AXA Global Healthcare AXA Global Health Plan für Privatkunden Standard: die Bedingungen im Volltext

[Seite 1] Global Health Plan Standard Your handbook Individual April 2023 [Seite 2] Welcome to your policy Claims and questions +44 (0)1892 503 856 Fax +44 (0)1892 508 256 24 hours a day Emergency Assistance +44 (0)1892 513 999 24 hours a day 24 hour medical help and information +44 (0)1892 556 753 Talk to a medical professional at any time, day or night Your online account axaglobalhealthcare.com/customer We may record and/or monitor calls for quality assurance, training and as a record of our conversation. Your policy documents are available in other formats. If you would like a Braille, large print or audio version, please contact us. This private medical insurance policy is arranged by AXA Global Healthcare (EU) Limited, administered by AXA Global Healthcare (UK) Limited and underwritten by AXA Insurance dac. Registered Office: Wolfe Tone House, Wolfe Tone Street, Dublin 1, Republic of Ireland. Page 1 [Seite 3] Contents Section Page 1 Introduction to your policy 5 This section explains the basics of your cover 2 Making a claim 19 Everything you need to know about making a claim 3 How your policy works 23 Including how we cover treatment, how we pay for it and rules for pre-existing conditions 4 Your cover for specific conditions, treatment, tests and costs 32 The rules that relate to specific conditions, treatment, tests and costs 5 Managing your policy 51 Including how to make changes to your cover, how your excess works and how to complain 6 Legal information 58 Details of the rights and responsibilities we have to each other 7 Glossary 65 A list of terms in this handbook that have specific meanings Page 2 [Seite 4] Expert health information Expert health information you can trust +44 (0)1892 556 753 We’re here whenever you need to talk to a medical expert – not just when you need to claim. Get the latest information on vaccinations or health precautions before travelling. Check on symptoms that are worrying you. Understand the facts on a health condition. Or simply call for support and reassurance. • Nurses, midwives, pharmacists and counsellors ready to talk to you. Nurses and counsellors are available 24/7. Midwives and pharmacists are available Monday to Friday from 08:00 to 20:00 GMT; Saturday and UK public holidays from 08:00 to 16:00 GMT; and Sunday 08:00 to 12:00 GMT • Completely confidential and completely separate from our claims service. You can choose to remain anonymous with no record of your call. Or you can ask us to make a note of your call in case you want to call again. We can’t diagnose medical conditions or prescribe medicine, but we can give the latest information about specific illnesses and conditions, treatments and medicine, as well as provide guidance and support. Page 3 [Seite 5] Manage your policy online The easy way to manage your policy, make claims and stay in touch. Sign up so you’re ready to go whenever you need us axaglobalhealthcare.com/customer You’ll need your policy number from your healthcare insurance statement to register. The main policyholder must register first.  Manage your policy and update your details  View your policy details  Check your treatment is covered  Send us a query  Make a claim  Check your claims and healthcare insurance statements  View your statements  Send us documents  Request money transfers  Find a hospital or medical practitioner  Case management  Access support when your health condition is complicated  Available to all family members on your policy aged 16 and over Page 4 [Seite 6] 1 Introduction to your policy This policy meets the demands and needs of someone seeking the cover set out in the 1.1 > Currency that applies to your policy following sections 1.2, 1.3, 1.4, 1.5, 1.6, 1.7 1.2 > Countries where you are covered and 1.8 and should be read alongside your healthcare insurance statement which 1.3 > Your overall policy limit shows which cover level and policy options 1.4 > Your cover you have bought. 1.5 > Optional covers This section explains the basics of what you 1.6 > The main things we don’t cover are covered for. It also tells you some of the 1.7 > Understanding what usual and key things that are not covered too. customary charges are Reading this section will help you to 1.8 > Your cover for emergency treatment in understand the rest of the information in the USA – for members who do not the handbook. have the added USA cover The table in this section only gives you an 1.9 > Your cover for emergency evacuation outline of your cover. For full details, please and repatriation read the rest of your handbook too. Words and phrases in bold type Some of the words and phrases we use in this handbook have a specific meaning, for example, when we talk about treatment. We’ve highlighted these words in bold. You can find their meanings in the glossary. You and your When we use ‘you’ and ‘your’, we mean the policyholder and any family members covered by your policy. We, us and our When we use ‘we’, ‘us’ or ‘our’, we mean AXA Global Healthcare (UK) Limited acting on behalf of AXA Insurance dac, which is the insurance company that underwrites this product. Page 5 [Seite 7] 1.1 > Currency that applies to your policy We will pay you in the currency that you request when you make a claim. The currency must be in our list of currencies we can pay in. To see the list, go to the ‘How bills are paid’ page on axaglobalhealthcare.com. We will use the exchange rate listed in the ICE foreign exchange rates on the day of your treatment for out-patient and day-patient treatment, and the day of your admission for in-patient treatment. Where there are currency or exchange rate controls in place, we may not use the rate listed in the ICE foreign exchange rates. In these circumstances, we may contact you to request evidence of the exchange rate used when you purchased the currency and we will use that exchange rate to reimburse you. 1.2 > Countries where you are covered Your healthcare insurance statement will show where you are covered for treatment. This will be either: • Worldwide; or • Worldwide excluding the USA. Country of residence The country of residence is the country where the policyholder lives or intends to live for most of the policy year. It will be shown on your healthcare insurance statement. You must tell us if there is any change to your country of residence. 1.3 > Your overall policy limit This table shows the maximum amount we will pay for claims a year, for each member covered by your policy. Some parts of your cover have their own separate limits, which are all listed in this handbook. Overall policy limit Overall policy limit per member  £1,000,000 or  $1,600,000 or  €1,275,000 • Does not apply to evacuation and repatriation costs. » See 1.9 > Your cover for emergency evacuation and repatriation Policy limits are shown in the following three currencies Only the currency you requested when you took out your policy applies to your policy. £ = Pound Sterling $ = United States dollar € = Euro Page 6 [Seite 8] 1.4 > Your cover In-patient or day-patient cover Limit details Notes Hospital and  Within your overall Fees for in-patient or day-patient: day-patient unit fees policy limit • standard accommodation • psychiatric treatment • diagnostic tests • use of the operating theatre • nursing care • drugs • dressings • radiotherapy and chemotherapy • physiotherapy • surgical appliances that the medical practitioner uses during surgery. » See 3.5 > Hospitals where you can have your treatment, 3.6 > Accommodation we will pay for at the hospital where you are treated, and 3.7 > Differences when you have your treatment in the UK Medical practitioner  Within your overall Fees for: surgeons, anaesthetists and physicians. fees policy limit » See 3.4 > Who can provide your treatment Emergency treatment  Up to six weeks This is to cover emergency in-patient or day-patient in the USA treatment with a treatment of a medical condition that arises suddenly (does not apply if you total limit of: whilst you are in the USA. have added USA cover)  £10,000 or Note: this benefit is only applicable if you do not have  $16,000 or the USA upgrade.  €12,750 Page 7 [Seite 9] In-patient or day-patient cover Limit details Notes Cash payment when  £100 a night or We pay this when: there has been no  $160 a night or • you are admitted for in-patient treatment before charge for your midnight; and  €125 a night treatment or your • we would have covered your treatment if you had stay in hospital had it privately. If your policy has an excess, we will not take this off this cash payment. This benefit is not available if the cost of treatment was funded by another party, such as another insurer. Hospital  Within your Covers the cost of one parent staying in hospital with a accommodation for overall policy limit child under 18. The child must be covered by your one parent while a policy and be having treatment that is covered by your child is in hospital policy. Hotel accommodation  Up to £100 a night Covers towards the costs for one parent to stay near to for one parent while a up to £500 a year. the hospital where a child under 18 is having child is in hospital  Up to $160 a night treatment. The child must be having treatment up to $800 a year. covered by the policy at a hospital that is not in their home town.  Up to €125 a night up to €625 a year. If your policy has an excess, we will not take this off this cash payment. Out-patient cover Limit details Notes Surgery  Within your overall » See 3.4 > Who can provide your treatment policy limit CT, MRI or PET scans  Within your overall CT = Computerised Tomography policy limit MRI = Magnetic Resonance Imaging PET = Positron Emission Tomography » See 3.4 > Who can provide your treatment, 3.5 > Hospitals where you can have your treatment, and 3.7 > Differences when you have your treatment in the UK Page 8 [Seite 10] Other cover Limit details Notes External prosthesis  Up to £5,000 We will pay this benefit towards the cost of providing an regardless of how external prosthesis. long you remain a If your policy has an excess, you do not have to pay the member of a plan excess if you claim for this cash benefit. arranged by the AXA Global Healthcare Group.  Up to $8,000 regardless of how long you remain a member of a plan arranged by the AXA Global Healthcare Group.  Up to €6,375 regardless of how long you remain a member of a plan arranged by the AXA Global Healthcare Group. Ambulance transport  Within your overall Type of ambulances covered: policy limit. • road ambulance • air ambulance if appropriate. Reasons when transport by ambulance is covered: • for emergency transport to or between hospitals; or • when a medical practitioner says that you need to have medical supervision while you are being transported. Emergency evacuation  If your policy has an excess, you do not have to pay the and repatriation excess if you claim for emergency evacuation. » See 1.9 > Your cover for emergency evacuation and repatriation Page 9 [Seite 11] Other cover Limit details Notes Virtual Doctor service  Unlimited video Access to a Virtual Doctor service for unlimited video appointments appointments and telephone consultations.  Unlimited doctor To register and use the service please visit: call backs axaglobalhealthcare.com/doctor If you have the optional Out-patient cover, using this service will not impact any out-patient limit on your policy. If your policy has an excess, you do not have to pay the excess if you claim for the Virtual Doctor service. Mind Health  Up to 6 sessions, Mind Health is available for certain conditions through per condition, each the Virtual Doctor service and provides telephone year consultation sessions with a psychologist. If you have the optional Out-patient cover, using this service will not impact any out-patient limit on your policy. If your policy has an excess, you do not have to pay the excess if you use the Mind Health service. Cash payment if you  £50 a day up to If you choose to have free day-patient or out-patient have free £5,000 a year or chemotherapy or radiotherapy to treat cancer. We will chemotherapy or  $80 a day up to only pay this if the treatment would have been covered radiotherapy $8,000 a year or by your policy.  €60 a day up to If your policy has an excess, you do not have to pay the €6,375 a year excess if you claim for this cash benefit. This cover only applies when you have not had to pay for your treatment or for your stay in hospital. » See 4.5 > Cancer Page 10 [Seite 12] Other cover Limit details Notes Nurse to give you  Paid in full for up to We will pay for treatment: chemotherapy or 14 days a year • at home antibiotics by • somewhere else that your medical practitioner or intravenous drip at nurse agree is appropriate. home We will pay for a nurse to give you either of the following by intravenous drip: • chemotherapy to treat cancer • antibiotics. This is so long as: • you would otherwise need to be admitted for in-patient or day-patient treatment • the nurse is working under the supervision of a medical practitioner. External prostheses A combined overall during active limit of: treatment of cancer.  £1,500 a year or Spinal supports, knee  $2,400 a year or braces, or pneumatic  €1,900 a year walking boots if they are part of a surgical procedure Wigs or other  £400 a year or If your policy has an excess, you do not have to pay the temporary head  $640 a year or excess. coverings during  €510 a year active treatment of cancer Medical conditions  Covered up to the Your policy does not cover routine childbirth, antenatal that arise during limits that apply in consultations, postnatal consultations, screening and pregnancy and the rest of this monitoring childbirth policy. » See 4.25 > Pregnancy and childbirth or call +44 (0)1892 503 856 Accidental damage to  £10,000 a year or The damage must be due to an external impact. Other teeth  $16,000 a year or conditions also apply.  €12,750 a year » See 4.36 > Teeth and dental conditions Page 11 [Seite 13] Other cover Limit details Notes Dental treatment 50% of the cost up to If your policy has an excess, you do not have to pay the a maximum of: excess on claims for dentist fees.  £320 a year or » See 4.36 > Teeth and dental conditions  $510 a year or  €405 a year 1.5 > Optional covers Your healthcare insurance statement will show if you have added any of these covers. Optional Out-patient cover Drugs and dressings £100 a year or The drugs and dressings must be for treatment of a $160 a year or medical condition that we cover and must be prescribed by a medical practitioner. €125 a year The following out-patient items have a combined limit of: • £1,000 a year • $1,600 a year • €1,275 a year some of the items have their own individual limits too. These are shown below: Limit details Notes Medical practitioner  Within combined This includes any out-patient medical practitioner’s consultation fees limit consultation fees that are related to in-patient or day-patient treatment you receive. Psychiatric treatment  Within combined » See 4.21 > Mental health limit Diagnostic tests  Within combined Including diagnostic tests related to in-patient or limit day-patient treatment. Physiotherapy  Within combined treatment limit Vaccinations  £150 a year or When given by a medical practitioner or nurse. Limit  $240 a year or applies to the combined cost of administering the vaccine and the cost of the vaccine itself.  €190 a year Combined limit applies Page 12 [Seite 14] Optional Out-patient cover Complementary  £200 a year or practitioner fees  $320 a year or  €250 a year. Combined limit applies If you would like to add cover to your membership you can usually do this: • within 14 days of receiving your documents, or • when you renew Just call us on +44 (0)1892 503 856 and we’ll be happy to help. 1.6 > The main things we don’t cover Like all health insurance plans, there are a few things that your policy is not designed to cover. We’ve listed the most significant things here, but please also check the detail later in your handbook. What are the key things my policy does not cover? Your policy does not cover For more information Notes  Conditions that last a » See 3.3 > How your policy long time or come back works with conditions (chronic conditions) that last a long time or come back (chronic conditions) or call us on +44 (0)1892 503 856  Out-patient drugs and dressings - Unless you have the optional out-patient cover  Out-patient diagnostic tests- Unless you have the optional out-patient cover Page 13 [Seite 15] Your policy does not cover For more information Notes  Out-patient medical practitioner charges for out-patient consultations– Unless you have the optional out-patient cover  Vaccinations – Unless you have the optional out-patient cover  Out-patient physiotherapy or complementary treatment – Unless you have the optional out-patient cover  Out-patient psychiatric treatment – Unless you have the optional out-patient cover  Antenatal and postnatal » See 4.25 > Pregnancy and Although we do not cover these routine consultations, childbirth or call us on aspects of pregnancy, we do cover monitoring or screening +44 (0)1892 503 856 treatment for medical conditions that arise during pregnancy up to the limits that apply in the rest of this policy.  Routine childbirth » See 4.25 > Pregnancy and Although we do not cover routine childbirth or call us on childbirth, we do cover treatment for +44 (0)1892 503 856 medical conditions that arise during childbirth up to the limits that apply in the rest of this policy.  Treatment of medical » See 3.2 > How your policy Your policy is designed to cover the conditions you had, or works with pre-existing necessary treatment of new medical had symptoms of before conditions and symptoms conditions that arise after you join. you joined of them Page 14 [Seite 16] Your policy does not cover For more information Notes  Treatment that you If you have treatment in the UK and receive in the UK from choose to use a different hospital, we providers that are not may pay you a small cash payment. listed in our UK We use a UK Directory of Hospitals as it Directory of Hospitals helps us to keep premiums affordable. » See our Directory of Hospitals at axaglobalhealthcare.com/ ukhospitals  Non-emergency If you have added USA cover, your cover treatment you receive in extends to treatment in the USA too. the USA, unless you have » See 1.2 > Countries where you are added USA cover covered and 1.8 > Your cover for emergency treatment in the USA  Charges that are above » See 1.7 > Understanding what usual the usual and customary and customary charges are charges for the treatment or service provided  The costs of arranging Your policy does not cover your costs for treatment arranging treatment, such as phone calls and travelling expenses. 1.7 > Understanding what usual and customary charges are We will only pay for charges for treatment or services that a hospital, medical facility, medical practitioner, complementary practitioner, physiotherapist or other medical professional would usually and customarily charge for that treatment or service in the country where you are receiving it. We will use guidelines published by a government health department or official medical body in the country where you are having treatment or using a service to decide if charges are within the usual and customary range. We may also use anonymised claims data or data from our local partners as a benchmark when we pay or assess claims. 1.8 > Your cover for emergency treatment in the USA – for members who do not have the added USA cover This section applies if you have worldwide cover excluding the USA. It does not apply if you have worldwide cover. Your policy gives you some emergency in-patient and day-patient cover in the USA. Page 15 [Seite 17] If you have worldwide cover excluding the USA, there is no cover for out-patient treatment in the USA. What cover do I have in the USA? We will pay for in-patient or day-patient treatment needed for an emergency medical condition that you suffer suddenly while you are in the USA. We will not pay if you have travelled to the USA to get treatment, or if you have travelled against medical advice (including the published advice of the Chief Medical Officer of the Department of Health of England). 1.9 > Your cover for emergency evacuation and repatriation Call us on +44 (0)1892 513 999 for emergency evacuation and repatriation. We will cover the costs of emergency evacuation if: • you are, or need to be, admitted as an emergency in-patient, and • our appointed doctor and the treating doctor believe your current or nearest medical facilities are not able to provide the treatment you need. We will cover the costs of repatriating you if we have agreed to cover your emergency evacuation. We will not cover the cost of evacuating or repatriating you if you decide to travel elsewhere for treatment and we believe the nearest medical facilities are adequate for your treatment. This includes if you decide you want to travel back to your country of residence for your treatment. What to do if you need emergency transportation in Africa If you receive an injury or suffer from an illness and cannot be medically treated in the area where the incident has occurred, we can arrange for you to be transported to the nearest and most appropriate medical facility, in Africa, to receive medical treatment. This service is offered: • to members who have been advised by a medical professional that they need to be admitted to hospital; and • when it is clear that it is not medically appropriate to be treated where you are. How emergency evacuation and repatriation cover works If you are admitted as an emergency in-patient and you or the treating doctor believes that the local medical facilities are not adequate to treat you, ask somebody to call our emergency number. We will appoint a doctor who will be able to assess the facilities and the evacuation or repatriation service detailed at the beginning of this section will apply. What costs we will cover If the doctor we appoint decides that the facilities are not adequate to treat you, we will cover the reasonable costs of either: • evacuating you to a suitable medical facility for treatment in the country you are in; or • evacuating you to a suitable medical facility in a different country for treatment. Page 16 [Seite 18] When you are discharged from the medical facility you were evacuated to, we will cover the costs of repatriating you to one of the following: • the place where you normally live or your country of residence • a country that you hold a passport for. We will cover these costs so long as we have agreed the method of transport to be used, and date and time of your evacuation or repatriation before it takes place. We will also cover the cost of any necessary treatment given to you by our chosen evacuation agency while they are moving you. Repatriation following death If you die outside a country that you hold a passport for, we will cover the cost of transporting your body back to a port or airport in: • your country of residence, or • a country you hold a passport for. The relevant exclusions for emergency evacuation and repatriation also apply to repatriation following death. Will other members of my family or friends be able to travel with me? If the member who needs to be evacuated or repatriated is under 18, we will cover the additional reasonable and necessary transport and accommodation costs for someone, aged 18 or over, to accompany them on their journey. If the member who needs to be evacuated or repatriated is over 18, we may agree to cover these costs if we believe it is medically appropriate. Once our member reaches their evacuation destination, we will not cover the accompanying person’s further costs. What cover do I have if a family member is evacuated or repatriated? Your cover depends on whether they are evacuated or repatriated either from the location where you both normally live or whether you are travelling together at the time. If you are travelling away from home with a family member who is covered by a product arranged by the AXA Global Healthcare Group and underwritten by AXA Insurance dac and they are evacuated or repatriated, we will pay for your additional reasonable and necessary transport and accommodation costs that result from the evacuation or repatriation. We will do this if it is medically appropriate for you to travel with the family member. If you are both at the location where you normally live and they have to be evacuated or repatriated from that location, we will pay for your additional reasonable and necessary transport costs that result from the evacuation or repatriation. We will do this if it is medically appropriate for you to travel with the family member. We will not cover your accommodation costs. What will happen to my travel ticket? Any unused portion of the travel tickets belonging to you or anyone that we evacuate with you will immediately become our property. You must give the tickets to us. Page 17 [Seite 19] Can I choose to travel to a particular country for treatment? You can choose to go to a particular country for treatment, but we will not cover the cost of travelling to that country. Once you are in that country, the terms of the policy apply as normal. Exclusions that apply to your cover for emergency evacuation and repatriation You are not covered for emergency evacuation or repatriation if any of the following apply: • the medical condition does not need immediate emergency in-patient treatment • the medical condition does not prevent you from travelling or working • the medical condition is directly or indirectly caused by a deliberately self-inflicted injury, suicide or an attempt at suicide • the medical condition is in any way connected with alcohol abuse, drug abuse or substance abuse • the medical condition is a result of engaging in or training for any sport for which you receive a salary or monetary reimbursement, including grants or sponsorship (unless you only receive travel costs) • the medical condition is a result of base jumping, cliff diving, flying in an unlicensed aircraft or as a learner, martial arts, free climbing, mountaineering with or without ropes, scuba diving to a depth of more than 10 metres, trekking to a height of over 2,500 metres, bungee jumping, canyoning, hang-gliding, paragliding or micro-lighting, parachuting, potholing, skiing off piste or any other winter sports activity carried out off piste • the evacuation would involve moving you from a ship, oil-rig platform or similar off- shore location • we have not approved the evacuation or repatriation first • we have not been told about the medical condition within 30 days of the condition becoming an emergency (unless this was not reasonably possible) • the medical condition is a result of nuclear, biological or chemical contamination, war (whether declared or not), act of foreign enemy, invasion, civil war, riot, rebellion, insurrection, revolution, overthrow of a legally constituted government, explosions of war weapons or any event similar to one of those listed • the emergency occurs when you are on a leisure trip to a destination to which the UK Foreign, Commonwealth & Development Office either advises against all travel, or advises against all travel on holiday or non-essential business. Limits on our liability under your cover for emergency evacuation and repatriation We will not be liable for: • any failure or delay in providing emergency evacuation or repatriation • injury or death while you are being moved. These limits do not apply if the failure or delay is caused by our negligence or the negligence of someone we have appointed to act for us. Page 18 [Seite 20] 2 Making a claim 1 2 Get in touch with us before you see the medical We’ll check your cover and let you know what practitioner happens next. • Go to your account at We may ask you to provide more information, axaglobalhealthcare.com/customer for example from your medical practitioner. • Call us on +44 (0)1892 503 856 You or your medical practitioner must provide • For treatment in the USA, call us on us with the information we ask for as soon as +1 800 308 2611 reasonably possible so that we can assess your claim. Make sure you contact us before you see the medical practitioner or have any treatment. We’ll be able to explain your cover, so you don’t end up having to pay for treatment you’re not covered for. Page 19 [Seite 21] 2.1 > How we pay claims About our network of hospitals We have arrangements for making direct payments with some hospitals. You can check these in our network of hospitals, which you will find at axaglobalhealthcare.com/customer The hospitals in the network of hospitals are continuously reviewed, so you should always check with us before arranging any treatment. Paying claims for in-patient and day-patient treatment at a hospital where we have arrangements for making direct payments If you have your treatment at a hospital listed in our network of hospitals, we will pay the hospital directly for treatment covered by your policy. Always remember to contact us before you have your treatment so that we can set up any direct payment arrangements with the hospital before your visit. Paying claims for in-patient and day-patient treatment at other hospitals Your policy covers you for in-patient and day-patient treatment at other hospitals. There are some hospitals who we won’t pay for treatment. This is because they don’t meet our billing criteria, or because we do not recognise them. You should check if we will pay the facility or hospital before you have your treatment. The current list of unrecognised providers is available through your online portal at axaglobalhealthcare.com/customer or you can call us to check if we will pay a particular provider. We won’t reimburse you for treatment you pay for yourself with one of these providers. If you have treatment that you are covered for at a hospital that is not in our network of hospitals, we may be able to pay the hospital directly. Always remember to contact us before you have your treatment so that we can get in touch with the hospital you’ve chosen and try to arrange to pay them directly for your treatment. If you have the optional out-patient cover - Paying claims for out-patient treatment If you have out-patient treatment, most providers will ask you to pay for your treatment and then make your claim to us. However, some providers will allow you to have your out-patient treatment on the understanding that they will claim the cost back from us. You can search for an out-patient provider at: axaglobalhealthcare.com/customer. You may be asked to show your AXA membership card and a separate form of photo ID when you have your treatment. The treatments that we will cover directly at certain medical providers are: • GP/family doctor consultations • specialist consultations • minor diagnostic tests, for example x-rays or ultrasounds Page 20 [Seite 22] • blood tests • up to the first five sessions of physiotherapy (you will need to ask us to pre-approve further sessions) • vaccinations. If it turns out that your treatment is not covered, you will be asked to pay for the cost of the treatment. How should I claim if I have already paid for my treatment? If you want to claim for medical bills you have paid yourself, you must make your claim within six months unless that is not reasonably possible. Please contact us on the claims number or at axaglobalhealthcare.com/customer and we will explain how to claim. If you pay for any treatment yourself, always get a fully receipted invoice that shows how much you have paid for the treatment. You will need this if you want to claim, and for your own records. If your treatment is being provided as part of a package, we will reimburse the cost of the package once all treatment has taken place. If your treatment provider is able to provide a breakdown of the treatment you have received to date, we may be able to reimburse some of the costs before the package of treatment is complete. We may ask you to provide more information to support your claim, for example your card receipt or a copy of your statement. You must provide us with the information we ask for as soon as reasonably possible so that we can assess your claim. We will pay you for the cost of the treatment we cover. If it turns out that your treatment or part of it is not covered, we will not reimburse you for the cost of the treatment that is not covered. What happens if I receive a bill? If you receive a bill, please contact us on the claims number or at axaglobalhealthcare.com/customer We’ll explain how to send the bill to us so that we can assess it. What should I do if I need further treatment? If you need further treatment, please call us first to confirm your cover. What currency will I be paid in? We will pay you in the currency that you request when you make a claim. The currency must be in our list of currencies we can pay in. To see the list, go to the ‘How bills are paid’ page on axaglobalhealthcare.com We will use the exchange rate listed in the ICE foreign exchange rates on the day of your treatment for out-patient and day-patient treatment, and the day of your admission for in-patient treatment. Where there are currency or exchange rate controls in place, we may not use the rate listed in the ICE foreign exchange rates. In these circumstances, we may contact you to request evidence of the exchange rate used when you purchased the currency and we will use that exchange rate to reimburse you. Page 21 [Seite 23] Charges from your bank You should contact your own bank to find out if they will make any charges for you to send or receive money, or to exchange currency. Any charges from your bank are not covered by your policy. 2.2 > The information we may need when you make a claim When you call us, we will explain if your treatment is covered. Usually, this all happens very quickly. However, sometimes we need more detailed medical information, including access to your medical records. What does ‘more detailed information’ mean? We may need more detailed information in any of the following ways: • We may need your medical practitioner to send us more details about your medical condition. Your medical practitioner may charge you for providing this information. This charge is not covered by your policy. • We may also ask you to give us consent to access your medical records. • In some cases, we may also ask you to complete additional forms. We will need you to complete these forms as soon as possible, but no later than six months after your treatment starts (unless there is a good reason why this is not possible). • Very rarely, we may have to ask a medical practitioner to advise us on the medical facts or examine you. In these cases, we will pay for the medical practitioner to do this and will take your personal circumstances into account when choosing the medical practitioner. What happens if I don’t want to give the information you’ve asked for? If you do not give us information we ask for, or do not consent to our accessing your medical records when we ask, we will not be able to assess your claim and so will not be able to pay it. We may also ask you to pay back any money that we have previously paid to do with this medical condition. 2.3 > What if my treatment isn’t covered? If your policy does not cover your treatment, we will explain this and also tell you if there’s any other way we can support you. 2.4 > What happens if I need emergency treatment? If you need emergency treatment you may not be able to call us before you have the treatment. Simply call us or ask someone to call us as soon as you can. If you can, give your membership card to the hospital so that they can contact us whenever they need to. Page 22 [Seite 24] 3 How your policy works 3.1 > The types of drugs, treatments and How your policy works surgery that are covered For full details of how your policy works, please 3.2 > How your policy works with pre-existing read the rest of your handbook too. conditions and symptoms of them Any questions? 3.3 > How your policy works with conditions If you’re unsure how something works, please send that last a long time or come back (chronic us a message using your Customer Online account conditions) at axaglobalhealthcare.com/customer 3.4 > Who can provide your treatment It’s usually quicker and easier than working it out 3.5 > Hospitals where you can have your from the handbook alone. treatment Or you can call us on +44 (0)1892 503 856 and we’ll be very glad to explain. 3.6 > Accommodation we will pay for at the hospital where you are treated Making a claim 3.7 > Differences when you have your treatment If you would like to make a claim, please see in the UK section 2 Making a claim. 3.8 > General restrictions Page 23 [Seite 25] 3.1 > The types of drugs, treatments and surgery that are covered Your policy covers you for established medical treatments. We call these conventional treatments. There is no cover for any treatment or procedure that is experimental or that has not been established as being effective. What do you mean by conventional treatment? We define conventional treatment as treatment that: • is established as best medical practice in the country where the treatment is taking place; and • is clinically appropriate in terms of necessity, type, frequency, extent, duration and the facility where the treatment is provided; and • has been proven to be effective and safe for the treatment of your medical condition through high quality clinical trial evidence (full criteria available on request). Conventional treatment does not cost more than an equivalent treatment that delivers similar therapeutic or diagnostic outcome. It must not be provided or used primarily for the convenience or financial or other advantage of you or your medical practitioner or health professional. Are there any additional requirements for drug treatments? We will pay for the use of drugs that have been established as being effective. This means the drug must be licensed for use by either: • the Medicines and Healthcare products Regulatory Agency (MHRA) if the treatment is to be provided in the United Kingdom; or • the European Medicines Agency (EMA) if the treatment is to be provided in Europe, but outside of the United Kingdom; or • the US Food and Drug Administration (FDA) if the treatment is to be provided outside Europe. The drug must be used within the terms of its licence. Are there any additional requirements for surgical treatments? For a surgical procedure to be covered it must be listed in our Schedule of Procedures and Fees. To get a copy of the schedule, go to axaglobalhealthcare.com/en/members/how-bills-are-paid or call us on +44 (0)1892 503 856 What happens if my medical practitioner says I need surgery that is not conventional treatment? We will also pay for surgery not listed in our Schedule of Procedures and Fees if, before the treatment begins, it is established that the treatment is recognised as appropriate by an authoritative medical body. This means procedures and practices must have undergone appropriate clinical trial and assessment and be sufficiently evidenced in published medical journals. Page 24 [Seite 26] What is not covered? We will not pay for treatment that is not conventional treatment or which is experimental. You are not covered for complications that arise as a result of authorised or unauthorised unproven or experimental treatment. » To check whether we will agree to cover a treatment, please call us on +44 (0)1892 503 856 before you start treatment 3.2 > How your policy works with pre-existing conditions and symptoms of them Your policy is designed to cover treatment of new medical conditions that begin after you join. You may also be covered for treatment of conditions you were aware of or had already had when you joined. We call these conditions pre-existing conditions. Your cover for pre-existing conditions depends on the underwriting terms you joined on. Your healthcare insurance statement shows which underwriting terms you joined on. Here are the options: • Fully underwritten (or full medical underwriting) • Continuing medical exclusions • Moratorium. Definition of a pre-existing condition A pre-existing condition is any disease, illness or injury that: • you have received medication, advice or treatment for in the five years before the start of your cover, or • you have experienced symptoms of in the five years before the start of your cover, whether or not the condition was diagnosed. Underwriting terms We have explained how each set of underwriting terms work and what cover you have for pre-existing conditions in the following panels. If you are unsure about your cover for treatment of pre-existing conditions, it is always best to contact us. Definition of fully underwritten or full medical underwriting ‘Fully underwritten’ means we asked you for details of your medical history, including any pre-existing conditions, before you joined. We then worked out your cover based on the information we received. We list any special terms or exclusions on your healthcare insurance statement – please check this carefully. For example, you may not have cover for something specific if you have had that condition in the past. Your statement will also show whether we can remove the exclusion after a period of time. Page 25 [Seite 27] Definition of continuing medical exclusions If you joined us on ‘continuing medical exclusions’ terms, we are carrying on your exclusions for medical conditions from your previous health insurer. This normally means we only asked you a few brief medical questions. We listed any special terms or exclusions on your healthcare insurance statement – please check this carefully. For example, you may not have cover for something specific if you have had that condition in the past. Your healthcare insurance statement will also show whether we will remove the exclusion after a period of time. If we carried on a moratorium from your previous healthcare insurance, the rules of your moratorium may be slightly different, and we may start the moratorium from when it originally began on your previous insurance. Your healthcare insurance statement will show when your moratorium started. Definition of moratorium If you joined us on moratorium terms, it means that you do not have cover for treatment of medical problems you had in the five years before you joined us until: • you have been a member for two years in a row, and • you have had a period of two years in a row that have been trouble-free from that condition. If you joined us from another health insurer or from a company plan, and we carried on your moratorium from that insurer, the rules may be slightly different, and we may start the moratorium from when it originally began on your previous insurance. If you joined on moratorium terms, what do we mean by trouble-free? Trouble-free means that, for the medical condition you need treatment for, you have not: • had a medical opinion from a medical practitioner • taken medication (including over-the-counter drugs) • followed a special diet • had medical treatment • visited a medical practitioner, complementary practitioner, optician or dentist. Specified conditions that we do not cover If you joined us on moratorium terms and you had a pre-existing condition, we will not cover the pre-existing condition or the specified conditions listed in this table. Pre-existing condition at the time Specified conditions that we will not you join us cover whatever their cause You have been diagnosed with diabetes. Diabetes Ischaemic heart disease Cataract Diabetic retinopathy Page 26 [Seite 28] Diabetic renal disease Arterial disease Stroke You have had treatment for raised blood pressure Raised blood pressure (hypertension) in the five years before you joined. Ischaemic heart disease Stroke Hypertensive renal failure You have been under investigation, had treatment Any disorder of the prostate or undergone monitoring as a result of a Prostate Specific Antigen (PSA) test in the five years before you joined. What if you didn’t tell us about a condition, symptom or treatment you knew about when we asked? Whichever form of underwriting you joined on, we may have asked you some medical questions before agreeing your cover. We worked out your terms or your premium based on your answers. If you did not answer fully or accurately, even if this was by accident, we will not cover treatment for the condition. This means we will not cover treatment for any conditions that you should have told us about when we asked, but that you either did not tell us about at all, or that you did not tell us the full extent of. This includes: • any pre-existing or previous condition, whether you had treatment for them or not; or • any previous medical condition that recurs; or • any previous medical condition that you should reasonably have known about, even if you did not speak to a doctor. Whenever you claim, we may ask your medical practitioner for more information to confirm whether you had any symptoms before you joined. If we need to look at your medical history, we will need some time to do this before we can confirm whether we can cover your claim. 3.3 > How your policy works with conditions that last a long time or come back (chronic conditions) Your policy is designed to cover unexpected illnesses and medical conditions that respond quickly to treatment (acute conditions). It also covers you for in-patient treatment of flare ups, exacerbations, and complications of illnesses that recur, continue or require longer term treatment (chronic conditions) to return the chronic condition to its controlled state. Your cover for in-patient treatment of chronic conditions is limited to 120 days per admission. If you have the optional out-patient cover your policy also covers you for the following phases of treatment for chronic conditions: Page 27 [Seite 29] • initial investigations to establish a diagnosis • an initial period of treatment that allows the medical practitioner to establish their ongoing approach to treatment. What are acute conditions and chronic conditions? Acute condition – An acute condition is a disease, illness or injury that is likely to respond quickly to treatment which aims to return you to the state of health you were in immediately before suffering the disease, illness or injury, or which leads to your full recovery. Chronic condition – A chronic condition is a disease, illness or injury that has one or more of the following characteristics: • It needs ongoing or long-term monitoring through consultations, examinations, check-ups and/or tests • It needs ongoing or long-term control or relief of symptoms • It requires your rehabilitation, or for you to be specially trained to cope with it • It continues indefinitely • It has no known cure • It comes back or is likely to come back. What happens if you need recurrent or long-term treatment? Some conditions are likely to always need ongoing treatment or are likely to recur. This is particularly the case if the condition is likely to get worse over time. Examples of these conditions are Crohn’s disease (inflammatory bowel disease) and long-term depression. If you need recurrent or long-term treatment for a condition that means the condition has become chronic and is no longer covered. If the treatment you are receiving becomes recurrent or long-term, we will tell you when we will stop cover for treatment of the condition. 3.4 > Who can provide your treatment Your policy covers you for in-patient and day-patient treatment that is provided by medical practitioners. There are some medical providers who we won’t pay for treatment. These may be providers who don’t meet our billing criteria, or we do not recognise. You should check if we will pay the medical provider before you have your treatment. The current list of unrecognised providers is available through your online portal at axaglobalhealthcare.com/customer or you can call us to check if we will pay a particular provider. We won’t reimburse you for treatment you pay for yourself with one of these providers. Page 28 [Seite 30]  Extra cover if you have the optional out-patient cover If you have the optional out-patient cover, your policy also covers you for out-patient treatment that is provided by: • medical practitioners • complementary practitioners • physiotherapists. Treatment providers’ normal charges We will pay for their usual and customary charges for the treatment. We will pay for the usual and customary charges for one surgeon and one anaesthetist for each operation unless we have agreed a different arrangement with you before your operation. 3.5 > Hospitals where you can have your treatment The hospital where you have your treatment must be licensed as a medical or surgical hospital by the authorities in the country where the hospital is located. » See section 3.7 > for details of differences to this when you have your treatment in the UK. Facilities that are not covered Treatment at the following types of facilities is not covered even if they are registered as a hospital: • health hydro; or • spa; or • nature cure clinic; or • other similar facilities. There are some other medical providers who we won’t pay for treatment. These may be providers who don’t meet our billing criteria, or we do not recognise. You should check if we will pay the facility or hospital before you have your treatment. The current list of unrecognised providers is available through your online portal at axaglobalhealthcare.com/customer or you can call us to check if we will pay a particular provider. We won’t reimburse you for treatment you pay for yourself with one of these providers. 3.6 > Accommodation we will pay for at the hospital where you are treated If your treatment is covered by your policy, we will pay reasonable charges for a standard, single room with bath or shower. We will also pay for your standard menu choices. What is not covered at the hospital? We will not pay for: • upgrades to your room; or • food or drink choices that are not on the standard menu; or • costs that would not normally be charged to a person staying in a standard, single room with bath or shower; or Page 29 [Seite 31] • visitors’ accommodation or meals; or • special nursing unless we have agreed that it is necessary first. 3.7 > Differences when you have your treatment in the UK There are some differences to your cover in the UK to other countries. The differences affect where you can have treatment and limits on the charges we will pay. Where you can have treatment in the UK If you have treatment in the UK, you must use a hospital, day-patient unit or scanning centre listed in our UK Directory of Hospitals. The hospitals, day-patient units and scanning centres listed in our UK Directory of Hospitals have each signed an agreement with us that sets out the standards of clinical care and range of services they will provide, and the fees they will charge for services they provide to our members. You can get a copy of our UK Directory of Hospitals at axaglobalhealthcare.com/ukhospitals or by calling us on +44 (0)1892 503 856. Note that there are restrictions on where you can have oral or cataract surgery. Where you can have oral or cataract surgery in the UK If you need oral or cataract surgery in the UK, we will pay for treatment at a UK facility that has an agreement with us to provide oral or cataract surgery. What happens if I have treatment in the UK at a centre that is not listed in the UK directory of hospitals? If you have in-patient or day-patient treatment in the UK at a centre that is not listed in our UK Directory of Hospitals, we will only pay you a cash payment. You will have to pay all charges related to the treatment. Treatment Cash payment In-patient treatment at a centre not in our UK  £100 per night or Directory of Hospitals  $160 per night or  €125 per night Day-patient treatment at a centre not in our UK  £100 per day or Directory of Hospitals  $160 per day or  €125 per day A CT, MRI or PET scan at a centre not listed as a  £100 per visit or scanning centre in our UK Directory of Hospitals.  $160 per visit or CT = Computerised Tomography  €125 per visit MRI = Magnetic Resonance Imaging PET = Positron Emission Tomography Page 30 [Seite 32] What happens if it’s medically necessary that I have treatment in the UK at a centre that is not listed in the UK Directory of Hospitals? If it’s medically necessary that you have in-patient or day-patient treatment in the UK at a centre that is not listed in our UK Directory of Hospitals, please tell us before you have the treatment. We will review your case and may be able to pay your hospital charges, but you must have our written agreement to this before you have the treatment. Agreements with medical practitioners, physiotherapists and complementary practitioners on what we will pay in the UK In the UK, we have a schedule of procedures and fees that sets out the limits that we will pay medical practitioners, physiotherapists and complementary practitioners. If you do not call us prior to treatment we will pay up to the usual amount charged by medical practitioners, physiotherapists or complementary practitioners for that treatment. To get a copy of the schedule, go to axaglobalhealthcare.com/en/members/how-bills-are-paid or call us on +44 (0)1892 503 856  Extra cover if you have the optional out-patient cover Remember that you are only covered for out-patient treatment that is provided by medical practitioners, complementary practitioners and physiotherapists if you have the optional out-patient cover. Checking which anaesthetist will be involved in your treatment If an anaesthetist will be involved in your treatment, we recommend that you ask your medical practitioner for their name and call to tell us. We will check whether that anaesthetist tends to charge within our schedule of procedures and fees or more. Even if you don’t know the anaesthetist’s name, you should still call us as we will be able to check which anaesthetist your medical practitioner regularly works with and look at what they tend to charge. Always contact us before you have treatment, wherever you are in the world. 3.8 > General restrictions Written reports We will not pay for the cost of any written reports. Administration charges We will not pay for any administration charges. Treatment and referrals by family members We will not pay for drugs or treatment if the person who refers you or treats you is a member of your family. In-patient stays We will not pay for more than 120 days per admission for in-patient treatment. Page 31 [Seite 33] 4 Your cover for specific conditions, treatment, tests and costs There are particular rules for how we cover some conditions, treatments, tests and costs. This section explains what these are. You should read this section alongside the other sections of the handbook as the other rules of cover will also apply, for example our rules about pre-existing conditions, chronic conditions and who we pay. If you’re in any way unsure about the cover you have with the plan - even if you don’t need to claim for it at the moment – please send us a message using your Customer Online account axaglobalhealthcare.com/customer or just give us a call on +44 (0)1892 503 856. We’ll always be glad to explain your cover, and it’s often quicker and easier than working it out from the handbook alone. 4.1 > Advanced therapies astigmatism 4.2 > Alcohol abuse, drug abuse, substance abuse 4.21 >Mental health 4.3 > Artificial life maintenance 4.22 >Natural ageing 4.4 > Breast reduction 4.23 >Nuclear, biological or chemical 4.5 > Cancer contamination and war risks 4.6 > Chiropody and foot care 4.24 >Organ or tissue donation 4.7 > Consequences of previous treatment, 4.25 >Pregnancy and childbirth medical intervention or body modification 4.26 >Preventative treatment and screening tests 4.8 > Contraception 4.27 >Reconstructive surgery 4.9 > Cosmetic treatment, surgery or products 4.28 >Rehabilitation 4.10 >Criminal activity 4.29 >Self-inflicted injury and suicide 4.11 >Drugs and dressings for out-patient 4.30 >Sexual dysfunction treatment 4.31 >Sexually transmitted diseases/infections 4.12 >External prostheses and appliances 4.32 >Social, domestic and other costs unrelated 4.13 >Fat removal to treatment 4.14 >Gender re-assignment or gender 4.33 >Sports and activity related treatment confirmation 4.34 >Sterilisation 4.15 >Genetic tests 4.35 >Supplements 4.16 >Hormone replacement therapy (HRT) 4.36 >Teeth and dental conditions 4.17 >Infertility and assisted reproduction 4.37 >Treatment that is not medically necessary 4.18 >Kidney dialysis 4.38 >Varicose veins 4.19 >Learning and developmental disorders 4.39 >Weight loss treatment 4.20 >Long-sightedness, short-sightedness and Page 32 [Seite 34] Support when your health condition is complicated If your medical condition or diagnosis is complicated and you’re unsure about what’s happening, we can help. Our medical experts have lots of experience of complex medical cases. They’ll listen to what’s happening and suggest how they could help. They may recommend getting a second opinion from a specialist, or they may offer to manage your case on your behalf so you feel like you’re back in control. This service is run for us by specialist independent consultants with particular expertise in complex cases. 4.1 > Advanced therapies There are a complex set of advanced therapies, including gene therapies and CAR-T treatment for cancer. They are known by different names across the world, for example Advanced therapy medicinal products (ATMPs), Cellular and gene therapy products (CGTPs) or Regenerative medicine advanced therapy (RMAT). We only cover a small number of ATMPs/CGTPs/RMATs under your policy. You must call us before you start your treatment to make sure its covered. For more information and for the current list of the ATMPs/CGTPs/RMATs we cover please visit axaglobalhealthcare.com/advanced-therapies or call us. We don’t cover any ATMPs/CGTPs/RMATs that aren’t on the list at the time you need the treatment, including any associated hospital or specialist costs. The list is subject to change so you should always check and call us before you start any treatment. 4.2 > Alcohol abuse, drug abuse, substance abuse We do not cover treatment you need as a result of, or in any way connected to, alcohol abuse, drug abuse or substance abuse. 4.3 > Artificial life maintenance We do not cover artificial life maintenance for more than 60 continuous days if you are in a persistent vegetative state and only being kept alive by medical intervention such as mechanical ventilation. 4.4 > Breast reduction We do not cover either male or female breast reduction. 4.5 > Cancer This section explains how we cover cancer treatment. The cover described elsewhere in your handbook also applies to treatment of cancer. About your cover for cancer treatment We will cover investigations into cancer and treatment to kill cancer cells. We will cover active treatment of cancer for any new cancer that starts after you join. We will also cover that cancer if it comes back and you are still a member. If you have exclusions to do with cancer because of your past medical history, we will not cover your treatment if this cancer comes back. Page 33 [Seite 35] » For more details of how we cover treatment of pre-existing medical conditions, see section 3.2 > How your policy works with pre-existing conditions and symptoms of them Cash payment when there has been no charge for your treatment or your stay in hospital If you receive radiotherapy or chemotherapy treatment for free and your policy would have covered that treatment, we will make the following cash payment to you: • £50 a day up to £5,000 a year • $80 a day up to $8,000 a year • €60 a day up to €6,375 a year Your cancer cover Place of treatment If I have the optional If I do not have the out-patient cover am I optional out-patient covered? cover am I covered? Active treatment of cancer at a hospital  Yes  Yes If the treatment takes If the treatment takes place in the UK, this place in the UK, this includes treatment at a includes treatment at a hospital, day-patient unit hospital, day-patient unit or scanning centre that is or scanning centre that is in our UK Directory of in our UK Directory of Hospitals. Hospitals. Chemotherapy by intravenous drip at  Yes, when agreed by  Yes, when agreed by home our clinical team. our clinical team.  Paid in full for up to 14  Paid in full for up to 14 days a year. days a year. Treatment at a hospice  No  No Diagnostic If I have the optional If I do not have the out-patient cover am I optional out-patient covered? cover am I covered? Page 34 [Seite 36] Specialist fees for the specialist treating  Yes  Yes your cancer If the consultations are Consultations after your before your diagnosis they diagnosis are covered as are covered as part of your part of your overall overall out-patient limit. day-patient and Consultations after your in-patient limit. diagnosis are covered as  Consultations as an part of your overall out-patient before day-patient and in-patient your diagnosis are not limit. covered. Diagnostic tests relating to cancer  Yes  Yes, when they are If the tests are before your done as an in-patient diagnosis they are covered or day-patient. as part of your overall Out-patient tests after out-patient limit. your diagnosis are covered Tests after your diagnosis as part of your overall are covered as part of your day-patient and overall day-patient and in-patient limit. in-patient limit.  Out-patient diagnostic tests before your diagnosis are not covered Surgery as shown below under ‘Surgery’  Yes  Yes CT, MRI and PET scans  Yes  Yes Genetic testing proven to help choose the  Yes  Yes appropriate chemotherapy » See section 3.1 > for more about effective treatment and 4.26 > Preventative treatment, genetic tests and screening tests Genetic testing to work out whether you  No  No have a genetic risk of developing cancer Surgery Surgery for the treatment or diagnosis of  Yes cancer, so long as that treatment has been shown to be effective » See section 3.1 > for more about effective treatment Page 35 [Seite 37] New or experimental surgical procedures Please contact us before having any new or experimental surgical procedures so that we can discuss the proposed procedure with you. We will write to tell you what we agree to pay for before your treatment starts. We will only pay up to the equivalent non-experimental surgical procedure as listed in the schedule of procedures and fees. To get a copy of the schedule, go to axaglobalhealthcare.com/en/members/how-bills-are-paid or call us on +44 (0)1892 503 856 Complications that arise from new or  No – even if we agreed to cover the procedure itself experimental surgical procedures Reconstructive surgery following breast cancer The first reconstructive surgery following  Yes surgery for breast cancer. We will cover: We will do this so long as: • one planned surgery to reconstruct the • you had continuous cover under a private medical diseased breast insurance policy since before the surgery happened • nipple tattooing, up to 2 sessions and; • one planned surgery to reconstruct the • we agree the method and cost of the treatment in nipple writing beforehand After the completion of your first  Yes reconstructive surgery, we will also cover: Symmetry and fat transfer operations must take place • one further planned surgery to the within three years of your first reconstructive surgery. The other breast, when it has not been removal and exchange of radiotherapy damaged implants operated on, to improve symmetry must take place within five years of you completing your • two planned fat transfer surgeries. The radiotherapy treatment. fat must be taken from another part of We will only pay for each of these operations once (or two your body and cannot be donated by fat transfer surgeries), regardless of how long you remain anyone else a member of a plan arranged by the AXA Global • one surgery to remove and exchange Healthcare Group. implants damaged by radiotherapy treatment for breast cancer If you choose not to have reconstructive  Yes surgery following treatment of breast No further reconstructive surgery will be covered on cancer, we will cover the cost of one either the diseased breast or the unaffected breast planned surgery to the unaffected breast to improve symmetry Page 36 [Seite 38] We do not cover treatment that is See also 4.9 > Cosmetic treatment, surgery or products connected to previous reconstructive surgery or any cosmetic operation to a reconstructed breast Preventative If I have the optional If I do not have the out-patient cover am I optional out-patient covered? cover am I covered? Preventative treatment, such as:  No  No Screening when you do not have symptoms of cancer. For example, if you had a screen to see if you have a genetic risk of breast cancer, we would not cover the screening or any treatment to reduce the chances of developing breast cancer in future (such as a preventative mastectomy). Vaccines to prevent cancer developing or  Yes  No coming back – such as vaccinations to Vaccines are covered as prevent cervical cancer part of your out-patient vaccination cover. Drug therapy Drug treatment to kill cancer cells –  Yes including: There is no time limit on how long we cover these • biological therapies, such as Herceptin drugs. or Avastin We will cover them if: • chemotherapy • they have been licensed by: o the Medicines and Healthcare products Regulatory Agency if you are receiving treatment in the United Kingdom; or o the European Medicines Agency if you are receiving treatment in Europe, but outside of the United Kingdom; or o the Food and Drug Administration if you are receiving treatment anywhere else in the world • they are used according to their licence, and • they have been shown to be effective. The drugs we cover will change from time to time to reflect any changes in drug licences. Please call us to find out the latest treatments that we cover. Page 37 [Seite 39] Chemotherapy and/or biological drug  Yes treatment to prevent a recurrence of cancer or to maintain remission Experimental drugs If you take part in a randomised clinical trial that the appropriate ethics committee has approved, we will pay for your stay in hospital and specialist’s fees while you are receiving the experimental drug. You need to call us before treatment so we can agree costs and cover in writing. There may be information we need you to provide before we can agree costs. For example, we will need you to provide us with a copy of your trial acceptance forms. Other drugs.  Yes. They are covered as long as you have them at the We cover: same time as you are having chemotherapy or biological therapy to kill cancer cells covered by your • Bone strengthening drugs such as policy. bisphosphonates or Denosumab • Hormone therapy that is given by injection (for example goserelin, also known as Zoladex) Drugs for treating conditions secondary to  Yes, while you are having chemotherapy that is covered cancer, such as erythropoietin (EPO) by your policy. Out-patient drugs or other drugs that a  No. medical practitioner could prescribe Advanced therapy medicinal products  Yes (ATMPs), Cellular and gene therapy We cover a small number of approved products (CGTPs) and Regenerative ATMPs/CGTPs/RMATs. For the current list of medicine advanced therapy (RMATs) ATMPs/CGTPs/RMATs that we cover, please see axaglobalhealthcare.com/advanced-therapies or call us. >> see section 4.1 > for more information on advanced therapies Page 38 [Seite 40] Radiotherapy Radiotherapy including when it is used to  Yes relieve pain Proton beam therapy (PBT)  Yes We will pay PBT for: • malignant solid cancers in members aged 21 and under • central nervous system (brain and spinal cord) cancer • chordomas or chondrosarcomas (types of spine cancer) in the base of the skull or cervical spine (neck bones) which have not spread (metastasised) • high naso-ethmoid, frontal and sphenoid tumours with base of skull involvement • adenoid cystic carcinoma with perineural invasion • esthesioneuroblastoma • cancer of the iris, ciliary body or choroid parts of the eye (uveal melanoma) which has not spread (metastasised) • conjunctival melanoma • choroidal haemangioma Accelerated charged particle therapies  No However, there is limited cover for Proton Beam Therapy in the circumstances shown above. Palliative Care to relieve pain or symptoms rather  Yes. We will provide cover and support throughout than cure the cancer your cancer treatment even if it becomes incurable. We cover radiotherapy, chemotherapy and surgery (such as draining fluid or inserting a stent) to relieve pain. End of life care End of life care  No Page 39 [Seite 41] Monitoring If I have the optional If I do not have the out-patient cover am I optional out-patient covered? cover am I covered? Follow ups – cover for follow up  Yes, so long as you are  No consultations and reviews for cancer still a member and have a policy that covers this. This is paid from your cover for out-patient treatment. Limits Time limits on cancer treatment. There is a limit of 120 days per in-patient admission on Your policy covers you while you are this policy. having treatment to kill cancer cells and for monitoring. If you have the out-patient upgrade, your policy also covers monitoring. Money limits on cancer treatment. No specific limits- the same rules apply to your cancer treatment as for any other treatment. Other cover Stem cell or bone marrow treatment  Yes If you plan to donate tissue as a live donor or receive tissue from a live donor, please call us so we can tell you what support we offer. We do not cover any related administration costs. For example, we will not cover transport costs or the cost of finding a donor. » See section 4.24 > Organ or tissue donation for more about this 4.6 > Chiropody and foot care We will not cover any general chiropody or foot care, even if a surgical podiatrist provides it. This includes things like gait analysis and orthotics. 4.7 > Consequences of previous treatment, medical intervention or body modification If you had treatment, medical intervention or body modification previously that would not be covered by your policy, we do not cover further treatment or increased treatment costs that are: • a result of the treatment, medical intervention or body modification you had previously; or • connected with the treatment, medical intervention or body modification you had previously. Page 40 [Seite 42] 4.8 > Contraception We do not cover contraception or any consequence of using contraception. 4.9 > Cosmetic treatment, surgery or products We do not cover: • Cosmetic treatment or cosmetic surgery; or • Treatment that is connected to previous cosmetic treatment or cosmetic surgery; or • Treatment that is connected with the use of cosmetic (beauty) products or is needed as a result of using a cosmetic (beauty) product. whether it is needed for medical or psychological reasons. » See also 4.13 > Fat removal and 4.27 > Reconstructive surgery 4.10 > Criminal activity We do not cover treatment you need as a result of your active involvement in criminal activity. 4.11 > Drugs and dressings for out-patient treatment We do not cover drugs and dressings for out-patient treatment.  Extra cover if you have the optional out-patient upgrade If you have the optional out-patient upgrade, we will cover vaccinations and drugs and dressings. » See also 4.35 > Supplements 4.12 > External prostheses and appliances We cover: • the cost of wigs or other temporary head coverings and external prostheses needed during active treatment of cancer; • the cost of spinal supports, knee braces and pneumatic walking boots if they are a part of a surgical procedure or integral to the treatment of a condition you are covered for; • up to the limits shown in the benefits table towards the cost of an external prosthesis needed following an accident or surgery for a medical condition. We will do this so long as: • you had continuous cover with us before the accident or surgery happened that has led to the need for the prosthesis; and • all claims are made within 12 months of the amputation or removal of the body part. If you want to claim this benefit you should call us on +44 (0) 1892 503 856 and we will explain what to do next. Please remember to ask the provider of your external prosthesis for a fully itemised receipt as we cannot pay claims without a receipt. What is not covered? We do not cover the costs of providing or fitting external prostheses or appliances needed for any other reason. Prostheses and appliances include items such as crutches, joint supports and orthotics. Page 41 [Seite 43] 4.13 > Fat removal We do not cover the removal of fat or surplus tissue, such as abdominoplasty (tummy tuck), whether the removal is needed for medical or psychological reasons. » See also 4.9 > Cosmetic surgery 4.14 > Gender re-assignment or gender confirmation What is not covered? We do not cover gender re-assignment or gender confirmation treatment. We will not cover any of the following when they are connected to gender reassignment or gender confirmation in any way: • gender reassignment operations or other surgical treatment; or • psychotherapy or similar services; or • any other treatment. 4.15 > Genetic tests What is covered for genetic tests? We will pay for genetic testing when it is proven to help choose the best course of drug treatment for your medical condition. This means that it must be recommended in the drug licence for a specific targeted therapy, such as HER2 testing for the use of Herceptin for breast cancer. We do not cover genetic tests: • to check whether you have a medical condition when you have no symptoms or if you have a genetic risk of developing a medical condition in the future; or • to find out if there is a genetic risk of you passing on a medical condition; or • where the result of the test wouldn’t change the course of treatment. This might be because the course of treatment for your symptoms will be the same regardless of the result of the test or what medical condition has caused them; or • that themselves are unproven or where they are used to direct treatment that is not established as being effective or is unproven.  Please call us before you have any genetic tests to confirm that we will cover them. Your medical practitioner may want to do a variety of tests and they might not all be covered. The cost to you could be significant if the tests aren’t covered under your policy. » See section 4.26 > Preventative and screening tests 4.16 > Hormone replacement therapy (HRT) We cover the cost of hormone replacement therapy (HRT) implants that are required following a medical intervention.  Extra cover if you have the optional out-patient cover. If you have the optional out-patient cover, we will pay for the associated medical practitioner’s consultations up to the limits shown in the benefits table. Page 42 [Seite 44] What is not covered? We do not cover patches and tablets for Hormone Replacement Therapy (HRT). 4.17 > Infertility and assisted reproduction We do not cover investigations or treatment of infertility and assisted reproduction. This includes: • treatment to prevent future miscarriage; or • treatment to increase fertility; or • investigations into miscarriage; or • assisted reproduction; or • anything that happens, or any treatment you need, as a result of these treatments or investigations. 4.18 > Kidney dialysis We cover kidney dialysis in the following situations: • for up to six weeks if you are being prepared for kidney transplant. What is not covered? We do not cover regular or long-term kidney dialysis if you have chronic kidney failure. » See also 4.24 > Organ or tissue donation 4.19 > Learning and developmental disorders We do not cover any treatment, investigations, assessment or grading to do with: • learning disorders • educational problems • behavioural problems • physical development • psychological development • speech delay. Some examples of the conditions we do not cover are the following (please call if you would like to know if a condition is covered): • dyslexia • dyspraxia • autistic spectrum disorder • attention deficit hyperactivity disorder (ADHD) • speech and language problems, including speech therapy needed because of another medical condition. 4.20 > Long-sightedness, short-sightedness and astigmatism We cover treatment of astigmatism only if the astigmatism is due to surgical replacement of the lens of the eye. Page 43 [Seite 45] What is not covered? We do not cover any other treatment to correct astigmatism. We do not cover any treatment to correct long-sightedness or short-sightedness. 4.21 > Mental health We will cover treatment for psychiatric illness as an in-patient or day-patient.  Extra cover if you have the optional out-patient cover If you have the optional out-patient cover, your policy also covers you for treatment for psychiatric illness as an out-patient. We will cover you for up to 100 days for treatment as an in-patient at a hospital providing evidence based treatment of psychiatric illness with 24 hour medical supervision. We will only pay for a maximum of 100 days regardless of how long you remain a member of a plan arranged by the AXA Global Healthcare Group. All the other conditions of your policy still apply to this cover. What happens if I need to go into hospital for a psychiatric condition? If you need to go into hospital for in-patient or day-patient treatment of a psychiatric condition, you or a family member must contact us to check your cover before you go in. If your treatment is covered, we will contact the hospital to ask them for a medical report. We will also arrange for the hospital to send the bills for your treatment directly to us. If the hospital is in the UK, they will contact us to check your cover before you go in. What if my condition goes on for a long time? If you need to stay in hospital for longer than initially agreed, we will ask your medical practitioner why you need further treatment, and let you know if we agree to cover the extended stay. What is not covered? We do not cover any treatment connected in any way to: • an injury you inflicted on yourself deliberately • a suicide attempt • alcohol abuse • drug or substance abuse. We do not cover any treatment at a health hydro, spa, nature cure clinic or other similar facility, even if it is registered as a hospital. 4.22 > Natural ageing We do not pay for treatment of symptoms generally associated with the natural process of ageing. This includes treatment for the symptoms of puberty and menopause which are not caused by another disease, illness or injury. Page 44 [Seite 46] 4.23 > Nuclear, biological or chemical contamination and war risks We do not cover treatment you need as a result of nuclear, biological or chemical contamination. We do not cover treatment you need as a result of your active involvement in war (declared or not), an act of a foreign enemy, invasion, civil war, riot, rebellion, insurrection, revolution, overthrow of a legally constituted government, explosions of war weapons, or any similar event. We do not cover treatment you need because you have put yourself in needless peril, such as going to a place of unrest as an onlooker. We do cover treatment due to a terrorist act so long as the act does not cause nuclear, biological or chemical contamination. 4.24 > Organ or tissue donation If you plan to donate an organ or tissue as a live donor or receive an organ or tissue from a live donor, please call us so that we can tell you what support we offer. What is not covered? We do not pay for: • the cost of collecting donor organs or tissue; or • any related administration costs – for example, the cost of searching for a donor; or • any costs towards organ or tissue donation that is not done in line with appropriate regulatory guidelines. 4.25 > Pregnancy and childbirth What is not covered for pregnancy and childbirth We do not cover the antenatal consultations, postnatal consultations, monitoring and screening that you will have during routine pregnancy and childbirth. We do not cover routine childbirth. What is covered for pregnancy and childbirth? We cover treatment you need for medical conditions related to your pregnancy and childbirth. The treatment is covered up to the limits that apply in the rest of this policy. Examples of medical conditions related to pregnancy and childbirth that we cover are: • ectopic pregnancy (pregnancy where the embryo or foetus grows outside the womb) • hydatidiform mole (abnormal cell growth in the womb) • retained placenta (afterbirth retained in the womb) • eclampsia (a coma or seizure during pregnancy and following pre-eclampsia) • postpartum haemorrhage (heavy bleeding in the hours and days immediately after childbirth) • miscarriage requiring immediate surgical treatment. Please always call us to check what you are covered for before starting any private treatment for pregnancy or childbirth that you intend to claim for. Page 45 [Seite 47] Adding a baby to your policy If you have a baby, we can often add them to your policy from birth. However, if you have a multiple birth and either parent has had fertility treatment, the pregnancy followed assisted reproduction, or you have held your policy for less than 10 months we will need to medically underwrite the babies. Please call us for more details. If you want to add a baby to your policy, you must tell us within three months of the baby’s birth. If you want to add the baby when they are older than three months, we may need to underwrite their cover separately. » See 5.1 > Adding a family member or baby 4.26 > Preventative treatment and screening tests Health insurance is designed to cover problems that you’re experiencing at the moment, so it generally doesn’t cover preventative treatment, genetic tests or screening tests. What is not covered for preventative treatment or screening tests? We do not pay for: • preventative treatment, such as preventative mastectomy; or • routine preventative examinations and check-ups; or • tests to check whether you have a medical condition when you have no symptoms; or • you have a risk of developing a medical condition in the future; or • there is a risk of you passing on a medical condition; or • tests where the result of the test wouldn’t change the course of treatment. This might be because the course of treatment for your symptoms will be the same regardless of what medical condition has caused them; or • preventative treatment or screening tests that are unproven or where they are used to direct treatment that is not established as being effective or is unproven; or • any other preventative treatment to see whether you have a medical condition if you do not have any symptoms. If you’re unsure whether your treatment is preventative or not, please call us before going ahead with the treatment. » See section 4.15 > Genetic tests 4.27 > Reconstructive surgery We cover reconstructive surgery in certain circumstances as detailed below. What is covered? We will cover your first reconstructive surgery following an accident or surgery for a medical condition that was covered by your policy. We will do this so long as: • you had continuous cover with us before the accident or surgery happened; and • we agree the cost of the treatment in writing beforehand. Page 46 [Seite 48] Please call us before agreeing to reconstructive surgery so we can tell you if you are covered. What is not covered? We do not cover treatment that is connected to previous reconstructive surgery or any cosmetic operation. » See also 4.5 > Cancer for details of the cover for breast reconstruction and 4.9 > Cosmetic surgery 4.28 > Rehabilitation We do cover in-patient rehabilitation for a short period, but there are some limits to our cover. What is covered for rehabilitation? We will cover in-patient rehabilitation for up to 28 days per event, so long as: • it follows an acute brain injury, such as a stroke; and • it is a part of treatment that is covered by your policy; and • it takes place in a hospital or unit that specialises in rehabilitation; and • a medical practitioner who specialises in rehabilitation is overseeing your treatment; and • we have agreed the costs before you start rehabilitation; and • the treatment could not be carried out on an out-patient basis. If you have severe central nervous system damage following external trauma or accident, we will extend this cover to up to 180 days of in-patient rehabilitation. What is not covered for rehabilitation? We do not cover day-patient rehabilitation. We do not cover treatment as an in-patient that you could have as an out-patient. This includes rehabilitation. If you need rehabilitation, please call us so we can tell you if you are covered. 4.29 > Self-inflicted injury and suicide We do not cover treatment you need as a direct or indirect result of a deliberately self-inflicted injury or a suicide attempt. 4.30 > Sexual dysfunction We do not cover treatment for sexual dysfunction or anything related to sexual dysfunction. 4.31 > Sexually transmitted diseases/infections We do not cover treatment for sexually transmitted diseases/infections. 4.32 > Social, domestic and other costs unrelated to treatment We do not cover the costs that you pay for social or domestic reasons, such as but not limited to travel or home help costs. This includes if your in-patient stay is extended for a reason not related to your treatment and you could have that treatment as an out-patient. Page 47 [Seite 49] We do not cover costs where you are required to quarantine but have no medical need for treatment or care as an in-patient. This includes state mandated quarantine even if it takes place in a hospital.  Extra cover if you have the optional out-patient cover If you have the optional out-patient cover, we will cover the costs of home visits that are necessary because of the sudden onset of an acute condition that means you’re not able to have your treatment or consultation in a medical clinic or consulting room or be assessed via telephone or virtual consultation. 4.33 > Sports and activity related treatment We do not cover treatment of injuries that are as a result of training for or taking part in any sport for which you: • are paid; or • receive a grant or sponsorship (we do not count travel costs in this); or • are competing for prize money. We do not cover treatment of injuries that are sustained when taking part in the following sports and activities: • base jumping • cliff diving • flying in an unlicensed aircraft • free climbing • scuba diving to a depth of more than 10 metres, or to a depth of more than 30 metres if you hold an appropriate diving qualification or you are being instructed by an appropriately qualified diving instructor, for example an instructor recognised by PADI (Professional Association of Diving Instructors) • any activity at a height of over 5,000 metres above sea level • canyoning • skiing off piste, or any other winter sports activity carried out off piste without an instructor with the appropriate qualifications. 4.34 > Sterilisation We do not cover: • sterilisation, or any consequence of being sterilised; or • reversal of sterilisation, or any consequence of a reversal of sterilisation. 4.35 > Supplements What is covered? We will cover the cost of vitamins to be administered by injection or infusion in case of a confirmed vitamin deficiency that requires medical management Page 48 [Seite 50] What is not covered? We do not cover any other supplements or substances that are available naturally, such as oral vitamins, minerals and organic substances. 4.36 > Teeth and dental conditions What dental treatment is covered? We cover dental treatment such as fillings. » See also dental treatment in section 1.4 > Your cover for details of the limits on your dental cover We do not cover: • check ups • scale and polish • cosmetic treatment • treatment that’s needed because you have not had at least one dental check-up every year, for example treatment for gingivitis and periodontitis • costs for treatment that has not yet taken place, even if it is being provided as part of a treatment package. What dental treatment is covered following accidental damage? We will cover dental treatment needed following accidental damage caused by external impact to the mouth and jaw when: • you had continuous cover with us before the accidental damage happened; and • we agree the cost of the dental treatment before it takes place. We will pay for: • the reasonable cost of replacing a crown, bridge-facing, veneer or denture with a replacement of equivalent quality to the original device • implants needed for clinical reasons (not cosmetic) – we will pay up to the cost of equivalent dental work to supply and fit a bridge • replacement dentures as long as you were wearing them when you suffered the injury. We will only pay for treatment if you noticed the damage within seven days of the accidental damage taking place and the treatment takes place within 18 months. We do not cover: • treatment needed following damage caused by any of the following: • normal wear • eating or drinking something, even if it contains a foreign body • boxing or playing rugby (except tag rugby) without wearing suitable mouth protection • brushing your teeth or any other oral hygiene procedure. 4.37 > Treatment that is not medically necessary Like most health insurers, we only cover treatment that is medically necessary. We do not cover treatment that is not medically necessary, or that can be considered a personal choice. Page 49 [Seite 51] 4.38 > Varicose veins We do cover treatment of varicose veins, but only in certain circumstances. What is covered? We will cover one surgical procedure per leg to treat varicose veins. This may be foam injection (sclerotherapy), ablation or other surgery. We will cover one follow up consultation with your medical practitioner and one simple injection sclerotherapy per leg to treat residual or remaining veins when it is carried out in the 6 months after you’ve had the main surgical procedure. What’s not covered? We do not cover more than one surgical procedure per leg, regardless of how long you stay a member on a plan arranged by the AXA Global Healthcare Group. There is no cover for the treatment of recurrent varicose veins under your policy. There is no cover for the treatment of thread veins or superficial veins. 4.39 > Weight loss treatment What is not covered? We do not cover weight loss treatment. We do not cover any fees for any kind of bariatric (weight loss) surgery or weight loss treatment, regardless of why the surgery or treatment is needed. This includes fitting a gastric band, creating a gastric sleeve, or other treatment. Page 50 [Seite 52] 5 Managing your policy 5.1 > Adding a family member or baby 5.2 > Making changes to your cover 5.3 > Paying your premium 5.4 > Paying your excess 5.5 > Cancelling your policy 5.6 > Keeping us informed 5.7 > Why premiums change 5.8 > Making a complaint Page 51 [Seite 53] 5.1 > Adding a family member or baby To add a family member or baby to your cover, call us on +44 (0)1892 503 856 and we will talk you through how it works. Who you can add You can apply to add the following family members to your policy: • Your partner in marriage, in a civil partnership, or when living together permanently in a similar relationship. (There may be certain circumstances where we cannot add a partner.) • Any of your children or your partner’s children. • A new baby. Adding a new baby If you would like to add a new baby to your cover, you can do this from their date of birth so long as you call us within three months of their birth. We will not normally need details of their medical history. There may be some limits to our cover if any of the following apply: • either parent has had any kind of fertility treatment and the babies are a multiple birth; or • the babies are a multiple birth and were born after assisted reproduction; or • you have adopted the baby; or • you add a baby within 10 months of your policy start date We have explained these limits in the following paragraphs. Babies born after fertility treatment, or following assisted reproduction, or who you have adopted, or who you add within 10 months of your policy start date You can add a baby born after fertility treatment, or following assisted reproduction (such as IVF), or who you’ve adopted, to your policy. As with most health insurance, our cover for treatment has a few limits in these situations. If you have adopted a baby, or if you have a multiple birth after fertility treatment or following assisted reproduction: • we may ask for more details of the baby’s medical history • we will not cover treatment in a Special Care Baby Unit or paediatric intensive care immediately after the birth • we may add other conditions to the baby’s cover. For example, we may limit their cover for pre-existing conditions. We count fertility treatment as either parent taking any prescription or non-prescription drug or other treatment to increase fertility. If you add a baby within 10 months of your policy start date: • we will ask for details of the baby’s medical history • we may add other conditions to the baby’s cover. For example, we may limit their cover for pre- existing conditions. Page 52 [Seite 54] 5.2 > Making changes to your cover You can normally make changes to your cover, such as changing your excess, during the cooling off period or when you renew. Please call us so we can talk about the options available to you. Depending on your underwriting style, any pre-existing medical conditions you have and any medical conditions that have developed since you joined, there may be some restrictions or limitations to the cover you can add. 5.3 > Paying your premium When you join, and shortly before your policy is up for renewal, we’ll let you know how much your premium will be. You can then choose to pay a yearly, quarterly or monthly premium. How can I pay my premium? You can pay in any of the following ways: • yearly, quarterly or monthly by Direct Debit if you have a UK bank account – payment will be in Sterling • yearly, quarterly or monthly by credit card • yearly or quarterly by cheque. Your policy documents will tell you exactly when we will collect your payments, or how to send in your cheque. What happens if I miss a payment? It is important that you pay your premium when it is due. If you miss a payment, we will cancel your policy and we will not pay any claim for any treatment that you had after the payment was due. If you have stopped paying for your policy, or you have missed or think you will miss a payment, please call us on +44 (0)1892 503 856. We will talk to you about your payment options or alternative cover options. Charges from your bank You should contact your own bank to find out if they will make any charges for you to send or receive money, or to exchange currency. Any charges from your bank are not covered by your policy. 5.4 > Paying your excess Your healthcare insurance statement will tell you if your policy has an excess and how much it is. This section tells you how to pay it. If your policy has an excess If your policy has an excess, you can see the amount on your healthcare insurance statement. Here is how excesses work: • We will take your excess off the amount covered by your policy for the first claim for each person in each year. For example, if the claim was covered for £800, and the excess was £100, we would pay £700. • If your claim is for a treatment that has a limit, we will apply the limit before we take the excess off. Page 53 [Seite 55] • We count the treatment costs for each year according to the date the treatment took place. • Even if treatment costs less than your excess, please tell us about it so we can make sure we take this into account if you claim again that year. • The excess applies per person. So, if two people covered by your policy make a claim, we will take the excess off both their claims. • It may take several claims before the full amount of the excess is paid. • Once the full amount of an excess has been paid in a year, we will not take it off any further claims in that year. • It does not matter whether you claim several times for the same medical condition, or for several medical conditions. • The excess applies for each year. This means that if you incur costs during this year, we will take the excess off what we pay for your claim. If you then incur more costs in the next year, even if it’s for the same condition, we will take the excess off that claim. • If your claim goes over your renewal, we will take the excess off the amount we pay for your claim before renewal, then we will take the excess off the amount we pay for your claim after renewal. • If you have any questions about how your excess works, please call us on +44 (0)1892 503 856. Claims that you do not have to pay an excess for If you claim for any of the following, you will not need to pay an excess: • cash payment when there has been no charge for your treatment or your stay in hospital • external prosthesis • evacuation or repatriation service • cash payment if you have free chemotherapy or radiotherapy • any claim for dental treatment (unless the claim relates to accidental damage, in which case you will have to pay an excess) • any claim for wigs or other temporary head coverings • Virtual Doctor service If you would like to change or add an excess Adding an excess, or increasing the amount of your excess, helps to lower your premium. If you would like to change or add an excess, you can normally do this: • during your cooling off period; or • when you renew. Call us on +44 (0)1892 503 856 and we will set this up for you. 5.5 > Cancelling your policy Cancelling your policy during the cooling off period You have a legal right to cancel your policy up to 14 days from the day that your contract is concluded, or the day that you receive the full policy terms and conditions, whichever comes later. This is known as the cooling off period. If you cancel your policy during this period, you will not have to pay anything, as long as you have not made a claim within that period. Page 54 [Seite 56] If you make a claim and we pay for your treatment during your cooling off period, we have a right to take payment for the services that we have provided. This means we may take some costs off any amount we refund to you. If you do not cancel your policy within the cooling-off period your policy will continue for a year so long as you continue paying your premiums. Cancelling your policy outside of the cooling off period After your cooling off period: • If you pay monthly, you can cancel your policy from the next monthly payment date. • If you pay quarterly, you can cancel your policy from the next payment date. • If you pay annually, you can cancel your policy and receive a pro-rata refund based on whole months remaining in the year. We will deduct an administration fee of £50/$70/€55 and the costs of any claims for that year. If you cancel during the year we will not pay for any claim for treatment you were given after the date of cancellation. Please call us on +44 (0) 1892 503 856 to cancel your policy or discuss other options. 5.6 > Keeping us informed If any of your personal details change, it’s important that you let us know as soon as possible. If you’re unsure whether the change is important, it’s best to tell us and we can explain if it affects your policy. Change of country of residence You must tell us if there’s a change of country of residence. We are not able to provide insurance in some countries, so it’s your responsibility to check that your cover is still valid if you move. Changes to any details you give us when you join If you send us any form, and anything changes between the time you send the form and the time we confirm that we have made the change shown in the form, you must tell us. This includes if there’s a change in your country of residence. 5.7 > Why premiums change Premiums for health insurance tend to increase every year, regardless of which health insurance company you use. Why does my premium increase every year? There are a number of reasons why the cost of your healthcare insurance could increase. We review premiums each year and make calculations based on a number of factors. Two of the more common reasons are because: • Your premium will tend to rise as you get older. This is because, unfortunately, as we get older we all tend to suffer more health issues • The cost of medical treatment tends to rise too as new and better ways of diagnosing and treating diseases are developed. We regularly review our plans to keep them up to date and to include new tests and treatments where we can. Page 55 [Seite 57] What happens if my premium is to change? Your premium will only change at renewal or if something changes, such as adding a new baby, during the year. We will tell you about any changes to your premium in plenty of time. Is there anything I can do to reduce my premium? There are a few things that you may be able to do to reduce your premium. For example you can: • add an excess, or set a higher excess • remove the out-patient optional upgrade . Please call us on +44 (0)1892 503 856 and we can talk about your options. 5.8 > Making a complaint Our aim is to make sure you’re always happy with your policy. If things do go wrong, it’s important to us that we put things right as quickly as possible. Making a complaint If you want to make a complaint, you can call us or write to us using the contact details below. To help us resolve your complaint, please give us the following details: • your name and policy number • a contact phone number • the details of your complaint • any relevant information that we may not have already seen. Please call us on +44 (0)1892 503 856, email us at AGHCustomerRelations@axa.com or write to: AXA Global Healthcare Phillips House, Crescent Road, Tunbridge Wells, Kent England TN1 2PL Answering your complaint We’ll respond to your complaint as quickly as we can. The Financial Services and Pensions Ombudsman If you are unhappy with the way we have dealt with your complaint, you may be able to refer the matter to: Financial Services and Pensions Ombudsman, Lincoln House, Lincoln Place, Dublin 2, D02 VH29. Tel - +353 1 567 7000. Email - info@fspo.ie Web - www.fspo.ie Page 56 [Seite 58] Your legal rights None of the information in section 5.8 > Making a complaint, affects your legal rights. Page 57 [Seite 59] 6 Legal information 6.1 > If you change your country of residence 6.2 > Rights and responsibilities 6.3 > Our authorisation and regulation details 6.4 > Your personal information 6.5 > What to do if somebody else is responsible for part of the cost of your claim 6.6 > What to do if your claim relates to an injury or medical condition that was caused by another person Page 58 [Seite 60] 6.1 > If you change your country of residence Your policy is underwritten by AXA Insurance dac, an EU based insurer. This means that if your country of residence changes to outside the European Economic Area it may not be possible for us to continue legally to meet our obligations under your policy when you move. In these circumstances we may cancel your policy from the date that you change your country of residence or on a specified date as agreed between us and you shall have a right to a pro-rata refund of the premium for any unused portion of your policy. We will endeavour to continue your cover by arranging for terms to be offered by an appropriate AXA Insurer. Please provide us with as much notice as possible prior to changing your country of residence to allow us to make appropriate arrangements with a new AXA Insurer or to allow you enough time to find alternative cover where we are unable to identify an appropriate AXA Insurer. 6.2 > Rights and responsibilities This section sets out the rights and responsibilities we have to each other. Your policy Your policy is for one year. You must pay the premium for your policy when the premium is due. In return for you paying the premium, we will provide you with the cover set out in your policy. We will pay for covered costs incurred during a period for which the premium has been paid. We will confirm the date that your policy starts and ends, who is covered, and any special terms that apply. Sales When AXA Global Healthcare (EU) Limited (AGH EU) sells our plans directly to customers, it provides information to help customers make the right decisions for their needs, but AGH EU does not offer a personal recommendation for any of our plans. You may also have bought your plan through an intermediary or broker, in which case they will inform you whether they offer a personal recommendation. Renewal Before the end of each policy year, AGH EU will contact the policyholder to tell them the terms the policy will continue on if the policy is still available. We will renew the policy on the new terms unless the policyholder asks AGH EU to make changes or tells AGH EU they wish to cancel the policy. AGH EU will collect your premium using the same payment method that you used for the previous year. If the policy you were on is no longer available, AGH EU we will do its best on our behalf to offer you an alternative. Requirements that may apply in your country of residence It is your responsibility to make sure you have cover that meets any requirements made by your country of residence. Page 59 [Seite 61] For example: • Some countries require residents to buy health cover through a local provider. This policy would not meet that requirement. • Some countries require residents to buy health cover that meets certain requirements. The cover offered under this policy may not meet such requirements, which means you would need to buy additional cover or a different policy. Providing us with information Whenever we ask you to give us information, you will make sure that all the information you give us is sufficiently true, accurate and complete for us to be able to work out the risk we are considering. If we later discover that it is not, we can cancel your policy or apply different terms of cover in line with the terms we would have applied if the information had been presented to us fairly. Cooling off period The 14-day cooling off period starts on the later of the following: • the day that the contract for your policy is concluded • the day that the policyholder receives the full policy terms and conditions. The policyholder may cancel the policy during the 14-day cooling off period. If they want to do this, they need to contact us to tell us. If the policy is cancelled during the 14-day cooling off period, we will return any premium paid for the policy. The exception to this is if one or more claims have been made relating to cover during the 14-day cooling period. If a claim is made during the 14-day cooling off period, the policyholder may have to pay for any services we have actually provided in connection with the policy to the extent permitted by law. We may deduct this from any returned premium. A new 14-day cooling off period applies from each renewal date. Our right to refuse to add a family member We can refuse to add a family member to your policy. We will tell the policyholder if we do this. Subrogated rights We, or any person or company that we nominate, have subrogated rights of recovery of the policyholder or any family members in the event of a claim. This means that we will assume the rights of the policyholder or any family member to recover any amount they are entitled to that we have already covered under this policy. For example, we may recover amounts from someone who caused injury or illness, or from another insurer or a state healthcare provider. The policyholder must provide us with all documents, including medical records, and any reasonable assistance we may need to exercise these subrogated rights. The policyholder must not do anything to prejudice these subrogated rights. We reserve the right to deduct from any claims payment otherwise due to you an amount that will be recovered from a third party or state healthcare provider. Page 60 [Seite 62] What happens if you break the terms of your policy If you break any terms of your policy that we reasonably consider to be fundamental, we may do one or more of the following: • refuse to pay any claims; • recover from you any loss caused by the break; • refuse to renew your policy; • impose different terms to your cover; • end your policy and all cover immediately. If you (or anyone acting on your behalf) claim knowing that the claim is false or fraudulent, we can refuse to pay that claim and may declare your policy void, as if it never existed. If we have already paid the claim, we can recover what we have paid from you. If we pay a claim and the claim is later found to be wholly or partly false or fraudulent, we will recover what we have paid from you. What happens if we make a payment to you in error If we transfer money to you in error or accidentally overpay you, you must return it to us immediately. If you become aware of an accidental payment or overpayment, you must let us know straight away so that we can arrange for the money to be returned to us. Our right to make changes to your policy We can change all or any part of your policy from any renewal date. We will give you reasonable notice of changes to your policy. International economic sanctions We will not do business with any individual or organisation that appears on an economic sanctions list or is subject to similar restrictions from any other law or regulation. This includes sanction lists, laws and regulations of the European Union, United Kingdom, United States of America or under a United Nations resolution. We will immediately end cover and stop paying claims on your policy if you or a family member are directly or indirectly subject to economic sanctions, including sanctions against your country of residence. We will do this even if you have permission from a relevant authority to continue cover or subscription payments under a plan. In this case, we can cancel your policy or remove a family member immediately without notice, but will then tell you if we do this. If you know that you or a family member are on a sanctions list or subject to similar restrictions you must let us know within 7 days of finding this out. Law applying to your policy You and we are free to choose the law within the European Union that applies to your policy. Irish Law will apply unless you and we agree otherwise. Language for your policy We will use English for all information and communications about your policy. Page 61 [Seite 63] Translations This policy is written in English and may be translated into another language. In the event of a discrepancy or other uncertainty, the English version of this policy will prevail. Legal rights Only the policyholder and we have legal rights under this policy. No one other than the parties to the policy shall have any rights to enforce any of its terms. 6.3 > Our authorisation and regulation details Our plans are arranged by AXA Global Healthcare (EU) Limited and underwritten by AXA Insurance dac. AXA Insurance dac AXA Insurance dac is regulated by the Central Bank of Ireland. Registered office Wolfe Tone House, Wolf Tone Street, Dublin 1. Registered in the Republic of Ireland, No. 136155. You can check details of AXA Insurance dac’s regulatory registration on the following Central Bank of Ireland website: registers.centralbank.ie AXA Global Healthcare (EU) Limited AXA Global Healthcare (EU) Limited is registered in the Republic of Ireland. No 630468 and is regulated by the Central Bank of Ireland. Registered Office: Wolfe Tone House, Wolf Tone Street, Dublin 1. Registered in the Republic of Ireland, No. 630468 6.4 > Your personal information Your policy is underwritten by AXA Insurance dac and administered by AXA Global Healthcare (UK) Limited (jointly AXA). This is a summary of AXA Insurance dac’s Privacy Policy that you can find on our website: axaglobalhealthcare.com/en/about-us/privacy-and-legal Please make sure that everyone covered by this policy reads this summary and the full data privacy policy on our website. If you would like a copy of the full Privacy Policy please call us on +44 (0) 1892 503 856 and we’ll send you one. We want to reassure you AXA never sells personal member information to third parties. We will only use your information in ways we are allowed to by law, which includes only collecting as much information as we need. We will obtain your consent to process information such as your medical information when it’s necessary to do so. We collect information about you and the family members who are covered by your policy from you, those family members, your healthcare providers, your employer (if you are on a company scheme), your insurance broker if you have one and third party suppliers of information. We process your information mainly for managing your membership and claims, including investigating fraud. We also have a legal obligation to do things such as report suspected crime to law enforcement agencies. We also do some processing because it helps us run our business, such as research, finding out more about you, statistical analysis for example to help us decide on premiums and marketing. Page 62 [Seite 64] We may disclose your information to other people or organisations. For example, we’ll do this to: • Manage your claims, e.g. to deal with your doctors or any reinsurers; and • Facilitate the provision of benefits or otherwise manage your policy; and • Help us prevent and detect crime and medical malpractice by talking to other insurers and relevant agencies; and • Allow other AXA companies to contact you if you have agreed. In order to be able to manage your policy we may transfer and access your information from countries anywhere in the world including India and the USA where some administration is undertaken and Switzerland where AXA has a European data centre. Before doing so we will ensure that your data is protected and disclosed only to authorised individuals solely for servicing your policy or claim. Any internal transfer of your data will be undertaken only in accordance with the relevant data protection laws and regulations. Where our using your information relies on your consent you can withdraw your consent, but if you do, we may not be able to process claims or manage your policy properly. We will inform you if a data breach occurs and your personal and medical information are disclosed to unauthorised parties. The notification will be provided within 72 hours of the confirmation of the incident. In some cases, you have the right to ask us to stop processing your information or tell us that you don’t want to receive certain information from us, such as marketing communications. You can also ask us for a copy of information we hold about you and ask us to correct information that is wrong. If you want to ask to exercise any of your rights just call us on +44 (0) 1892 503 856 or write to us at AXA Global Healthcare (UK)Limited, Phillips House, Crescent Road, Tunbridge Wells, Kent TN1 2PL. If you want to contact the Data Protection Officer you can do so by writing to us at the same address, or by emailing; AGHComplianceReporting@axa.com. 6.5 > What to do if somebody else is responsible for part of the cost of your claim You must tell us if you are able to recover any part of your claim from any other party. Other parties would include: • an insurer that you have another insurance policy with • a state healthcare system • a third party that has a legal responsibility or liability to pay. We will pay our proper share of the claim. Paying only our proper share helps us to keep the cost of premiums down. If another party is responsible for part of your claim, it may mean they will pay for costs you would otherwise have to pay yourself, such as your excess on this policy or private treatment not covered by this policy. Page 63 [Seite 65] 6.6 > What to do if your claim relates to an injury or medical condition that was caused by another person If your claim relates to an injury or medical condition that was caused by another person, they may be liable to pay some of the costs of your claim. This means you must tell us as quickly as possible if you believe a third party caused the injury or medical condition, or if you believe they were at fault. If we need further information, we may contact you or the third party. We will pay our proper share of the claim and recover what we pay from the third party. We do this so we can keep the cost of premiums down. It also means that you can be repaid for any costs you paid yourself, or if you paid for private treatment that wasn’t covered by your policy. You must include all amounts (including interest) paid by us in respect of the injuries in your claim against the third party. You (or your solicitors) must keep us informed: • on the progress of your claim and any action against the third party or any pre-action matters • on the progress of and outcome of any action or settlement discussions, including providing us with access to the details of any settlement reached. Repaying us if the third party pays you If we have paid you for your claim and you are subsequently paid by the third party, you must repay us within 21 days of being paid by the third party. The amount you must repay depends on what you are paid: • If the third party settles in full, you must repay our payment to you in full; or • if the third party pays you a percentage of your claim for damages, you must repay us the same percentage of our payment to you; or • if your claim is paid as part of a global settlement and our payment to you is not individually identified, you must repay us the same proportion that the global settlement is of your total claim for damages against the third party. • If you are paid interest by the third party, you must include that when working out what to pay us. • If you do not repay us, we will be entitled to recover what you owe us from you and your policy may be cancelled in accordance with the section: ‘What happens if you break the terms of your policy’. The rights and remedies in this section are in addition to and not instead of rights or remedies provided by law. Page 64 [Seite 66] 7 Glossary Certain terms in the handbook have specific meanings. The terms and their meanings are listed in the glossary. Where we’ve used these terms, we’ve highlighted them in bold to help you know that they have a specific meaning. ◆The terms marked with this symbol have meanings that have been agreed by the Association of British Insurers. These meanings are used by most UK medical insurers. active treatment of cancer – treatment intended to shrink, stabilise, or slow the spread of the cancer, and not given solely to relieve the symptoms. acute condition ◆ – a disease, illness or injury that is likely to respond quickly to treatment which aims to return you to the state of health you were in immediately before suffering the disease, illness or injury, or which leads to your full recovery. AXA Global Healthcare Group – AXA Global Healthcare (UK) Limited and its subsidiaries globally, including AXA Global Healthcare (EU) Limited and AXA Global Healthcare (Hong Kong) Limited AXA Insurer - An insurer in the AXA global group of companies, or its network of partner insurers, that is able to offer you insurance cover in your country of residence. cancer ◆ – a malignant tumour, tissues or cells, characterised by the uncontrolled growth and spread of malignant cells and invasion of tissue. chronic condition ◆ – a disease, illness or injury that has one or more of the following characteristics: • it needs ongoing or long-term monitoring through consultations, examinations, check- ups and/or tests • it needs ongoing or long-term control or relief of symptoms • it requires your rehabilitation or for you to be specially trained to cope with it • it continues indefinitely • it has no known cure • it comes back or is likely to come back. complementary practitioner Definition for treatment given outside the UK: a practitioner who is qualified and registered to practice in the country where the treatment will be given as one of the following: • homeopath • acupuncturist • osteopath • chiropractor • practitioner of Chinese herbal medicine Definition for treatment given in the UK: Page 65 [Seite 67] a medical practitioner who meets all of the following conditions: • is fully registered under the Medical Acts • specialises in at least one of the following: acupuncture, osteopathy or chiropractic • is registered under the relevant Act • is recognised by us as a complementary practitioner for out-patient treatment. » The full criteria we use when recognising medical practitioners are available on request country of residence – the country where the policyholder lives or intends to live for most of the year. day-patient ◆ – a patient who is admitted to a hospital or day-patient unit because they need a period of medically supervised recovery but does not occupy a bed overnight. day-patient unit – a medical unit where day-patient treatment is carried out. » The units we recognise for treatment in the UK are listed in our Directory of Hospitals at axaglobalhealthcare.com/ukhospitals diagnostic tests ◆ – investigations, such as x-rays or blood tests, to find or to help to find the cause of your symptoms. external prosthesis - an artificial, removable replacement for a part of the body. facility – a hospital or a centre with which we have an agreement to provide a specific range of medical services and which is listed in the UK Directory of Hospitals. In some circumstances treatment may be carried out at an establishment that provides treatment under an arrangement with a facility listed in the UK Directory of Hospitals. family member – 1) the policyholder’s current spouse or civil partner or any person living permanently in a similar relationship with the policyholder; and 2) any of their or the policyholder’s children. hospital Definition outside the UK: a hospital that is licensed as a medical or surgical hospital in the country where it is based Definition within the UK: a hospital that is in our UK Directory of Hospitals in-patient ◆ – a patient who is admitted to hospital and who occupies a bed overnight or longer, for medical reasons. medical condition – any disease, illness or injury, including psychiatric illness. medical practitioner Definition for treatment outside the UK: a person who has primary degrees in the practice of medicine and surgery from a medical school that is listed in the World Health Organisation’s World Directory of Medical Schools. Definition for treatment within the UK: a person who meets all of the following conditions: • has specialist training in an area of medicine, such as training as a consultant surgeon, consultant anaesthetist, consultant physician or consultant psychiatrist Page 66 [Seite 68] • is fully registered under the Medical Acts • is recognised by us as a specialist. In the UK, the definition of a specialist who we recognise for out-patient treatment only is widened to include those who meet all of the following conditions: • specialise in psychosexual medicine, musculoskeletal or sports medicine, podiatric surgery. • is fully registered under the Medical Acts • is recognised by us as a specialist. In the UK, the definition of a medical practitioner includes a general practitioner (GP) on the General Medical Council (GMC) GP register. » The full criteria we use when recognising specialists are available on request multiple birth – the birth of more than one baby from a single pregnancy. out-patient ◆ – a patient who attends a hospital, consulting room, or out-patient clinic and is not admitted as a day-patient or in- patient. physiotherapist Definition for treatment outside the UK: a person who is licensed to practice as a physiotherapist where the treatment is to take place. Definition for treatment within the UK: a person who meets all of the following conditions: • is fully registered under the Medical Acts • specialises in physiotherapy • is recognised by us as a physiotherapist for out-patient treatment. » The full criteria we use when recognising specialists are available on request policy – the insurance contract between you and us. The full terms of your policy are set out in the latest versions of: • any application form we ask you to fill in • any statement of fact we send you • this handbook • your healthcare insurance statement and our letter of acceptance policyholder– the first person named on your healthcare insurance statement. If the first person named on your healthcare insurance statement is under 18 then we will treat the person who pays the premium as the policyholder. In this case, the policyholder will not be entitled to cover under this policy. scanning centre – a centre in the UK where out-patient CT (computerised tomography), MRI (magnetic resonance imaging) and PET (positron emission tomography) is carried out. » The centres we recognise are listed in our UK Directory of Hospitals at axaglobalhealthcare.com/ukhospitals surgery / surgical procedure – an operation or other invasive surgical intervention listed in the schedule of procedures and fees. Page 67 [Seite 69] To get a copy of the schedule, go to axaglobalhealthcare.com/en/members/how-bills-are-paid or call us on +44 (0)1892 503 856 terrorist act – any act of violence by an individual terrorist or a terrorist group to coerce or intimidate the civilian population to achieve a political, military, social or religious goal. treatment ◆ – surgical or medical services (including diagnostic tests) that are needed to diagnose, relieve or cure a disease, illness or injury. UK Directory of Hospitals – the list of hospitals, day-patient units and scanning centres that are available for you to use under the terms of your policy. The list changes from time to time, so you should always check with us before arranging treatment. Some treatments are only available in certain facilities. » The Directory of Hospitals is on our website at axaglobalhealthcare.com/ukhospitals United Kingdom (UK) – Great Britain and Northern Ireland, including the Channel Islands and the Isle of Man. year – the 12 months from your policy start date or last renewal date. Page 68 [Seite 72] PB108540a/04.23 This policy is underwritten by AXA Insurance dac and administered by AXA Global Healthcare (UK) Limited. AXA Insurance dac is registered in the Republic of Ireland. No. 136155. Registered Office: Wolfe Tone House, Wolfe Tone Street, Dublin 1. AXA Insurance dac is regulated by the Central Bank of Ireland.