Simplyhealth Tesco Brochure

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  • 1. SIMPLY CASHplan brochureProtecting yourhealth. Moneyback towards yourhealthcare costs.For Staff InformationH e l p i n g y o u s p e n d l e s s
  • 2. 1 Enjoy all these benefits with the Simply CASH plan: Affordable, cash plans to suit your needs Tax-free money towards your healthcare Fast claims settlement Straightforward plans to suit all needs, claim 100% of your money back on dental and optical benefits up to your annual limitSimply Cash PlanWould you like peace of mind for you and yourfamily when it comes to health matters?WHO is Simplyhealth?You might have known us in the past as HSA. Our name may have changed but ourcommitment to helping people take care of themselves hasn’t.what is a CASH plan?The cash plan provides cover towards the cost of everyday healthcare including dental andoptical costs, complementary therapies and consultation costs up to an annual can i benefit?A visit to the dentist or optician can be expensive, so wouldn’t it be great if someone gave youmoney towards the bill?The Simply Cash Plan provides tax-free payments to help you with the cost of your healthcare.Money towards glasses or contact lenses, money towards dental bills and even money backfor acupuncture. Simply Cash Plan benefits give you the choice of using the NHS or goingprivate.about the planYou can take cover for you as an individual, or extend the cover to include your partner. Eitherway resident children up to the age of 18 are covered at no extra cost.This policy offers excellent value for money. Simplyhealth pays 100% of your dental and opticalbills and 75% towards the cost of physiotherapy, osteopathy, chiropractic, acupuncture andhomeopathy costs up to an annual limit.
  • 3. 2For Staff Informationhow do i join?Please turn to the back of this booklet and complete the Priority Application Form. Alternatively, call Simplyhealthfree on 0800 072 6704 or visit quoting codeHOW MUCH DOES THE SCHEME COST?There are six levels of cover to choose from, you simply decide which option suits you and make a regular payment from aslittle as £5.50 per month.The healthcare benefits covered and payment options are detailed in the table below.FOR STAFF INFORMATIONYOUR TABLE OF COVER OPTION 1 OPTION 2 OPTION 3 OPTION 4 OPTION 5 OPTION 6INDIVIDUAL COVER (MONTHLY PREMIUM)PAYBACKLEVEL£5.50 £11.00 £16.50 £22.00 £27.50 £33.00FAMILY COVER (MONTHLY PREMIUM) £11.00 £22.00 £33.00 £44.00 £55.00 £66.00WHAT’S COVERED ANNUAL LIMIT PER PERSONDental100% £70 £100 £130 £160 £190 £220Includes check-ups, hygienist’s fees, fillings,dentures, crowns and bridgesOptical100% £70 £100 £130 £160 £190 £220Includes sight tests and fitting fees,prescription glasses, sunglasses and contactlensesPhysiotherapy, Osteopathy,Chiropractic, Acupuncture, Homeopathy75% £100 £200 £300 £400 £500 £600Treatment carried out by a qualifiedpractitioner that we recogniseChiropody/Podiatry75% £100 £200 £300 £400 £500 £600Treatment for your feet carried out by aqualified practitioner that we recogniseDiagnostic consultation75% £100 £200 £300 £400 £500 £600Diagnostic consultations with a specialist,including allergy testing/blood testsHospital coverUP TO20 DAYS/NIGHTSIN TOTALEACH YEAR£10 £20 £30 £40 £50 £60Cash amount for each day or night to helptowards everyday expenses if you need to stayin hospital. This includes day-case, in-patient,parental stayPre-existing conditions are excluded for thefirst 12 monthsNew child payment*EACHCHILD £100 £200 £300 £400 £500 £600*A 12 month qualifying period applies to New child paymentFree helpline Your plan gives you access to a free confidential helpline to advise you on health and lifestyle issues,as well as an over the phone counselling service. This service is available 24 hours a day, 7 days a week.European cover You’ll receive these benefits for stays up to and including 28 days, on business or pleasure,wherever you are in the EEA and Switzerland.The joining age for this policy is from 18 years old up to 80. If you or anyone on the policy are aged 80 or overyou will not be able to increase the level of cover.Premiums include Insurance Premium Tax.For full details of the plan please refer to the policy document.
  • 4. 3Your questions answeredHow old do I need to be to join?You can apply to join if you are aged between 18 and 80 atthe time of application and are a UK resident.When can I claim?You can claim from your policy start date, by using the claimform provided in your welcome pack. The only exceptionsare the New child payment which has a 12 month qualifyingperiod and Hospital cover which excludes pre-existingconditions for the first 12 months.When do my annual benefits start and end?Your annual benefits commence from your policy start dateand begin again on the same date every year.What is the duration of my cover?The cover under your plan is monthly and runs from month tomonth until it is cancelled or otherwise comes to an end.Are existing conditions covered?The great thing about Simplyhealth is that you can startclaiming from your policy start date for the majority of benefits,even if you already have a problem that needs treatmentwhen you join. However, Hospital cover excludes pre-existingconditions for the first 12 months.Does cover continue when i reach 81?Yes, cover doesn’t cease when you reach a certain age. Youcan keep your policy for as long as you wish. However thereare some circumstances where cover will end.How are my benefits paid?To make life easier for you, Simplyhealth provides a servicewhich pays your benefits directly into your bank account viadirect credit, sending you confirmation in the post.When will I receive money back from my claim?We usually settle claims within a few days. For some otherbenefits we will ask for further information which may delaypayment of your claim.What happens if my personal circumstanceschange?So that your cover remains appropriate for your needs, it isimportant that you review it regularly and let us know aboutany significant changes to your healthcare requirements.Where can I get more information or additionalhelp when making a claim?If you have any queries, please call Simplyhealth CustomerServices on 0800 072 1000 who will be pleased to help you.What do I do if I have changed my mind?You have 14 days from receipt of your welcome pack inwhich to change your mind and receive a full refund fromSimplyhealth, provided no claims have been made. Simply callCustomer Services on 0800 072 1000. After this period ourstandard cancellation rights apply – please refer to section 5of the terms and conditions for full details.How do I make a complaint?At Simplyhealth we aim to provide you with the very highestlevels of customer service and care at all times. In order tomaintain this service standard, we encourage feedback fromour customers and have put in place a procedure that youcan use to raise any concern or complaint that you may have.In the first instance you should write to: Customer Services,Simplyhealth, Hambleden House, Andover, Hants. SP10 1LQor contact customer services direct on 0800 072 1000.If you are not satisfied with our response, or we have notreplied within eight weeks, you have the right to refer yourcomplaint to: Financial Ombudsman Service. Please refer tosection 6 of the terms and conditions.
  • 5. 4For Staff InformationSection one – how to join1.1 You can apply to join if you are aged between 18 and 80at the time of application and are a UK resident. You must livepermanently at an address in the UK and this must be yourcorrespondence address. We do not have to accept yourapplication or provide an explanation of our refusal. If you arealready covered then this section may not apply.1.2 You can apply to include your partner on your policy atthe same level as you if they are aged between 18 and 80at the time of application, live permanently with you and youpay the appropriate increase in premium. We do not have toaccept your partner’s application or provide an explanation ofour refusal.1.3 You can also apply to include your or your partner’schildren on the policy if they permanently live with you and areunder the age of 18. On a child’s 18th birthday they will ceaseto be covered by this policy. We may request your child’soriginal birth certificate if they are covered on the policy.1.4 Any information you provide to us must be accurate, trueand completed to the best of your knowledge and belief. If youfail to comply with this condition, we may either refuse yourapplication or cancel the policy.1.5 Cover under the policy is monthly and starts from yourregistration date. It continues from month to month until it iscancelled or otherwise comes to an end.Section two – premiums2.1 Premiums are payable by direct debit in advance of anycover under the policy being provided. We may require yourfirst payment by debit or credit card. You must continue topay your premiums to be entitled to claim. Failure to do so willmean we will suspend the policy.2.2 Your premium level sets the cover that is available toyou, as detailed in the table of cover. You can increase ordecrease your premium at any time but you must stay on thatpremium level for at least 12 months before you can increaseor decrease your premium level again. Any changes to yourpremium will not change your claiming year.2.3 If you increase or decrease your premium, any claims paidin the claiming year under the previous premium level willcount towards the maximum entitlement available under thenew premium level.2.4 You are not able to increase your premium level if anyonecovered under the policy is older than 80.2.5 If we change your premiums, we will give you advancenotice of the change. The minimum notice is detailed in section10.2.6 Insurance Premium Tax (IPT) is included in your premium.If the Government changes IPT, we may have to amend yourpremium from the date that the IPT change is implemented. Wewill notify you of this change separately.Section three – how to claim3.1 We will only pay you for treatment already received andpaid for. If you undertake a staged course of treatment, youcan only claim for the treatment already undertaken and paidfor. We do not pay in advance for a course of treatment not yetreceived, whether or not you have paid for it.3.2 Claims will be offset against the claiming year in whichyou receive the treatment or in which the dates of admissionand discharge from hospital fell. If a claim spans a claimingyear, the claim will be allocated in line with the dates thetreatment took place. You must use the claim form we providefor making claims. If you do not have a claim form, please or call Customer Services on 0800072 1000.3.3 If you paid for treatment with vouchers or coupons, we willnot accept the claim or reimburse you.3.4 When making a claim you need to send a fully completedclaim form and original receipt for any bill that you are seekingreimbursement for. The original receipt must:a) be on official headed paperb) show the name of the patientc) the name, address and qualifications of the person providingtreatmentd) a description of the treatmente) the date of treatment and the amount paid for thattreatment. That amount paid for must be in UK currencyunless falling under 3.21and it is your sole responsibility to ensure that the receipts thatyou submit comply with each of these requirements.3.5 For hospital claims the appropriate section of the claimform needs to be completed, and either you send us a copyof your hospital discharge letter with your claim or a claimform that has been stamped and endorsed by the relevanthospital authorities. Claims for a new child payment should besupported by the original birth certificate, appropriate stillbirthcertificate or official documents regarding an adoption.3.6 Our claims procedures are designed to ensure we payvalid claims quickly. They rely on you submitting your claimwithin a reasonable time of your date of treatment, so pleasesend in your claim as soon as possible and in any event withinsix months of the date of treatment.3.7 The longer the time between date of treatment andsubmitting your claim the more difficult it is likely to be for usto validate it. We may seek information to validate your claimfrom you or a health professional. You must give us anyinformation or proof to support your claim if we make areasonable request for you to do so. We may seek yourwritten consent for medical information relating to a claimto be disclosed to a Simplyhealth medical practitioner.We may not be able to process your claim if youor your health professional refuses to providethe information we have requested. We alsoTerms & Conditions
  • 6. 5reserve the right to deduct from your claim any extra costswe incur in taking these additional steps; in which case we willexplain how we have arrived at those costs. You should beaware your practitioner may also charge you for the cost ofproviding confirmation of treatment or additional evidence.3.8 If you delay your claim for more than two years from thedate of treatment, we will not pay your claim unless you canprovide evidence of exceptional circumstances which justifythe delay.3.9 We will only accept claim forms that have been completedand sent by you. We will not accept any claims sent directly bya healthcare professional or institution.3.10 We reserve the right to request a second opinion froman optician, dentist, or any other specialist in their field ofexpertise appointed by us. This may require you to attend anappointment, with a healthcare professional appointed by us,at our expense.3.11 We only accept original receipts and do not acceptreceipts that have been altered, invoices, credit or debit cardreceipts or photocopies of any accounts. We do not return anyreceipts or invoices.3.12 For the avoidance of doubt, where we are seeking tovalidate a claim by requesting further information from you ora health professional, neither this claim nor any other claimson the policy will be paid until such time as we have receivedsuch further information and have been able to validate theclaim in question.3.13 We aim to pay claims as quickly as possible; however weare not obliged to pay claims within a specific timescale.3.14 We monitor claiming behaviour on all policies and mayrequest an appointment with you to discuss your claims.If you do not co-operate with our reasonable requests, wemay not pay claims and we may cancel all your policies withSimplyhealth.3.15 We will not pay any claim while you are in breach of thesepolicy conditions or in arrears with your payments.3.16 We reserve the right to pay claims only via direct creditinto a bank account nominated by you. It is your responsibilityto keep us informed of any change to where you require usto pay claims. If you do not provide us with details of a bankaccount, we reserve the right to withhold payment of the claimuntil you do.3.17 We do not pay any amounts you may be charged forcompleting your claim form or for medical information werequest in support of your claim. These charges are yourresponsibility.3.18 When you join you can claim straight away, except forbenefits that have a qualifying period. If you increase yourpremium level, then where a benefit has a qualifying period,a further qualifying period will apply. During this time we willpay any claims for the benefit with a qualifying period at theprevious benefit rate that applied before the increase, providedyou have already served the original qualifying period.3.19 You can only claim under one area of cover for eachtreatment you receive.3.20 We will only accept claims for treatment received in theUK unless you send your claim in line with We will cover you for business or holiday visits within theEEA only of up to and including 28 days’ duration. We will notcover you where the purpose of the trip is to receive medicaltreatment outside the UK, and we will only pay claims whereyou have provided suitable evidence including evidence thatyour visit did not exceed 28 days in total. We will require atranslation of the invoice in English and a relevant receipt, bothgiving details of the claim.3.22 Where receipts are in a foreign currency we will use therate published by Oanda ( applicable onthe date of treatment for calculating the rate of exchange tosterling.3.23 We will not provide cover for any treatment provided toyou by a member of your family or a business establishmentwhere a member of your family works.3.24 We reserve the right to recover any overpayment ofclaims from any sums payable to you or to recover suchoverpayments directly from you, or both.3.25 If you are bringing or are entitled to bring a legalcompensation claim against a third party, which would coverclaims met under the policy, then you must tell us about thisas we may have the right to recover these sums from that thirdparty. To enable us to do this, you must notify us of the claim,keep us informed of its progress, and act in accordance withour instructions.3.26 If we consider that you have a legal right to compensationfrom another party for costs which you have claimed for underthe policy, we are entitled to take legal action against thatthird party (including legal action in your name) to recover theamount you have claimed.3.27 Other insurance held by you with us – if you or anyoneincluded on your policy holds or is covered under anotherinsurance policy with us, then you can claim on both policiesup to your maximum (subject to specific policy restrictions). Itis your responsibility to inform us if you wish to claim from twopolicies by contacting customer services or by completing theappropriate claim forms. The total we pay under all policies willnot exceed the value of the costs you have incurred.3.28 Other insurance held by you with a different company – ifyou are making a claim to us and you have insurance withanother insurance company that covers you for any of thesame benefits under your policy, you must tell us. We mayneed to contact this other company as we will not be liable topay more than our proportionate share when split between theinsurance companies.
  • 7. 6For Staff InformationSection four – Fraud4.1 The contract between you and us is based on mutualtrust. To protect the vast majority of members who are honest,we have rigorous anti-fraud measures. These include:a) investigating claims through the use of private investigatorsb) passing details of suspected fraudulent claims to the policeor the Crown Prosecution Service for them to investigateand prosecute through the criminal courtsc) working with the NHS Counter-Fraud team, HealthProfessionals’ Trade Associations, other insurancecompanies and other agencies with an interest in controllingfraud of this nature (as detailed in section 8)4.2 Fraud is a criminal offence that can result in a large fineor even a prison sentence. When we find examples of fraud,we will always seek to prosecute offenders. If a member actsfraudulently, we will always seek to recover the costs of allfraudulent claims plus interest and our own legal costs.4.3 If we reasonably suspect that you have submitted afraudulent claim, or that you are acting without the utmostgood faith, we are unlikely to pay claims and may suspend thepolicy. We may also cancel all your insurance policies with usand with any other company within the Simplyhealth Group. Toavoid doubt, the following list contains examples of practiceswe would class as fraudulent or failing to act with utmost goodfaith:a) Deliberately giving us false information about you, a personon the policy or a claim on the policyb) Making any claim under the policy where you know theclaim is false, or is exaggerated in any respectc) Making a statement in support of a claim where you knowthe statement is false in any respectd) Sending us a document in support of a claim where youknow the document is forged, false or otherwise misleadingin any respecte) Making claims under more than one insurance policy inorder to receive a sum greater than the cost of treatment(this is called ‘betterment’)f) Submitting claims for costs which are clearly outside thoserecoverable under these Terms and Conditionsg) Failing to provide us with support to verify the validity of aclaimh) Failing to tell us of another means by which you couldrecover costs of treatmentSection five – How does cover end?5.1 All cover under this policy will end automatically and wewill not cover you for any claims you have not yet sent us foryou and all other people included on the policy in the followingcircumstances:a) You cancel the policy by giving us one month’s notice inwriting. We will not refund any premiums you have alreadypaidb) You, or any third party who is paying premiums on yourbehalf, miss paying three consecutive monthly premiums.We may reinstate that cover once all outstanding premiumshave been paidc) You die. Your partner will be able take out an equivalentpolicyd) We exercise our right to cancel the policy if we make acommercial decision to stop providing this policy or anequivalent policy. We will give you at least three months’written notice of our decisione) We exercise our right to cancel the policy at any time(backdated where appropriate) if: – We have reason to suspect that you submitted afraudulent claim – please see section 4.3 – You breach the terms and conditions of this policy – You fail to act with utmost good faith – If you do not comply with section 5.35.2 All cover under this policy for a partner or child includedon the policy will end when he or she dies or stops satisfyingthe criteria in sections 1.2 and To protect our staff, we ask that you treat us in the wayyou wish to be treated. If you are abusive during our contactwith you, we will terminate the contact. If you continue to beabusive, we reserve the right to cancel all policies you holdwith Simplyhealth.Section six – Customer care6.1 We aim to provide you with the very highest levels ofcustomer service and care at all times. To maintain this servicestandard, we have a procedure you can use to raise anyconcern, complaint or recommendation you have. In the firstinstance you should contact Customer Services on 0800072 1000 or write to Simplyhealth Customer Services, at ourregistered office address of Hambleden House, WaterlooCourt, Andover, Hampshire SP10 1LQ. We will investigate anycomplaint and issue a final response.6.2 If you are not satisfied with our response, or we have notreplied within eight weeks, you have the right to refer yourcomplaint to: Financial Ombudsman Service, South QuayPlaza,183 Marsh Wall, London, E14 9SR, Telephone: 0845080 1800The Financial Ombudsman Service will only consider yourcomplaint if you have given us the opportunity to resolve thematter first. Making a complaint to the Ombudsman will notaffect any legal rights that you may have.We will send you full details of our complaints procedure ifyou ask us for them.6.3 Changing your mind – you have 14 days from receivingyour welcome letter to change your mind and receive a fullrefund of any premiums you have paid, provided you havenot made any claims. If you change your mind, please call0800 072 1000 or write to Simplyhealth Customer Services atour registered office address, and we will cancel the policyfor you.6.4 Changes to your details – you must inform us as soonas reasonably possible of any changes to the informationyou have given to us, including any change of address,marital status or any other material change. Failure to doso may result in changes being made to the policywithout notification, for example your premium beingincreased.
  • 8. 7Section seven – Financial servicescompensation scheme7.1 You are protected by the Financial Services CompensationScheme (FSCS) – in the unlikely event that we go out ofbusiness or into liquidation the FSCS protects you. Should thishappen, any valid outstanding claims you have at that pointwould be paid by the scheme. For more details on the schemeplease visit or contact the FSCS direct on0207 741 4100.Section eight – How we use information thatwe hold about you8.1 We will store and process your personal data (‘yourinformation’) in accordance with the Data Protection Act 1998.8.2 We and other companies within the Simplyhealth group willuse your information for providing our services, for assessmentand analysis, for assessing premiums and risks, for handlingclaims, for improving our services, and for protecting ourinterests.8.3 We and other companies within the Simplyhealth group willuse your information to keep you informed by post, telephone,e-mail or other means about products and services that maybe of interest to you. If you do not wish your information to beused for these purposes, please write to: The Data Controller,Simplyhealth, Hambleden House, Waterloo Court, Andover,Hampshire SP10 1LQ.8.4 We will keep your information confidential. However, wemay give your information and information about how you useour products to the following:– Fraud prevention agencies and other organisations who mayrecord, use and give out information to other insurers– People who provide a service to us or act as our agentson the understanding that they will keep the informationconfidential and in accordance with the Data Protection Act1998– Anyone to whom we may transfer our rights and dutiesunder this agreement– We may also give out your information if we have a duty todo so (such as to regulatory bodies), or if the law allows usto do so or if the person requesting your information has, inour opinion, a legitimate interest in the disclosure8.5 Sensitive data – to assess the terms of the insurancecontract or administer claims, we may collect data that theData Protection Act 1998 defines as sensitive. By agreeingto these terms and conditions, you consent to us processingthis data and assessing the terms of the insurance contract oradministering claims.8.6 You have the right to see your information which is heldby us. There may be a charge if you want to do this. For moredetails, write to the Data Controller at the address shownabove.8.7 You are declaring that you have a right to give usinformation about your partner and anyone else referred toby you.8.8 Your calls may be recorded and monitored for training andquality assurance purposes.Section nine – General terms and conditions9.1 Waiver – the failure or delay by either you or us to insistupon the strict performance of any term or condition of thepolicy or to exercise any related right or remedy does notwaive any breach or subsequent breach of that term orcondition.9.2 Enforcement – no term of this policy or any part of it isenforceable under the Contracts (Rights of Third Parties) Act1999 (‘the Act’) by a person who is not party to it. For thepurposes of the Act your partner or children (or both) are notparty to the policy.9.3 Choice of law and jurisdiction – the parties to insurancecontracts in the United Kingdom may choose which lawwill apply. Unless we agree otherwise in writing, English lawwill apply to the policy. The Courts of England have solejurisdiction over any claims arising in connection with thepolicy.9.4 Language – we will communicate with you in English.9.5 We make no claims about the effectiveness and safetyof treatments. You take full responsibility for your treatmentdecisions.Section ten – What happens if we change theterms and conditions of the policy10.1 We have the absolute right to change any of the termsand conditions relating to the policy if we give you onemonth’s notice for changes to:a) The cover the policy providesb) Terms and conditionsc) Premiums10.2 We will notify you of any such changes at your homeaddress. We will not be responsible if, for any reason, you donot receive them. You may cancel the policy in accordancewith section 5.1 if you do not like the changes we have made.10.3 Where you have been notified of a change to the termsand conditions, we will pay claims in accordance with theterms and conditions in operation at the time treatment wassupplied or diagnosis made.
  • 9. 8For Staff InformationIntroductionThese Terms and Conditions set out the way in which we provide you with cover under theplan. They bind you, as a member, whether or not you have signed the application formor other documents. Please read them carefully and keep them in a safe place for futurereference. If you have any questions about these Terms and Conditions, please contactCustomer Services on 0800 072 1000.Making information about us accessible – we aim to make information about us accessibleto you, whatever your needs. You may call us on our minicom service on 0800 072 5840and information is available in large print or audio. Please call us if we can help in any otherway.DefinitionsTo avoid repetition, the following words or expressions,wherever used in this policy, have the specific meanings givenbelow.To assist you in identifying the defined words or expressionsthese are shown in bold print throughout this policy.Acupuncturist/homeopathA practitioner who is qualified and registered with an approvedprofessional organisation recognised by us in the appropriatefield. To check the organisations that we recognise please callCustomer Services on 0800 072 1000.Child/childrenNatural or legally adopted dependent children of you or yourpartner, who are under the age of 18 and permanently livewith you.Claiming yearThe period of time during which you can claim the benefit foryour chosen level of cover. Your first claiming year starts onyour registration date and runs for 12 months. Subsequentclaiming years start on the anniversary of your registrationdate and run for 12 months.Date of treatmentThe date the treatment was supplied, the date of adoptionor birth/stillbirth of the child or the date when you weredischarged from hospital.Day-caseA patient who is admitted to hospital or day-patient unitbecause they need a period of medically supervised recoverybut does not occupy a bed overnight. This does not includein-patient treatment.EEAThe countries of the European Economic Area plusSwitzerland.MemberA policyholder with Simplyhealth.PartnerA husband, wife or civil partner under the Civil Partnership Act2004, or a person who lives with you permanently as if theywere your legal spouse or civil partner.PolicyOur contract of insurance with you.Policy documentThis policy document and the table of cover, which comprisethe terms and conditions that relate to the policy.Pre-existing conditionAny condition for which you• have been referred to a consultant or hospital for eitherinvestigation or treatment prior to the date of joining or• are receiving consultant or hospital treatment orinvestigations prior to the date of joining or• reasonably believe that you would be referred to aconsultant or hospital for investigation or treatment within 12months of joining the policyThese conditions will be excluded for 12 months from yourapplication to join the policy.Qualifying periodA period of time that must elapse before we will acceptclaims for the particular benefit. This applies on anindividual basis from the date you join the policy.
  • 10. 9Registration dateThe date the policy begins, as shown in your welcome letter.Table of coverA table (current at the date of treatment) issued by us giving thelevels of cover that apply to each of the premium levels (whereapplicable) of the policy and terms and conditions for joining,changing your premium level and where applicable adding achild or partner to the policy. The table of cover forms part ofthe policy document.We/our/usSimplyhealth Access trading as Simplyhealth, a companyincorporated in England and Wales.You/yourThe member and, where applicable, any partner or childrencovered under the policy.Cover and BenefitsThe table of cover shows what each member covered can claim annually based on the chosen premium level. The table of covercan be found in the plan brochure. For the following benefits we will pay you up to the maximum amount of your chosen level shownin the table of cover. You are required to pay the cost of your treatment and claim this back from us, up to your maximum entitlementin your claiming year.Dental coverWhat is covered• Dental check-ups• Treatment provided by a dentist, periodontist or orthodontist• Endodontic treatment• Hygienist fees• Local anaesthetic fees and intravenous sedation• Dental brace or gum-shield provided by a dentist ororthodontist• Dental crowns, bridges and white fillings• Dentures• Laboratory fees and dental technician fees referred by adentist or orthodontist• Dental X-rays• Denture repairs or replacements by a dental technicianWhat is not covered• Dental prescription charges• Dental consumables, for example toothbrushes, mouthwashand dental floss• Dental practice plan premiums and dental insurancepremiums• Dental implants and bone augmentation procedures, forexample sinus lift, bone graft• Cosmetic procedures, for example dental veneers, toothwhitening and the replacement of amalgam fillings with whitefillings• Joining fees• Laboratory fees not connected to dental treatment orperformed by a dentist• Missed appointment fees and administration fees• Dental treatment provided at a hospital as a day case orin-patient (this may be claimed under Hospital cover)Optical coverWhat is covered• Sight test fees, scans or photos for an eye test• Fitting fees• Prescribed glasses, including frames and prescribed lenses• Adding new prescribed lenses to existing frames• Spectacle frames• Contact lenses• Consumables supplied as part of an optical prescription, forexample solutions and tints• Repairs to glasses• Sunglasses, safety spectacles and swimming goggles withprescription lenses• Contact lenses paid for by instalmentWhat is not covered• Eye laser surgery• Optical consumables, for example contact lens cases,spectacle cases and spectacle chains/ cords, or cleaningmaterials• Solutions that are not part of a prescription• Magnifying glasses• Non-prescription glasses• Lenses supplied under an optical insurance plan• Contact lens replacement insurance premiums
  • 11. 10• Opticians’ insurance premiums• Ophthalmic consultant charges or tests related to anophthalmic consultation (these may be covered underDiagnostic Consultation cover)• Postage and packing costsPhysiotherapy/Osteopathy/Chiropractic/Acupuncture/Homeopathy coverWhat is covered• Treatment provided by a physiotherapist, osteopath,chiropractor, acupuncturist or homeopath in their specificfield of expertise• Homeopathic medicines prescribed by a registeredhomeopath where payment is made directly to thehomeopath• Consultations with a physiotherapistWhat is not covered• Treatment that is not physiotherapy, osteopathy, chiropractic,acupuncture or homeopathy• All other treatments, for example reflexology, aromatherapy,herbalism, sports / remedial massage, Indian head massage,reiki and Alexander technique• X-rays and scans• Appliances, for example lumbar roll, back support, TENSmachine• Homeopathic medicines purchased from a chemist, healthfood shop, by mail order or over the internet• Internet or telephone homeopathic consultations• Homeopathic medicines prescribed by or purchased from aprofessional who is not a registered homeopath• Physiotherapist treatment provided by an individual notregistered with the Health Professions Council (HPC)• Chiropractic treatment provided by a chiropractor who is notregistered with the General Chiropractic Council• Osteopathy treatment provided by a osteopath who is notregistered with the General Osteopathic CouncilChiropody/Podiatry coverWhat is covered• Treatment supplied by a chiropodist or podiatrist who isregistered with the Health Professions Council (HPC)• Assessments, for example gait analysis, performed by achiropodist or podiatrist• Consumables prescribed and supplied by the chiropodist orpodiatrist at the time of treatment, for example orthotics anddressings• Consultations and treatment with a podiatric surgeonWhat is not covered• Cosmetic pedicures• X-rays• Consumables not prescribed or supplied by the chiropodistor podiatrist at the time of treatment, for example cornplasters, insoles, dressings• Surgical footwear, for example corrective footwear• Treatment supplied by a chiropodist or podiatrist who is notregistered with the Health Professions Council (HPC)Diagnostic consultation coverWe will pay you for your diagnostic consultation for the sumyou have paid directly to a medically qualified consultant,surgeon or physician. The consultant, surgeon or physicianmust meet the following criteria:• Their name is included on the register of consultants/surgeons/physicians maintained by the General MedicalCouncil / General Dental Council and they must hold acurrent licence to practise (please see• They hold or have held a substantive appointment (i.e. not alocum) as a consultant in a National Health Service Hospital/ the Armed Services.If you have any questions as to whether your consultant meetsthese criteria then please contact Customer Services on 0800072 1000.A diagnostic consultation is typically to establish what iswrong and to discuss treatment options. We will pay up tothe appropriate maximum entitlement detailed in your table ofcover available in your claiming year under your cover level.What is covered• A consultant’s fee for a diagnostic consultation (typically toestablish what is wrong and to discuss treatment options)• Blood tests or visual field tests directly connected to adiagnostic consultation• Allergy tests performed by a GP or consultantWhat is not covered• Cost of a referral• Treatment charges• Consultations with a podiatric surgeon (these may beclaimed under chiropody/podiatry)• Operation fees• Medical examinations and reports• Private hospital charges, for example room fees• Health-screening services• Visits to clinics and GPs• X-rays and diagnostic scans, for example mammograms, CTscans, ultrasounds and MRI scans
  • 12. 11• Investigative procedures, for example colonoscopy,laparoscopy, colposcopy and sigmoidoscopy• Pathology and biopsy• Medical tests, for example ECG, EEG and lung function tests• Anaesthetic fees• Counselling services, for example psychiatric, psychologicaland bereavement• Dietician/nutritional services• Speech therapy and dyslexia services• Assisted conception, fertility treatment and pregnancy care• Pregnancy termination• Post-operative consultations• Check-ups including cancer remission checks• Food intolerance/nutrition tests• Consultations on a cruise ship where the cruise itinerary isoutside the waters of the EEAHospital coverWe will pay you the amount shown in the table of cover foryour chosen premium level for each day/night where you areadmitted to a recognised hospital. The maximum number ofdays/nights you can claim for per claiming year is detailedwithin the table of cover.The claim form must be completed and signed by a doctor,nurse, or medical record department from the hospital whereyou were a patient. As an alternative you may also send a copyof your discharge letter as evidence of admission.Pre-existing conditions are not covered for the first 12 monthsof cover and we will ask for evidence that your condition is notpre-existing if you claim for this benefit during this time period.Hospital day case, parental-stay and hospital in-patient covershare the same maximum entitlement, please see the table ofcover.Hospital in-patient coverWhat is covered• Any period of overnight stay in a recognised hospital fortreatment or investigation of a medical condition which is nota pre-existing condition. The day of admission and the dayof discharge will be counted as oneWhat is not covered• Any period of overnight stay in a recognised hospital fortreatment of a pre-existing condition during the first 12months of cover• The first 14 nights of any stay in hospital during whichchildbirth takes place• Respite care (short term temporary relief for a carer of afamily member)• Out-patient treatment• Attendance at an accident and emergency department• Hospital day case• Hotel ward admission• Pregnancy termination• Laser eye surgery• Cosmetic surgery• Ante or post natal admission for a child registered on thepolicy• Administration fees for completing the claim formHospital day-caseWhat is covered• An admission to a day case ward or unit for treatment orinvestigation of a medical condition which is not a pre-existing condition• Out-patient cancer treatment, for example chemotherapy,radiotherapy which is not related to a pre-existingconditionWhat is not covered• The period immediately before or after an overnightin-patient stay for which we have paid under hospitalin-patient cover• Out-patient appointments, including injections and scans• Any period of hospital day case admission for treatment of apre-existing condition during the first 12 months of cover• Kidney dialysis• Day care, for example psychiatric, respite care, care for theelderly and maternity• Cancelled operations before admission• Treatment not in a hospital, for example operations carriedout in a GP’s surgery or clinic or attendance at an accidentand emergency department• Pre-admission appointments• X-rays or scans• Pregnancy termination• Laser eye surgery• Cosmetic surgery• Administration fees for completing the claim form
  • 13. 12Parental stay coverIn order to claim under this benefit we require your parentalstay claim to be supported by written confirmation from thehospital that one parent accompanied their child overnight.What is covered• Any period of overnight stay in a recognised hospital for oneadult who is registered on this policy who has accompaniedtheir child where they have been admitted as an in-patient.The child must be covered under the policy and thecondition must not be a pre-existing conditionWhat is not covered• Any period of overnight stay in a recognised hospital wherethe child has been admitted for a pre-existing conditionduring the first 12 months of cover• More than one parent accompanying their child• An adult who is not registered on the policy• The post-natal period following the birth of a child• A child’s attendance at an accident and emergencydepartment• A child’s respite care (short term temporary relief for a carerof a family member)• A child’s hospital day-case admission• A child’s out-patient treatment• Administration fees for completing the claim formNew child paymentWe will pay a single payment at the appropriate rate under yourchosen premium level for each child born to you or adoptedwhile you are covered by this policy, provided you havecompleted the 12 month qualifying period at the date of birthor adoption. We only make one payment per child no matterhow many policies you or your partner have; whether you areregistered on other policies or whether you and your partnerare registered on the same policy. If you have more than onepolicy you will have to choose which one to claim the new childpayment under.We will also make a payment at the appropriate rate for yourpremium level following a still birth of your child after 24 weeksof pregnancy.What is covered• The birth of your child after the 12 month qualifying period• The stillbirth of your child after 24 weeks of pregnancy andafter the 12 month qualifying period• The legal adoption of a child other than a child who isrelated to you after the 12 month qualifying periodWhat is not covered• A miscarriage up to 24 weeks of pregnancy• Foster children• Adoption of a child if the child is related to you or yourpartner before adoption• A baby born to a child who is aged under 18 and is coveredunder the policy• Pregnancy termination• A child born or adopted before or during the qualifyingperiodHealth and Counselling HelplineThis service allows you to call for advice on a range of basicmedical, health and wellbeing matters, as well as telephonecounselling. This service is available 24 hours a day, 7 daysa week and can be accessed by calling free on 0800 975 3345.Simplyhealth will not be held responsible if you experience anydelay or failure in the provision of this helpline that is beyondour, or the service providers’, control.If you have questions about the administration of the policyand claims, please contact the Simplyhealth Customer Servicesteam on 0800 072 1000.What is covered• Advice on health and lifestyle issues (smoking, weight lossetc)• Provision of basic medical advice and symptom information• Pre-travel medical advice• Childcare and eldercare advice• Telephone counselling support on a wide range of issuesaffecting youWhat is not covered• Any questions about the administration of the policy with us– for example, terms and conditions of the policy, current orpast claims, cover levels• Diagnosis of medical condition or prescription of treatments• Counselling or advice that the helpline does not give ororganise
  • 14. Here’s how Simplyhealth couldbenefit youWe understand that everyone’s needs are different, so what do you spend in anaverage year?Fill in the blanks and see how much you could benefit from a Simply Cash Plan. Don’tforget, if you have a partner or any children, to include what their treatments cost too.Now take a look at our table of benefits on page 2 and see how much money you couldbe claiming back each year.13Fill in youraverage costper yearHow much do you (and your family) spend at theDentist?How much do you (and your family) spend at theOpticians?What else do you spend on other healthcare costs,such as Physiotherapy, Chiropody, Homeopathy,Osteopathy?Total cost £294
  • 15. 14How to joinSimply look at the table of cover inside this brochure and choose the right level foryou, fill in this application form and pass to your Simplyhealth representative.Claiming is as easy as 1,2,31. You will receive your first claim form in the post with your welcome letter andconfirmation of your new policy2. When visiting your registered health practitioner, don’t forget to get a receipt3. Send in your claim form with your receipt to us here at SimplyhealthFor more information or to join, call us on0800 072 6704quoting codeor visit
  • 16. Priority Application FormI would like: cover for me (remember to include details below of any resident children to be covered, at no additional cost) cover for me and my partner (remember to include details below of any resident children to be covered, at no additional cost) to transfer my membership to the new Simply Cash Plan. My Plan number is to change my payment. My Plan number isYour detailsSurname Name Mr/Mrs/Miss/MsDate of birth Married/single Telephone no.Address PostcodeCompany name Employee no.Your Partner’s Details (only complete if cover is to be provided for both of you)Surname Name Mr/Mrs/Miss/MsDate of birth Married/singlePlan no. (if appropriate)Your Children’s Details (children only covered if resident at the above address and under 18 years of age)Name Surname Date of birth SexIf more than three children, please continue on a separate sheet of paper.How much cover would you like? (PLEASE TICK APPROPRIATE BOX)Please choose from the following monthly payment levels:Choose your individual cover levelChoose your family cover levelEnclosed are our standard terms and conditions which form the basis of our insurance contract for this policy. For your own benefit and protection you should readthese carefully before signing the declaration. By signing this declaration you are agreeing to abide by the terms and conditions of this policy, therefore if you donot understand any point then please contact us for further information before signing. We rely on the information you declare within the application in making ourdecision whether or not to accept your application; if any information you declare is found to be false we may cancel your policy. I understand that I have 14 daysfrom the receipt of my welcome pack in which to change my mind and to cancel the policy, after which the standard cancellation period detailed within the terms andconditions will apply. I confirm that those named on this application are 80 years of age or below, are UK residents and are not sports professionals.Data Protection Act - The answers on this form contain your personal data. We record, process and hold your personal data inaccordance with the law in the United Kingdom and in particular the Data Protection Act. We may, from time to time, wish to offer you other products and serviceswhich we believe will be of interest to you. Should you not wish to receive such communications, pleasetick the boxSignature DateSimplyhealth plan number (for office use only)Simplyhealth S.E. No.7 7£5.50 £11.00 £16.50 £22.00 £27.50 £33.00£11.00 £22.00 £33.00 £44.00 £55.00 £66.00For Staff Information
  • 17. Simplyhealth is a trading name of Simplyhealth Access, registered and incorporated in England and Wales, no.183035. Registered office: Hambleden House,Waterloo Court, Andover, Hampshire SP10 1LQ. Authorised and regulated by the Financial Services Authority. Your calls may be recorded and monitored fortraining and quality assurance purposes.Service user number9 5 9 4 4 2Instruction to your Bank or Building Society to pay by Direct DebitPlease fill in the whole form including official use box using a ball point pen and send to: Simplyhealth, Hambleden House, WaterlooCourt, Andover, Hants SP10 1LQName(s) of account holder(s)Bank/building society account number Branch sort codeName and full postal address of your bank or building societyTo the Manager: Bank or Building SocietyAddress:Postcode:ReferenceThis is not part of the instruction to your bank or building society - This information will only be used by SimplyhealthSimplyhealth will automatically pay your benefits into the bank account details listed above. If you have any queries,please phone 0800 072 6704.Day of the month on which you’d like the Direct Debit to becollected from your account:If premiums are to be paid by a party other than the policy holder please complete the boxes below.Name:Address:Telephone no:Your policy starts the day you sign this form. Please check your welcome pack for confirmation of your policy details.Instruction to your bank or building societyPlease pay Simplyhealth Direct Debits from the account detailed in this instruction subject to the safeguards assured by the DirectDebit Guarantee.I understand that this instruction may remain with Simplyhealth and, if so, details will be passed electronically to my bank or buildingsociety.Signature (s): 7 Date: 7Banks and Building Societies may not accept Direct Debit instructions for some types of account.
  • 18. A great place to workQ: How can I join SIMPLYHEALTH?A: You can join Simplyhealth by filling in the applicationform in this leaflet, calling us free on 0800 072 6704 orvisiting the internet at Can I join at any age?A: Anyone between the ages of 18 and 80 at the time ofapplication can join.Q: Do I need to have a medical to join?A: No, we just ask you to sign the health declaration onthe application form.Q: Who can be covered by my policy?A: This Simply Cash Plan is designed to suit yourcircumstances. Cover can be provided for individualsor you can include a partner. Additionally, any residentchildren, up to 18 years of age, are covered at thehighest option chosen at no extra cost.Q: Can I upgrade my cover after I have joined?A: Yes. Call Simplyhealth on 0800 072 6704. Please referto section 2.1 to 2.6 of the Terms & Conditions forfurther details.Q: How do I make a claim?A: Complete a claim form (included in your Welcome packor phone 0800 072 6704 to request one), encloseoriginal receipts, and send it directly to Simplyhealth.Q: How quickly can I expect to receivebenefit settlement?A: Once we have received your claim, we will normally paywithin a few days.Q: Do I have to pay tax on these benefits?A: No, we will pay you a tax-free amount of cash.Q: What happens if I leave Tesco?A: You may continue your membership with its currentTerms and Conditions.Your questions answeredSimplyhealth is a trading name of Simplyhealth Access, registered and incorporated in England and Wales, no. 183035. Registered office:Hambleden House, Waterloo Court, Andover, Hampshire SP10 1LQ. Authorised and regulated by the Financial Services Authority. Your callsmay be recorded and monitored for training and quality assurance purposes.About us and our insurance servicesSimplyhealth is a trading name of Simplyhealth Access which is authorised and regulatedby the Financial Services Authority (FSA). Our FSA register number is 202183. You cancheck this on the FSA’s Register by visiting the FSA website at orby telephoning the FSA directly on 0845 606 1234.We can only provide you with information on our own products and you will not receiveany advice or a personal recommendation from us for our health plans. We may askyou some questions to narrow down the product option on which we provide you withinformation, but you will then need to make your own choice about how to proceed.TESCO.HP.SB.06.12JUNE 2012The Direct Debit Guarantee• This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits• If there are any changes to the amount, date or frequency of your Direct Debit Simplyhealth will notify you 10 working days inadvance of your account being debited or otherwise agreed. If you request Simplyhealth to collect a payment, confirmation ofthe amount and date will be given to you at the time of the request• If an error is made in the payment of your Direct Debit, by Simplyhealth or your bank or building society you are entitled to a fulland immediate refund of the amount paid from your bank or building society– If you receive a refund you are not entitled to, you must pay it back when Simplyhealth asks you to• You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may berequired. Please also notify us1203045