Ccp Cc Cce Membership Guide 09

8/9/2019 Ccp Cc Cce Membership Guide 09

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BUPAClientChoice Plus,BUPA ClientChoice

and

BUPA ClientChoiceEssentialMembership

Guide

From 1 May 2007

CLC/ 521 0/MAY0 7 6 422 3 UNI

THE WORLD OF BUPA

Cover is provided by BUPA Insurance Limited. Registered in England and Wales No 3956433 #

#Authorised and regulated by the Financial Services Authority

Registered Office BUPA House 15-19 Bloomsbury Way London WC1A 2BA

BUPA 2007. BUPA and the heartbeat symbol are registered trademarks.

www.bupa.com

Call 0800 00 10 10

Lines are open 24 hours

www.bupa.com

Calls from landlines are free, however, mobile phoneproviders may charge.

Calls may be recorded and monitored.


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Contents

page

Your BUPA membership 2

About this guide

What to do if you need treatment

BUPA ClientChoice Plus, BUPA ClientChoice andBUPA ClientChoice Essential your rules and benefits

effective from 1 May 2007 6

How your membership works 7

1.1 The agreement between you and us 7

1.2 When your membership starts, renews and ends 8

1.3 Paying subscriptions and other charges 11

1.4 Making changes 121.5 General information 13

1.6 If you have cause for complaint 13

What you are covered for 15

2.1 Notes about your cover 15

The type of treatment covered

BUPA recognised medical practitioners andtreatment facilities

2.2 Summary of benefits table 18

2.3 Benefit notes 20

What is not covered 42

Claiming 56

4.1 Making a claim 56

4.2 How we will deal with your claim 58

4.3 If you want to withdraw a claim 59

4.4 If you have an excess 59

Glossary 61

Data Protection Notice 70

Contacting us

If you have any questions about your membership or your cover please call

the helpline and we will be happy to help you.

Call the helpline on 0845 60 09 673*(lines open 8am to 8pm, Monday to Friday and9am to 1pm Saturday).

For those with hearing or speech difficulties who use a textphone, call our

dedicated line on 0845 60 66 863* (lines open 9am to 5pm, Monday to

Friday).

Or write to us at: BUPA, Staines, TW18 4XF

Or fax us on: 01784 465 232

* BT landline calls to 0845 numbers will cost no more than 3 pence per minute.

Charges from other providers may vary and calls made from mobiles usually cost more. Calls may be recorded and may be monitored.


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Your BUPA membership

Wed like to thank you for choosing BUPA.

Whether youre new to BUPA or youve enjoyed the reassurance of BUPA private medical

insurance over the years, wed like to remind you that your BUPA cover gives you access

to prompt private medical treatment that you can arrange at a time and place that suits

you. Above all youll enjoy the peace of mind of knowing that your health cover is in

safe hands.

About this guide

ClientChoice is based on BUPAs LocalCare. This membership guide has been written to

take you through every aspect of your membership. It has been written in two parts. This

first part is designed to help you get the most from your membership. The second part

sets out the scheme rules and benefits which form part of the agreement between you

and us and they explain:

how your membership works

what you are and are not covered for

about making a claim and how an excess works

words and phrases that have a specific meaning under the scheme.

Please do not leave reading the rules and benefits until you need treatment. Although itmay seem a little daunting at first it is important that you understand how your cover

works should you need to arrange treatment at any time. If there is anything at all you

are unsure about when reading through this guide please call the helpline and we will be

happy to answer any queries you have. Youll find the helpline number and other contact

details on the inside fr ont cover.

We also recommend that you keep this guide, together with your membership

certificate, in a safe place as you may need to refer to them from time to time.

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What to do if you need treatment

We understand that it is only natural to feel anxious at a time of ill-health, so we will do

everything we can to help make arranging your treatment as simple and straightforward

as possible. You should always call us bef ore arranging any consultation, diagnostic tests

or treatment; we can then explain the cover available to you and help you in arranging

your treatment.

Please refer to Claiming in section 4 of Your rules and benefits and then follow these

simple steps.

If you are a moratorium member steps to making a claim

Please follow steps 1 and 2 below, then steps 3 to 7 on page 5.

Call BUPA

When you call the helpline we will confirm whether your consultant, therapist or, for members whose scheme is BUPA

ClientChoice Plus or BUPA ClientChoice, complementary medicine practitioner is recognised by BUPA.

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If your GP refers you for a consultation or treatment

Before you arrange any consultations or treatment

Explain to your GP that you are a BUPA member

Call the helpline before you and/or your GP arrange any private consultations or treatment We will send you a pre-treatment form. You and your GP will need to complete the form in full and return it to us.

Once we have received all the information we ask for we will contact you to confirm whether or not your proposed

treatment is covered under your moratorium membership and the benefits available to you.

Arranging your treatment

If we have confirmed your consultation, therapy or, for members whose scheme is BUPA ClientChoice Plus or BUPAClientChoice, complementary medicine treatment is covered you can go ahead and arrange your consultation ortreatment.

If you need to see a consultant ask your GP to refer you to a BUPA recognised consultant who charges within

BUPA benefit limits and who has admitting rights to a BUPA partnership network hospital. The rules and benefitsexplain about partnership consultants, non-partnership consultants and partnership network hospitals or you cancall the helpline and we will explain.

If you need to see a therapist or, for members whose scheme is BUPA ClientChoice Plus or BUPA ClientChoice,complementary medicine practitioner ask your GP to refer you to a BUPA recognised practitioner. The rules andbenefits explain why this is important for you or you can call the helpline and we will explain.

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Call BUPA

When you call the helpline we will confirm whether:

your consultant, therapist or, for members whose scheme is BUPA ClientChoice Plus or BUPA ClientChoice,complementary medicine practitioner is recognised by BUPA

your proposed treatment is covered

you need a claim form in some cases you may not need to complete a claim form and we will tell you about thiswhen you call us.

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If your GP refers you for a consultation or treatment

Explain you are a BUPA member.

If you need to see a consultant ask your GP to refer you to a BUPA recognised consultant who charges withinBUPA benefit limits and who has admitting rights to a BUPA partnership network hospital. The rules and

benefits explain about partnership consultants, non-partnership consultants and partnership network hospitalsor you can call the helpline and we will explain.

If you need to see a therapist or, for members whose scheme is BUPA ClientChoice Plus or BUPAClientChoice, complementary medicine practitioner ask your GP to refer you to a BUPA recognised

practitioner. The rules and benefits explain why this is important for you or you can call the helpline andwe will explain.

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If you are an underwritten member steps to making a claim

Helping us to help you

So we can confirm whether your proposed treatment, diagnostics, healthcare

practitioner or facility is covered under the scheme we will need to ask you some

questions. We will always ask you for your BUPA membership number. We will also ask

you some, or all, of the following so please have the information to hand when you call.

What condition are you suffering from?

When did your symptoms first begin?

When did you first see your GP about them?

What treatment has been recommended?

On what date will you receive the treatment?

What is the name of the consultant or other healthcare practitioner?

Where will your proposed treatment take place?

Will you need to stay in hospital? If so, for how long?

Please follow steps 1 and 2 below, then steps 3 to 7 on page 5.


7 If your consultant recommends home nursing or out-patient treatment after yourhospital stay

Call the helpline and we will confirm your cover and the benefits available to you.

When you leave hospital

Settle any personal expenses such as newspapers, phone calls or guest meals.

We will settle the medical and hospital bills covered under your membership.

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When you go into hospital

Take your membership certificate with you and, if you are an underwritten member, your special conditionsupplement (if any).

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If your consultant recommendsout-patient diagnostic tests ortreatment

Call the helpline and we will confirm whether thetests and/or treatment are covered under yourmembership and the benefits available to you.

4a If your consultant recommends day-patient orin-patient treatment

Call the helpline and we will:

confirm whether your treatment is covered under yourmembership and the benefits available to you

help you choose a partnership network hospital inyour area.

4b

3 When you see the consultant, therapist or, for members whose scheme is BUPA ClientChoicePlus or BUPA ClientChoice, complementary medicine practitioner

Show them your membership certificate and, if you are an underwritten member, your special condition

supplement if you have one. See rule 1.1.a, The agreement between you and us in Your rules and benefits.

For all members


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How your membership works

1.1 The agreement between you and us

In return for you, the main member, paying ussubscriptions, weagree to provide you

and your dependants(if any) with cover under the terms of our agreement.

Only youand BUPA have legal rights under our agreement, although wewill allow

anyone who is covered under yourmembership complete access to ourcomplaints

process (see rule 1.6, If you have cause for complaint, in this section).

All the following make up our agreementand must be read together as they set out the

terms and conditions of your membership.

Yourapplication for cover: this includes any quote request, applications for cover

for youand your dependants(if any) and the declarations that youmade during

the application process

Your rules and benefits in the schemeMembership Guide: wepay for treatment

costs under the rules and benefits of the schemethat applied to you on the date

you received your treatment

Your membership certificate:this shows yourcurrent membership details including:

the schemeyou are covered under, who is covered, the dates when the cover

started and when your membership is due for renewal

the subscriptions youwill be paying, the method of payment youhave chosen

and yourno claims discount level

the excessamount youhave chosen (if any)

whether you have moratorium membershipor underwritten membership

if you are an underwritten member, any special conditions(youwill only receive

a special conditionsupplement if there are any special conditionsthat apply to

youor anyone covered under yourmembership).

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BUPA ClientChoice Plus, BUPA ClientChoice andBUPA ClientChoice Essential your rules andbenefitseffective from 1 May 2007

These are the rules and benefits of the schemeand they form part of

our agreement. They apply to anyone joining the schemeor renewing

their membership on or after the effective from date.

For anyone joining the schemethey apply from their start date.

For anyone renewing their membership of the schemethey apply for the period

from their first renewal dateon or after the effective from date.

Please also see rule 1.4, Making changes in section 1.

Words in bold and italic in these rules and benefits are defined terms which have a

specific meaning. You should check their meaning in the glossary.

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All membership documents and correspondence are sent to the main member.

Wewill only pay for treatmentcosts that are covered under the scheme. Treatment

costs that you incur that are not covered under the schemeare your sole responsibility.

1.2 When your membership starts, renews and ends

Starting membership

Yourmembership starts on your start date.

Your dependantsmembership starts on their start date.

Covering your new born baby: youmay apply to cover yournew born baby under your

membership as one ofyour dependants, free of charge, until yourfirst renewal date

after their birth.

if you are a moratorium memberand have been a member of the schemefor at

least 12 months before the babys birth and youinclude the baby under your

membership before the baby is three months old wewill not apply any

moratorium conditionsto the babys cover

if you are an underwritten memberand have been a member of the schemefor

at least 12 months before the babys birth and youinclude the baby under your

membership before the baby is three months old wewill not apply any special

conditionsto the babys cover.

Please also see Neo-natal treatment in section 3, What is not covered.

Your right to cancel within 21 days of joining

Youmay cancel yourmembership for any reason by writing to uswithin 21 days of

receiving the first membership certificate wesend youconfirming yourcover. As long as

youhave not made any claims wewill refund all yoursubscriptions.

Youmay cancel any ofyour dependantsmembership for any reason by writing to us

within 21 days of receiving the first membership certificate wesend youconfirming their

cover. As long as no claims have been made in respect of their cover wewill refund all

yoursubscriptions paid in respect of that dependantscover.

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How your membership worksHow your membership works

Renewing your membership

Our agreementis an annual one and your membership must be renewed each yearon

your renewal date, subject to rule 1.4, Making changes in this section. Your

membership will renew automatically as long as youcontinue to pay yoursubscriptions

and any other charges unless:

youdecide to end your membership, or

wedecide to end the scheme. Ifwedecide to end the scheme wewill write to let

youknow at least 28 days before your renewal date.

How your membership can end

Youcan end yourmembership or the membership of any ofyour dependantsat any

time by writing to us. Ifyourmembership ends the membership of all your dependants

will also end.

Yourmembership and that ofyour dependantswill automatically end if:

youdo not renew yourmembership

youdo not pay yoursubscriptions, or any other payment youhave to make in

respect of the cover, on or before the date they are due

youstop living in the UK

youdie, or

wedecide to end the scheme.

Your dependantsmembership will automatically end if:

yourmembership ends

youdo not renew the membership of that dependant

that dependantstops living in the UK

that dependantdies, or

wedecide to end the scheme.


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1.3 Paying subscriptions and other charges and your no claims discount

Subscriptions and other charges

Youmust pay subscriptions to usin advance for youand your dependantsthroughout

yourmembership. The amount youmust pay and yourmethod of payment is shown on

your membership certificate.

Youmust also pay to usthe amount of any insurance premium tax (IPT) that is payable

in respect of the cover provided. Youmust also pay to usthe amount of any other taxes,

levies or charges that may be introduced which are payable in respect of the cover and

which either weor youhave to pay by law. Youmust pay usthese amounts when you

pay us yoursubscriptions unless otherwise required by law. The amount youhave to

pay is shown on your membership certificate.

No claims discount

Yourno claims discount level is based on yourand your dependants(if any) claimshistory during your claiming period.

If, during your claiming period, wedo not pay any claims for youor any ofyour

dependantswewill increase yourno claims discount by one level.

If, during your claiming period, wedo pay a claim for youor any ofyour

dependants wewill reduce yourno claims discount by two levels.

Weapply yourno claims discount to yournet subscription rate (excluding IPT).

No claims discount scale: this scale shows the amount of discount that applies for each

no claims discount level. Discount level 7 is the maximum discount level available.

If you are unwell, you should not delay seeking treatmentbecause of the impact it will

have on yourno claims discount.

Discount level you are on | 1 | 2 | 3 | 4 | 5 | 6 | 7Discount you will receive | 0% | 5% | 10% | 15% | 20% | 25% | 30%

Wecan end a persons membership if there is reasonable evidence that youor they

misled usor attempted to do so. By this wemean, giving false information or keeping

necessary information from us, either intentionally or carelessly, which may influence us

when deciding:

whether or not wewill provide cover for them

what subscriptions should be paid for that person, or

whether wehave to pay any claim.

Refund of subscriptions if your membership ends

Ifyourmembership ends for any reason wewill refund any subscriptions youhave paid

which relates to a period after yourcover ends.

Ifyour dependantsmembership ends for any reason wewill refund any subscriptions

youhave paid in respect of that dependantwhich relate to a period after their cover

ends.

Joining another BUPA scheme

Ifwedecide to end the scheme wewill offer youthe opportunity to join the BUPA

private medical scheme that replaces this schemeon the basis of the terms and

conditions of the new scheme and:

if you are a moratorium member wemay assess your application and apply

special conditionsto yourcover and/or that ofyour dependantsunder the new

scheme

if you are an underwritten memberand you transfer within one month wewill

not add any special conditionsto yourmembership or that of any ofyour

dependantsunder the new scheme other than those that apply under this

scheme.

If your membership ends for any other reason you may apply to join another BUPA

private medical scheme. You may only do this as long as your membership didnt end

because you misled usor attempted to mislead us. Wewill consider your application at

oursole discretion.


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1.5 General information

Change of address

Youshould call or write to tell usifyouchange youraddress. Ifyoudo not contact usto

tell us youhave changed youraddress and youpay yoursubscriptions by direct debit,

yourmembership of the schemewill automatically end on yournext renewal dateifwe

cannot contact you.

Correspondence between us

Letters between us must be sent with the postage costs paid before posting. We can

each assume that the letter will be received three days after posting.

Documents you send to us

Wecannot return original documents to you. However wewill send youcopies if you

ask usto do so at the time you give usthe documents.

1.6 If you have cause for complaint

If something has gone wrong, wewant to do everything wecan to put it right. Heres a

simple procedure to ensure your concerns are dealt with as quickly and effectively as

possible.

The helpline is always the first number to call if you have any complaints:

Please call uson: 0845 60 09 673* between 8am and 8pm, Monday to Friday and

9am to 1pm on Saturdays. Or write to usat: Envoy Team, BUPA, Staines TW18 4XF

or fax uson 01784 893 232.

For members with special needs:

for hearing and speech impaired members who have a textphone, please call us

on: 0845 60 66 863*, between 9am and 5pm Monday to Friday

wecan also offer a choice of Braille, large print or audio for correspondence.

Please let usknow which you would prefer.

1.4 Making changes

Changes we can make

Wecan change the terms and conditions of the membership at your renewal date.

These changes could affect:

how wecalculate subscriptions, the amount youhave to pay, how often youpay

them, the method of payment and the no claims discount (the cost of

subscriptions has typically risen higher than the retail price index (RPI) over the

same period, but this does not mean that they will increase by the same rate in

the future)

the amount and type of cover provided under the scheme.

If you are an underwritten member wewill not add any special conditionsto

someones cover for medical conditions that started after their start dateprovided they

gave usall the information weasked for before their start date.

Wecan, at any time, change the amount youhave to pay usin respect of IPT or any

other taxes, levies or charges that may be introduced and which are payable in respect

of your cover if there is a change in the rate of IPT or if any such taxes, levies or charges

are introduced.

Ifwedo make any changes to the terms and conditions ofyourmembership wewill

write to tell youat least 28 days before the change takes effect.

Changes you can make

At your renewal date youcan apply to add, remove or change an excessunder the

scheme. Wewill consider yourapplication at oursole discretion. Ifyouare an

underwritten memberand apply to increase cover under the scheme wemay ask you

to agree to special conditionsbefore weaccept yourapplication.

Other parties

No other person is allowed to make or confirm any changes to the agreementon our

behalf or decide not to enforce any ofourrights. Equally, no change to the agreement

will be valid unless it is confirmed by usin writing.


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Ifwehave not been able to resolve the problem and you wish to take your

complaint further, you can contact ourCustomer Relations Department. Please call:

0845 60 66 726* between 8:30am and 5:30pm, Monday to Friday. Or write to:

BUPA, Staines TW18 4XF.

Its very rare that wecant settle a complaint, but if this does happen, you may refer

your complaint to the Financial Ombudsman Service. You can write to them at:

South Quay Plaza, 183 Marsh Wall, London E14 9SR or call them on 0845 08 01 800*

between 9am and 5pm, Monday to Friday.

Please let usknow if you want a full copy ofourcomplaints procedure.

None of these procedures affect your legal rights.

Applicable law

The agreementbetween youand BUPA is governed by English law. Any dispute that

cannot otherwise be settled will be dealt with by the courts in the UK.


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What you are covered forThis section 2 should be read as a whole and sets out what you are covered for under

the schemesubject to the terms and conditions of the schemeincluding the exclusions

and any special conditionsor moratorium conditionsthat may apply to you.

2.1 Notes about your cover

2.1.a The type of treatment covered

You are only covered for eligible treatmentthat is carried out in the UK. Your GP must

have initially referred you for the treatment. However for eligible day-patient

treatmentor eligible in-patient treatmentprovided by a consultantsuch referral is not

required in the case of a medical emergency.

By eligible treatment wemean treatmentof an acute conditiontogether with the

products and equipment used as part of the treatmentthat:

are consistent with generally accepted standards of medical practice and

representative of best practices in the medical profession in the UK

are clinically appropriate in terms of type, frequency, extent, duration and the

facility or location where the services are provided

are demonstrated through scientific evidence to be effective in improving health

outcomes, and

are not provided or used primarily for the expediency of you or yourconsultant

or other health care professional

and the treatment, services or charges are not excluded under the terms and conditions

of the scheme.

There are certain treatments, services or charges that are not covered under the

schemeincluding treatmentofchronic conditions. These are explained in section 3,

What is not covered.

2

* BT landline calls to 0845 numbers will cost no more than 3 pence perminute. Charges from other providers may vary and calls made frommobiles usually cost more.

Calls may be recorded and may be monitored.


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2.1.b BUPA recognised medical practitioners and treatment facilities

Your cover for eligible treatmentcosts depends on you using certain BUPA recognised

medical practitioners and treatment facilities as explained in the benefit notes.

Please note:

the medical practitioners, other health care professionals and treatment facilities

you use can affect the level of benefits wepay you

certain medical practitioners, other health care professionals and treatment

facilities that werecognise may only be recognised by usfor certain types of

treatmentor certain levels of benefits

the medical practitioners, other health care professionals and treatment facilities

that werecognise and the type oftreatmentand/or level of benefit that we

recognise them for can change from time to time.

You are not covered for treatmentcosts where:

the person who has overall responsibility for your treatmentis not a consultant

the only exception to this is where your GP refers you for eligible out-patient

treatmentby a therapistor, for members whose schemeis BUPA ClientChoice

Plus or BUPA ClientChoice, complementary medicine practitionersas set out in

benefit note 2a

the medical practitioner, other health care professional or treatment facility is not

recognised by BUPA for providing either the type oftreatmentyou need or for

treating the medical condition you have.

You should always call usbefore arranging any treatmentto check your cover and

whether your chosen medical practitioner, other health care professional or treatment

facility is recognised by us.

What you are covered for How your membership works

2.1.c The type of membership you have

There are two different types of membership under the scheme. These are moratorium

membershipand underwritten membership. Youand your dependantswill have the

same type of membership. The type of membership youhave is shown on your

membership certificate.

Moratorium members

Ifyouare a moratorium member, when youjoined the scheme youagreed that you

and your dependants, if any, would not be covered for any moratorium conditions.

See Moratorium conditions in section 3 for full details including details of other medical

conditions and treatmentsthat are not covered under the scheme.

Underwritten members

Ifyouare an underwritten member, when youjoined the scheme youagreed that you

and your dependants, if any, would not be covered for any pre-existing conditions.See Pre-existing conditions in section 3 for full details including details of other medical

conditions and treatmentsthat are not covered under the scheme.


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What you are covered for

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2.2 Summary of benefits table

This table only shows the headings for the type ofeligible treatmentcosts wewill pay

for. Each heading refers to a benefit note. Weonly pay the eligible treatmentcosts we

say wepay for in the benefit notes and only up to the limits set out in them, subject to

the rules and benefits of the schemeincluding the exclusions and any special

conditionsthat may apply to you.

Wedo not pay for any charges or fees incurred for treatmentthat is not covered under

the scheme, including any costs for treatment, including consultations that take place

after the date your membership ends. Any costs you incur that are not covered under

the schemeare your responsibility.


Type of eligible treatment costs covered

Reasonable and customary charges benefit note 1:

this note appliesequally to all theother benefit notes

When you are not admitted to hospital

Out-patient consultations, treatment and diagnostic testsand investigations benefit note 2

Out-patient consultations and therapies benefit note 2a

Out-patient consultations and treatment benefit note 2a(i)for members whose schemeis BUPA ClientChoice Plus orBUPA ClientChoice, out-patient consultations with a consultantand out-patient therapies and complementary medicine on GP orconsultant referral

Out-patient consultations and treatment for members benefit note 2a(ii)whose schemeis BUPA ClientChoice Essentialout-patient consultations with a consultant and out-patient therapieson GP or consultant referral when following and directly relatedto day-patient or in-patient treatment

Out-patient diagnostics

out-patient tests and investigations on consultant referral benefit note 2b

out-patient MRI , CTand PET scans on consul tant referra l benef it note 2c

Type of eligible treatment costs covered

When you are admitted to hospital

Consultants fees for med ical and surgical hosp ita l t reatment benef it note 3

Hospital charges benefit note 4what we pay for hospital charges benefit note 4a

out-patient surgical operations benefit note 4b

day-patient and in-patient treatment

hospital accommodation benefit note 4c

parent accommodation benefit note 4d

theatre charges, nursing care, drugs and surgical dressings benefit note 4e

intensive care benefit note 4f

pathology, radiology, diagnostic tests, MRI, CT and PETscans benefit note 4g

therapies, such as physiotherapy benefit note 4h

prostheses and appliances benefit note 4itreatment at home benefit note 4j

Additional benefits

Private ambulance charges benefit note 5a

Home nursing after private eligible in-patient treatment benefit note 5b

Benefits for specific medical conditions

Cancer treatment benefit note 6a

Psychiatric treatment for members whose schemeisBUPA ClientChoice Plus benefit note 6b


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benefit note 2a(i) for members whose schemeis BUPAClientChoice Plus or

BUPA ClientChoice:

out-patient consultations with a consultant and out-patient therapies and complementary

medicine treatment on GP or consultant referral

Consultations with a consultant

For members who schemeis BUPA ClientChoice Plus or BUPA ClientChoice wepay

consultantsfees for out-patient consultations that are to assess your acute condition

when carried out as eligible out-patient treatment.

Consultantscharges for the use of consulting rooms are not treated as consultants

fees for a consultation. Wemay pay consultantscharges for the use of consulting

rooms. Where wedo agree wewill treat the charge as falling under this benefit note 2a

and subject to the benefit limit in this benefit note.

Wedo not pay hospitalcharges for the use of a consulting room.

Therapies and complementary medicine treatment

For members who schemeis BUPA ClientChoice Plus or BUPA ClientChoice wepay

therapistsfees and complementary medicine practitionersfees for eligible

out-patient treatmentwhen you are referred for the treatmentby your GP or

consultant.

Please note: for members whose schemeis BUPA ClientChoice Plus psychiatric

treatmentprovided by therapistsand carried out as out-patient treatmentis only paid

at ourdiscretion. Wewill exercise ourdiscretion as set out in benefit note 6b. You

should refer to that benefit note if you need that type ofout-patient treatment.

If your consultantrefers you to a medical or health practitioner who is not a BUPArecognised therapistor complementary medicine practitioner, wemay pay the

charges as if the practitioner were a therapistor complementary medicine practitioner

if all of the following apply:

your consultantrefers you to the practitioner before the eligible out-patient

treatmenttakes place and remains in overall charge of your care, and

the practitioner has applied for BUPA recognition and wehave not written to say

he/she is not recognised by BUPA.


2.3 Benefit notes

Wepay the eligible treatmentcosts wesay wepay for in these benefit notes subject to

the rules and benefits of the schemeincluding the exclusions and any special

conditionsor moratorium conditionsthat may apply to you. The benefit notes set out

the type oftreatmentcosts wepay for and how much wepay, which in most cases is in

a table within the relevant benefit note.

Benefit note 1 reasonable and customary charges

This benefit note 1 applies equally to benefit notes 2 to 6 and should be read in

conjunction with all those benefit notes.

Weonly pay eligible treatmentcharges that are reasonable and customary. This means

that the amount you are charged by medical practitioners, other health care

professionals and/or treatment facilities and what you are charged for have to be in line

with what the majority ofourother members are charged for similar treatmentor

services.

When you are not admitted to hospital

Benefit note 2 out-patient consultations, treatment and diagnostic tests

and investigations

Benefit notes 2a to 2c set out your cover for eligible out-patient treatment. Your

treatmentmust follow an initial referral f rom your GP.

benefit note 2a out-patient consultations and therapies

What wepay for out-patient consultations and therapies depends on the schemethatyou are covered under. If your schemeis:

BUPAClientChoice Plus you should read benefit note 2a(i)

BUPAClientChoice you should read benefit note 2a(i)

BUPAClientChoice Essential you should read benefit note 2a(ii).


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If your consultantrefers you to a medical or health practitioner who is not a BUPA

recognised therapist, wemay pay the charges as if the practitioner were a therapistif

all of the following apply:





Consultantscharges for the use of consulting rooms are not treated as consultants

fees for a consultation. Wemay pay consultantscharges for the use of consulting

rooms. Where wedo agree wewill treat the charge as falling under this benefit note 2a

and subject to the benefit limit in this benefit note.

Wedo not pay hospitalcharges for the use of a consulting room.

benefit note 2b out-patient tests and investigations on consultant referral

When requested by your consultantto help determine or assess your condition as part

ofeligible out-patient treatment wepay hospitalcharges (including the charge for

interpretation of the results) for diagnostic tests. Wedo not pay charges for diagnostic

teststhat are not from the hospital.

(MRI, CT and PET scans are not paid under this note see benefit note 2c.)

hospital We pay in full

consultantsand therapists We pay up to a total amount of 500 each yearfor

all such eligible out-patient treatment. This is theoverall amount wepay for all such consultationsand treatmentand not for each type ofconsultation or treatmentindividually.

benefit note 2a (ii) for members whose scheme is BUPA ClientChoice Essential:

out-patient consultations with a consultant and out-patient therapies on GP or consultant

referral when following and directly related to day-patient or in-patient treatment

For members whose schemeis BUPA ClientChoice Essential wepay:

consultantsfees for out-patient consultations that are to assess your acute

conditionwhen carried out as eligible out-patient treatment

therapistsfees for eligible out-patient treatmentwhen you are referred for the

treatmentby your GP or consultant

but weonly pay when:

the consultation or treatmentfollows and is directly related to eligible

day-patient treatmentor eligible in-patient treatment

is received within six months of the date you are discharged from the hospital

after the eligible day-patient treatmentor eligible in-patient treatmentit is

related to, and

for consultations with a consultant weonly pay for up to two such consultations

during the six months period.

complementary medicine You can use up to 250 of your available cover topractitioners pay for eligible out-patient treatmentprovided by

complementary medicine practitioners.

consultantsand therapists for members whose schemeis BUPA ClientChoicePlus: wepay up to a total amount of 1,000 eachyearfor all such eligible out-patient treatment.

for members whose schemeis BUPA ClientChoice:

wepay up to a total amount of 500 each yearforall such eligible out-patient treatment.

These are the overall amounts wepay for all suchconsultations and treatmentand not for each typeof consultation or treatmentindividually.


22 23


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What you are covered forWhat you are covered for

24 25

benefit note 2c out-patient MRI, CT and PET scans on consultant referral


ofeligible out-patient treatment wepay imaging centreor hospitalcharges (including

the charge for interpretation of the results), for:

MRI scans (magnetic resonance imaging)

CT scans (computed tomography)

PET scans (positron emission tomography).

Wedo not pay charges for MRI, CT and PET scans that are not from the imaging centre

or hospital.

Details ofimaging centresand the type of scan werecognise them for are available on

request.

When you are admitted to hospital

Benefit note 3 consultants fees for medical and surgical hospital

treatment

Wepay consultantsfees for eligible treatmentbut the amount wewill pay depends on:

whether your treatmentis provided by a partnership consultantor a consultantwho is not a partnership consultant, and

where your treatmentis carried out.

If you need eligible cancer treatmentthis is dealt with separately under benefit note 6a

and you should refer to that benefit note if you need that type oftreatment.

For members whose schemeis BUPA ClientChoice Plus if you need psychiatric

treatmentthis is dealt with separately under benefit note 6b and you should refer to

that benefit note if you need that type oftreatment.

hospitalthat is not an Wepay up to 100 towards the totalimaging centre hospital charges

imaging centre We pay in full

Wedo not have to pay your consultantsfees if your eligible treatmentis carried out in

a hospitalthat is not a partnership network hospitalwithout ourprior written approval.

Surgeons and anaesthetists

Wepay consultantsurgeons fees and consultantanaesthetists fees for eligible

surgical operationscarried out in a partnership network hospital.

Please note: the benefits available for consultantsurgeons and consultantanaesthetists

may differ for the same operation.

Physicians

Wepay consultantphysicians fees for eligible day-patient treatmentor eligible

in-patient treatmentin a partnership network hospitalif the treatmentdoes not

include a surgical operationor cancer treatment.

If your treatmentdoes include an eligible surgical operation weonly pay consultant

physicians fees if the attendance of a physician is medically necessary because of your

eligible surgical operation.

If your treatmentdoes include eligible cancer treatment weonly pay consultant

physicians fees if the attendance of a consultantphysician is medically necessary

consultantswho are not Wepay up to the benefit limits set out in thepar tne rship consultants consultant fee s schedule based on:

the type and complexity of the eligible surgicaloperationcarried out

the BUPA recognition status of the consultant

where the eligible surgical operationis carriedout, both in terms of the hospitalor facility andthe location.

The consultant fees schedulemay change fromtime to time. Details of the schedule are available onrequest. Before receiving your treatmentyou areadvised to check with your consultantwhether theycharge within the benefit limits set out in theconsultant fees schedule.

partnership consultants We pay in full


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What you are covered forWhat you are covered for

26 27

because of your eligible cancer treatment, for example if you develop an infection that

requires eligible in-patient treatment.

Benefit note 4 hospital charges

benefit note 4a what we pay for hospital charges

Wepay hospitalcharges for eligible treatment. The hospitalcharges wepay for are set

out in benefit notes 4b to 4i. The amount wepay for those hospitalcharges is explained

in this benefit note 4a and depends on where your treatmentis carried out and whether

your treatmentis out-patient, day-patientor in-patient treatment.

Out-patient surgical operations

Wepay the type ofhospitalcharges set out in benefit note 4b for eligible surgical

operationscarried out as eligible out-patient treatmentup to the amounts below.

hospitalthat is not a Wepay up to a total amount of 100 for thepartnership network hos pital hospital charges. This is the total amount wepay

for all the hospitalcharges and not the amount wepay for each type of service, charge or itemindividually.

Please note: wedo not have to pay your claim forconsultantsfees if you use a hospitalthat is not apartnership network hospitalwithout ourpriorwritten agreement.

par tner ship ne twor k hospital We pay in full

consultantswho are not Wepay up to 55 each day for eligible day-patientpartnership consultants treatment and for eligible in-patient treatment.

Wepay up to an additional 80 each night for atotal of 14 nights each yearfor eligible in-patienttreatmentfor certain major medical illnesses asclassified in the consultant fees schedule.


Day-patient and in-patient treatment

Wepay the type ofhospitalcharges set out in benefit notes 4c to 4i for eligible

day-patient treatmentand eligible in-patient treatmentup to the amounts below.

benefit note 4b out-patient surgical operations

Wepay hospitalcharges for eligible surgical operationscarried out as eligible

out-patient treatment. Wepay for theatre use, including equipment, and drugs and

surgical dressings used during the surgical operation.

benefit note 4c hospital accommodation

Wepay hospitalaccommodation charges for eligible day-patient treatmentor eligible

in-patient treatmentincluding your own meals and refreshments while you are

receiving your treatment.

Wedo not pay for personal items such as telephone calls, newspapers, guest meals or

personal laundry.

hospitalthat is not a Wedo not have to pay your claim for hospitalpartnership network hospital charges if you receive your treatmentin a hospital

that is not a partnership network hospitalwithoutourprior written agreement.

If, for medical reasons, your proposed eligibleday-patient treatmentor eligible in-patienttreatmentcannot take place in a partnershipnetwork hospital wemay agree to your treatmentbeing carried out in a hospitalthat is not apartnership network hospital. Weneed full clinical

details from your consultantbefore wecan give ourdecision. Ifwedo agree, wepay benefits for thetreatmentas if the hospitalhad been a partnershipnetwork hospital. When you contact uswewillcheck your cover and help you to find a suitablealternative hospital. Please note, an en suite orsingle room may not be available in a hospitalthatis not a partnership network hospital.

par tner ship ne twor k hospital We pay in full


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benefit note 4f intensive care

Wepay hospitalcharges for intensive carewhen needed as an essential part of your

eligible day-patient treatmentor eligible in-patient treatmentbut weonly pay if all

the following conditions are met:

the intensive careis required routinely by patients undergoing the same type of

treatmentas yours

you are receiving private eligible treatmentin a hospitalequipped with a critical

care unit

the intensive careis carried out in the critical care unit, and

it follows your planned admission to the hospitalfor private treatment.

Wealso pay for intensive carefor eligible day-patient treatmentor eligible in-patient

treatmentif unforeseen circumstances arise from a medical or surgical procedure which

does not routinely require intensive careas part of the treatmentbut only if:

you are receiving private eligible treatmentin a hospitalequipped with a critical

care unit, and

the intensive careis carried out in the critical care unit

in which case your consultantor hospitalshould contact usat the e arliest opportunity.

Wedo not pay for any intensive carein any of the following circumstances:

it follows an unplanned or an emergency admission to an NHS hospital or facility

it follows a transfer (whether on an emergency basis or not) to an NHS hospital or

facility from a private hospital

it is carried out in a unit or facility which is not a critical care unit.

Please also see Intensive care in the What is not covered section.

Wedo not pay hospitalcharges for accommodation if:

the charge is for an overnight stay for treatmentthat would normally be carried

out as out-patient treatmentor day-patient treatment

the charge is for use of a bed for treatmentthat would normally be carried out as

out-patient treatment.

benefit note 4d parent accommodation

Wepay hospitalaccommodation charges for each night a parent needs to stay in the

hospitalwith their child. Weonly pay for one parent each night. The child must be:

under 12

a member under the scheme, and

receiving eligible in-patient treatment.

This benefit applies to the childs cover and any charges are payable from the childs

benefits.

benefit note 4e theatre charges, nursing care, drugs and surgical dressings

Wepay hospitalcharges for use of the operating theatre and for nursing care, drugs

and surgical dressings when needed as an essential part of your eligible day-patient

treatmentor eligible in-patient treatment.

Wedo not pay for extra nursing services in addition to those that the hospitalwould

usually provide as part of normal patient care without making any extra charge.

Wedo not pay for drugs and surgical dressings used for out-patient treatmentor for

you to use after your stay in hospital.


28 29


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benefit note 4j treatment at home

Wemay, at ourdiscretion, pay for you to receive eligible treatmentat home. You must

have ourwritten agreement before the treatmentstarts and weneed full clinical details

from your consultantbefore wecan make ourdecision. Wewill only consider

treatmentat homein the following circumstances:

your consultanthas recommended that you receive the treatmentat homeand

remains in overall charge of your treatment

if you did not have the treatmentat homethen, for medical reasons, you would

need to receive the treatmentin a hospital, and

the treatmentis provided to you by a medical treatment provider.

medical treatment provider Ifweagree to pay for eligible treatmentat homewepay in full for the charges weagree to pay onyour behalf unless wetell you that a benefit limitapplies.

Wedo not pay for any fees or charges fortreatmentat homethat has not been provided toyou by the medical treatment provider.

benefit note 4g pathology, radiology, diagnostic tests, MRI, CT and PET scans

When recommended by your consultantto help determine or assess your condition as

part ofeligible day-patient treatmentor eligible in-patient treatment wepay hospital

charges for:

pathology (such as checking blood and urine samples)

radiology (such as X-rays)

diagnostic tests(such as ECGs)


CT scans (computed tomography), and


benefit note 4h therapies, such as physiotherapy

Wepay hospitalcharges for eligible treatmentprovided by therapists(such as

physiotherapy) when needed as part of your eligible day-patient treatmentor eligiblein-patient treatment.

benefit note 4i prostheses and appliances

Wepay hospitalcharges for a prosthesisor applianceneeded as part of your eligible

day-patient treatmentor eligible in-patient treatment.

Please note: see the Glossary for the definitions ofprosthesisand applianceas these set

out the extent of the cover.

Wedo not pay for any treatmentwhich is for or associated with or related to a

prosthesis or appliance that wedo not cover under the scheme.


30 31


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Benefits for specific medical conditions

Benefit note 6a cancer treatment

This benefit note 6a sets out what wepay for:

eligible cancer treatmentcarried out as eligible out-patient treatment,

out-patient drugs for eligible cancer treatment,

radiotherapy (the use of radiation to treat cancer) and chemotherapy (the use of

drugs to treat cancer), and

day-patient treatmentand in-patient treatmentfor eligible cancer treatment

that includes a bone marrow or stem cell transplant.

For all other eligible cancer treatment wepay on the same basis and up to the same

limits as wepay for other eligible treatmentas set out in benefit note 1 and benefit

notes 3 to 5.

benefit note 6a(i).1 out-patient consultations for cancer with a consultant,out-patient therapies for cancer on GP or consultant referral and out-patient

tests and investigations for cancer on consultant referral

Out-patient consultations for cancer with a consultant

Wepay consultantsfees for out-patient consultations that are to assess your acute

conditionofcancerwhen carried out as eligible out-patient treatment.

Out-patient therapies for cancer on GP or consultant referral

Wepay therapistsfees for eligible out-patient treatmentfor cancerwhen you are

referred for the treatmentby your GP or consultant.

Additional benefits

Benefit note 5a private ambulance charges

Wepay for travel by private road ambulance if you need private eligible day-patient

treatmentor eligible in-patient treatment, and it is medically necessary for you totravel by ambulance:

from your home or place of work to hospital

between hospitalswhen you are discharged from one hospitaland admitted to

another hospitalfor eligible in-patient treatment

f rom hospitalto home, or

between an airport or seaport and hospital.

Benefit note 5b home nursing after private eligible in-patient treatment

Wepay for home nursing immediately following private eligible in-patient treatmentif

the home nursing:

i s for eligible treatment

is needed for medical reasons ie not domestic or social reasons

is necessary ie without it you would have to remain in hospital

starts immediately after you leave the hospital

is provided by a qualified nursein your own home, and

is carried out under the supervision of your consultant.

Wedo not pay home nursing provided by a community psychiatric nurse.

If your home nursing is payable wepay up to 600 each year.

Wemay pay more than 600 for home nursing, but only ifwehave agreed this in advance.Weneed full clinical details from your consultantbefore wecan give ourdecision.

Wepay up to 60 for each single trip up to an overall maximum amount of120 each year.


32 33


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recognised therapist, wemay pay the charges as if the practitioner were a therapistif

all of the following apply:





Out-patient tests and investigations for cancer on consultant referral


ofeligible out-patient treatmentfor cancer wepay hospitalcharges (including the

charge for interpretation of the results) for diagnostic tests. Wedo not pay charges for

diagnostic teststhat are not from the hospital.

(out-patient MRI, CT and PET scans for cancerare not paid under this benefit note see

benefit note 6a(ii))

benefit note 6a(i).2 for members whose schemeis BUPA ClientChoice Plus or

BUPA ClientChoice: out-patient complementary medicine for cancer on GP or

consultant referral

For members whose schemeis BUPA ClientChoice Plus or BUPA ClientChoice wepay

complementary medicine practitionersfees for eligible out-patient treatmentfor

cancerwhen you are referred for the treatmentby your GP or consultant.

consultants, therapists, Wepay up in full

and hospitals


34 35



recognised complementary medicine practitioner, wemay pay the charges as if the

practitioner were a complementary medicine practitionerif all of the following apply:





benefit note 6a(ii) out-patient MRI, CT and PET scans on consultant referral


ofeligible out-patient treatmentfor cancer wepay imaging centreor hospitalcharges

(including the charge for interpretation of the results), for:


CT scans (computed tomography)


Wedo not pay charges for MRI, CT and PET scans that are not from the imaging centre

or hospital.

Details ofimaging centresand the type of scan they are recognised for are available on

request.

hospitalthat is not an Wepay up to 100 towards the total hospitalchargesimaging centre

imaging centre We pay in full

complementary medicine Wepay up in fullpractitioners


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benefit note 6a(iv) out-patient cancer drugs

Wepay hospitalcharges or specialist treatment centrecharges for drugs (such as

cytotoxic drugs) that are related specifically to planning and carrying out eligible cancer

treatmentwhich you receive as out-patient treatment.

hospitalor specialist Wepay in fulltreatment centre

continued

1 week, wepay up to a maximum of 137;

2 weeks, wepay up to a maximum of 257;

3 weeks, wepay up to a maximum of 386; or 4 weeks, wepay up to a maximum of 515.

By 1 week wemean your Start Date to the 7th dayoftreatment.

By 2 weeks wemean your Start Date to the 14th dayoftreatment.

By 3 weeks wemean your Start Date to the 21st dayoftreatment.

By 4 weeks wemean your Start Date to the 28th dayoftreatment.

Wedo not pay each week of a course of chemotherapytreatmentseparately when the treatmentbegins onyour Start Date and lasts more than one week. Twenty-eight days after your Start Date, wewill consider anyfurther costs you incur for chemotherapy treatmenttobe new treatmentfor the purpose of the schemeand anew Start Date will apply to your chemotherapytreatment.

benefit note 6a(iii) consultant oncologists fees for chemotherapy and

radiotherapy

Wepay consultantoncologists fees for planning and carrying out eligible cancer

treatmentin a partnership network hospitalor, if your eligible cancer treatment

includes a bone marrow or stem cell transplant, in a specialist treatment centre.

Wedo not have to pay your consultantoncologists fees if:

your eligible cancer treatmentis carried out in a hospitalthat is not a

partnership network hospital, or

your eligible cancer treatmentincludes a bone marrow or stem cell transplant

and is carried out in a hospitalthat is not a specialist treatment centre.

consultantswho are not For radiotherapy treatment weonly pay up to apartnership consultants maximum of 380 for consultantsfees for each course

of radiotherapy treatment. By a course of radiotherapytreatment wemean up to 15 attendances forradiotherapy.

For chemotherapy treatment weonly pay consultantsfees up to the amounts set out below according to yourStart Date (by Start Date wemean the date yourchemotherapy treatmentbegins, or weconsider itbegins) and the date your treatmentends. Fortreatmentbeginning on your Start Date andcontinuing for:

continued



36 37


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Benefit note 6b for members whose schemeis BUPA ClientChoice Plus:

psychiatric treatment after two years membership

For members whose schemeis BUPA ClientChoice Plus wemay, at ourdiscretion, pay

for eligible treatmentof a psychiatric condition(ie psychiatric treatment) that you

receive from a consultantor therapist. Before wewill consider paying for psychiatric

treatmentyou must have been covered under BUPA ClientChoice Plus (or any BUPA

scheme which included cover for psychiatric treatment) for the whole of the two years

leading up to the psychiatric treatment. It is then at ourdiscretion whether or not we

will pay. Before receiving any psychiatric treatmentyou must ask your consultantto

get ourwritten agreement. Otherwise wewill not be obliged to pay the consultantsor

therapistsfees, or the hospitalcharges or any other charges. Weneed full clinical

details from your consultantbefore wecan give our decision.

Psychiatric treatment that is not covered

Wedo not pay for treatmentof a psychiatric conditionin the following circumstances: if you have received two episodes oftreatmentfor that psychiatric conditionor

any related psychiatric conditionduring your membership of the scheme(and

any other BUPA scheme which has cover for psychiatric treatment) whether your

membership is continuous or not. By an episode oftreatment wemean:

seven nights or more in-patient treatment, whether consecutive or not, or

20 or more separate attendances for out-patient treatmentor day-patient

treatmentin any 12 month period;

if either before or during your membership of the schemeyou suffer from any

psychiatric conditionfor a continuous period of two years or more which

requires any form oftreatmentat any time during that period. The treatment

need not be ongoing or continuous during the period of the psychiatric

condition.

benefit note 6a(v) eligible cancer treatment that includes a bone marrow or stem

cell transplant

If your eligible cancer treatmentincludes a bone marrow or stem cell transplant and is

carried out as day-patient treatmentor in-patient treatmentwhat wepay for and how

much wepay is explained below.

In a specialist treatment centre

In a hospitalthat is not a specialist treatment centre

hospital We do not have to pay the hospitalcharges.

consultants We do not have to pay your consultantsfees.

specialist treatment centre We pay the specialist treatment centrecharges onthe same basis and up to the same limits as hospitalcharges for other eligible treatmentcarried out in apartnership network hospitalas set out in benefit

note 4.

consultants We pay consultantsfees on the same basis and upto the same limits as consultantsfees for othereligible treatmentcarried out in a partnershipnetwork hospitalas set out in benefit note 3.


38 39


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Consultants fees

Ifweagree wepay consultantsfees for psychiatric treatmentcarried out as

day-patient treatmentor in-patient treatmentin a psychiatric network hospital.

Please note: wedo not have to pay your claim for consultantsfees if you use a hospital

which is not a psychiatric network hospital.

Hospital charges

Ifweagree to pay for psychiatric treatmentcarried out as day-patient treatmentor

in-patient treatment wepay the type ofhospitalcharges wesay wepay for in benefit

notes 4c to 4i.

Please also see Chronic conditions in section 3, What is not covered.

hospitalthat is not a Ifweagree wepay up to a total amount of:psychiatric network hospital

50 each day for day-patient treatment, or

80 each night for in-patient treatment.

This is the overall total amount wepay for thehospitalcharges in these circumstances. It is not

the amount wepay for each type of service or itemindividually.

psychiatric network hospital Ifweagree wepay in full

consultantswho are not Ifweagree wepay up to a maximum of 55 eachpartnership consultants day for day-patient treatmentor in-patient

treatment.

partnership consultants Ifweagree wepay in full.

What we will pay for psychiatric treatment

Ifweagree to pay for psychiatric treatment wepay consultantsand therapistsfees

and hospitalcharges as follows:

Out-patient treatment

Ifweagree to pay for psychiatric treatmentcarried out as out-patient treatment we

pay for:

consultantsfees for out-patient consultations to assess your psychiatric

condition

psychiatric treatmentprovided by a consultantor therapistand carried out as

out-patient treatment.

Day-patient and in-patient treatment

Ifweagree to pay for psychiatric treatmentcarried out as day-patient treatmentor

in-patient treatment wemay pay for up to a maximum of 28 days psychiatric

treatmentcosts in total each year. This is the maximum number of days wemay pay for

psychiatric treatmentfor all psychiatric conditionseach yearand not for each

psychiatric conditionindividually. Ifweagree to pay wepay consultantsfees and

hospitalcharges as set out below.

consultants and therapists Ifweagree wepay in accordance with benefit note2a(i) and subject to the overall limit set out inbenefit note 2a(i) for members whose schemeisBUPA ClientChoice Plus


40 41


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What is not covered

Exception: Wepay for eligible treatmentfor, or arising from AIDS or HIV if the person

with AIDS or HIV became infected five years or more after their current continuous

membership began, or has been a member of this scheme(or any BUPA scheme which

included cover for this type oftreatment) since at least July 1987 without a break in

their cover.

Allergies or allergic disorders

Wedo not pay for treatmentto de-sensitise or neutralise any allergic condition or

disorder.

Birth control, conception, sexual problems and sex changes

Wedo not pay for treatmentfor any type of:

contraception, sterilisation, termination of pregnancy

sexual problems (including impotence, whatever the cause)

assisted reproduction (eg IVF treatment), surrogacy, the harvesting of donor eggs

or donor insemination

sex changes or gender reassignments

or treatmentfor or arising from any of these.

Exception: Where your consultantconsiders that there are symptoms and/or medical

evidence to suggest that youand/or your partnerare infertile, wepay for eligible

treatmentfor either youand/or your partner(where your partneris a dependant

under this scheme) for reasonable investigations into the medical cause of infertility, if:

neither younor your partnerhad been aware of any such symptoms and/or

medical problems before joining, and

you have both been members of the scheme(or any BUPA scheme which

included cover for this type of investigation) for a continuous period of two years

before receiving the treatment.

Once the cause is confirmed, no further payment is made for additional investigations or

treatmentin the future.

Please also see Pregnancy and childbirth in this section.

42 43

What is not coveredThis section explains the treatment, services and charges that are not covered under this

scheme. Part 1 sets out the general exclusions that apply to all BUPA personal schemes

including this scheme. Part 2 sets out the additional exclusions which apply to this

scheme.

The exclusions are grouped under headings and listed alphabetically. The headings are

just signposts, they are not part of the exclusion. If there is an exception to an exclusion

this is shown. Where werefer to specific treatments or medical conditions in the

exceptions these are examples only and not evidence of cover.

This section does not contain all the limits and exclusions to your cover. For example the

benefit notes in section 2 also describe some limitations and restrictions for particular

types oftreatment, services and charges. Also, you may have special conditionsor

moratorium conditionsthat limit or restrict your individual cover.

Ageing, menopause and puberty

Wedo not pay for treatmentto relieve symptoms commonly associated with any bo dily

change arising from any physiological or natural cause such as ageing, menopause or

puberty and which is not due to any underlying disease, illness or injury.

AIDS/ HIV

Wedo not pay for treatmentfor, or arising from, AIDS or HIV, including any condition

which is related to, or results from, AIDS or HIV.

PART 1

3


24/38

What is not covered

Contamination, wars, riots and terrorist acts

Wedo not pay for treatmentfor any disease, illness or injury resulting from nuclear or

chemical contamination, war, riot, revolution, terrorist act or any similar event.

Convalescence, rehabilitation and general nursing care

Wedo not pay for private hospitalaccommodation if it is primarily used for any of the

following purposes:

convalescence, rehabilitation, supervision or any purpose other than receiving

eligible treatment

receiving general nursing care or any other services which could have been

provided in a nursing home or in any other establishment which is not a hospital

receiving services from a therapist.

Exception: Wemay, at ourdiscretion, pay for eligible treatmentfor rehabilitation. By

rehabilitation wemean treatmentwhich is aimed at restoring health or mobility or toallow you to live an independent life, such as after a stroke. Wewill only consider cases

where the rehabilitation:

is an integral part ofeligible in-patient treatment

starts within 42 days from and including the date you first receive thateligible

in-patient treatment, and

takes place in a rehabilitation centre.

You must have ourwritten agreement before the rehabilitation starts and weneed full

clinical details from your consultantbefore wecan give ourdecision. Ifweagree wepay

for up to a maximum of 21 consecutive days rehabilitation.

Cosmetic, reconstructive or weight loss treatment

Wedo not pay for treatmentto change your appearance, such as a remodelled nose or

facelift whether or not it is needed for medical or psychological reasons.

Wedo not pay for breast enlargement or reduction or any other treatmentor

procedure to change the shape or appearance of your breast(s) whether or not it is

needed for medical or psychological reasons, for example, for backache or

gynaecomastia (which is the enlargement of breasts in males).

44 45

Chronic conditions

Wedo not pay for treatmentofchronic conditions. By this, wemean a disease, illness

or injury which has at least one of the following characteristics:

it continues indefinitely and has no known cure

it comes back or is likely to come back

it is permanent

you need to be rehabilitated or specially trained to cope with it

it needs long term monitoring, consultations, check-ups, examinations or tests.

Exception: Wepay for eligible treatmentarising out of a chronic condition, or for

treatmentof acute symptoms of a chronic conditionthat flare up. However, weonly

pay if the treatmentis likely to lead quickly to a complete recovery or to you being

restored fully to your previous state of health, without you having to receive prolonged

treatment. For example, wepay for treatmentfollowing a heart attack arising out of

chronic heart disease.

Please note: for members whose schemeis BUPA ClientChoice Plus this exception does

not apply to treatmentof a psychiatric condition.

Please note: in some cases it might not be clear, at the time oftreatment, that the

disease, illness or injury being treated is a chronic condition. Weare not obliged to pay

the ongoing costs of continuing, or similar, treatment. This is the case even where we

have previously paid for this type of or similar treatment.

Please also see Temporary relief of symptoms in this section.

Complications from excluded or restricted conditions/ treatment

Wedo not pay any treatmentcosts, including any increased treatmentcosts, you incur

because of complications caused by a disease, illness, injury or treatmentfor which

cover has been excluded or restricted from your membership. For example, if cover for

diabetes is excluded from your cover (either because it is a moratorium conditionif you

are a moratorium memberor is a special conditionif you are an underwritten

member), and you have to spend any extra days in hospital after an operation because

you have diabetes, wewould not pay for these extra days.

What is not covered


25/38

What is not coveredWhat is not covered

Exception: Wepay for an eligible surgical operationcarried out by a consultantto:

put a natural tooth back into a jaw bone after it is knocked out or dislodged in an

unexpected accidental injury

treat a jaw bone cyst, but not if it is related to a cyst or abscess on the tooth root

or any other tooth or gum disease or damage

surgically remove a complicated, buried or impacted tooth root, such as an

impacted wisdom tooth, but not if the purpose is to facilitate dentures or the

acute conditionrelates to a pre-existing condition.

Dialysis

Wedo not pay for treatmentfor or associated with kidney dialysis (haemodialysis),

meaning the removal of waste matter from your blood by passing it through a kidney

machine or dialyser.

Wedo not pay for treatmentfor or associated with per itoneal dialysis, meaning the

removal of waste matter from your blood by introducing fluid into your abdomen which

acts as a filter.

Exception: Wepay for eligible treatmentfor short-term kidney dialysis or peritoneal

dialysis if the dialysis is needed temporarily for sudden kidney failure resulting from a

disease, illness or injury affecting another part of your body.

Please also see Transplant surgery in this section.

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

Wedo not pay for any drugs or surgical dressings provided or prescribed for out-patient

treatmentor for you to take home with you on leaving hospital or a treatment facility.

Exception: Wepay for out-patient drugs (such as cytotoxic drugs) for eligible cancer

treatmentas set out in benefit note 6a, in section 2.

Please also see Experimental drugs and treatment in this section.

Wedo not pay for any treatment, including surgery,

which is for or involves the removal of healthy tissue (ie tissue which is not

diseased), or the removal of surplus or fat tissue, or

where the intention of the treatment, whether directly or indirectly, is the

reduction or removal of surplus or fat tissue including weight loss (for example,

surgery related to obesity including morbid obesity)

whether or not the treatmentit is needed for medical or psychological reasons.

Wealso do not pay for scar revision.

Exception: Wepay for an eligible surgical operationto restore your appearance after

an accident, or as a direct result of surgery for cancer, if either of these takes place

during your current continuous membership of the scheme. Wewill only pay if this is

part of the original eligible treatmentresulting from the accident or cancerand you

have obtained ourwritten agreement before receiving the treatment.

Please also see Screening and preventive treatment in this section.

Deafness

Wedo not pay for treatmentfor or arising from deafness caused by a congenital

abnormality, maturing or ageing.

Dental/oral treatment (such as fillings, gum disease,

jaw shrinkage, etc)

Wedo not pay for any dental or oral treatment.

Wedo not pay for the provision of dental implants or dentures, the repair or

replacement of damaged teeth (including crowns, bridges, dentures, or any dentalprosthesis made by a laboratory technician).

Wedo not pay for the management of, or any treatmentrelated to, jaw shrinkage or

loss as a result of dental extractions or gum disease.

Wealso do not pay for surgical operationsfor the treatmentof bone disease when

related to gum disease or tooth disease or damage.

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What is not covered

Intensive care (other than routinely needed after private day-patient

treatment or in-patient treatment)

Wedo not pay for any intensive careif:

it follows an unplanned or an emergency admission to an NHS hospital or facility

it follows a transfer (whether on an emergency basis or not) to an NHS hospital or

facility from a private hospital

it is carried out in a unit or facility which is not a critical care unit.

Wedo not pay for any intensive care, or any other treatmentin a critical care unit, if it

is not routinely required as a medically essential part of the eligible treatmentbeing

carried out.

Exception: Wepay for eligible treatmentfor intensive carebut only as set out in

benefit note 4, in section 2.

Learning difficulties, behavioural and developmental problemsWedo not pay for treatmentrelated to learning difficulties, such as dyslexia, or

behavioural problems, such as attention deficit hyperactivity disorder (ADHD), or

developmental problems, such as shortness of stature.

Overseas treatment and repatriation

Wedo not pay for treatment, including treatmentfor medical emergencies, that you

receive outside the UKor for repatriation to the UK.

Physical aids and devices

Wedo not pay for supplying or fitting physical aids and devices (eg hearing aids,spectacles, contact lenses, crutches, walking sticks, etc).

Exception: Wepay for prosthesesand appliancesas set out in benefit note 4, in

section 2.

Experimental drugs and treatment

Wedo not pay for treatmentor procedures which, in ourreasonable opinion, are

experimental or unproved based on established medical practice in the United

Kingdom, such as drugs outside the terms of their licence or procedures which have not

been satisfactorily reviewed by NICE (National Institute for Clinical Excellence).

Exception: Wemay pay for this type oftreatmentof an acute condition. However, you

will need ourwritten agreement before the treatmentis received and weneed full

clinical details from your consultantbefore wecan give ourdecision.

Please also see Drugs and dressings for out-patient or take-home use in this section.

Eyesight

Wedo not pay for treatmentto correct your eyesight, for example for long or short

sight or failing eyesight due to ageing, including spectacles or contact lenses.

Exception: Wepay for eligible treatmentfor your eyesight if it is needed as a result of

an injury or an acute condition, such as a detached retina.

HRT and bone densitometry

Wedo not pay for treatmentfor hormone replacement therapy (HRT) or bone densitometry.

Exception: Wemay pay for bone densitometry recommended by your consultantto

help determine or assess your condition as part ofeligible treatment. However, weneed

full clinical details from your consultantbefore wecan give ourdecision. Ifweagree to

pay for bone densitometry weonly pay for an initial bone densitometry scan and for

one follow-up scan if this is carried out:

within three years of you starting treatment, and

during your current continuous period of membership of the scheme.

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

What is not covered

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What is not covered

Screening and preventive treatment

Wedo not pay for:

health screening, such as routine tests or health checks

tests or procedures which, in ourreasonable opinion based on established clinical

and medical practice, are carried out for screening or monitoring purposes, such

as endoscopies when no symptoms are present

preventive treatment, procedures or medical services, for example, removing

breast tissue when there is no disease or tumour present.

Sleep problems and disorders

Wedo not pay for treatmentfor or arising from sleep problems or disorders such as

insomnia, snoring or sleep apnoea (temporarily stopping breathing during sleep).

Speech disorders

Wedo not pay for treatmentfor or relating to any speech disorder, for example

stammering.

Exception: Wemay at ourdiscretion pay for eligible treatmentfor short-term speech

therapy which is part ofeligible in-patient treatment. The speech therapy must take

place during and/or immediately following the eligible in-patient treatmentand be

provided by a therapistwho is a member of the Royal College of Speech and Language

Therapists.

Temporary relief of symptoms

Wedo not pay for treatment, the main purpose or effect of which is to provide

temporary relief of symptoms or which is for the ongoing management of a condition.

Exception: Wemay pay for this type oftreatmentif you need it to relieve the symptoms

of a terminal disease or illness.

Pregnancy and childbirth

Wedo not pay for treatmentfor, or any condition arising from, pregnancy, childbirth or

termination of pregnancy. This includes:

pre-eclampsia (a condition in which elevated blood pressure, fluid retention and

the presence of protein in urine occurs in late pregnancy)

eclampsia (a seizure or coma during pregnancy)

pregnancy induced hypertension (raised blood pressure during pregnancy)

treatmentof an embryo or foetus.

Exception 1: Wepay for eligible treatmentof the following conditions:

miscarriage or when the foetus has died and remains with the placenta in the

womb

still birth

hydatidiform mole (abnormal cell growth in the womb)

foetus growing outside the womb (ectopic pregnancy)

heavy bleeding in the hours and days immediately after childbirth (post-partum

haemorrhage)

afterbirth left in the womb after delivery of the baby (retained placental

membrane)

complications following any of the above conditions.

Exception 2: Wemay pay for eligible treatmentfor delivering a baby by caesarean

section when the mother has been a member of the schemefor at least 12 months

before the delivery. However,weneed full clinical details from your consultantbefore

wecan give ourdecision.Please also see Birth control, conception, sexual problems and sex changes and

Neo-natal treatment in this section.

What is not covered

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What is not covered

that moratorium conditionfor a continuous period of two years after your start dateof

the scheme(or your joining date of your previous ClientChoice schemeor, if your cover

under the schemeis arranged by youremployer or membership association, your joining

date of the previous scheme).

Exception 2: Wewill not apply this exclusion to any baby ofyoursincluded under your

membership as a dependantifyouhave been a member of the schemefor at least 12

months before the babys birth and youinclude the baby under yourmembership

before the baby is three months old.

Please also see Covering your new-born baby in rule 1.2 in section 1.

Pre-existing conditions

For underwritten members wedo not pay for treatmentfor a pre-existing condition,

or a disease, illness or injury which results from or is related to a pre-existing condition.

Exception: Wepay for eligible treatmentof a pre-existing condition, or a disease,

illness or injury which results from or is related to a pre-existing condition, if all the

following requirements have been met:

youhave been sent your membership certificatewhich lists the person with the

pre-existing condition(whether this is youor one ofyour dependants)

yougave usall the information weasked youfor, before wesent youyourfirst

membership certificate listing the person with the pre-existing conditionfor their

current continuous period of cover under the scheme

neither younor the person with the pre-existing conditionknew about it before we

sent youyourfirst membership certificate which lists the person with the pre-existing

conditionfor their current continuous period of cover under the scheme, and

wedid not exclude cover (for example under a special condition) for the costs of

the treatment, when wesent you your membership certificate.

Unrecognised providers or facilities

Wedo not pay for any treatmentwhere the consultant in overall charge of the

treatmentis not recognised by BUPA.

Wedo not pay for treatmentprovided by a consultant, therapist or other health care

professional who is not recognised by BUPA.

Wedo not pay for treatmentin any hospital or by any other provider of services whom

wehave not recognised or to whom wehave sent a written notice saying that weno

longer recognise them for the purpose ofourschemes.

BUPA does not recognise consultants, therapists or other health care professionals in the

following circumstances:

where BUPA does not recognise them as having specialised knowledge of, or

expertise in, the treatmentof the disease, illness or injury being treated

where BUPA does not recognise them as having specialised expertise and

ongoing experience in carrying out the type oftreatmentor procedure needed

where wehave sent a written notice to them saying that weno longer recognise

them for the purposes ofourschemes.

Moratorium conditions

For moratorium members wedo not pay for any treatmentfor any moratorium

conditions.

Exception: Wepay for treatmentfor a moratorium conditionafter two years continuous

membership of the schemefrom your start date(or your joining date of your previous

ClientChoice schemeor, if your cover under the schemeis arranged by youremployer

or membership association, your joining date of the previous scheme) if you have not:

received any medication for,

asked for or received any medical advice or treatment for, or

experienced symptoms of

PART 2

What is not covered

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