or -f your

oes ot clue ac or of cc.

ifoes clue a c oly pay c

physcas fees f the atteace of a physca s mecally ecessary because of your

c.

if your clue cover for of cca your oes

clue of cc oly pay cphyscas fees f the atteace

of a cphysca s mecally ecessary because of your of cc,

for example, f you evelop a fecto that requres -.

Benefit C4 acilit chages


Benefit C4.1 ot-atient sgical eatins

w pay c c for c carre out as -.

w pay for theatre use, clug equpmet, a rugs a surgcal ressgs use urgthec.

Benefit C4.2 da-atient an in-atient teatment

w pay c c for -a -a the charges

pay for are set out 4.2.1 to 4.2.7.

Benefit C4.2.1 ccmmatin

w pay for your accommoato clug your ow meals a refreshmets whle you are

recevg your .




o the charge s for a overght stay for that woul ormally be carre out as

-or -

o the charge s for use of a be for that woul ormally be carre out as

-

o the accommoato s prmarly use for ay of the followg purposes:

covalescece, rehabltato, supervso or ay purpose other tha recevg

recevg geeral ursg care or ay other servces whch coul have bee

prove a ursg home or ay other establshmet recevg servces from a or c c

(f covere).

Benefit C4.2.2 paent accmmatin

w pay for each ght a paret ees to stay wth ther chl. w oly pay for oe paret

each ght. hs beeft apples to the chls cover a ay charges are payable from the

chls . he chl must be:

o a member uer the

o uer 16 years of age; a

o recevg -.

Benefit C4.2.3 Theate chages, nsing cae, gs

an sgical essings


whe eee as a essetal part of your -or -.



w o ot pay for rugs a surgcal ressgs use for -or for you to

use after your stay the faclty except for-cacer rugs as set out beeft 5.



Benefit C4.2.4 ntensive cae

w pay for c whe eee as a essetal part of your -

or -but oly pay f all the followg cotos are met:

o the c s requre routely by patets uergog the same type of

as yours

o you are recevg prvate a faclty equppe wth a cc

c

o the c s carre out the cc c ; a

o t follows your plae amsso to the faclty for prvate

w also pay for c for -or -f

uforesee crcumstaces arse from a mecal or surgcal proceure whch oes ot

routely requre c as part of the but oly f:o you are recevg prvate a faclty equppe wth a cc c

; a

o the c s carre out the cc c

whch case your cor faclty shoul cotact at the earlest opportuty.

w o ot pay for ay c ay of the followg crcumstaces:

o t follows a uplae or a emergecy amsso to a nhshosptal or faclty

o t follows a trasfer (whether o a emergecy bass or ot) to a nhshosptal or

faclty from a prvate faclty

o t s carre out a ut or faclty whch s ot a cc c .

lease also see Exclusion 20, Intensive care in the section Glossary.

Benefit C4.2.5 diagnstic tests an r, CT an pET scans

Whe recommee by your cto help eterme or assess your cc

as part of -or - pay c c for:

o c


o scas (compute tomography); a

o scas (postro emsso tomography).

Benefit C4.2.6 Theaies

w pay c c for prove by whe eee as part

of your -or -.

Benefit C4.2.7 pstheses an aliances

w pay c c for a or c eee as part of your -

or -.

w o ot pay for ay whch s for or assocate wth or relate to a prosthess or

applace that you are ot covere for uer your .

BE E T or pE C C E d CL Cod T o

Benefit C5 Cance teatment


hs beeft 5 explas what pay for:

o - for cc25


15/27

o out-patet rugs for for cc.

or all other for cc, clug out-patet i, a scas, you

are covere o the same bass a up to the same lmts as your for other

as set out beefts 2.4, 3, 4 a 7 to 9.

Benefit C5.1 ot-atient cnsltatins f cance

w pay c fees for cosultatos that are to assess your cc of

ccwhe carre out as -a you are referre for the -


w may agree to pay a cor c c for the use of a cosultg room use

urg your out-patet cosultato, where o agree pay the charge uer ths

beeft 5.1.

Benefit C5.2 ot-atient theaies an chages elate

t t-atient teatment f cance

ot-atient theaies

w pay fees for -for ccwhe you are referre

for the by your gpor c.

if your crefers you to a mecal or health practtoer who s ot a

may pay the charges as f the practtoer were a f all of the followg apply:o your crefers you to the practtoer before the -taes

place a remas overall charge of your care; a

o the practtoer has apple for b recogto a have ot wrtte to say

he/she s ot recogse by b.

Chages elate t t-atient teatment

w pay prover charges for -whe the s relate to a s

a tegral part of your -or out-patet cosultato for cc.

Benefit C5.3 ot-atient iagnstic tests f cance

Whe requeste by your gpor cto help eterme or assess your cc

as part of -for cc pay c c (clug the charge for

terpretato of the results) for c.


Benefit C5.4 ot-atient cance gs

w pay c c for rugs (such as cytotoxc rugs) that are relate specfcally to

plag a carryg out -for cc.

w o ot pay for ay complemetary, homoeopathc or alteratve proucts, preparatos

or remees for of cc.

lease see Exclusion 15, Drugs and dressings for out-patient and take home use and

complementary and alternative products in the section What you are not covered for.Benefit C5.5 H cash benefit f H teatment f cance


if you are covere, your cc shows the beeft lmts that apply.

Benefit C5.5.1 H in-atient teatment f cance

w pay n cash beeft for each ght you receve -for, or rectly

relate to, ccthat s prove to you free uer your nhs. w oly pay n cash

beeft f your woul otherwse have bee covere for prvate -

uer.

Ay costs you cur for choosg to occupy a amety be whle recevg your -

are ot covere uer your . y a amety be mea a be whch the

hosptal maes a charge for but where your s stll prove free uer your nhs.

Benefit C5.5.2 H t-atient, a-atient an hme teatment

f cance

w pay n cash beeft for each ay you receve:

o raotherapy

o chemotherapy; or

o ac

whch s for cccarre out as - , -

or your , that s prove to you free uer your nhs. w oly pay n cash

beeft f your woul otherwse have bee covere for prvate -or

-uer your . w oly pay ths beeft oce for each ay

you have eve f you have more tha oe o the same ay.

Benefit C6 ental health teatment


Your cover s esge to prove help for short- or meum-term mecal treatmet that

restores you bac to health. m c are ofte log-term ature a may

chage ature over tme.

w o ot pay for ay for ay member who has suffere from or

s sufferg from a cc c (see Exclusion 34, chronic mental health

conditions). if ths excluso apples you wll ot be covere for ths beeft eve f your

cc shows t s covere.

What we a f mental health teatment

w pay c a fees a c c

for as follows:

Benefit C6.1 ot-atient mental health teatment

w pay fees a charges for - as set out beefts

6.1.1 to 6.1.3.

Benefit C6.1.1 Cnsltants fees

w pay c fees for -cosultatos to assess your

c a for - .

Benefit C6.1.2 ental health an wellbeing theaists fees

w pay fees for -

whe the s recommee by your gpor c.

if your gpor crefers you to a mecal or health practtoer who s ot a

may pay the charges as f the practtoer were a

f all of the followg apply:

o your gpor crefers you to the practtoer before the -

taes place a remas overall charge of your care, a

o the practtoer has apple for b recogto a have ot wrtte to say he/

she s ot recogse by b.

Benefit C6.1.3 diagnstic tests

Whe requeste by your gpor cto help eterme or assess your cc

as part of - pay c c (clug the charge

for terpretato of the results) for c.


Benefit C6.2 da-atient an in-atient mental health teatment

Your cc shows the maxmum umber of ays that may pay up to for

- a - uer your .

w pay c fees a c c for - or

- as set out below.

Cnsltants fees

w pay c fees for .

acilit chages

w pay the type of c c say pay for beeft 4.

Please also see E xclusion 6, Chronic conditions and Exclusion 31, Telephone consultations

in the section What you are not covered for. 27


16/27

d d T o L B E E T

Benefit C7 Teatment at hme


w may, at screto, pay for you to receve at home. You must have

wrtte agreemet before the starts a ee full clcal etals from

your cbefore ca mae ecso. w wll oly coser at

f all the followg apply:

o your chas recommee that you receve the at a

remas overall charge of your

o f you ot have the at the, for mecal reasos, you woul ee

to receve the a c c, a

o the s prove to you by a c.

w o ot pay for ay fees or charges for at that has ot bee prove to

you by the c.

Benefit C8 Hme nsing afte ivate eligible

in-atient teatment


wpay for home ursg mmeately followg prvate -f the home ursg:

o s for

o s eee for mecal reasos .e. ot omestc or socal reasos

o s ecessary .e. wthout t you woul have to rema the faclty

o starts mmeately after you leave the faclty

o s prove by a your ow , a

o s carre out uer the supervso of yourc.

You must have wrtte before the starts a ee full clcal

etals from your cbefore ca mae ecso.

w o ot pay for home ursg prove by a commuty psychatrc urse.

Benefit C9 pivate amblance chages


w pay for travel by prvate roa ambulace f you ee prvate -or

-, a t s mecally ecessary for you to travel by ambulace:

o from your home or place of wor to a c c

o betwee c c whe you are scharge from oe c c

a amtte to aother c cfor -

o from a c cto home, or

o betwee a arport or seaport a a c c

Benefit C10 H cash benefit f H hsital

in-atient teatment


if you are covere, your cc shows the beeft lmts that apply.

hs beeft oes ot apply to for cc that s explae beeft 5.5.

w pay n cash beeft for each ght you receve -prove to you

free uer your nhs. w oly pay n cash beeft f your woul otherwse have

bee covere for prvate -uer your .

Ay costs you cur for choosg to occupy a amety be whle recevg your -

are ot covere uer your . y a amety be mea a be whch the

hosptal maes a charge for but where your s stll prove free uer your nhs.

dd o

Benefit 1 Cmlementa Theaies Cve


w pay c cfees up to the maxmum aual beeft lmt

show your cc for -whe you are referre for

the by your gpor c.

he aual beeft lmt apples to a vually. it s the total

maxmum amout of we pay up to each. it s ot the amout we pay for each

type of servce or vually.

w o ot pay for ay complemetary or alteratve proucts, preparatos or remees.

lease see Exclusion 15, Drugs and dressings for out-patient or take-home use and


Benefit 2 Cance ssist


w wll pay the cash amout show your cc f or oe of

(f ay) s agose wth ccwhlst ths beeft apples to you. he beeft

apples to a vually.

he beeft wll oly be pa:

o upo a ew agoss of ccmae after the or the ate upo whch ths

beeft was ae to your cover, whchever s later

o oce ay

o subject to you complyg wth the requremets set out the ag a clam a

ow we eal wth your clam sectos of ths membershp gue; a

o f your clam s ot exclue by ay of the crcumstaces lste the What you are

ot covere for secto of ths membershp gue.

Benefit 3 Health Exenses Cve

Your cc shows whch ealth xpeses over (f ay) apples to your

(ealth xpeses over 20 or ealth xpeses over 10), a the maxmum aual

beeft lmt that apples to you. if ay ealth xpeses beeft oes ot appear o your

cc, or appears but s state as ot covere the you are ot covere

for that beeft.

Benefit 3.1 dental cash benefit

w pay the proporto show your cc of the amout you pay (up

to the maxmum aual beeft lmt also show your cc) for

a cosultatos prove by a etal hygest, or orthootst, whch

you receve urg a, ot for each type of servce or tem charge vually.w o ot pay for ay of the followg etal or oral surgcal or mecal servces:

o costs relatg to ay servces covere by a etal paymet pla a ay amouts

payable for a etal paymet pla. (A etal paymet pla s a surace polcy wth

regular ogog paymet whch covers that you may requre.)

o tooth cleag a tooth whteg materals purchase for home use

o ay mecatos, whether or ot they are prescrbe for you.

Benefit 3.2 otical cash benefit

w pay the proporto show your cc of the amout you pay (up to

the maxmum aual beeft lmt also show your cc) for the optcal

goos a servces show below, whch you receve urg a, ot for each type of

servce or tem charge vually.

We a benefits f the fllwing gs an sevices:

o glasses wth prescrbe leses, cotact leses a route sght tests whe prove by

a optca

add

ons

29


17/27

o a cosultatos relate to correctve laser eye treatmet carre out by a

ophthalmc surgeo who s a c.

We nt a f an f the fllwing tical gs sevices:

o ustral spectacles f they have ot bee prescrbe for

o suglasses wthout prescrbe leses

o les solutos, cleag materals a other optcal accessores.

Benefit 3.3 pescitins cash benefit

w pay the proporto show your cc of the amout you pay

(up to the maxmum aual beeft lmt also show your cc) for

prescrpto charges you cur urg a relato to prescrptos prove by your

gpor , ot for each tem charge vually.

Benefit 4 dental Cve

Your cc shows whch detal over (f ay) apples to your

(detal over 20 or detal over 10) a the maxmum aual beeft lmts that apply.

if ay detal over beeft oes ot appear o your cc, or appears but

s state as ot covere the you are ot covere for that beeft.

w o ot pay uer detal over relato to ay-x c.

nnal benefit limits

he aual beeft lmts apply to a vually. hey are the

maxmum amout of we pay up to each. he amouts show are the total

amouts of we pay up to each. hey are ot the amouts we pay for each

type of servce or treatmet vually.

Benefit 4.1 dental Cve 20

Benefit 4.1.1 rtine ental teatment

w pay the proporto show your cc of the amout you pay (up to

the maxmum aual beeft lmt also show your cc) for

that you receve urg a .

Benefit 4.1.2 dental teatment

w pay the proporto show your cc of the amout you pay (up


(whch s ot , c or

j ) that you receve urg a.

Benefit 4.1.3 Emegenc ental teatment

w pay the proporto show your cc of the amout you pay

(up to the maxmum aual beeft lmt also show your cc) for

cthat you receve urg a.

Benefit 4.1.4 dental inj teatment

w pay the proporto show your cc of the amout pay (up


j that you receve urg a.

Benefit 4.1.5 oal cance teatment

w pay faclty charges full for -or -ccsubject to

your maxmum aual beeft lmt show your cc for cc

.

w pay csurgeos a caaesthetsts fees full for -or

-ccsubject to your maxmum aual beeft lmt show

your cc for cc.

w pay for cosultatos a servces, pathology, a X-rays receve as -

. w pay up to a total amout of 400 eachfor all such servces collectvely

a ot for each type of servce or charge vually subject to your maxmum aual

beeft lmt for cc

w pay c fees for raotherapy a chemotherapy . w pay up to the

lmts below subject to your maxmum aual beeft lmt for cc.

aotherapy up to 380 for each course of raotherapy . e course

s 15 atteaces for raotherapy.

Chemthea teatment

w wll oly pay up to the followg amouts from the ate chemotherapy begs or

coser t begs, whch shall call the start ate, utl the ate the treatmet es:

1 wee up to 137 (1 wee s start ate to 7th ay of treatmet)

2 wees up to 257 (2 wees s start ate to 14th ay of treatmet)

3 wees up to 386 (3 wees s start ate to 21st ay of treatmet)

4 wees up to 515 (4 wees s start ate to 28th ay of treatmet)

w o ot pay each wee of a course of ccseparately whe such

ccbegs o the start ate a lasts more tha oe wee. wety-eght ays

after the start ate, wll coser ay further costs you cur for ccto

be ew ccfor the purpose of thec a a ew start ate wll apply.

Benefit 4.2 dental cve 10

Benefit 4.2.1 H ental teatment

w pay the proporto show your cc of the amout you pay for

that you receve uer the nhsurg aup to the same amout as

the nhsb1, 2 or 3 charge applcable to the you have receve at the

tme receve that .

if you wsh to clam charges you have pa for that you have receve

prvately rather tha uer the nhs, wll pay up to the nhsbcharge that s

applcable to the you have receve ha you receve the same

uer the nhs.

Benefit 4.2.2 oal cance teatment

b are pa o the same bass as those for ccuer beeft A4.1.5.

Please also see Exclusion 12 Dental/oral treatment (Exclusion 12B) in the section What

you are not covered for for an explanation of what is not covered under your Dental Cover

(Benefit A4).

31


18/27

4. WA Y A n d

hs secto sets out

xclusos from cover

er Bupa By You.

Whatever polcy you

ave, the formatoere wll be equally

elevat.

WHaTyoua

rEnoTCoVErEdf

or

hs secto explas the , servces a charges that are ot covere uer

Bupa By You. he exclusos are groupe uer heags. he heags are just sgposts,

they are ot part of the excluso. if there s a excepto to a excluso ths s show. i

the exceptos where, as a example, refer to specfc treatmets or mecal cotos

these are examples oly a ot evece that t s covere uer your .

hs secto oes ot cota all the lmts a exclusos to cover. or example the beefts,

set out the secto eefts, also escrbe some lmtatos a restrctos for partcular

types of , servces a charges.

hs secto oes ot apply to ealth xpeses over (eeft A3).

Exclsin 1 geing, menase an bet

w o ot pay for to releve symptoms commoly assocate wth ay boly

chage arsg from ay physologcal or atural cause such as ageg, meopause or

puberty a whch s ot ue to ay uerlyg sease, lless or jury.

Exclsin 2 d/HV

w o ot pay for for, relate to or arsg from, Aid or i, clug ay

c whch s relate to, or results from, Aid or i.

Excetin:w pay for for or arsg from Aid or i f the perso wth

Aid or i

o became fecte fve years or more after ther curret cotuous membershp bega,or

o has bee covere for ths type of uer a b prvate mecal surace

scheme (clug uer the ) sce at least July 1987 wthout a brea

ther cover

Exclsin 3 llegies allegic ises

w o ot pay for to e-sestse or eutralse ay allergc coto or sorer.

Exclsin 4 Benefits that ae nt cvee an/ ae abve

benefit limits

w o ot pay for ay , servces or charges that are ot covere uer your

. w also o ot pay for ay costs excess of the amouts for whch you

are covere uer your .

Exclsin 5 Bith cntl, cncetin, sexal blems

an sex changes

w o ot pay for :

o for ay type of cotracepto, sterlsato, termato of pregacy

o for ay type of sexual problems (clug mpotece, whatever the cause)

o for ay type of assste reproucto (e.g. i vestgatos or ), surrogacy,

the harvestg of oor eggs or oor semato

o where t relates solely to the of fertlty

o sex chages or geer reassgmets

or for or arsg from ay of these.

Please also see Pregnancy and childbirth in this section.

Exclsin 6 Chnic cnitins

w o ot pay for of ccc. y ths, mea a sease, lless or

jury whch has at least oe of the followg characterstcs:

o t ees ogog or log-term motorg through cosultatos, examatos,

chec-ups a/or tests

o t ees ogog or log-term cotrol or relef of symptoms

o t requres your rehabltato or for you to be specally trae to cope wth t

o t cotues eftely

o t has o ow cure

o t comes bac or s lely to come bac.

33


19/27

Excetin:w pay for arsg out of a ccc, or for

of acute symptoms of a ccc that flare up. owever, oly pay f the

s lely to lea qucly to a complete recovery or to you beg restore fully

to your prevous state of health, wthout you havg to receve prologe . or

example, pay for followg a heart attac arsg out of chroc heart sease.

hs excepto oes ot apply to of a c.

please nte: i some cases t mght ot be clear, at the tme of , that the sease,

lless or jury beg treate s a ccc. w are ot oblge to pay the ogog

costs of cotug, or smlar, . hs s the case eve where have prevously

pa for ths type of or smlar .

Please also see Temporary relief of symptoms in this section.

Exclsin 7 Cmlicatins fm excle cnitins/teatment

an exeimental teatment

w o ot pay ay costs, clug ay crease costs, cur

because of complcatos cause by a sease, lless, jury or for whch cover

has bee exclue or restrcte from your membershp. or example, f cover for abetes

s exclue by acc, a you have to spe ay extra ays hosptal or a

treatmet faclty after a operato because you have abetes, woul ot pay for these

extra ays.

w o ot pay ay costs you cur because of ay complcatos arsg orresultg from expermetal that you receve or for ay subsequet you

may ee as a result of you uergog ay expermetal .

Exclsin 8 Cntaminatin, was, its an teist acts

w o ot pay for for ay sease, lless or jury resultg from uclear or

chemcal cotamato, war, rot, revoluto, terrorst act or ay smlar evet.

Exclsin 9 Cnvalescence, ehabilitatin an geneal

nsing cae

w o ot pay c c for accommoato f t s prmarly use for ay of the

followg purposes:

o covalescece, rehabltato, supervso or ay purpose other tha recevg

o recevg geeral ursg care or ay other servces whch coul have bee prove a

ursg home or ay other establshmet whch s ot a c c

o recevg servces from a , c cor

Excetin:w may, at screto, pay for for rehabltato. y rehabltato

mea whch s ame at restorg health or moblty or to allow to lve a

epeet lfe, such as after a stroe. w wll oly coser cases where the rehabltato:

o s a tegral part of -

o starts wth 42 ays from a clug the ate you frst receve that -

, a

o taes place a c c

y must have wrtte agreemet before the rehabltato starts a ee full

clcal etals from your cbefore ca gve ecso. if agree pay for

up to a maxmum of 21 cosecutve ays rehabltato.

Exclsin 10 Csmetic, ecnstctive weight lss teatment

w o ot pay for to chage your appearace, such as a remoelle ose or

facelft whether or ot t s eee for mecal or psychologcal reasos.

w o ot pay for breast elargemet or reucto or ay other or proceure to

chage the shape or appearace of your breast(s) whether or ot t s eee for mecal

or psychologcal reasos, for example, for bacache or gyaecomasta (whch s the

elargemet of breasts males).

w o ot pay for ay , clug surgery,

o whch s for or volves the removal of healthy tssue (.e. tssue whch s ot sease),

or the removal of surplus or fat tssue, or

o where the teto of the , whether rectly or rectly, s the reucto or

removal of surplus or fat tssue clug weght loss (for example, surgery relate to

obesty clug morb obesty)

whether or ot the t s eee for mecal or psychologcal reasos.

w o ot pay for of elo scars. w also o ot pay for scar revso.

Excetin:w pay for a c to restore your appearace after:

o a accet, or

o f your clue cover for for cc, as a rect result of

surgery for cc.

w oly pay f the accet or the ccsurgery taes place urg your curret

cotuous pero of cover uer thsc a ay other b scheme prove there

has bee o brea your cover betwee thsc a the other b scheme. w wll

oly pay f ths s part of the orgal resultg from the accet or cc

surgery a have obtae wrtte before recevg the .

Please also see Screening, monitoring and preventive treatment in this section.

Exclsin 11 deafness

w o ot pay for for or arsg from eafess cause by a cogetal

abormalty, maturg or ageg.

Exclsin 12 dental/al teatmentExclsin 12 hs excluso 12A oes ot apply to detal over (eeft A4).

w o ot pay for ay etal or oral clug:

o the provso of etal mplats or etures, the repar or replacemet of amage

teeth (clug crows, brges, etures, or ay etal prosthess mae by a

laboratory techca)

o the maagemet of, or ay relate to, jaw shrage or loss as a result of

etal extractos or gum sease

o the of boe sease whe relate to gum sease or tooth sease

or amage.

Excetin 1:w pay for a c carre out by a cto:

o put a atural tooth bac to a jaw boe after t s oce out or sloge a

uexpecte accetal jury

o treat a jaw boe cyst, but ot f t s relate to a cyst or abscess o the tooth root or

ay other tooth or gum sease or amage

Excetin 2:w pay for a c carre out by a cto

surgcally remove a complcate, bure or mpacte tooth root, such as a mpacte

wsom tooth, but ot f the purpose s to facltate etures or the cc relates

to a-xc or a c.

Exclsin 12B hs excluso apples to detal over (eeft A4).

w o ot pay beefts uer detal over (eeft A4) for:

o c ;

o c or ay volvg or mag use of or ay way

relate toc ;

o mouthguars;

o ay or servces ot ormally prove by etsts the uk;

o the replacemet of ac c:

whch has bee lost or stole;

whch coul have bee repare accorg to geerally accepte etal staars

(except etures);

wth fve years of t havg bee ftte;

o ay resultg from or relate to ay jury sustae whlst

partcpatg a physcal cotact sport such as rugby or boxg;

o ay resultg from or relate to a self-flcte jury;

o ay obtae overseas whch reasoable opo base o

establshe etal a mecal practce that jurscto s expermetal or uprove.35


20/27

Exclsin 16 Excle teatment meical cnitins

w o ot pay for:

o of ay mecal coto; or

o ay type of

that s specfcally exclue from your .

Exclsin 17 Exeimental gs an teatment

w o ot pay for or proceures whch, reasoable opo, are

expermetal or uprove base o establshe mecal practce the u k,

such as rugs outse the terms of ther lcece or proceures whch have ot bee

satsfactorly revewe by ni (natoal isttute for lcal xcellece).

Excetin:w may pay for ths type of of a cc. owever, you

wll ee wrtte before the s receve a ee full clcal

etals from your cbefore ca gve ecso.

Please also see Complications from excluded conditions/treatment and experimental

treatment and Drugs and dressings for out-patient or take-home use and complementary

and alternative products in this section.

Exclsin 18 Eesight

w o ot pay for to correct your eyesght, for example for log or short sght or

falg eyesght ue to ageg, clug spectacles or cotact leses.

Excetin:w pay for for your eyesght f t s eee as a result of a

jury or a cc, such as a etache reta.

Exclsin 19 HrT an bne ensitmet

w o ot pay for for hormoe replacemet therapy () or boe estometry.

Excetin:w may pay for boe estometry recommee by your cto help

eterme or assess your coto as part of . owever, ee full

clcal etals from your cbefore ca gve ecso. if agree to pay for

boe estometry oly pay for a tal boe estometry sca a for oe follow-up

sca f ths s carre out:

o wth three years of you startg , a

o urg your curret cotuous pero of membershp uer thec.

Please also see Ageing, menopause and puberty in this section.

Exclsin 20 ntensive cae (the than tinel neee afte

ivate a-atient teatment in-atient teatment)

w o ot pay for ay c f:

o t follows a uplae or a camsso to a nhshosptal or faclty

o t follows a trasfer (whether o a emergecy bass or ot) to a nhshosptal or

faclty from a prvate c c

o t s carre out a ut or faclty whch s ot a cc c

w o ot pay for ay c, or ay other a cc c , f t s ot

routely requre as a mecally essetal part of the beg carre out.

Excetin: w pay for for c but oly for those covere

uer a as set out beeft 4.2.4 the secto eefts.

Exclsin 21 Leaning ifficlties, behavial an

evelmental blems

w o ot pay for relate to learg ffcultes, such as yslexa, or behavoural

problems, such as atteto efct hyperactvty sorer (Add), or evelopmetal

problems, such as shortess of stature.

Exclsin 22 atim cnitins

or members o ot pay for of a c, or a

sease, lless or jury that results from or s relate to a c.

Excetin 1: or , pay for of a c f at

ay tme after your you o ot:

o receve ay mecato for

w may, at sole screto, mae paymets the evet that you requre such

;

o costs a expeses for expermetal or uprove etal treatmet wll be

remburse uless curre wth upas pror wrtte approval;

o ay receve outse the ukwhch s ot

or c ;

o self amstere rugs such as atbotcs a pallers or prescrpto charges;

o ay cc receve by you f the oral cacer was agose:

before you bega your curret cotuous pero of membershp of thec

(or ay upa etal scheme whch clue cover for those types of treatmet)

urg the frst sx moths of your curret cotuous pero of membershp of

thec.

o ay j arsg as a rect or rect result of a exteral mpact

whch occurre before your .

o ay j arsg as a rect or rect result of a exteral mpact

whch occurre outse the uk.

Exclsin 13 diagnstic tests sgical eatins that incle

teatment vie at the same time

i relato to the rompt dagoss ore health surace beeft (eeft d1) o ot

pay for ay c or c uertae for the of

your coto that clue or are performe at the same tme as that s prove

as part of the ctest or c urg the same theatre tme,

whch s tee to releve or cure a sease, lless or jury.

Excetin:w pay for that s prove as part of a c urg the

same theatre tme oly f t s commece solely for the purposes of the agoss of your

sease, lless or jury a relates to certa:

o arthroscopy proceures (teral jot vestgatos) of the ee; or

o coroary agoplasty proceures (a coroary agoplasty s a proceure to ubloc

bloo vessels that supply the heart muscle wth bloo)

that are ether a c c or a c c.

Exclsin 14 dialsis

w o ot pay for for or assocate wth ey alyss (haemoalyss), meag

the removal of waste matter from your bloo by passg t through a ey mache or alyser.

w o ot pay for for or assocate wth pertoeal alyss, meag the removal

of waste matter frombloo by troucg flu to your abome whch acts as a flter.

Excetin 1:w pay for for short-term ey alyss or pertoeal

alyss f the alyss s eee temporarly for sue ey falure resultg from a

sease, lless or jury affectg aother part of your boy.

Excetin 2:w pay for for short-term ey alyss or pertoeal

alyss f you ee ths mmeately before or after a ey trasplat.

Exclsin 15 dgs an essings f t-atient take-hme

se an cmlementa an altenative cts

w o ot pay for ay rugs or surgcal ressgs prove or prescrbe for -

or for you to tae home wth you o leavg hosptal or a treatmet faclty.

w o ot pay for ay complemetary or alteratve therapy proucts or preparatos,

clug but ot lmte to homoeopathc remees or substaces, regarless of who they

are prescrbe or prove by or the type of or mecal coto they are use

or prescrbe for.

Excetin: if your clue cover for for cc, pay for t-

atient rugs (such as cytotoxc rugs) for of ccbut oly as set out

beeft 5 secto 3 the secto eefts.

Please also see Experimental drugs and treatment in this section.

37


21/27

o as for or receve ay mecal avce or for; or

o experece symptoms

of that c for a cotuous pero of two years cover uer thec.

w may tae your cover uer a c to accout whe assessg your clam

for a c but oly f specfcally agree that woul o ths whe

you joe thec.

Excetin 2: if you apply to aewbor baby as a uer your

membershp a the babys membershp woul be as a member wll ot

apply ths excluso to the babys cover f have bee a member uer yourc

for at least 12 cotuous moths before the babys brth a clue the baby as a

wth three moths of ther brth.

Exclsin 23 oveseas teatment

w o ot pay for that you receve outse the unite ingm.

Exclsin 24 phsical ais an evices

w o ot pay for supplyg or fttg physcal as a evces (eg hearg as,

spectacles, cotact leses, crutches, walg stcs, etc).

Excetin:w pay for a c for those covere uer a as set out

beeft 4.2.7 secto 3, the secto eefts.

Exclsin 25 pe-existing cnitinsor o ot pay for of a-xc, or a

sease, lless or jury that results from or s relate to a-xc.

Excetin: or pay for of a-x

c, or a sease, lless or jury whch results from or s relate to a -x

c, f all the followg requremets have bee met:

o have bee set cc whch lsts the perso wth the

-xc (whether ths s or oe of )

o gave all the formato ase for, before setfrst

membershp certfcate lstg the perso wth the-xc for ther

curret cotuous pero of cover uer the c

o ether or the perso wth the-xc ew about t before

setfrst membershp certfcate whch lsts the perso wth the -x

c for ther curret cotuous pero of cover uer thec, a

o ot exclue cover (for example uer a cc) for the costs of the

, whe set cc.

Exclsin 26 pegnanc an chilbith

w o ot pay for for:

o pregacy or chlbrth, clug of a embryo or foetus

o termato of pregacy, or ay coto arsg from termato of pregacy

Excetin 1:w pay for of the followg cotos:

o mscarrage or whe the foetus has e a remas wth the placeta the womb

o stll brth

o hyatform mole (abormal cell growth the womb)

o foetus growg outse the womb (ectopc pregacy)

o heavy bleeg the hours a ays mmeately after chlbrth

(post-partum haemorrhage)

o afterbrth left the womb after elvery of the baby (retae placetal membrae)

o complcatos followg ay of the above cotos

Excetin 2:w may pay for for elverg a baby by caesarea secto.

owever, ee full clcal etals from your cbefore ca gve ecso.

Excetin 3:w pay for of a cc of the mother that relates

to pregacy or chlbrth but oly f all the followg apply:

o the s requre ue to a flare-up of the mecal coto, a

o the s lely to lea qucly to a

2236869 bby pmi membership guide

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