Business

Health Select 6

Membership handbook
October 2019
Welcome to your membership Contents
Welcome to your membership of AXA PPP healthcare. Section Page

We know there’s a lot in this handbook, but we want to make sure you’ve 1 Quick start guide 3
got all the information you need. This section explains the basics of your cover
These are exciting times in health and medicine. The human race has
2 Making a claim 10
never seen such a pace of new discoveries and developments, and it’s
Everything you need to know about making a claim
pretty likely the speed of things will only increase.
In an ideal world, we’d cover all proven treatment for all health conditions, all 3 How membership works 12
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Including how we cover treatment, how we pay for it
– or health service for that matter – in the world could ever do that. So we give and rules for pre-existing and chronic conditions

you the fullest cover we can and cover the vast majority of the thousands of у
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tests and costs
covered than to simply tell you all that is, but there’s nothing to hide so we tell
you everything. 5 Managing your membership 34
Including how to add and make changes to your cover,
Everyone here – all of our nurses, doctors, health experts, phone advisers, how your excess works and how to complain
claims handlers, technicians… everyone – wants you to enjoy the best
possible health and healthcare. 6 Legal information 37
Details of the rights and responsibilities we have
We wish you the best of health.
to each other
AXA PPP healthcare
7 Glossary 40

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Questions about your plan Claims 24 hour medical help and information
0800 587 0955 0800 206 1808 0800 003 004
Monday to Friday 8:30am to 5:30pm Monday to Friday 8am to 8pm and Saturday 9am to 5pm Talk to a medical professional at any time, day or night


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18001. For example, our team of Personal Advisers can be contacted by Next Generation Text on 18001 0800 206 1808. For Health queries and information 18001 0800 003 004.

Page 2
1 Quick-start guide to your membership

Words and phrases in bold type

This section explains the basics of the cover your group has chosen. *(
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Reading this section will help you to understand the rest of the information glossary or in the section they apply to.
in the handbook. You and your
The tables in this section only give you an outline of your cover. For full When we use you and your, we mean the lead member and any family members
covered by your plan.
details of your cover, please read the rest of your handbook too.
We, us and our
Cover is provided under a group insurance contract provided to the When we use we, us or our, we mean AXA PPP healthcare, who is the insurance
group, who is the policyholder. The group has chosen this plan to provide company who underwrite this product.
cover for its members or employees. 1.1 > Your core cover – applies to all members
Lead members covered under the group insurance contract are entitled This table shows you the core cover your membership gives you.
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Core cover table
premium from the group.
If you’re an in-patient or day-patient
You do not have legal rights under the group insurance contract as
the contract is with the group. Renewal of your cover under the group Private hospital and Paid in full so long as
9 Including fees for in-patient or day-patient:
insurance contract is dependent on the group renewing the group day-patient unit fees you use a hospital or raccommodation
day-patient unit in our
rdiagnostic tests
insurance contract and your cover under that contract. rusing the operating theatre
Directory of Hospitals rnursing care
If you have any questions about your membership to the plan or want to rdrugs
rdressings
make any changes such as adding a family member or ending your cover rradiotherapy and chemotherapy
under the plan please contact your group administrator. rphysiotherapy
rsurgical appliances that the specialist
uses during surgery.
» For details, see 3.8
1.1 > Your core cover – applies to all members Cash payment if you £50 a night for
9 If you have eligible private in-patient
use a hospital or in-patient treatment treatment or day-patient treatment at a
1.2 > Extra cover from Options hospital or day-patient unit that is not in our
day-patient unit that £50 a day for
9 Directory of Hospitals.
1.3 > The main things we don’t cover is not in our Directory day-patient treatment » For details, see 3.8
1.4 > Expert Help of Hospitals
This cash payment
does not apply if you
have the Extended
Cover Option
The tables in this section only give you an outline of your cover.
For full details of your cover, please read the rest of your handbook too. Page 3
Specialist fees No yearly limit
9 Includes fees for: /# -
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rsurgeons
ranaesthetists Ambulance transport Paid in full If you are having private in-patient or
rphysicians. 9
day-patient treatment and it is medically
» For details, see 3.6 necessary to use a road ambulance to
transport you to another medical facility.
Hospital Paid in full
9 Covers the cost of one parent staying in
accommodation for hospital with a child under 16. The child
must be covered by your membership and External prosthesis Up to £5,000 for
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one parent while a the lifetime of your providing an external prosthesis.
having treatment covered by it.
child is in hospital membership

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this cash payment. For details, see 4.10
Hotel accommodation Up to £100 a night up to
9 Covers towards the costs for one parent to
for one parent while a £500 a year stay near to the private hospital where a Cash payment if you £50 a day up to £2,000
9 If you choose to have day-patient or
child under 16 is having treatment. The child
child is in hospital have chemotherapy or a year out-patient chemotherapy or radiotherapy
must be covered by the membership and
radiotherapy free on to treat cancer on the NHS. We will only
having treatment covered by it. We will not
pay this if the treatment would have been
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the NHS covered by your membership.
If you have an excess, you do not have to pay
If you’re an out-patient
this if having this treatment.

Surgery No yearly limit

9 » For details, see 3.8 » For details, see 4.1

CT, MRI or PET scans Paid in full at a

9 A specialist must refer you.
Expert Help Direct access to
9 » For details, see 1.4
CT = Computerised Tomography healthcare experts for
scanning centre, or
MRI = Magnetic Resonance Imaging members 24/7
hospital listed as a
PET = Positron Emission Tomography
scanning centre, in our
Directory of Hospitals » For details, see 3.8 1.2 > Extra cover from Options
The following tables show you what cover your Options give you. Your membership guide shows
Cash payment if you £50 each visit
9 If you have a private CT, MRI or PET scan at a which Options you have.
have a private CT, scanning centre that is not in our Directory
MRI or PET scan at a of Hospitals. Out-patient Options
hospital or » For details, see 3.8
day-patient unit that Standard Out-patient Option table
is not in our Directory
of Hospitals Cover applies when you’re an out-patient

This cash payment

Specialist Up to two specialist
9 We pay for consultations in the order we
does not apply if you assess the claims, which may not be the same
consultations consultations a year
have the Extended order that you had the consultations. So the
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two that you had.
» For details, see 3.7

Page 4
Diagnostic tests No yearly limit
9 Therapies Option table
performed by your
specialist or when Fees for out-patient No yearly limit on
9 We call physiotherapists, osteopaths and
your specialist refers treatment by fees: up to an overall chiropractors therapists.
you physiotherapists, maximum of ten » For details, see 3.7
acupuncturists, sessions in a year
Enhanced Out-patient Option table homeopaths, when your GP refers
osteopaths or you or when you have
Cover applies when you’re an out-patient chiropractors therapist treatment
through our Working
Specialist A combined yearly limit
9 Practitioners are nurses, dieticians, *4
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consultations of £1,000 orthoptists, speech therapists and rfurther sessions (as long
audiologists.
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» For details, see 3.7 when your specialist
specialist or when refers you
your specialist refers
you Mental Health Option table
Practitioner fees when
your specialist refers If you’re an in-patient or day-patient
you
Private hospital and Paid in full
9 So long as you use a hospital or day-patient
day-patient unit unit in our Directory of Hospitals. Including
Full Out-patient Option table fees for psychiatric
fees for:
raccommodation
treatment rdiagnostic tests
Cover applies when you’re an out-patient
rdrugs.
Specialist No yearly limit
9 Practitioners are nurses, dieticians, » For details, see 3.8
consultations orthoptists, speech therapists and
audiologists. Cash payment if you £50 a night for
9 If you have private in-patient treatment
Diagnostic tests or day-patient treatment for a psychiatric
» For details, see 3.7 use a hospital or day- in-patient treatment
performed by your condition at a hospital or day-patient unit
patient unit that is £50 a day for
9
specialist or when that is not in our Directory of Hospitals.
not in our Directory of day-patient treatment
your specialist refers
Hospitals » For details, see 3.8
you
Practitioner fees when Specialist fees for No yearly limit
9 » For details, see 3.7
your specialist refers psychiatric treatment
you

The tables in this section only give you an outline of your cover.
For full details of your cover, please read the rest of your handbook too.

Page 5
If you’re an out-patient Oral surgery Paid in full so long as
9 So long as your dentist refers you, we will pay
you use a facility that for:
Specialist No yearly limit
9 » For details, see 3.7 we have an agreement
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consultations for with covering oral rsurgical removal of impacted teeth, buried
psychiatric treatment surgery teeth and complicated buried roots; or
rremoval of cysts of the jaw (sometimes
Psychiatric treatment No yearly limit
9 » For details, see 3.7 '' 
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by psychologists and » To check if we have an agreement
cognitive behavioural with a facility for oral surgery,
therapists see our Directory of Hospitals at
axappphealthcare.co.uk/hospitals or
Extra Care Option table visit your member site
» For details, see 4.32
Nurse to give you Paid in full
9 We will pay for treatment:
chemotherapy rat home or
rsomewhere else that is appropriate. Chiropody and Up to £150 a year
9 So long as your chiropodist or podiatrist
or antibiotics by podiatry fees $.
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We will pay for a nurse to give you either of
intravenous drip at the following by intravenous drip: not have to pay the excess if having this
home rchemotherapy to treat cancer treatment.
rantibiotics. » For details, see 4.4
This is so long as:
rwe have agreed the treatment beforehand; Dentist and Optician Cashback Option table
and
ryou would otherwise need to be admitted
for in-patient or day-patient treatment; Dentist fees 80% of your dentist’s
9 If you have an excess, you do not have to pay
and fees, up to £400 a year the excess if you claim for dentist fees.
rthe nurse is working under the supervision » For details, see 4.32
of a specialist who is in our ‘fee-approved’
category – see 3.6; and
Optician fees 80% of the cost of
9 We will pay this so long as the glasses or
rthe treatment is provided through a lenses are used to correct your vision.
healthcare services supplier that we have a prescribed glasses and
If you have an excess, you do not have to pay
contract with for this kind of service. contact lenses, up to
the excess if you claim for optician fees.
£200 a year
Cash payment when £100 a night up to
9 You have the Six week option, but this does » For details, see 4.18
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We pay this when: Eye test Up to £25 a year for an
9 If you have an excess, you do not have to pay
patient treatment the excess if you claim for an eye test.
ryou are admitted for in-patient treatment eye test
under the NHS
before midnight; and » For details, see 4.18
rwe would have covered your treatment if
you had had it privately.
Extra Cancer Cover Option table
You can also receive this cash payment if you
have treatment in an NHS Intensive Therapy
or Intensive Care unit, whether it follows This cover extends the » For details, see 4.1
private treatment or not. cancer cover you have

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this cash payment. and any extra out-
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Page 6
 1.3 > The main things we don’t cover
Extended Cover Option table
Like all health insurance plans, there are a few things that are not covered. We’ve listed the most
Extra cover for Paid in full up to the
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treatment at any normal daily rates
hospital, day-patient published and charged
Does my membership mean I don’t need to use the NHS?
unit or scanning by the facility No. Your insurance is not designed to cover every situation. It is designed to add to, not replace, the
centre in the UK that NHS. There are some conditions and treatments that the NHS is best at handling – emergencies are
is not listed in the a good example.
Directory of Hospitals
What are the key things my membership doesn’t cover?
Extra cover for Up to the cost
9 So long as:
rthe treatment is carried out by a medical Your plan does For more information Notes
treatment received we would pay for
outside of the UK equivalent treatment
practitioner; and not cover
rwe have agreed the fee before you go
in the UK abroad for the treatment Routine pregnancy
8 » For details, see 4.24 or call us Few health insurance plans cover
You will need to pay for treatment and claim and childbirth on 0800 206 1808 pregnancy and childbirth because
the costs back from us. they are not illnesses, and the NHS is
set up to deal with them.
» For details, see 4.33
Extra cover for Fee Paid in full
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to use a hospital hospital, we may pay you a small cash
limited specialists more than they usually do for that, or similar,
payment.
treatment. that is not in
We use a Directory of Hospitals
our Directory of as it helps us to keep premiums
Fees for visits to Up to £500 a year
9 Hospitals Ȃ*-' ѵ

a private GP for
» See our Directory of Hospitals
consultations
at axappphealthcare.co.uk/
hospitals or visit your member
Doctor@Hand 9
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Access to a GP service for online, video
or telephone consultations. For more site
consultations a year with a Doctor@
information about how to register and what
Hand GP
is included in this service please visit
axappphealthcare.co.uk/DAH Treatment of
8 » For details, see 3.4 Your plan is designed to cover

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medical conditions necessary treatment of new medical
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you had, or had
symptoms of,
Travel cover
before you joined.
» Please see your
Travel cover
handbook

The tables in this section only give you an outline of your cover.
For full details of your cover, please read the rest of your handbook too.

Page 7
 Treatment of
8 » For details, see 3.5 Key things that may not be covered depending on the Options you have
ongoing, recurrent *0-
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and long-term you have.
conditions (chronic
conditionsҘ Your Options Your cover

Treatment that the

8 » For details, see 3.9 As you have the Six week option, if If you do not have an out-patient Option You do not have any cover for out-patient
8
NHS can give you the NHS can give you the hospital diagnostic tests or consultations
treatment you need within six weeks
within six weeks of
of when you need it, you’ll need to If you do not have the Therapies Option You do not have cover for fees for
8
when you need it use the NHS.
physiotherapists, acupuncturists,
If you have an out-patient Option,
there are some exceptions where you homeopaths, osteopaths or chiropractors
can go private straight away.
If you do not have the Mental Health Option You do not have cover for any psychiatric
8
treatment

If you do not have the Dentist and Optician You do not have cover for dentists’ or
8
Cashback Option opticians’ fees

If you do not have the Extended Cover Optioni hospital fees if you if you choose to use
8
a hospital that is not in our Directory of
Hospitals.
You will be able to claim a cash payment as
shown in the Core Cover table if you use a
hospital or day-patient unit that is not in our
Directory of Hospitals for treatment that
would have been covered by your plan.

If you have any questions about your cover please call us on 0800 206 1808.


Page 8
 1.4 > Expert Help Health information you can trust
Have you ever wished a friend or someone in your family was a medical expert? You’d be able to
talk to them whenever you liked and they’d have time to listen, reassure and explain in words you
Our online Health Centres bring together the latest information from our own experts, specialist
understand.
organisations and NHS resources.
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Our medical teams including nurses and a wide variety of healthcare professionals can answer the discussions.
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The experts
Call with your health queries any time – just ask ғ
Extensive panel, including doctors, psychologists, nurses, physiotherapists and dieticians.

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medication and treatment or simply need a little guidance and reassurance.
You can speak to them whenever you want to – day or night. Support from our Dedicated Nurse Service

Health at Hand
Our members have access to our Dedicated Nurse service, 24/7, 365 days a year. If you are
0800 003 004 diagnosed with a heart condition or cancer, our dedicated nurses will be there for you and your
24 hours a day, 365 days a year. family.
Midwife and pharmacist services – Monday to Friday 8am to 8pm, Saturday 8am to 4pm
and Sundays 8am to 12pm.  -.*)'
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dedicated nurses.

Page 9
2 Making a claim

For muscle, bone and joint pain, you can use Working Body – no GP referral
1 Ask your GP for an open referral
needed
If your GP says you need specialist treatment, tell them you
When you experience muscle, bone or joint pain, it’s important that you get the
want to go private and ask for an ‘open referral’. most appropriate support early.
With an open referral your GP doesn’t name a particular specialist, but $/#
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instead gives you the type of specialist you need to see, for example a for a GP referral. As soon as you develop a problem, just call your Personal Advisory
cardiologist. This means our Fast Track Appointments service can help you team. We’ll check what cover you have and you’ll get a call back by the end of the
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Occasionally the NHS will be best placed to provide care locally (for example During your phone assessment, a physiotherapist will listen to your concerns, take
specialist paediatric (children’s) care at an NHS centre of excellence). When you through an initial assessment and then advise the most appropriate treatment
this is the case we will talk to you about your NHS options as well. for you.
2 Contact us on 0800 206 1808 or through your online account before you see Members under the age of 18 will need a GP referral for these types of conditions as
the specialist /#
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Contact us as soon as you’ve seen your GP. It’s important you contact us
before you see the specialist or have any treatment so that we can tell you
what you’re covered for. This will mean you don’t end up having to pay for For skin concerns you can use our self-referral service
treatment that you’re not covered for. You can pre-authorise treatment
If you are concerned about any marks or moles on your skin, you can call your
by phone or online, but if your claim is urgent we recommend you call us
Personal Advisers to see whether the self-referral service can help. You can choose
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treatment.
Call us on 0800 206 1808 - You can call your Personal Advisers as soon as you
3 We’ll check your cover and let you know what happens next experience problems or have any concerns. They will check your cover and take you
We may ask you to provide more information, for example from your GP through some questions designed to show whether the service can help.
or specialist. You, your GP or your specialist must provide us with the Next steps - If your answers show the service can help and you decide to use it, we’ll
information we ask for by the date that we ask for it or you may not be refer you to the service who can arrange a diagnostic appointment. We’ll ask for
covered for your claim. your consent before transferring you and the service will take things from there.
They will be responsible for making a diagnosis.
You can also use our Fast Track Appointments if you would like a second
If the service isn’t suitable for you, or you decide you’d rather not use it, it’s best to
opinion from another specialist. Simply call us and we can discuss the options
make an appointment with your GP as soon as possible for further advice.
with you.
Over 18’s only. Children under 18 will need a GP referral.

Page 10
How we pay claims
What happens if I don’t want to give the information you’ve asked for?
We normally settle any bills directly with the specialist or the hospital where you’ve had your
treatment. If your treatment is not covered for any reason, we will let you know. 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
How do you pay my medical bills? ask you to pay back any money that we have previously paid to do with this medical condition.
Specialists and hospitals normally send their bills to us, so we can pay them directly. If you need to
pay an excess, we will let you know how to pay it. What if my treatment isn’t covered?
» For more details, see 5.2 If your membership does not cover your treatment, we’ll explain this and also tell you about what
we can do to support you through your NHS treatment.
Do I need to tell the place where I have my treatment that I am an AXA PPP healthcare member?
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member. This will mean that the fees charged for your treatment are those we have agreed with the
We always recommend that you ask your GP for an open referral. That’s a referral that does not
hospital or centre.
name a specialist. With an open referral, you’ll have a choice of specialist and we can make your
What happens if I’ve paid the bills myself already or if I receive a bill? appointment for you. This will also mean we can check that we cover that specialist’s fees.
If you paid your medical bills yourself and your treatment is covered, we will refund you the rates *2 1 -Ѷ
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we have agreed with the hospital or centre, minus any excess. Please send the original receipts from specialist, simply call us as soon as you can and we can tell you whether we cover that specialist’s
the specialist or hospital to AXA PPP healthcare, Phillips House, Crescent Road, Tunbridge Wells, fees. If we don’t, we can suggest an alternative and make the appointment for you if you wish.
Kent TN1 2PL.
If you receive a bill, please call us and we’ll explain what to do next.
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In an emergency, please call for an NHS ambulance or go to a hospital A&E department. Most
any forms. private hospitals are not set up for emergency treatment.
Usually, this all happens very quickly. However, sometimes we need more detailed medical As your membership includes the Six week option, we will not cover urgent or emergency
information, including access to your medical records. treatment anyway, as this means you will need treatment earlier than six weeks.

What does ‘more detailed information’ mean? » Please see page 18 for more about how your Six week option works
We may need more detailed information in any of the following ways: If you need further treatment
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treatment, please call us as we may be able to
cover this.
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rWe may also ask you to give us consent to access your medical records.
Extra cover if you have the Extra Care Option
9
rIn some cases, we may also ask you to complete additional forms. We will need you to complete
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rVery rarely, we may have to ask a specialist to advise us on the medical facts or examine you. In » For more details, see the Extra Care Option table on page 5
these cases, we will pay for the specialist to do this and will take your personal circumstances into
account when choosing the specialist.

Page 11
3 How your membership works

3.1 > Looking at who should provide treatment

3.1 > Looking at who should provide treatment
Your membership does not cover primary care services such as any service that could be provided
3.2 > Eligible treatment by GPs, dentists and opticians. This includes drugs and treatment.
3.3 > Our cover for treatment and surgery When diagnostic tests are routinely required as part of your referral to a specialist we may arrange
3.4 > How your membership works with pre-existing conditions and symptoms of these for you. We do this to help the specialist
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treatment may be required.
them
3.5 > How your membership works with conditions that last a long time or come Extra cover if you have the Dentist and Optician Cashback Option
9
back (chronic conditions)
If you have the Dentist and Optician Cashback Option, some services provided by dentists
3.6 > Paying the specialists and practitioners that treat you – cover for all and opticians will be covered.
members
» For more details, see the Dentist and Optician Cashback Option table
3.7 > Paying the specialists and practitioners that treat you – extra cover that Extra cover if you have the Extended Cover Option
9
depends on your Options
If you have the Extended Cover Option you have some cover for private GP consultations
3.8 > Paying the places where you’re treated – cover for all members and access to Doctor@Hand.
3.9 > How the Six week option works
» For more details, see the Extended Cover Option table
3.10 > General restrictions
3.2 > Eligible treatment
How your membership works Your membership covers ‘eligible treatment’.
For full details of how your membership works, please read the rest of your You will need to read all sections of this handbook to understand whether treatment is eligible
handbook too. treatment.
‘Eligible treatment’ is treatment of a disease, illness or injury where that treatment:
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your online account and we’ll be able to check your cover for you and tell you or diagnostic outcome; and
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your specialist or other health professional.
Manage your membership online Treatment needs to meet all of these requirements. There are some exceptions which will be
described in the relevant sections of this handbook. For example there are times when we do
You can make a claim or pre-authorise treatment online at
cover treatment of chronic conditions or unproven treatmentѵ
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message us and manage your policy securely.
Page 12

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treatment is eligible treatment. In these cases, we will pay for the specialist to do The amount we pay for unproven treatment will depend on how much it costs and how much we
this. would pay if you have conventional treatment for your medical condition instead.
3.3 > Our cover for treatment and surgery ‡If the unproven treatment costs less than the equivalent conventional treatment we will pay the
cost of the unproven treatment; or
We cover treatment and surgery that is conventional treatment.
‡If the unproven treatment costs more than the equivalent conventional treatment we will pay
What do you mean by conventional treatment? up to the cost we would have paid for the equivalent conventional treatment. We will pay up

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treatment that: to the amount we would have paid a fee-approved specialist and hospital in the Directory of
‡is established as best medical practice and is practised widely within the UK; and Hospitals. To understand what the equivalent conventional treatment is we will look at the
treatment other patients with the same medical condition and prognosis would be given.
‡is clinically appropriate in terms of necessity, type, frequency, extent, duration and the facility
or location where the treatment is provided; and has either Do I need to let you know if I want unproven treatment?
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treatment of your medical condition through Yes, if you would like an unproven treatment you or your specialist must contact us at least 10
substantive peer reviewed clinical evidence in published authoritative medical journals; or working days before you book that treatment. This is so we can:
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Regulatory Agency; and will pay towards your treatment.

‡used according to that licence. We recommend you check with the hospital, specialist, anaesthetist and/or other provider how
much they will charge for your treatment so you know how much will be your responsibility to pay.
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send you a copy
» To check whether we will agree to cover a treatment, please call us on 0800 206 1808 before you
What happens if my specialist says I need treatment that is not conventional treatment? book your treatment.
We know our members may want to have access to developing treatments as they become
available. So, we will consider covering the following treatment when it is carried out by a 3.4 > How your membership works with pre-existing conditions and symptoms
specialist: of them
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In this handbook we refer to this treatment as unproven treatment. you joined depends on the type of cover your group has chosen and what you told us about your
The cover for unproven treatment is more restrictive than for conventional treatments. Unproven medical history when you joined.
treatment must: Am I covered for treatment of any conditions I was aware of when I joined?
‡be authorised by us before it takes place; and We call conditions you were aware of when you joined pre-existing conditions.
‡take place in the UK; and
‡be agreed by us as a suitable equivalent to conventional treatment.
If there is no suitable equivalent conventional treatment, there won’t be any cover for the
unproven treatment.
Page 13
 #
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information we received.
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If you joined us on ‘continuing medical exclusions’ terms, we are carrying on your exclusions for therapist, optician or dentist.
medical conditions from your previous health insurer. This normally means we only asked you a
What if you didn’t tell us about a condition, symptom or treatment you knew about when we
few brief medical questions.
asked?

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period of time. for the condition.
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Page 14
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. What are acute conditions and chronic conditions?
This includes: $&
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rany pre-existing or previous condition, whether you had treatment for them or not; and/or Acute condition
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not speak to a doctor. disease, illness or injury, or that leads to your full recovery.
Whenever you claim, we may ask your GP, specialist or practitioner for more information to
Chronic condition
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whether we can cover your claim. characteristics:
rIt needs ongoing or long-term monitoring through consultations, examinations, check-ups or
3.5 > How your membership works with conditions that last a long time or tests.
come back (chronic conditions) rIt needs ongoing or long-term control or relief of symptoms.
rIt requires your rehabilitation, or for you to be specially trained to cope with it.
Like most health insurance, your membership is designed to cover unexpected illness and
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of conditions.
What happens if a condition I have is a chronic condition?
Does my membership cover me for treatment of conditions that last a long time or come back
If your condition is chronic, unfortunately there will be a limit to how long we cover your treatment.
(chronic conditions)?
If we are not able to continue to cover your treatment, we will tell you beforehand so that you can
Your membership does not cover you for conditions that: decide whether to start paying for the treatment yourself, or to transfer to the NHS.
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rare likely to continue for a while; or There is a full explanation of how we cover cancer treatment in section 4 of this handbook
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chronic
condition – that is, unexpected complications or worsening of a chronic condition. Extra cover if you have an out-patient Option
9
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treatment for chronic conditions, this means
If you have an out-patient Option, we will make an exception for treating some heart
we will not cover:
conditions.
rmonitoring a medical condition; or
If you have any of the following surgery on your heart, we will carry on paying for long-term
rany treatment
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monitoring, consultations, check-ups, scans and examinations related to the surgery. We will
underlying condition; or
continue to pay for this while you are still a member and have out-patient cover.
rroutine follow-up consultations. rcoronary artery bypass
However, please see the notes on treatment for cancer and heart conditions below, as there are
rcardiac valve surgery
some exceptions to these rules.
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We will not pay for routine checks that a GP would normally carry out, such as anticoagulation,
lipid monitoring or blood pressure monitoring.

Page 15
 rFee-approved specialist. Using a fee-approved specialist gives you the maximum reassurance,
If you do not have an out-patient Option, we will not cover long-term monitoring,
8 as we pay all their fees. If you use our Fast Track Appointments service, and you would like us to
consultations, check-ups, scans or examinations related to your heart condition. book your appointment for you we will book it with a fee-approved specialist.
rFee-limited specialist. You may need to pay some costs yourself.
Whether you have an out-patient Option or not, we will still be here to support you if you are
rSpecialists we do not pay for. We do not pay any of their costs.
diagnosed with a heart condition. At any time, you can speak to one of our specialist nurses for
heart patients. They will be able to give you guidance and information about your condition We use these arrangements for anaesthetists too – please also see below if you think your
and the treatment you are having. treatment will involve an anaesthetist.
Please also see the rest of this section for more about the people we pay.
What other treatment is covered for chronic conditions?
Fee-approved specialists – what we pay
If you do not have an out-patient Option, your cover for treatment of chronic conditions
8
We will recommend you see a fee-approved specialist, as this will give you the maximum
is likely to be limited, as most of the treatment happens when you are an out-patient.
reassurance that the costs will be covered.
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in-patient treatment to take your condition back to its controlled state. Call us as soon as you have seen your GP, and our Fast Track Appointments team can make
your appointment with a fee-approved specialist for you.
This will mean that so long as your treatment is covered, we will pay for the following for a fee-
Extra cover if you have an out-patient Option
9 approved specialist:
If you have an out-patient Option, we will cover the following up to your out-patient limits: rconsultations (including remote consultations by telephone or via a video link. These will be
rthe initial investigations to diagnose your condition covered under the out-patient
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Are there any conditions that are always regarded as chronic? rsurgery.
Yes. Some conditions are likely to always need ongoing treatment or are likely to recur. This is This is so long as a GP, dentist or a medical professional that we recognise and we have
particularly the case if the condition is likely to get worse over time. An example is Crohn’s disease approved to make referrals has referred you for treatment with that type of specialist.
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If you have one of these conditions, we will contact you to tell you when we will stop cover for Fee-limited specialists – what we pay
treatment of the condition. We will contact you so that you can then decide whether to start paying We still pay fee-limited specialists, but you may also need to pay some costs yourself.
for the treatment yourself, or to transfer to the NHS.
So long as your treatment is covered, and a GP or dentist refers you, we will still pay some of
the fees for a fee-limited specialist. However, we will only pay up to the amount we show in
» For more information about how we cover treatment for chronic conditions, including
the schedule of procedures and fees. This means that you will probably need to pay something
some examples of how our cover works, please see axappphealthcare.co.uk/chronic
towards the cost of your treatment.
When you call to make your claim, we can tell you what you may need to pay for that particular
3.6 > Paying the specialists and practitioners that treat you – cover for all specialist. However, you may also want to ask them for a quote before starting treatment to
members make sure you know what you may need to pay.
Does my plan cover the full fees charged by specialists?
If your treatment
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Page 16
 Specialists we do not pay for r dietician
We will not pay any of their costs, so you will need to pay all their costs yourself.
r orthoptist
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There are some specialists that are not on either our ‘fee-approved’ or ‘fee-limited’ lists. This raudiologist.
means that we will not pay any of their fees, or any fees for treatment under their direction. If
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What about anaesthetists?
We pay practitioner fees up to the level shown in our schedule of procedures and fees.
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which anaesthetist they will use and let us know before your treatment starts. We will then be able » *0
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you to choose from, and can even book your appointment for you. rphysiotherapists
Just call us on 0800 206 1808. racupuncturists
rhomeopaths
3.7 > Paying the specialists and practitioners that treat you – extra cover that rosteopaths
depends on your Options rchiropractors.
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the diagnostic tests that they say you need. We will pay so long as a GP refers you.
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in chapter 21 of our schedule of procedures and fees.
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We pay physiotherapists, osteopaths and chiropractors in full if we recognise them. All
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out-patient treatment you need with a practitionerѵ
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Page 17
Who will be paid under the Mental Health Option? rnursing care
rdrugs
Extra cover if you have the Mental Health Option
9 rdressings
If you have the Mental Health Option, we will pay for covered in-patient or day-patient rradiotherapy and chemotherapy
psychiatric treatment, including specialist fees, as shown in the Mental health Option table rphysiotherapy
on page 5. rsurgical appliances that the specialist uses during surgery.
We will pay for out-patient treatment by any of the following: » For more about how we pay for treatment, please also see sections 3.6 and 3.7
ra mental health specialist There are special rules about the following kinds of treatment:
ra cognitive behavioural therapist, so long as a specialist in our ‘fee-approved’ category rout-patient treatment
oversees your treatment rintensive care
ra psychologist, so long as a specialist in our ‘fee-approved’ category oversees your rcataract surgery
treatment.
roral surgery as part of the Extra Care Option.
We will pay cognitive behavioural therapists or psychologists up to the level shown in our » See next page for more details about these
schedule of procedures and fees.
What you must tell the place where you have your treatment
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and we’ll send you a copy You must tell the place where you have your treatment that you are an AXA PPP healthcare
member. This will help to ensure that the fees charged for your treatment are those we have agreed
» See section 3.6 for details on the specialists’ fees we will pay with the hospital or centre.
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they usually charge for that, or similar treatment. If you do not have the Extended Cover Option and you have private in-patient or day-patient
treatment at a hospital, day-patient unit or use a scanning centre that is not in our Directory of
Hospitals, we will not pay for your treatment. We will only pay a small cash payment as shown in
3.8 > Paying the places where you’re treated – cover for all members the Core Cover table when the treatment received would have been covered by your membership.
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If your treatment is covered by your membership, we will pay your hospital fees in full. This is so Where can I have out-patient treatment?
long as a specialist is overseeing your treatment, and you use one of the following listed in our The cover you have for out-patient treatment depends on whether you have an out-patient Option.
Directory of Hospitals:
We will pay fees at an authorised out-patient facility in full. We will pay these so long as:
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In-patient and day-patient hospital fees include costs for things like:
raccommodation Please always check with us beforehand to make sure the facility you want to go to is recognised.
CT, MRI or PET scans received as an out-patient will be paid in full at a scanning centre listed in our
rdiagnostic tests
Directory of Hospitals.
rusing the operating theatre
We do not pay for out-patient drugs or dressings.

Page 18
What about intensive care?
Extra cover if you have the Extended Cover Option
9
If you have private intensive care treatment in a private hospital or in an NHS Intensive Therapy or
Intensive Care unit, we will pay for this so long as: If you have the Extended Cover Option you have extra cover for treatment at hospitals,
day-patient units and scanning centres that are not in our Directory of Hospitals. As long
rit immediately follows private treatment that was covered by your membership and
as your treatment is covered we will pay for you to have it at any hospital, day-patient unit,
ryou or your next of kin have asked for you to have the intensive care treatment privately. out-patient facility or scanning centre in the UK.
Where can I have cataract surgery?
If you need cataract surgery, we will pay for your treatment at any facility where we have an 3.9 > How the Six week option works
agreement covering cataract surgery. These are shown in our Directory of Hospitals. You have the Six week option with your membership. This means that your cover is for in-patient
If your GP
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treatment and day-patient treatment and any surgical procedure if the NHS can’t give you that
facility for your treatment. The facility will put you in contact with one of their specialists. treatment within six weeks of when treatment should take place.
What about treatment on the NHS?
Extra cover if you have Option
9
If you do not have the Extra Care Option, we do not pay anything else when you have
8 If you have the Extended Cover Option you have extra cover for treatment at hospitals,
treatment on the NHS. day-patient units and scanning centres that are not in our Directory of Hospitals. As long
as your treatment is covered we will pay for you to have it at any hospital, day-patient unit,
out-patient facility or scanning centre in the UK.
Extra cover if you have the Extra Care Option
9
If you have the Extra Care Option, and have free treatment on the NHS that would have been
Does my Six week option mean there are types of treatment that are never covered?
covered by your membership, we will pay you a cash payment. This includes treatment in
an NHS Intensive Therapy or Intensive Care unit, or treatment received in a private facility. Yes. You are not able to claim for any of the following:
rUrgent or emergency treatment because the NHS will cover this quickly. This includes
» For more details, see the Extra Care Option table on page 6
emergency in-patient or day-patient treatment for mental health problems, even if you have
the Mental Health Option.
Does my plan cover payment for treatment anywhere else?
rTreatment while you are pregnant or giving birth as the NHS will treat these quickly.
We only pay for treatment at the places listed. For example, we do not pay anything for treatment
at a health hydro, spa, nature cure clinic or any similar place, even if it is registered as a hospital. -
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Yes. We will cover the following treatment regardless of the NHS waiting time. This is because, except for
radiotherapy and chemotherapy, they are usually not available within six weeks on the NHS.
Where can I have oral surgery under the Extra Care Option?
rday-patient or out-patient radiotherapy or chemotherapy
If you do not have the Extra Care Option, we do not cover any oral surgery.
8 rvaricose veins surgery
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specialist and facility for your treatment. rcataract surgery.

Page 19
Do I have to wait until I get an NHS specialist appointment to claim?
No. You do not need to wait to see whether you can get an NHS specialist appointment within six
weeks. Call us as soon as you have seen your GP and we will talk you through what happens next.
If you ask your GP for an ‘open referral’ and your treatment
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Consultations within 10 days of treatment
We will not pay any separate fee that your specialist makes for consultations within 10 days of
carrying out surgery.
Treatment and referrals by family members
We will not pay for drugs or treatment if:
rthe person who refers you is a member of your family
rthe person who treats you is a member of your family.

Page 20
у

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4.1 > Cancer 4.26 > Rehabilitation

4.2 > Alcohol abuse, drug abuse, substance abuse 4.27 >
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4.3 > Breast reduction 4.28 > Sexual dysfunction
4.4 > Chiropody, podiatry and foot care 4.29 > Social, domestic and other costs unrelated to treatment
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4.6 > Contraception 4.32 > Teeth and dental conditions
4.7 > Cosmetic surgery 4.33 > Treatment abroad and restrictions if you live outside of the UK
4.8 > Criminal activity 4.34 > Treatment that is not medically necessary
4.9 > Drugs and dressings 4.35 > Varicose veins
4.10 > External prosthesis or appliances 4.36 > Warts
4.11 > Fat removal 4.37 > Weight loss treatment
4.12 >
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4.13 > Genetic tests, preventative treatment and screening tests There are particular rules for how we cover some conditions, treatments, tests
4.14 > GP and primary care services and costs. This section explains what these are.
4.15 > Infertility and assisted reproduction You should read this section alongside the other sections of this handbook as
4.16 > Kidney dialysis the other rules of cover will also apply, for example our rules about pre-existing
4.17 > Learning and developmental disorders conditions, chronic conditions and who we pay.
4.18 > Long sightedness, short sightedness and astigmatism If you’re at all unsure about the cover you have with your membership – even if
4.19 >  #)$'
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4.20 > Mental health than working it out from the handbook alone.
4.21 > Natural ageing
4.22 > Nuclear, biological or chemical contamination and war risks )4
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4.23 > Organ or tissue donation Just call us on 0800 206 1808 and we’ll be very glad to help explain anything that’s
unclear.
4.24 > Pregnancy and childbirth

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check your cover for you and tell you what to do next.

Page 21
4.1 > Cancer Cover for all members
Due to the nature of cancerѶ
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would have covered that treatment, we will make a cash payment.
described elsewhere in your handbook applies.
Extra cover if you have the Extra Care Option
9
About your cover for cancer treatment
If you have the Extra Care Option, we will also make a cash payment for in-patient
We will cover treatment for any new cancer
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cancer treatment on the NHS (as well as out-patient and day-patient radiotherapy or
if it comes back and you are still a member. # (*/# -+4Ҙѵ

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. Do the rules about chronic or recurring conditions apply to cancer?
» For more details of how we cover treatment of pre-existing medical conditions, see section 3.4 We don’t apply our rules about chronic or recurring conditions to cancer. Please carefully read all of
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treatment for cancer.
Our registered nurses and case managers provide support over the phone
Comparing our cancer cover
and have years of experience of supporting patients and their families. When
To help make our cancer cover clearer, the following information is in a format that the Association
you call, we will put you in touch with a nurse or case manager who will then
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support you throughout your treatment.
This will also help you to compare the cover you get as standard with the cover you get with the
Your nurse or case manager will be happy to speak to your specialist or Extra Cancer Cover Option.
doctor directly if you need them to check any details. They can also give you
guidance on what to expect during treatment and how to talk about your Place of treatment If I have the Extra Cancer If I do not have the Extra Cancer
illness to friends and family. Cover Option, am I covered? Option, am I covered?

Supporting you if you’re diagnosed with cancer Private hospitals, Yes

9 Yes
9
day-patient units or
Expert support if you choose to have your treatment on the NHS. scanning centres listed in our
We have developed extra support services to help you and your family if you are diagnosed with Directory of Hospitals.
cancer and you decide to have your treatment on the NHS instead of using this plan to have private
treatment. We may be able to help you with everyday concerns, such as childcare or domestic help. Chemotherapy by Yes
9 If you have the Extra Care
9
Please call us before your treatment begins, so that we can discuss with you what kind of expert intravenous drip at home. Option.
support is available. » For more details, see the
Extra Care Option table on
page 5.

If you are diagnosed with cancer – please call us on 0800 206 1808 so we can explain how
 Treatment at a hospice. We will make a donation
9 We will not make a
8
we can support you.
of £100 for every night you donation.
spend in a hospice or have
hospice at home care.

Page 22
Diagnostic If I have the Extra Cancer If I do not have the Extra Cancer If you’re an out-patient
Cover Option, am I covered? Option, am I covered?
Specialist consultations
9 Yes
9 If you do not have an
8
Whether you are an in-patient, day-patient or out-patient with the specialist treating If you have an out-patient out-patient Option: no.
your cancer when you are Option, the consultations If you have an out-patient
9
Surgery as shown below Yes
9 Yes
9 an out-patient. will not come out of your Option: yes.
under ‘Surgery’. out-patient limit.
As you have the Six week If the consultations are before
option, we cover this so your diagnosis, consultations
long as it is not available on are covered as part of your
the NHS within six weeks of overall out-patient limit.
when you need it. However,
» For more details, see the
please note the NHS is usually
out-patient Option tables
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on page 4
for cancer within six weeks,
so you are unlikely to have Diagnostic tests as an out-
9 Yes
9 If you do not have an
8
cover for surgery under your patient when ordered by If you have an out-patient out-patient Option: no.
membership. the specialist treating your Option, the tests will not come If you have an out-patient
9
cancer. out of your out-patient limit. Option: yes.
CT, MRI and PET scans. Yes
9 Yes
9 If the tests are before your
diagnosis, consultations are
Genetic testing proven to help Yes
9 Yes
9 covered as part of your overall
choose the best chemotherapy. out-patient limit.
» See section 4.13 for more » For more details, see the
information on genetic tests out-patient Option tables
on page 4
Genetic testing to work out No
8 No
8
whether you have a genetic
risk of developing cancer.

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

Specialist fees for the

9 Yes
9 Yes
9
specialist treating your
cancer when you are an in-
patient or day-patient.

Diagnostic tests as an
9 Yes
9 Yes
9
in-patient or day-patient.

Page 23
Surgery If I have the Extra Cancer If I do not have the Extra Cancer Preventative If I have the Extra Cancer If I do not have the Extra Cancer
Cover Option, am I covered? Option, am I covered? Cover Option, am I covered? Option, am I covered?

Whether you are an in-patient, day-patient or out-patient

Preventative treatment, such No
8 No
8
as:
Surgery for the treatment Yes, but only if the NHS
9 Yes, but only if the NHS
9
or diagnosis of cancer, so wait is over six weeks, wait is over six weeks, Screening when you do not
long as it is conventional which is unlikely. which is unlikely. have symptoms of cancer.
treatment. For example, if you had a
screen to see if you have a
As you have the Six week
genetic risk of breast cancer,
option, we cover this so
we would not cover the
long as it is not available on
screening or any treatment
the NHS within six weeks of
to reduce the chances of
when you need it. However,
developing breast cancer in
please note the NHS is usually
future (such as a preventative
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for cancer within six weeks,
so you are unlikely to have Vaccines to prevent cancer
cover for surgery under your developing or coming back
membership. – such as vaccinations to
» See page 41 for how we prevent cervical cancer.
 ‫
)ޔ‬.0-" -4ѵ

» See page 12 for more Drug therapy If I have the Extra Cancer If I do not have the Extra Cancer
about conventional and Cover Option, am I covered? Option, am I covered?
unproven treatment.
Out-patient drugs or other Please call us about these Please call us about these
drugs that a GP could drugs. We don’t cover them, drugs. We don’t cover them,
prescribe or could be but we can help you apply to but we can help you apply to
bought over the counter. get these paid for by the NHS. get these paid for by the NHS.
This includes drugs or Call us on 0800 206 1808 and Call us on 0800 206 1808 and
prescriptions you are given we can talk you through this. we can talk you through this.
to take home if you have had
in-patient, day-patient or
out-patient treatment.

Page 24
Drug treatment to kill cancer 9 Yes Yes
9 Other drugs. Yes. They are covered as
9 We will cover these for up
9
cells – including: There is no time limit on how We cover these drugs for up We cover: long as you have them to three months as long
rbiological therapies, such long we cover these drugs. to one year, or for the time at the same time as you as you have them at the
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as Herceptin or Avastin We will cover them if: allowed by the licence – are having chemotherapy same time as you are
such as bisphosphonates
rthey have been licensed by whichever is shorter if: or biological therapy to having chemotherapy or
rchemotherapy. or Denosumab
the European Medicines rthey have been licensed by kill cancer cells covered by biological therapy to kill
We will cover these drugs if rHormone therapy that your membership. cancer cells that is covered
Agency or the Medicines the European Medicines
you have them as an is given by injection (for by your membership.
and Healthcare products Agency or the Medicines
out-patient or day-patient, example goserelin, also
Regulatory Agency, and and Healthcare products
which is how they are usually &)*2)
.
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rthey are used according to Regulatory Agency, and
given. rAntivirals, antibiotics,
their licence, and rthey are used according to
antifungals, anti-sickness
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and anticoagulant drugs.
the Six week option, we will 
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Drugs for treating conditions Yes, while you are
9 Yes, while you are
9
in-patient treatment if they We start the time limit
change, this means that the secondary to cancer, such as having chemotherapy having chemotherapy
are available on the NHS
drugs we cover will change !-*(
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җҘ. that is covered by your that is covered by your
within six weeks of when you treatment that we paid for.
from time to time. membership. membership.
need them.
Please call us once you know  0.
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your treatment plan. change, this means that the
Radiotherapy If I have the Extra Cancer If I do not have the Extra Cancer
drugs we cover will change Cover Option, am I covered? Option, am I covered?
from time to time.
Please call us once you know Radiotherapy including when Yes
9 Yes
9
your treatment plan. it is used to relieve pain.
Unproven drugs. Not covered.
8 Not covered.
8 Even though you have the Six
There is no cover for week option, we will cover
unproven drugs or drugs that day-patient or out-patient
are being used outside of radiotherapy regardless of the
their licence. NHS waiting time.
» Please see section 3.3 If you have radiotherapy as an
for more information on in-patient, we will cover it so
unproven treatment long as it is not available on
the NHS within six weeks of
when you need it. However,
please note the NHS is usually
1$''
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within six weeks, so you are
unlikely to have cover for
in-patient radiotherapy under
your membership.

Page 25
-*/*)
 (
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җҘ Yes
9 Yes
9 Donation to a hospice where you £100 a night
9 No
8

2$''
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2$''
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donation to a service providing
rcentral nervous system rcentral nervous system
hospice at home care.
җ-$)
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cancer or malignant solid cancer or malignant solid
cancers in members aged cancers in members aged Monitoring If I have the Extra Cancer If I do not have the Extra Cancer
21 and under 21 and under Cover Option, am I covered? Option, am I covered?
rchordomas or rchordomas or
Follow ups – cover for follow Yes, so long as you are still
9 If you do not have an
8
chondrosarcomas (types of chondrosarcomas (types of
up consultations and reviews a member and have a plan out-patient Option: no.
spine cancerҘ
$)
/#
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spine cancerҘ
$)
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for cancer. that covers this. If you have an out-patient
9
the skull or cervical spine the skull or cervical spine
Option: yes, for ten
җ) &
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years from your last
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.+- 
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surgery, chemotherapy
rcancer of the iris, ciliary rcancer of the iris, ciliary
or radiotherapy for that
body or choroid parts of body or choroid parts of
cancer so long as you are
/#
4
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( ')*(Ҙ
/#
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still a member and have a
which has not spread which has not spread
plan that covers this.
җ( /./.$. Ҙ җ( /./.$. Ҙ
.

$.

 1 '*+$)"
- 
.

$.

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- 
Routine monitoring or checks No
8 No
8
of medicine there are only a of medicine there are only a that a GP or someone else in a
limited number of facilities limited number of facilities GP surgery (or other primary
that provide this treatment. that provide this treatment. -
. //$)"Ҙ
*0'
--4
*0/.
Please contact us before you Please contact us before you
have your treatment. have your treatment. Follow up procedures that are No
8 No
8
for monitoring rather
Accelerated charged particle No.
8 No.
8 than treatment.
therapies However, there is limited However, there is limited Some cancer patients need
*1 -
!*-
-*/*)
 (
*1 -
!*-
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 (
procedures to check whether
Therapy in the circumstances Therapy in the circumstances cancer is still present or has
shown above. shown above. returned. For example, these
could include colonoscopies
to check the bowel or
Palliative and end of life If I have the Extra Cancer If I do not have the Extra Cancer
cystoscopies to check the
care Cover Option, am I covered? Option, am I covered?
bladder.
These procedures are
Care to relieve pain or other We will provide cover and
9 We will provide cover and
9 planned in advance, and so
symptoms rather than cure support throughout your support throughout your they are usually available on
the cancer. cancer treatment even if it cancer treatment even if it the NHS within six weeks of
becomes incurable. We cover becomes incurable. We cover when they should happen. As
radiotherapy, chemotherapy radiotherapy, chemotherapy you have the Six week option,
and surgery (such as draining and surgery (such as draining your membership does not
‫ޕ‬0$
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./ )/Ҙ
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cover them.
relieve pain. relieve pain.
Page 26
Limits If I have the Extra Cancer If I do not have the Extra The cost of wigs or other Up to £400 a year for wigs
3 No
8
Cover Option, what limits are Cancer Cover Option, what temporary head coverings or or head coverings and
there on treatment under my limits are there on treatment external prostheses needed up to £5,000 a year for
membership? under my membership? because of cancer whilst you prostheses.
are having treatment to kill
Time limits on cancer None There are some time limits on cancer cells.
treatment. drug treatment for cancer.
Your membership covers For example, we will cover drug 4.2 > Alcohol abuse, drug abuse, substance abuse
you while you are having treatment to kill cancer cells We do not cover treatment you need as a result of, or in any way connected to, alcohol abuse, drug
treatment to kill cancer cells. (such as biological therapies or abuse or substance abuse.
# (*/# -+4Ҙ
!*-
0+
/*
*)

4.3 > Breast reduction
year, and bone strengthening
drugs or hormone therapy We do not cover either male or female breast reduction.
by injection for up to three 4.4 > Chiropody, podiatry and foot care
months as described in this Our cover for chiropody, podiatry and foot care depends on whether you have the Extra Care
table. Option.
We will not cover any general chiropody, podiatry or foot care, even if a surgical podiatrist provides
Money limits on cancer *
.+ $‫'
ޔ‬$($/.
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/#
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*
.+ $‫'
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/#
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it. This includes things like gait analysis and orthotics.
treatment. rules apply to your cancer rules apply to your cancer
treatment as for any other treatment as for any other Extra cover under the Extra Care Option
9
treatment. treatment. If you have the Extra Care Option, we will cover fees for chiropody or podiatry up to £150 per
yearѶ
.*
'*)"
.
4*0-
#$-*+*$./
*-
+*$/-$./
$.
,0'$‫ ޔ‬ѵ

/# -
 ) ‫ޔ‬/. If I have the Extra Cancer If I do not have the Extra » For more details, see the Extra Care Option table on page 6
Cover Option, what other Cancer Cover Option, what
 ) ‫ޔ‬/.
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Stem cell or bone marrow Yes
9 Yes
9 If you had treatmentѶ
( $'
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*-
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treatment. not be covered by your membership, we do not cover further treatment or increased treatment
This includes paying costs that are:
reasonable costs to a live ra result of the treatmentѶ
( $'
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*-
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(*$‫ޔ‬/$*)
4*0
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donor to donate bone previously, or
marrow or stem cells. rconnected with the treatmentѶ
( $'
*-
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It does not include any previously.
related administration costs.
4.6 > Contraception
For example, we will not
cover transport costs or the We do not cover contraception or any consequence of using contraception.
*./
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*)*-. 4.7 > Cosmetic surgery
» See page 30 for more We do not cover:
about this. rCosmetic treatment or cosmetic surgery; or
rTreatment that is connected to previous cosmetic treatment or cosmetic surgery.
» See also 4.25
Page 27
4.8 > Criminal activity 4.12 >
 ) -
- Ҋ..$")( )/
*-
" ) -
*)‫ޔ‬-(/$*)
We do not cover treatment you need as a result of your active involvement in criminal activity. 
*
)*/
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*-
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*)‫ޔ‬-(/$*)
treatment or anything connected
with them in anyway, such as:
4.9 > Drugs and dressings rgender reassignment operations or other surgical treatment; or
We don’t cover drugs, dressings or prescriptions that: rpsychotherapy or similar services; or
r4*0
-
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4*0
#1
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in-patient, day-patient or out-patient treatment;
rany other treatment.
or
rcould be prescribed by a GP or bought without a prescription; or 4.13 > Genetic tests, preventative treatment and screening tests
rare taken or administered when you attend a hospital, consulting room or clinic for Health insurance is designed to cover problems that you’re experiencing at the moment, so it
out-patient treatment. generally doesn’t cover preventative treatment or screening tests, including genetic tests.
There are some exceptions for drugs given for cancer treatment.
What is not covered for genetic tests, preventative treatment and screening tests?
» There is a full explanation of how we cover cancer treatment in section 4.1 of this handbook.
We do not pay for:
4.10 > External prosthesis or appliances rpreventative treatment, such as preventative mastectomy; or
We will pay up to £5,000 towards the cost of an external prosthesis needed following an accident or rpreventative screening tests; or
surgery for a medical condition. rroutine preventative examinations and check-ups; or
We will do this so long as: rgenetic screening tests to check whether:
ryou had continuous cover on a private medical insurance policy before the accident or surgery ryou have a medical condition when you have no symptoms; or
happened that has led to the need for the prosthesis; and
rall claims are made within 12 months of the amputation or removal of the body part ryou have a genetic risk of developing a medical condition in the future; or
rthere is a genetic risk of you passing on a medical condition.

2$''
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healthcare. rgenetic tests to identify a medical condition where the result of the test isn’t proven to change
the course of treatment. This might be because the course of treatment for your symptoms will
What is not covered? be the same regardless of what medical condition has caused them; or
We do not cover replacement of teeth or hair, including wigs or hair transplants. rany other preventative screening or treatment to see if you have a medical condition whether or

*
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.0#
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not you have symptoms; or
joint supports and braces, mechanical walking aids and contact lenses or any external device. rvaccinations.
How to claim What is covered for genetic tests?

!
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We will pay for genetic testing when it is proven to help choose the best course of drug treatment
next. Please remember to ask the provider of your external prosthesis for full receipts as we cannot for your medical condition. This means that it must be recommended in the drug licence for a
pay claims without a receipt. .+ $‫
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specialist
Extra cover if you have the Extra Cancer Cover Option
9 might want to do a variety of tests and they might not all be covered. The cost to you might be
If you have the Extra Cancer Cover Option, we will pay towards the cost of wigs or or other .$")$‫)ޔ‬/
$!
/#
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- )ҁ/
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0) -
4*0-
plan.
temporary head coverings or external prostheses needed because of cancer whilst you are
If you’re unsure whether your treatment is preventative or not, please call us on

having treatment to kill cancer cells.
0800 206 1808 before going ahead with the treatment.

4.11 > Fat removal


*
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whether the removal is needed for medical or psychological reasons.

Page 28
4.14 > GP and primary care services 4.17 > Learning and developmental disorders
We do not cover any treatment, investigations, assessment or grading to do with:
If you do not have the Dentist and Optician Cashback Option, we do not cover any fees for
8 rlearning disorders
services that a GP or dentist could normally carry out, or any other primary care services. rspeech delay
We do not pay for prescriptions, appliances or other ancillary services provided by GPs.
8 reducational problems
8

*
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.
.0.-$+/$*)
! .Ҙ
!*-

. -1$ .ѵ rbehavioural problems
rphysical development
Extra cover if you have the Dentist and Optician Cashback Option
9 rpsychological development.
If you have the Dentist and Optician Cashback Option, we will pay towards dentists’ and Some examples of the conditions we do not cover are the following (please call if you would like to
&)*2
$!

*)$/$*)
$.
*1 - Ҙѷ
opticians’ fees but not fees for services that a GP could normally carry out or any other
primary care services. rdyslexia
rdyspraxia
» See also 3.1
rautistic spectrum disorder
r// )/$*)
 ‫ޔ‬$/
#4+ -/$1$/4
$.*- -
җ Ҙ
Extra cover if you have the Extended Cover Option
9 rspeech and language problems, including speech therapy needed because of another medical
If you have the Extended Cover Option, you have cover for private GP consultations and condition.
access to Doctor@Hand for online, video and telephone consultations as shown in the
4.18 > Long sightedness, short sightedness and astigmatism
Extended Cover Options table.
We do not cover any treatment to correct refractive errors, including long sightedness, short
sightedness or astigmatism.
4.15 > Infertility and assisted reproduction
We do not cover investigation or treatment of infertility and assisted reproduction or treatment Extra cover if you have the Dentist and Optician Cashback Option
9
designed to increase fertility. This includes:
If you have the Dentist and Optician Cashback Option, we will pay towards the cost of eye
rtreatment to prevent future miscarriage; or tests, prescribed glasses and prescribed contact lenses.
rinvestigations into miscarriage; or
» For more details, see the Dentist and Optician Cashback Option table on page 6
rassisted reproduction; or
ranything that happens, or any treatment you need, as a result of these treatments or investigations. What is not covered under this Option?
We will not pay towards the cost of:
4.16 > Kidney dialysis
rcontact lens check ups
We do cover kidney dialysis, but only in some situations.
rcontact lens solutions
What is covered for kidney dialysis?
rrepairs to non-prescribed glasses
We will cover kidney dialysis for up to six weeks if you are being prepared for kidney transplant.
rnew frames
However, we will not cover regular or long-term kidney dialysis if you have chronic kidney failure.
rreplacements that you need because of accidental damage
» See also 4.23
rnon-prescribed items that you buy as part of an eye care
contract scheme.
If you have an eye care contract scheme and want to claim for anything that you have paid
for as part of that scheme, please ask your optician for a receipt showing the cost of all the
items you have paid for under the scheme.

Page 29
 What you need to claim cashback If you need to stay in hospital for a longer period, we will ask your specialist why you need
further treatment, and let you know if we agree to cover the extended stay.
If you want to claim cashback under this Option, please ask your optician for fully itemised
receipts for everything you wish to claim for. We cannot pay any claims without an itemised What if my condition goes on for a long time?
receipt showing how much you have paid. Then call us on 0800 206 1808 and we will explain Our normal rules on chronic conditions apply to mental health problems. So if your
what to do. condition becomes chronic, unfortunately we may no longer be able to cover your
treatment. If this happens, we will contact you beforehand so that you can decide whether
4.19 >
 #)$'
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+0(+.
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..$./
 1$ .
җҘ
)
-/$‫ޔ‬$'
to start paying for the treatment yourself, or to transfer to the NHS.
Hearts) » For more details, see 3.5
There is no cover for the provision or implantation of a mechanical heart pump. There is also no
What is not covered under the Option?
cover for the long-term monitoring, consultations, check-ups, scans and examinations related to
the implantation or the device. Even if you have the Mental Health Option, we do not cover any treatment connected in any
way to:
4.20 > Mental health r)
$)%0-4
4*0
$)‫ޕ‬$/ 
*)
4*0-. '!
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*-
Our cover for mental health depends on whether you have the Mental Health Option. ra suicide attempt; or
If you do not have the Mental Health Option, we do not cover any treatment of psychiatric
ralcohol abuse; or
8
illness. rdrug or substance abuse.

4.21 > Natural ageing

Extra cover under the Mental Health Option
9 We do not pay for treatment of symptoms generally associated with the natural process of ageing.
If you have the Mental Health Option, we will cover your treatment for psychiatric illness. This includes treatment for the symptoms of puberty and menopause, including symptoms as a result
This includes: of medical intervention.
rin-patient and day-patient treatment in hospital; and 4.22 > Nuclear, biological or chemical contamination and war risks
rout-patient treatment.
We do not cover treatment you need as a result of nuclear, biological or chemical contamination.
» For more details, see the Mental Health Option table on page 5
We do not cover treatment
4*0
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- .0'/
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*-
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)
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) (4Ѷ

All your other membership rules still apply to your cover. invasion, civil war, riot, rebellion, insurrection, revolution, overthrow of a legally constituted
*2
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(4
$3
2 &
*+/$*)
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0) -
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+/$*)Ѽ government, explosions of war weapons, or any similar event.
The Six week option still applies to cover under the Mental Health Option. This means that you do We do cover treatment due to a terrorist act so long as the act does not cause nuclear, biological or
not have cover for urgent in-patient or day-patient psychiatric treatment, as this will be available chemical contamination.
on the NHS within six weeks of the date you need it. If you need in-patient psychiatric treatment, it
is usually needed urgently so it is unlikely that you would get cover on your plan. 4.23 > 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
You will still have cover for treatment that you cannot get on the NHS within six weeks of
*)*-Ѷ
+' .
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2
)
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4*0
2#/
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2
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when you need it.
What happens if I need to go into hospital for a psychiatric condition? What we don’t cover
We do not pay for:
If you need to go into hospital for in-patient or day-patient treatment of a psychiatric
condition, the hospital will contact us to check your cover before you go in. If your
rthe cost of collecting donor organs or tissue; or
treatment is covered, we will agree to pay the hospital for an initial period of time in
rany related administration costs – for example, the cost of searching for a donor; or
hospital. The hospital will tell you how long this period is.
rany costs towards organ or tissue donation that is not done in line with appropriate regulatory
guidelines.

Page 30
4.24 > Pregnancy and childbirth 4.26 > Rehabilitation
As pregnancy and childbirth are not medical conditions and because the NHS provides for them, We do cover in-patient rehabilitation for a short period, but there are some limits to our cover.
our cover is limited.
What is covered for rehabilitation?
We don’t cover the checks or other interventions, such as antenatal and postnatal monitoring and
We will cover in-patient rehabilitation for up to 28 days, so long as:
screening, that you will have during pregnancy and birth.
rit follows an acute brain injury, such as a stroke; and
What is covered? rit is part of treatment of an acute condition that is covered by your membership; and
We will cover the additional costs for treatment of medical conditions that arise during pregnancy ra specialist in rehabilitation is overseeing your treatment; and
or childbirth. These conditions are generally urgent and the NHS will usually treat them quickly. As
ryou have your treatment in a rehabilitation hospital or unit that is included in our Directory of
you have the Six week option, this means it is likely that you will get your treatment on the NHS. Hospitals; and
rthe treatment can’t be carried out as a day-patient or an out-patient, or in another suitable

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location; and
to check what you are covered for before starting any private treatment.
rwe have agreed the costs before you start rehabilitation.
If you have severe central nervous system damage following external trauma, we will extend this


!
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cover to up to 180 days of in-patient rehabilitation.
4
2.
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treatment or assisted reproduction, there are a few limits on our
cover. Please call us on 0800 206 1808 so we can explain what we can cover.


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we recognise the hospital or unit where you are having the rehabilitation.
4.25 > Reconstructive surgery
We do cover reconstructive surgery, but only in certain situations. 4.27 >
 '!Ҋ$)‫ޕ‬$/ 
$)%0-4
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.0$$
What is covered? We do not cover treatment
4*0
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injury or a suicide attempt.

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surgery following an accident or surgery for a medical
condition that was covered by your membership. We will do this so long as: 4.28 > Sexual dysfunction
ryou had continuous cover under a private medical health insurance plan since before the We do not cover treatment for sexual dysfunction or anything related to sexual dysfunction.
accident or surgery happened; and
4.29 > Social, domestic and other costs unrelated to treatment
rwe agree the method and cost of the treatment in writing beforehand.
We do not cover the costs that you pay for social or domestic reasons, such as home help costs.

)
/#
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- *)./-0/$1 surgery means:

We do not cover the costs that you pay for any reasons that are not directly to do with treatment such
rone planned surgery to reconstruct the diseased breast as travel to or from the place you are being treated.
rone further planned surgery to the other breast, when it has not been operated on, to improve
symmetry 4.30 > Sports related treatment
rnipple tattooing, up to 2 sessions. We do not cover treatment you need as a result of training for or taking part in any sport for which
you:
Please call us on 0800 206 1808 before agreeing to reconstructive surgery so we can tell you
rare paid; or

if you are covered. r-  $1

"-)/
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rare competing for prize money.
What is not covered?
We do not cover treatment that is connected to previous reconstructive surgery or any cosmetic
operation to a reconstructed breast.
» See also 4.7

Page 31
4.31 > Sterilisation 4.33 > Treatment abroad and restrictions if you live outside of the UK
We do not cover: We do not cover any costs for treatment you receive outside the UK. We do not cover any costs for
rsterilisation; or treatment if you live outside the UK. If you are going to live outside of the UK please call us on
rany consequence of being sterilised; or 0800 587 0955 as you may be able to set up a new plan with our international team.
rreversal of sterilisation; or
Extra cover if you have the Travel Cover Option
9
rany consequence of a reversal of sterilisation.
If you have the Travel Cover Option, please see the Travel cover handbook for details of your
4.32 > Teeth and dental conditions cover for treatment abroad.
Our cover for treating teeth and dental conditions depends on whether you have the Extra Care
Option or Dentist and Optician Cashback Option. If you do not have either Option, your membership Extra cover if you have the Extended Cover Option
9
will not cover dental problems or any routine dental care.
If you have the Extended Cover Option you have cover for treatment you receive outside of
Cover for all members the UK.
You do not have cover for treating dental problems or any routine dental care including oral We will pay up to the cost we would have paid for you to have the treatment in the UK.
surgery, treatment of cysts in the jaw that are tooth related or are of a dental origin, this also means
we will not pay any fees for dental specialists, such as orthodontists, periodontists, endodontists or We will pay so long as:
prosthodontists. rthe treatment is planned before you go abroad
rthe treatment is carried out by a medical practitioner
Extra cover if you have the Extra Care Option
9 rwe have agreed the fee before you go abroad for the treatment
If you have the Extra Care Option, we will cover the following types of oral surgery when you rthe treatment would have been covered in the United Kingdom.
are referred for treatment by a dentist:
r- $). -/$)"
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rremoving impacted teeth, buried teeth and complicated buried roots What is not covered?
r- (*1'
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)0' /$*)Ҙѵ We do not cover the cost of complications which you get as a result of treatment you
have outside of the UK. We recommend you talk about possible complications and their
costs with your medical practitioner before you travel. You would be liable for the cost of
Extra cover if you have the Dentist and Optician Cashback Option
9 *(+'$/$*).
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If you have the Dentist and Optician Cashback Option, we will pay towards your dentist’s
fees, as shown in the table on page 6. We will pay for fees that you have paid directly to a
4.34 > Treatment that is not medically necessary
dentist or dental hygienist, so long as they are registered with the General Dental Council. 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.

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premiums you have paid for this scheme. 4.35 > Varicose veins
We do cover treatment of varicose veins, but only in certain circumstances.
What you need to claim cashback
What is covered?
If you want to claim cashback under this Option, please ask your dentist for full receipts for
everything you wish to claim for. We cannot pay any claims without a receipt. Then call us on We will cover one surgical procedure per leg to treat varicose veins, for the lifetime of your
0800 206 1808 and we will tell you what to do next. ( ( -.#$+
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you’ve had the main surgical procedure.

Page 32
What is not covered?
We do not cover more than one surgical procedure per leg, regardless of how long you stay a
member with us.
There is no cover for the treatment of recurrent varicose veins under your plan.
» Please see 3.5
There is no cover for the treatment
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4.36 > Warts

We do not cover treatment of skin warts.

4.37 > Weight loss treatment

We do not cover treatment for weight loss.
What is not covered?

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treatment.

Page 33
5 Managing your membership

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5.1 > Adding a family member or baby a baby:

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rWe may add other conditions to the baby’s cover. For example, we may limit their cover for pre-
5.4 > If you move abroad existing conditions.
5.5 > Paying income tax on your subscription We count fertility treatment as taking any prescription or non-prescription drug or other treatment
5.6 > Cancelling your membership to increase fertility.
5.7 > Leaving your employer
5.2 > Paying your excess
5.8 > Making a complaint
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you how to pay it.
5.1 > Adding a family member or baby If you have an excess
Whether you can add family members, including babies, to your cover will depend on the
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may be restrictions on when you can add family members.
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Please call us if you wish to add a family member or baby. To add any family member or a membership year. For example, if the claim was covered for £800, and the excess was £100, we would

new baby to your cover, call us on 0800 587 0955 or speak to your intermediary. pay £700.
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rYour partner. You must be either married, in a civil partnership, or living together permanently in into account if you claim again that year.
a similar relationship. rYour excess applies per person. So if two people covered by your membership claim, we will take the
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who you’ve adopted, to your membership. As with most health insurance, our cover for treatment  !*-
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has a few limits in these situations.

Page 34
If you have any questions about how your excess works, please call us on 0800 587 0955. 5.3 > Keeping us informed
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rIf you have the Dentist and Optician Cashback Option: any claim for dentist’s fees, optician’s fees 5.4 > If you move abroad
or eye tests
If you move abroad, you won’t be able keep your current membership and you will not be able to
rIf you have the Extra Cancer Cover Option: any claim for wigs, head coverings or hospice make any claims for treatment. You may be able to set up a new plan with our international team.
donations
Can I stay on the same plan if I move abroad?
rIf you have the Extended Cover Option: Doctor@Hand consultations.
If you go to live abroad, you cannot stay on the same healthcare insurance plan. However, you
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An example of how we work out the excess
5.5 > Paying income tax on your subscription
Excesses can be complicated, so we’ve included an example of how it works here.
If cover is available under an arrangement with your employer, you will have to pay income tax on
the premiums paid by your employer, less any amount made good by you as the employee.
Situation:
5.6 > Cancelling your membership
rAnn has the Enhanced Out-patient Option, which has a limit of £1,000 for out-patient
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not able to cancel it. If you want to stop your membership to the plan, please contact your group
rShe also has an excess of £100. administrator.
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1 Ann has a medical problem that is covered by her Option. She claims for £700 for out-patient 5.7 > Leaving your employer
treatment
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the year. When you transfer to a personal plan with similar cover, we can usually continue to cover
5 A month later, but in the same membership year, Ann needs some more out-patient any existing medical conditions without the need for medical underwriting – so you won’t
treatment that’s covered by her Option. This costs £450. #1
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for any existing or previous medical conditions later.
So we’ll pay £300 towards the cost. Ann will need to pay the remaining £150 herself to the We’ll arrange everything over the phone.
hospital.

Page 35
5.8 > Making a complaint The Financial Ombudsman Service
Your cover is provided under our group insurance contract with your group. However we do give Exchange Tower
all members full access to the complaint resolution process. Our aim is to make sure you’re always Harbour Exchange Square
happy with your membership. If things do go wrong, it’s important to us that we put things right as London E14 9SR
quickly as possible. Phone: 0300 123 9 123 or 0800 023 4567
Making a complaint ($'ѷ
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rany relevant information that we may not have already seen.
Please call us on 0800 206 1808.
Or write to:
AXA PPP healthcare
Phillips House
Crescent Road
Tunbridge Wells
Kent TN1 2PL
Answering your complaint
We’ll respond to your complaint as quickly as we can.

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concerns. If it looks like it will take us longer than this, we will let you know the reasons for the delay
and regularly keep you up to date with our progress.
The Financial Ombudsman Service
You may be entitled to refer your complaint to the Financial Ombudsman Service. The ombudsman
service can liaise with us directly about your complaint and if we can’t fully respond to a complaint
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Ombudsman Service for an independent review.

Page 36
6 Legal information

Providing us with information

6.1 > Rights and responsibilities Whenever we ask you to give us information, you will make sure that all the information you give us
6.2 > Our authorisation and regulation details $.
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6.3 > The Financial Services Compensation Scheme (FSCS) terms we would have applied if the information had been presented to us fairly. You must write and
6.4 > Your personal information tell us if you change your address.
6.5 > What to do if somebody else is responsible for part of the cost of your Our right to refuse to add a family member
claim We can refuse to add a family member to the plan. We will tell the lead member if we do this.
6.6 > What to do if your claim relates to an injury or medical condition that was
Subrogated rights
caused by another person
We, or any person or company that we nominate, have subrogated rights of recovery of the lead
member or any family members in the event of a claim. This means that we will assume the rights
of the lead member or any family members to recover any amount they are entitled to that we
6.1 > Rights and responsibilities have already covered under this plan.
This section sets out the rights and responsibilities you, your group and we have to each other. For example, we may recover amounts from someone who caused injury or illness, or from another
The plan insurer or a state healthcare provider.
The cover is provided under a group insurance contract. The lead member must provide us with all documents, including medical records, and any
reasonable assistance we may need to exercise these subrogated rights.
The plan is for one year.
The lead member must not do anything to prejudice these subrogated rights.
Only those people listed in the group insurance contract can be members of this plan.
We reserve the right to deduct from any claims payment otherwise due to you an amount that will
All cover ends when the group’s group membership ends. Cover for family members ends when
be recovered from a third party or state healthcare provider.
the lead member’s cover ends.
We will pay for covered costs incurred during a period for which the premium has been paid. What happens if you break the terms of your plan
The group is responsible for paying the premium. If you pay a contribution to the group towards If you break any terms of your plan that we reasonably consider to be fundamental, we may do one
cover for the lead member or family members җ!*-
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plan starts and ends, who is covered, and any special terms rrecover from you any loss caused by the break;
that apply.
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rend your membership to the plan and all cover immediately.
Renewal

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At the end of each plan year, we will contact the group to tell them the terms the plan will continue refuse to pay that claim and may declare your membership to the plan void, as if it never existed. If
on if the plan is still available. We will renew the plan on the new terms unless the group asks us to we have already paid the claim we can recover what we have paid from you.
make changes or tells us they wish to cancel. You will be bound by those terms.
If we pay a claim and the claim is later found to be wholly or partly false or fraudulent, we will be
able to recover what we have paid from you.
Page 37
International Sanctions 6.3 > The Financial Services Compensation Scheme (FSCS)
We will not do business with any individual or organisation that appears on an economic sanctions 

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lists, laws and regulations of the European Union, United Kingdom, United States of America or it may not be able to honour its contracts of insurance. It may do this by:
under a United Nations resolution. We will immediately end cover and stop paying claims on your r+-*1$$)"
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plan if you or a family member are directly or indirectly subject to economic sanctions, including rtransferring policies to another insurer
sanctions against your country of residence. We will do this even if you have permission from a
rpaying compensation to lead members.
relevant authority to continue cover or subscription payments under a plan. In this case, we can
cancel your plan or remove a family member immediately without notice, but will then tell you The Scheme was established under the Financial Services and Markets Act 2000 and is administered
if we do this. If you know that you or a family member are on a sanctions list or subject to similar 4
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What happens if the group insurance contract ends 6.4 > Your personal information
If the group insurance contract ends, you can apply to transfer to another plan. -
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Legal rights axappphealthcare.co.uk/privacynotice.

Each family member may make individual claims under the plan, which may be without the Please make sure that everyone covered by this plan reads this summary and the full data privacy
knowledge of the lead member in accordance with our approach to personal data. Only the group notice on our website. If you would like a copy of the full notice call us on 0800 587 0955 and we’ll
and we have legal rights under this plan. No clause or term of this plan will be enforceable, by send you one.
1$-/0
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family We want to reassure you we never sell personal member information to third parties. We will only
member. Consequently, the lead member remains liable for excesses and shortfalls incurred by a use your information in ways we are allowed to by law, which includes only collecting as much
family member under the plan. information as we need. We will get your consent to process information such as your medical
Law applying to your plan information when it’s necessary to do so.

The group and we are free to choose the law that applies to your plan. The law of England and We get information about you, your employees and family members who are covered by your plan.
Wales will apply unless you and we agree otherwise. This information can be provided by you, those family members, your healthcare providers, you
.
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Language for your plan one and third party suppliers of information, such as credit reference agencies.
We will use English for all information and communications about your plan. 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
6.2 > Our authorisation and regulation details to law enforcement agencies. We also do some processing because it helps us run our business,
AXA PPP healthcare Limited is authorised by the Prudential Regulation Authority and regulated by .0#
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premiums and marketing.
The FCA sets out regulations for the sale and administration of general insurance. We must follow We may disclose your information to other people or organisations. For example we’ll do this to:
these regulations when we deal with you. rmanage your claims, e.g. to deal with your doctors or any reinsurers;
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спсшуцѵ
rmanage your policy with your insurance broker;
You can check details of our registration on the FCA website: fca.org.uk rhelp us prevent and detect crime and medical malpractice by talking to other insurers and
relevant agencies; and
rallow other AXA companies in the UK to contact you if you have agreed.
Where our using your information relies on your consent you can withdraw your consent, but if you
do we may not be able to process your claims or manage your plan properly.

Page 38
In some cases you have the right to ask us to stop processing your information or tell us that you In the event you recover our Outlay and interest and do not repay us this recovered amount in
don’t want to receive certain information from us, such as marketing communications. You can also full we will be entitled to recover from you what you owe us and your plan may be cancelled in
ask us for a copy of information we hold about you and ask us to correct information that is wrong. accordance with ‘What happens if you break the terms of your plan’ on page 35.
If you want to ask to exercise any of your rights just call us on 0800 587 0955 or write to us. Even if you decide not to make a claim against a third party for the recovery of damages we retain
6.5 > What to do if somebody else is responsible for part of the cost of your /#
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claim and interest. You must co-operate with all reasonable requests in this respect.
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would include: provided by law.
ran insurer that you have another insurance policy with If you have any questions please call 0800 048 1206 and ask for the Third Party Recovery team.
ra state healthcare system
ra third party that has a legal responsibility or liability to pay.
We will pay our proper share of the claim.

6.6 > What to do if your claim relates to an injury or medical condition that was
caused or contributed to by another person
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that you can potentially be repaid for any costs you paid yourself, such as your excess or if you paid
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against the third party;
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party or any pre-action matters;
ғagree any proposed reduction to our Outlay and interest with us prior to settlement. If no such
agreement has been sought we retain the right to recover 100% of our Outlay and interest directly
from you;
ғrepay any recovery of our Outlay and interest from the third party directly to us within 21 days of
settlement;
ғprovide us with details of any settlement in full.

Page 39
 7 Glossary

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day-patient ˓ – a patient who is admitted to a hospital or day-patient unit because they need a
illness or injury, or which leads to your full recovery. period of medically supervised recovery, but does not occupy a bed overnight.
cancerġ˓ – a malignant tumour, tissues or cells, characterised by the uncontrolled growth and day-patient unit – a medical unit where day-patient treatment is carried out.
spread of malignant cells and invasion of tissue. » The units we recognise are listed in our Directory of Hospitals at axappphealthcare.co.uk/
chronic condition ˓ – a disease, illness or injury that has one or more of the following hospitals
characteristics: diagnostic tests ˓
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rit needs ongoing or long-term monitoring through consultations, examinations, check-ups and/ of your symptoms.
or tests
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rit needs ongoing or long-term control or relief of symptoms of the schedule of procedures and fees.
rit requires your rehabilitation or for you to be specially trained to cope with it
Directory of Hospitals – the list of hospitals, day-patient units and scanning centres that are
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rit has no known cure
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rit comes back or is likely to come back. Some treatments are only available in certain facilities.
cognitive behavioural therapist – a medical practitioner who meets all of the following conditions: » The Directory of Hospitals is on our website at axappphealthcare.co.uk/hospitals
rpractices cognitive behavioural therapy
ris recognised by us as a cognitive behavioural therapist.
Page 40
eligible members - the individuals currently employed by the group
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accepted by AXA PPP healthcare as members under the plan or any other category of alternative the latest versions of:
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fee-limited specialist – a specialist whose fees for covered treatment we pay up to the amount If the treatment is as an in-patient or day-patient, that treatment will be included as part of your
shown in the schedule of procedures and fees. private hospital charges.
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private hospital – a hospital listed in our current Directory of Hospitals.
group - the company or legal entity who hold the group insurance policy with AXA PPP healthcare
that the plan is part of. psychologist – a medical practitioner who meets all of the following conditions:
group insurance contract - the contract we have with the group for the group private medical rpractices psychology
insurance policy. ris recognised by us as a psychologist.
homeopath –a medical practitioner with full registration under the Medical Acts, who specialises in We will pay for treatment by a psychologist if both the following apply:
homeopathy who is registered under the relevant Act or a practitioner of homeopathy who holds ra specialist refers you to them
full membership of the Faculty of Homeopathy is registered with the Faculty of Homeopathy; and
rthe treatment is as an out-patient.
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in-patient ˓– a patient who is admitted to hospital and who occupies a bed overnight or longer, for scanning centre – a centre where out-patient

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ris recognised by us as a specialist.

Page 41
#
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out-patient treatment only is widened to include
those who meet all of the following conditions:
rspecialise in musculoskeletal medicine, sports medicine or podiatric surgery.
ris fully registered under the Medical Acts
ris recognised by us as a specialist.
» The full criteria we use when recognising specialists are available on request
surgery/surgical procedure – an operation or other invasive surgical intervention listed in the
schedule of procedures and fees.
terrorist act – any act of violence by an individual terrorist or a terrorist group to coerce or
intimidate the civilian population to achieve a political, military, social or religious goal.
therapist – a medical practitioner who meets all of the following conditions:
ris a practitioner in physiotherapy, osteopathy or chiropractic treatment
ris fully registered under the relevant Acts
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treatment ˓ – surgical or medical services (including diagnostic testsҘ
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Page 42
Page 43
 цпххпҝрпѵрш


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AXA PPP healthcare Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the
Prudential Regulation Authority.
Write to us at: AXA PPP healthcare, Phillips House, Crescent Road, Tunbridge Wells, Kent TN1 2PL.
We may record and/or monitor calls for quality assurance, training and as a record of our conversation.