Introduction
Welcome to the Nuffield Health Employee Healthcare Scheme guide.
These pages are designed to provide a summary of the benefits payable under the Nuffield Health Employee Healthcare Scheme (the ‘scheme’), the process of joining the scheme and the procedures you should follow to make a claim.
In the event of illness or injury, the scheme aims to provide you with fast access to treatment in a Nuffield Health hospital or other approved hospital.
Joining the scheme gives you peace of mind and the reassurance of knowing you’ll get the treatment you need, when you need it and be cared for and treated the Nuffield Health way.
Nuffield Health have appointed us, Healix Health Services Ltd, to manage this scheme. Our role is to assess and manage medical needs that you might have as well as the care and treatment you receive.
The scheme is designed to cover you for the diagnosis and/or treatment of a short term medical condition, if the treatment is medically necessary.
The scheme is not intended to cover all medical conditions. There are some medical conditions and treatments that are excluded from cover (please see exclusions and limitations for further details on this).
All treatment (including consultations and diagnostic tests) should be authorised in advance. Therefore it is essential that you contact us before you receive treatment, to ensure that your proposed treatment is eligible for cover under the scheme.
Joining the scheme
Employees of Nuffield Health are eligible to join the scheme from their date of hire or when they experience a qualifying lifestyle event. You can join within three months of this date, or alternatively at the scheme renewal date which is 1st January.
To join the scheme, you need to apply via Workday. You will be liable for income tax on the amount Nuffield Health pays towards this benefit. This will be processed through your monthly payroll, and more information can be found here.
If you choose to add a newborn baby to your scheme, you can do this from their date of birth and we will not apply any underwriting as long as you let us know within 90 days of its birth. If you add your baby after this 90 day timeframe, they will still be covered but the standard moratorium underwriting will apply. Further details are available here.
Table of benefits
Your scheme benefits are set out in the table below.
Benefit limits apply to each individual member or dependant in any one year of cover, unless otherwise stated.
All claims are subject to your excess, which will be applied to the first eligible treatment within each scheme year.
The scheme will commence on 1st January 2024.
| Outpatient Diagnostics and Treatment | Level of cover | Benefit note |
Outpatient consultations with a specialist following GP referral Outpatient consultations with a specialist on self-referral for breast, bowel, prostate or testicular cancer symptoms |
Up to £2,000 per scheme year | 1a |
Outpatient diagnostic tests and investigations following GP or specialist referral Outpatient treatment following specialist referral |
Full cover | 1b |
Outpatient monitoring consultations, therapies and diagnostic tests for management of chronic conditions |
Up to £500 per scheme year | 1c |
Outpatient MRI, CT and PET scans on specialist referral |
Full cover | 1d |
Outpatient surgical procedures |
Full cover | 1e |
| Outpatient Therapies | ||
Outpatient physiotherapy, osteopathy and chiropractic treatment |
Up to £2,000 per scheme year | 2a |
Outpatient acupuncture following GP or specialist referral |
Up to £300 per scheme year | 2b |
Outpatient mental health treatment |
Up to £2,000 per scheme year | 2c |
| Inpatient and Daycase Treatment | ||
Specialist fees for inpatient and daycase treatment |
Full cover | 3a |
Hospital charges for inpatient or daycase treatment |
Full cover | 3b |
Parent accommodation |
Full cover | 3c |
Mental health treatment - Inpatient and daycase |
Up to 28 days per scheme year | 3d |
| Cancer Treatment | ||
Cancer treatment |
Full cover | 4a |
Wigs when related to cancer treatment |
£100 per cancer occurence | 4b |
Mastectomy bras and prosthesis |
£200 per mastectomy procedure | 4c |
| Benefits for Specified Treatment | ||
Oral surgical procedures |
Full cover for specified treatments | 5a |
Disorders of the eye |
Full cover for specified treatments | 5b |
Pregnancy and childbirth |
Full cover for specified treatment of complications | 5c |
| Additional Benefits | ||
Private ambulance charges |
Up to £300 per scheme year | 6a |
Home healthcare |
Up to £600 per scheme year | 6b |
Note: The above benefits only apply when the covered person has treatment in the UK unless otherwise specified.
Outpatient consultations
We will pay within your overall outpatient limit for outpatient consultations with a specialist following GP referral.
Cover is subject to our reasonable and customary fees. For further information please refer to our fee schedule, or contact the claims helpline.
Outpatient consultations with a specialist on self-referral for breast, bowel, prostate or testicular cancer symptoms
We will pay within your overall outpatient limit for self-referred consultations and investigations for breast, bowel, prostate or testicular cancer symptoms.
Please refer to the self-referred cancer benefits page for further information on how to access this benefit.
If a diagnosis of cancer is made, cover for eligible treatment will be subject to any limits as detailed in your cancer treatment benefit.
Back to topWe will pay within your overall outpatient limit for:
- outpatient diagnostics and investigations following GP or specialist referral
- outpatient treatment following specialist referral
Cover is subject to our reasonable and customary fees. For further information please refer to our fee schedule, or contact the claims helpline.
Back to topWe will pay up to £500 per scheme year for outpatient monitoring consultations, therapies and diagnostic tests required as a result of a chronic condition following GP or self-referral*. Please call the claims helpline to speak with one of our case managers for further advice and support on accessing this benefit. All treatment must be pre-authorised to be eligible for cover. This benefit is for outpatient treatment only and is subject to all other terms and conditions.
*Please note, cover for self-referral is subject to the medical underwriting on your scheme.
Back to topWe will pay in full for MRI, CT and PET scans on specialist referral.
Back to topWe will pay in full for hospital charges and specialist fees for outpatient surgical procedures, and drugs and dressings used during an outpatient appointment.
Cover is subject to our reasonable and customary fees. For further information please refer to our fee schedule, or contact the claims helpline.
Back to topWe will pay up to £2,000 per scheme year for outpatient physiotherapy, osteopathy and chiropractic treatment following GP, specialist or self-referral when treatment takes place within a Nuffield Health facility.
For further information on support available for musculoskeletal conditions through Nuffield Health, please click here.
Back to topWe will pay up to £300 per scheme year for acupuncture following GP or specialist referral. You must be referred to an acupuncturist we have recognised for benefit purposes.
Back to topWe will pay up to £2,000 per scheme year for outpatient consultations for eligible mental health conditions following GP or self-referral when taken within a Nuffield Health Facility.
For further information on support available for mental health conditions through Nuffield Health, please click here.
Back to topWe will pay for specialist fees for inpatient and daycase treatment.
Cover is subject to our reasonable and customary fees. For further information please refer to our fee schedule, or contact the claims helpline.
Back to top
We will pay hospital charges in full for the following:
- accommodation and nursing care for inpatient or daycase treatment
- operating theatre and recovery room
- prescribed medicines and dressings, for use whilst an inpatient or for daycase treatment
- eligible surgical appliances - for example, a knee brace following ligament surgery
- prosthesis or device which is inserted during eligible surgery
- pathology, radiology, diagnostic tests, MRI, CT and PET scans
- physiotherapy received during inpatient or daycase treatment
- intensive care
- short-term dialysis when needed temporarily for sudden kidney failure resulting from an eligible condition or treatment
- skin and corneal grafts.
We will pay reasonable hospital costs for one parent or legal guardian to stay with a child who is under 17 years old, if a child is admitted to hospital as an inpatient. Cover for this benefit will stop on the child’s 17th birthday. If your child is an inpatient on their 17th birthday, then cover will extend until they are discharged on that occasion. We will only pay the cost if:
- it is the parent or legal guardian who stays with the child
- the treatment the child receives is covered by the scheme.
We will pay up to a maximum of 28 days per scheme year for eligible inpatient and daycase mental health treatment. All treatment must be under the direct control and supervision of a consultant psychiatrist, and must be authorised by us in advance and in writing.
Where treatment is for an addiction treatment programme, cover is limited to once per scheme lifetime.
Back to topWe will pay for cancer treatment as detailed in the cancer cover explained table.
Back to topWe will pay up to £100 per cancer occurrence towards the cost of a wig if you need one due to hair loss caused by cancer treatment.
Back to topWe will reimburse up to £200 per mastectomy procedure for the cost of mastectomy bras and other mastectomy related prosthesis required following eligible cancer treatment.
Back to topWe will pay for the following specified oral surgical operations carried out by a specialist:
-
surgically remove a complicated, buried, infected or impacted tooth root
-
apicectomy or removal of the tip of a tooth’s root
-
enucleation of a cyst of the jaw (removing a cyst from the jaw bone)
-
surgical drainage of a fascial space (tracking) abscess
-
putting a natural tooth back into a jaw bone after it is knocked out or dislodged in an accident
-
treatment of facial and mandibular fractures.
We will pay for eligible acute treatment of the following conditions:
-
cataracts
-
detached retina
-
surgical correction of a squint
-
drooping eyelids (ptosis) – we will only provide benefit for ptosis (drooping eyelids) if your optometrist identifies visual impairment and you are referred by your general practitioner or optician to a consultant ophthalmologist
-
wet aged-related macular degeneration, where we will pay for a short course of treatment following initial diagnosis.
We will pay for the following specified obstetric procedures / treatment:
-
pelvic girdle pain in pregnancy
-
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)
-
ectopic pregnancy (foetus growing outside the womb)
-
Diastasis recti or Rectus Abdominis (splitting of the abdominal muscles during pregnancy)
-
post-partum haemorrhage (heavy bleeding in the hours and days immediately after childbirth)
-
retained placental membrane (afterbirth left in the womb after the delivery of the baby)
-
eligible mental health treatment for post-natal depression subject to the conditions and limitations set out in the mental health benefit.
-
medically essential caesarean section where this is an inevitable consequence of a complication to the current pregnancy.
-
complications following any of the above conditions.
-
flare up of a non-pregnancy related medical condition that has been made worse by pregnancy
We will require full clinical details from your specialist before we can give our decision on cover.
In the event that the newborn requires immediate treatment as a result of an eligible caesarean section, this should be administered by the NHS free of charge. If the newborn is not entitled to NHS care and is not accepted as a dependant on the scheme we will pay for treatment for up to 7 days following the birth, to allow you time to make alternative arrangements. In cases where they are accepted as a member of the scheme they will only be entitled to benefits outlined in the benefits table and will be subject to the exclusions listed within the scheme.
Back to topWe will pay up to £300 per scheme year for transport by a private ambulance to and/or from a hospital when ordered for medical reasons.
Back to topWe will pay up to £600 per scheme year for home nursing charges for registered nurses when recommended by a specialist and where treatment is:
-
medically necessary and without it you would have to receive treatment as an inpatient or daycase admission
-
needed for medical reasons (i.e. not social or domestic reasons)
-
under the direct supervision of a specialist.
Mental health treatment delivered at home or in the community is not covered by the scheme.
Back to topCancer cover explained
We know that a cancer diagnosis can be a life changing event. Therefore we have provided a specific section within your scheme to help you understand the level of cover available to you for cancer treatment.
The scheme provides benefit for eligible outpatient, daycase and inpatient treatment for cancer as detailed below.
One of our nurse case managers will be able to provide information on the treatment options available to you and support you through your treatment.
The table below provides a summary of the cancer cover available and should be read alongside your table of benefits.
| Summary of cancer benefits | What’s covered | What’s not covered |
| Where will I be covered to have treatment? |
You will be covered in full for eligible treatment:
|
You will not be covered for:
|
| What diagnostic tests will I be covered for? |
You will be covered in full for:
|
You will not be covered for any diagnostic tests that are:
|
| Will I be covered for surgery? |
You will be covered in full for:
|
You will not be covered for surgery that is:
|
|
Will I be covered for preventative treatment? |
You will be covered for prophylactic (preventative) surgery if:
For example, we will pay for a mastectomy to a healthy breast in the event that you have been diagnosed with cancer in the other breast and your specialist indicates that prophylactic surgery is medically necessary and will be carried at the same time as surgery to the diseased breast. You must have our written agreement before you have tests, procedures or treatment and we will need full clinical details from your specialist before we can give our decision. |
You will not be covered for any preventative treatment, including:
|
|
What drug treatments will I be covered for? |
You will be covered in full for:
|
You will not be covered for:
|
| Will I be covered for radiotherapy? |
You will be covered in full for radiotherapy, including when given for pain relief. |
You will not be covered for radiotherapy that is:
|
| Will I be covered for end of life care? |
|
You will not be covered for:
|
|
What cover will be available for routine monitoring when |
You will be covered for follow-up tests and specialist consultations to monitor you once you have completed treatment for a cancer. No time limits are placed on follow up tests and consultations as long as these are medically necessary and your specialist confirms this in writing. |
|
|
What other benefits and services are available? |
You will be covered for:
Please note that these are subject to any limits as detailed in your table of benefits. |
You will not be covered for:
|
Your excess
Excess
All members and dependants are liable for an excess of £100, which is payable once every scheme year, if you make an eligible claim.
Your excess will be applied to the first eligible treatment that you receive in each scheme year. This is regardless of when the last excess payment was made and whether the treatment is for the same condition, a related condition, or for an entirely new condition. Please contact us before you receive any treatment, so that we can advise you on when your excess will apply.
Refer to your scheme changes section for details of how your excess will apply in the 2024 scheme year.
Hospital cover
Restricted network
The Nuffield Health Employee Healthcare Scheme will typically only cover eligible treatment when taken within the Nuffield Health hospital network.
For help in finding a hospital, please refer to the Nuffield Health hospital finder.
Please note; if you do not have a Nuffield Health facility within 25 miles of your home address or if treatment is not available at a Nuffield Health facility, the scheme may cover treatment outside of this restricted network.
Should you have any queries regarding this list or your chosen hospital/clinic, please contact us on the claims helpline.
Pre-existing medical conditions
Employees
For employees, pre-existing eligible conditions are covered on joining the scheme and as such medical history is disregarded.
Dependants
Dependants' pre-existing medical conditions/symptoms, whether or not advice has been sought, are excluded from treatment for a period of two years after the date of joining the scheme.
Second medical opinion
Should you decide that you would like to receive a second medical opinion to ensure you are fully confident with your specialists recommendations please contact us on the claims helpline to discuss pre-authorisation. Our team of nurse case managers will be able to advise and support you through this process.
Second medical opinions will be arranged with a specialist who is an expert in their field and is recognised for the purposes of providing such second opinions. Following your second medical opinion your nurse case manager will contact you to discuss the suggested treatment plan and eligibility for benefit. Without written authorisation for a second opinion payment cannot be made for any recommended or resulting treatment.
What happens in an emergency?
Most private hospitals are not set up to receive emergency admissions. In the event of an emergency you should:
- call for an NHS ambulance
- visit the accident and emergency department at the local NHS hospital.
If you would like to be transferred to a private facility, please contact us to discuss this. We will then be able to confirm whether your proposed treatment is eligible under the healthcare plan. Please note you must contact us before you transfer to a private facility.
You will not be covered for:
- the cost of emergency treatment in a private walk-in centre, accident and emergency department or clinic
- the cost of treatment in an intensive care or high dependency unit if you have been transferred specifically to receive this care
- the costs of the transfer to a private facility specifically to receive treatment in an intensive care or high dependency unit.
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide, the list of 'How to Claim' in Section 4
Active treatment
Acute condition
Annual renewal date
Benefit
Benefits
Biological therapies
Cancer
Chronic condition
Complementary practitioner
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council). <
Daycase
Dependant
- a member’s unmarried dependent children.
Dependants
- a member’s unmarried dependent children.
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Disorder
Emergency
Employer
End of life care
General practitioner
GP
High dependency unit
Home healthcare
Hospital
Private hospital - an independent hospital which can provide acute medical, surgical or psychiatric care. It must be registered under The Registered Homes Act (1984) and approved by the Healthcare Commission or any future law. It may also include a private bed in an NHS hospital.
Inpatient
Intensive care unit
Medical condition
Medically necessary
-
In accordance with professional standards of medical practice in the United Kingdom
-
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
-
Required for reasons other than the comfort or convenience of the patient or specialist
-
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition
-
Provided only for an appropriate duration of time
-
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.
<
Member
Members
Mental health condition
Outpatient
Palliative care
Partner
Physiotherapist
Pre-existing condition
-
you have received medication, advice or treatment, or
-
you have experienced symptoms whether the condition was diagnosed or not.
<
Private ambulance
Prosthesis
Psychological therapist
-
a psychologist who is either:
-
Registered with the Health and Care Professions Council (HCPC)
-
Registered with the British Psychological Society (BPS) as a chartered Psychologist.
-
a therapist who is either:
-
An accredited member of the British Association of Counselling and Psychotherapy (BACP)
-
An Accredited Member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP)
-
An Accredited Member of Scotland’s Professional Body for Counselling and Psychotherapy (COSCA)
-
A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP).
Registered nurse
Related condition
Specialist
- a medical practitioner with full current registration with the General Medical Council
-
a dentist with full current registration with the General Dental Council.
and:
-
a specialist in the treatment you are referred for (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
The scheme
Practitioner
- an occupational therapist
- an orthoptist
- a podiatrist
- a speech and language therapist
- a dietician or;
- a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number. <
Treatment
Treatments
Trust Deed
Trustee, Trustees
United Kingdom
Waiting period
We, Us, Our
You, Your
Gender Dysphoria
Gender Incongruence
High-risk activities
Scheme
Pandemic
Epidemic
Neurodevelopmental disorders
Diagnostic
- outpatient and daycase tests or investigations used to reach a diagnosis of an illness or injury
Making a claim
Register your claim using our My Healix app. Alternatively, you can call the claims helpline to confirm if cover is available.
In order for us to accurately assess cover under the terms and conditions of your scheme, we may ask to see a copy of your GP referral letter when you open a new claim. Please see How to claim for further information.
Always contact the claims team before arranging or receiving any treatment.
Download the My Healix app
Call the claims helpline:
0208 481 7769
Monday-Friday 08.00-19.00 (Excl. bank holidays)
Saturday 09.00-13.00
We will confirm:
-
whether your proposed treatment is eligible for cover under the scheme
-
whether your proposed treatment costs will be covered under the scheme
-
any benefit limits or excess that may apply to your claim.
How to claim
We aim to keep your claim experience with Healix as straight forward and hassle-free as possible. We understand that making a claim can be an uncertain time for our members, and the information below will help guide you through the process.
Step One: Referring for Treatment
| Self referral | GP referral |
|
Through your healthcare scheme, you can self-refer for: |
A GP referral is required for anything else. This should include details of the type of specialist you are being referred to, the nature of your symptoms, and any relevant medical history. |
Step Two: Contacting the Claims Team
Once your referral is in place, you can contact the claims team via the My Healix app, telephone, or webchat using the chat icon in the online booklet.
We will provide you with a pre-authorisation code for your treatment, and send details of this authorisation to your providers. The team will also advise you at what stage of your claim you need to contact us again for further authorisation.
Claims for muscle, bone and joint conditions
Musculoskeletal conditions affect your muscles, bones and joints. They are very common and tend to increase with age.
Pain and discomfort can affect your daily activities but early diagnosis and treatment may help to ease your symptoms and improve the length of time it takes to recover.
How to make a claim
As soon as you experience muscle, bone or joint pain you can contact the claims helpline for support and advice. There is no need to see your GP or obtain a referral letter.
Our experienced team will take your details and arrange for you to have an initial telephone consultation with a senior physiotherapist at a convenient time for you who will recommend the most appropriate treatment pathway.
This could be one of three options:
- Face to face physiotherapy with an approved physiotherapist
- Guided self-management using a bespoke, evidence-based exercise programme and regular one-to-one calls with a physiotherapist
- Referral on to a specialist – we can help locate a specialist at an approved hospital near you.
Claims for mental health conditions
The importance of mental health and wellbeing is becoming increasingly recognised in today’s busy world. Acknowledging stress and anxiety and seeking help are the first steps to developing coping strategies and recovery.
How to make a claim
If you are experiencing stress, anxiety or depression or any other mental health problem, you can contact the claims helpline for support and advice. There is no need to see your GP or obtain a referral letter.
Our experienced claims team will take your details and transfer you to the Emotional Wellbeing Team at Nuffield Health. They will be able to listen to your symptoms and arrange a telephone consultation to agree on the best treatment pathway for you.
This could be one of several options including:
-
Face to face cognitive behavioural therapy (CBT)
-
Guided online CBT
-
Counselling
-
Referral onwards to see a psychiatrist.
Healix will pre-authorise your assessment and treatment (within benefit limits) and settle all invoices directly.
Claims for cancer symptoms
Having symptoms of cancer can be a worrying time, which is why we want to be able to support you to receive timely investigations for suspected cancer symptoms.
If you experience symptoms of breast, bowel, prostate or testicular cancer then you are able to call and speak directly to our claims team to self-refer for a consultation and diagnostic tests.
This means that you no longer need to see your GP before accessing private treatment for these concerns in order to prevent any delays in reaching a diagnosis.
If you are experiencing any of the symptoms below, call the claims helpline and our experienced claims team will be able to help direct you to the most appropriate specialist to help reach a diagnosis.
| Type of cancer | Signs and symptoms to watch out for |
|
Breast cancer |
|
|
Bowel cancer |
|
|
Prostate cancer |
|
|
Testicular cancer |
|
Please remember that these signs are also features of common health problems that are not caused by cancer, such as a cyst, piles or infection.
In the event that a cancer diagnosis is made, cover will be available as detailed in your cancer cover explained and one of our nurse case managers will support you and be able to provide information on the treatment options available to you.
Please contact us via the My Healix app or by calling the claims helpline to get further advice and to open a new claim. As with all of your healthcare benefits it is important that you obtain pre-authorisation before receiving any treatment to ensure your claim is eligible and to prevent you incurring any unwanted costs.
Supporting you with your claim
When you make a claim it is important to be able to speak to someone who really understands your condition.
Our claims team is made up of assessors, co-ordinators and nurses. Our team will be able to help you understand your condition, guide you to access treatment, authorise your eligible appointments and support you during your treatment journey.
Nurse case managers are available to any member who is experiencing a complex claim. Our claims assessors will refer you through to a nurse where this is deemed appropriate. If you believe that your claim would benefit from this additional support please speak to our claims assessors when you call. Our nurse case managers will be contactable by phone and will be able to guide you through your treatment pathway, offering expert advice and guidance every step of the way.
Exclusions and limitations
The following are conditions and treatments which are not covered under your scheme. If you are unsure about anything in this section, please contact us on the claims helpline.
Exclusions and limitations
We do not pay for treatment to relieve symptoms commonly associated with or caused by ageing, puberty or other natural physiological cause.
We do not pay for any treatment required for alcohol, solvent or drug abuse, or any treatment arising from such abuse or addiction, this includes mental health treatment.
Please note: Cover is available for one addiction treatment programme per lifetime of the scheme as detailed within the inpatient mental health benefit in your table of benefits.
We do not pay for treatment to desensitise or neutralise any allergic condition or disorder.
We do not pay for the supply or fitting of appliances, physical aids or devices (including but not limited to hearing aids, spectacles, contact lenses, external prostheses and orthotics etc) which do not fall within our definition of a surgical appliance. Any consultations relating to these are also not covered.
We do not pay for:
- birth control
- sterilisation and/or reversal
- termination of pregnancy.
We do not pay for treatment of chronic conditions. By this we mean any medical condition which has at least one of the following characteristics:
- it needs ongoing or long-term monitoring through consultations, examinations, check-ups and/or tests
- it needs ongoing or long-term control or relief of symptoms
- it requires rehabilitation or for you to be specially trained to cope with it
- it continues indefinitely
- it has no known cure
- it comes back or is likely to come back.
Please note: this will apply to all medical conditions, whether or not a diagnosis has been made.
Exception: we will pay for eligible treatment arising out of a chronic condition, or for treatment of acute symptoms of a chronic condition that flare up. However, we only pay if the treatment is likely to lead quickly to a complete recovery or to you being fully restored to your previous state of health, without you having to receive prolonged treatment. For example, we pay for treatment following a heart attack arising out of chronic heart disease. This exception does not apply to treatment of a mental health condition.
Please note: in some cases it might not be clear, at the time of treatment, that the disease, illness or injury being treated is a chronic condition. We are 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 note this exclusion does not apply to the treatment of cancer.
We do not pay for treatment which arises from, or is related to any exclusion listed in this booklet or treatment which arises from or is related to a surgical procedure we do not cover.
We do not pay for treatment of any medical condition which is caused or contributed to by; nuclear, radioactive, biological or chemical contamination, war (whether declared or not), act of foreign enemy, riot, revolution, invasion, civil war, rebellion, insurrection, overthrow of a legally constituted government, explosions of war weapons, terrorist act or military activity. We will not pay for treatment of any medical condition which is received while you or your dependants are carrying out army, naval or air services duties.
We do not pay for treatment if it is primarily used for domestic and/or social reasons.
We do not pay for any treatment to change your appearance even when required for psychological reasons.
We do not pay for any treatment, including surgery:
-
where the intention of treatment, whether directly or indirectly, is the reduction or removal of healthy, surplus or fat tissue (for example, weight reduction surgery / treatment)
-
where the aim is to aesthetically enhance the appearance of the face or body where no functional condition is present (for example, botox, fillers or asymptomatic rhinoplasty).
Exception: we will pay for medically necessary treatment to restore your appearance in the following circumstances:
-
where it results from an eligible underlying disease process
-
following eligible treatment (including cancer treatment)
-
where the condition is causing a functional problem.
Please note: we use NHS guidance as a benchmark for deciding whether the exceptions above are eligible for cover. All requests for cover must be submitted in writing with supporting medical information.
We do not pay for any dental or oral treatment other than as specified in your table of benefits.
We do not pay for treatment for or associated with dialysis.
We do not pay for drugs and dressings provided or prescribed for use as an outpatient or for you to take home, other than those outlined in the cancer cover explained page.
We do not pay for:
- the cost of emergency treatment in a private walk-in centre, accident and emergency department or clinic
- the cost of an emergency admission into a private hospital
- the cost of treatment in an intensive care or high dependency unit if you have been transferred specifically to receive this care
- the costs of the transfer to a private facility specifically to receive treatment in an intensive care or high dependency unit.
We do not pay for treatments (including medication) which in our reasonable opinion are experimental or not yet approved by the National Institute for Health and Care Excellence (NICE), are being researched or lack sufficient evidence to conclude that:
- the harmful effects are outweighed by the beneficial effects
- they are likely to lead to the same or better outcomes than available alternatives
- they are based on established medical practice in the United Kingdom.
Examples of the criteria we use for considering a treatment as experimental include:
- the treatment is still undergoing clinical trials and/or yet to undergo a phase III clinical trial for the indication in question
- the treatment does not have approval from the relevant government body
- the treatment does not conform to usual clinical practice in the view of the majority of medical practitioners in the relevant field
- the treatment is being used in a way other than that previously studied or that for which it has been granted approval by the relevant government body
- the treatment is rarely used, novel, or unknown and there is a lack of authoritative evidence of safety and efficacy.
We do not pay for any treatment required for complications arising or resulting from experimental treatment that you receive or for any subsequent treatment you may need as a result of you undergoing any experimental treatment.
We do not pay for treatment to correct your sight other than as specified in your table of benefits.
We do not pay for:
- any type of fertility investigations
- fertility treatment
- assisted reproduction, surrogacy, harvesting of donor eggs or donor insemination
- sperm collection and storage
- complications following any of the above.
We do not pay for any treatment of gender dysphoria, or any treatment arising from or relating to gender dysphoria.
We do not pay for any GP consultations or visits. We do not pay for any charges for the completion of claim forms or referral letters, unless we have requested these specifically to assess your claim.
We do not pay for holistic or alternative medicine or therapies, unless these are specifically listed in your table of benefits. For example yoga, massage, spas and health resorts.
We do not pay for:
- any treatment caused by or resulting from you carrying out an illegal act
- any treatment resulting from a road accident where you were not wearing a seat belt (as required by law).
We do not pay for any treatment (including assessment) of adult or childhood neurodevelopmental disorders.
Exception: we will pay for eligible diagnostic tests to rule out ADHD and ASD only when a mental health condition is suspected. You must have our confirmation before any diagnostic tests are carried out and we need full clinical details from your GP or specialist before we can confirm cover.
We do not pay for any weight loss treatment including treatment required as a result of obesity.
We do not pay for treatment outside the United Kingdom including evacuation or repatriation.
We do not pay for treatment for or arising from pandemic and / or epidemic disease.
We do not pay for personal comfort and convenience items or services including but not limited to travel expenses, television, WIFI, telephone costs, newspapers, and guest meals.
We do not pay for any treatment related to pregnancy or childbirth, other than as specified in your table of benefits.
We will not pay for charges that are over our schedule of reasonable and customary (R&C) fees for specialist fees. For further information please refer to our fee schedule, or contact the claims helpline.
We will not pay for routine monitoring of any implanted devices including, but not limited to, cardiac pacemakers, internal defibrillators and nerve stimulators after insertion
We do not pay for any form of genetic testing or screening, health screening, health checks or preventative treatment, procedures or medical services where no disease is present.
We do not pay for treatment;
- recommended because of a genetic predisposition towards developing a medical condition
- recommended because of a family history of a medical condition.
Please see cancer cover explained for information on preventative cancer treatment.
We do not pay for treatment for or arising from sleep disorders. This includes but is not limited to: sleep apnoea, snoring, insomnia, sleep walking, narcolepsy, and night terrors.
We do not pay for any transplants, adoptive cell transfer, gene therapies and/or any complications related to, or resulting from these treatments. This includes, but is not limited to CAR T-cell therapy, Tumour Infiltrating Lymphocyte therapy and stem cell/bone marrow treatments. We also do not pay for:
- donor costs
- harvesting
- storage
- administration
- and/or any complications/treatment arising from any of the above.
Exception: we will pay for recipient costs for skin or corneal grafts when eligible for benefit. We will also pay for T-VEC within its license indications when recommended by a specialist.
We do not pay for treatment carried out by a provider who we do not recognise as being qualified and/or registered to provide the type of treatment you need or for treating the medical condition you have.
We do not pay for treatment with sports therapists, massage therapists, or anyone who does not meet our definition of a practitioner or complementary practitioner.
We do not pay for any treatment carried out by you, your spouse, parents or children.
Payment of invoices and reimbursements
All treatment should be authorised in advance so that we can place a guarantee of payment with your healthcare provider, subject to your benefit limits and our reasonable and customary guidelines. If you have pre-authorised your treatment, we will settle the bill (up to applicable limits) directly with your specialist, therapist or hospital. You are responsible for making sure we have all the information we need to pay your claims.
In some circumstances it may be necessary for you to pay for pre-authorised treatment yourself and request a reimbursement from us for the cost of the treatment. In these cases, please send us a copy of your receipt via email, along with your bank account details (full name, sort code and account number) and we will arrange reimbursement via bank transfer.
We will not pay for claims:
- if the invoice or reimbursement claim is not submitted within six months of your treatment date or within six months of the end of the scheme year you wish to claim against - whichever comes soonest
- if the treatment takes place after you have left the scheme
- if you break any terms and conditions of your membership
- if you incur a fee for non-attendance or late cancellations.
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide, the list of 'How to Claim' in Section 4
Active treatment
Acute condition
Annual renewal date
Benefit
Benefits
Biological therapies
Cancer
Chronic condition
Complementary practitioner
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council). <
Daycase
Dependant
- a member’s unmarried dependent children.
Dependants
- a member’s unmarried dependent children.
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Disorder
Emergency
Employer
End of life care
General practitioner
GP
High dependency unit
Home healthcare
Hospital
Private hospital - an independent hospital which can provide acute medical, surgical or psychiatric care. It must be registered under The Registered Homes Act (1984) and approved by the Healthcare Commission or any future law. It may also include a private bed in an NHS hospital.
Inpatient
Intensive care unit
Medical condition
Medically necessary
-
In accordance with professional standards of medical practice in the United Kingdom
-
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
-
Required for reasons other than the comfort or convenience of the patient or specialist
-
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition
-
Provided only for an appropriate duration of time
-
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.
<
Member
Members
Mental health condition
Outpatient
Palliative care
Partner
Physiotherapist
Pre-existing condition
-
you have received medication, advice or treatment, or
-
you have experienced symptoms whether the condition was diagnosed or not.
<
Private ambulance
Prosthesis
Psychological therapist
-
a psychologist who is either:
-
Registered with the Health and Care Professions Council (HCPC)
-
Registered with the British Psychological Society (BPS) as a chartered Psychologist.
-
a therapist who is either:
-
An accredited member of the British Association of Counselling and Psychotherapy (BACP)
-
An Accredited Member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP)
-
An Accredited Member of Scotland’s Professional Body for Counselling and Psychotherapy (COSCA)
-
A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP).
Registered nurse
Related condition
Specialist
- a medical practitioner with full current registration with the General Medical Council
-
a dentist with full current registration with the General Dental Council.
and:
-
a specialist in the treatment you are referred for (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
The scheme
Practitioner
- an occupational therapist
- an orthoptist
- a podiatrist
- a speech and language therapist
- a dietician or;
- a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number. <
Treatment
Treatments
Trust Deed
Trustee, Trustees
United Kingdom
Waiting period
We, Us, Our
You, Your
Gender Dysphoria
Gender Incongruence
High-risk activities
Scheme
Pandemic
Epidemic
Neurodevelopmental disorders
Diagnostic
- outpatient and daycase tests or investigations used to reach a diagnosis of an illness or injury
End of cover
Cover for you (the member) will end in the following situations:
-
if your employment with Nuffield Health has come to an end for any reason
-
if you no longer live full time in the United Kingdom
-
if you pass away
-
if for any reason you or Nuffield Health ask us to end cover
- If you or any of your dependants have given us misleading information, have kept something from us, or have broken the conditions of this scheme.
If your cover ends, your dependant's cover will also end on the same day as your cover.
Cover for dependants will end in the following situations:
Your partner's cover will end:
-
if you no longer live together, then your partner will no longer be considered a dependant for the purposes of this scheme.
Your dependant child’s cover will end:
-
after they have turned 25. They will be removed from cover on the next annual renewal date following their 25th birthday
-
if they get married, then they will no longer be considered a dependant for the purposes of this scheme
- if they no longer live full time in the United Kingdom.
Members must email mybenefits@nuffieldhealth.com as soon as possible to notify of any changes of this matter.
If treatment has been authorised, but has not yet taken place, you will be responsible for any treatment costs if the scheme then terminates or you leave the scheme.
Leaving the Scheme - Individual Cover
If you are leaving the scheme for one of the above reasons and would like to continue with your own medical cover, we have arranged for Howden Employee Benefits to assist you. They will discuss your specific requirements and provide you with independent advice on the most suitable insurance policy for you. This service is available to you at no cost.
To avoid a gap in cover it is important to act quickly. Please contact groupleavers@howdengroup.com.
How to make a complaint
It is always our intention to provide a first class standard of service: however, we recognise that on occasions, your requirements may not have been met.
Should you have any cause for complaint, you should contact us.
How your complaint will be handled
Stage 1
You will receive a written acknowledgement of your complaint within five business days of receipt. This will include the name and job title of the individual handling the complaint.
Stage 2
Within four weeks of receiving your complaint, you will receive either:
-
A final response or
-
A holding response, explaining why we are not yet in a position to resolve the complaint and indicating when we will be making further contact (this will be within eight weeks from receiving the complaint).
Stage 3
If you have not received a final response within four weeks, by the end of eight weeks after receipt of the complaint, you will receive either:
-
A final response.
-
A response explaining why we are still not in a position to provide a final response and explaining when we believe we will be able to do so.
If we are unable to provide a final response, due to the delay which has now occurred, you may refer your complaint to the trustees. If, during stage 2 or 3, we issue our final response but you remain dissatisfied, you may refer your complaint to the trustees. To do this, please set out your reasons fully in writing to the Claims Coordination Manager via email or post, asking for referral to the trustees for further consideration.
Requests for additional information
We may ask you to provide information to help us assess your claim. For example, we may ask you for one or more of the following:
-
medical reports and other information about the treatment for which you are claiming. If we request a medical report from your specialist and they charge for providing this we will pay the cost
-
original accounts and invoices in connection with your claim
-
obtain results of an independent medical examination or second opinion for which we may ask you to make an appointment with a with a specialist. We will pay for the cost of any independent medical examination or second opinion we require and we will authorise this in writing, in advance
-
results of any second opinion you have independently sought under the care of another specialist. On such occasions we may additionally request our own, independent, second opinion from an expert in that field to assess eligibility of cover. We will pay the costs of any second opinion we organise on your behalf, this includes the cost of the consultation and any tests undertaken as a result of that consultation.
We will liaise with you and your medical specialists throughout your treatment and will request medical information when we deem this to be necessary for the assessment of your claim. You will be asked for your consent before we do this.
Throughout your claim we will make you aware of the options that are available to you. If your medical specialist recommends treatment, you should contact the claims helpline as soon as possible to be sure that continued treatment is covered.
Our team of case managers will assess the level of cover available to you for planned treatment within the terms and conditions of the scheme. In some instances it may be necessary to refer your claim to our specialist nurses, along with our panel of independent specialist advisors, who will advise on the level of cover available for the recommended treatment.
Duplicate cover
You must tell us if you are able to make a claim for the cost of any of your treatment from anyone else either under another healthcare scheme or under an insurance policy. For example, if you received an injury that was caused by someone else such as a road traffic accident in which you are not at fault, the scheme will only pay a share of the total costs as appropriate.
If benefits are claimed for treatment to you when the injury or medical condition was caused by a third party, the scheme shall, at its own expense, have the right to pursue such claims in any way considered appropriate in your name. You must co-operate with all reasonable requests in this respect and advise us of any amount you recover directly from the third party.
Healix privacy notice
If you would like to know more about how Healix store and process your personal data, please find our Privacy Notice by clicking here.
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide, the list of 'How to Claim' in Section 4
Active treatment
Acute condition
Annual renewal date
Benefit
Benefits
Biological therapies
Cancer
Chronic condition
Complementary practitioner
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council). <
Daycase
Dependant
- a member’s unmarried dependent children.
Dependants
- a member’s unmarried dependent children.
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Disorder
Emergency
Employer
End of life care
General practitioner
GP
High dependency unit
Home healthcare
Hospital
Private hospital - an independent hospital which can provide acute medical, surgical or psychiatric care. It must be registered under The Registered Homes Act (1984) and approved by the Healthcare Commission or any future law. It may also include a private bed in an NHS hospital.
Inpatient
Intensive care unit
Medical condition
Medically necessary
-
In accordance with professional standards of medical practice in the United Kingdom
-
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
-
Required for reasons other than the comfort or convenience of the patient or specialist
-
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition
-
Provided only for an appropriate duration of time
-
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.
<
Member
Members
Mental health condition
Outpatient
Palliative care
Partner
Physiotherapist
Pre-existing condition
-
you have received medication, advice or treatment, or
-
you have experienced symptoms whether the condition was diagnosed or not.
<
Private ambulance
Prosthesis
Psychological therapist
-
a psychologist who is either:
-
Registered with the Health and Care Professions Council (HCPC)
-
Registered with the British Psychological Society (BPS) as a chartered Psychologist.
-
a therapist who is either:
-
An accredited member of the British Association of Counselling and Psychotherapy (BACP)
-
An Accredited Member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP)
-
An Accredited Member of Scotland’s Professional Body for Counselling and Psychotherapy (COSCA)
-
A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP).
Registered nurse
Related condition
Specialist
- a medical practitioner with full current registration with the General Medical Council
-
a dentist with full current registration with the General Dental Council.
and:
-
a specialist in the treatment you are referred for (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
The scheme
Practitioner
- an occupational therapist
- an orthoptist
- a podiatrist
- a speech and language therapist
- a dietician or;
- a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number. <
Treatment
Treatments
Trust Deed
Trustee, Trustees
United Kingdom
Waiting period
We, Us, Our
You, Your
Gender Dysphoria
Gender Incongruence
High-risk activities
Scheme
Pandemic
Epidemic
Neurodevelopmental disorders
Diagnostic
- outpatient and daycase tests or investigations used to reach a diagnosis of an illness or injury
Contact us
The Healix Team
We have a team of experienced case managers and nurses available to advise and help you, who can be contacted on the helpline number below:
Email: nuffieldhealth@healix.com
Monday-Friday 08.00-19.00 (Excl. bank holidays)
Saturday 09.00-13.00
Telephone calls to and from our organisation are recorded for the purposes of quality and training.
Any written correspondence should be sent to the following address:
Claims Administration Department
Healix Health Services
Healix House, Esher Green
Esher, Surrey
KT10 8AB
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide, the list of 'How to Claim' in Section 4
Active treatment
Acute condition
Annual renewal date
Benefit
Benefits
Biological therapies
Cancer
Chronic condition
Complementary practitioner
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council). <
Daycase
Dependant
- a member’s unmarried dependent children.
Dependants
- a member’s unmarried dependent children.
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Disorder
Emergency
Employer
End of life care
General practitioner
GP
High dependency unit
Home healthcare
Hospital
Private hospital - an independent hospital which can provide acute medical, surgical or psychiatric care. It must be registered under The Registered Homes Act (1984) and approved by the Healthcare Commission or any future law. It may also include a private bed in an NHS hospital.
Inpatient
Intensive care unit
Medical condition
Medically necessary
-
In accordance with professional standards of medical practice in the United Kingdom
-
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
-
Required for reasons other than the comfort or convenience of the patient or specialist
-
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition
-
Provided only for an appropriate duration of time
-
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.
<
Member
Members
Mental health condition
Outpatient
Palliative care
Partner
Physiotherapist
Pre-existing condition
-
you have received medication, advice or treatment, or
-
you have experienced symptoms whether the condition was diagnosed or not.
<
Private ambulance
Prosthesis
Psychological therapist
-
a psychologist who is either:
-
Registered with the Health and Care Professions Council (HCPC)
-
Registered with the British Psychological Society (BPS) as a chartered Psychologist.
-
a therapist who is either:
-
An accredited member of the British Association of Counselling and Psychotherapy (BACP)
-
An Accredited Member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP)
-
An Accredited Member of Scotland’s Professional Body for Counselling and Psychotherapy (COSCA)
-
A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP).
Registered nurse
Related condition
Specialist
- a medical practitioner with full current registration with the General Medical Council
-
a dentist with full current registration with the General Dental Council.
and:
-
a specialist in the treatment you are referred for (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
The scheme
Practitioner
- an occupational therapist
- an orthoptist
- a podiatrist
- a speech and language therapist
- a dietician or;
- a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number. <
Treatment
Treatments
Trust Deed
Trustee, Trustees
United Kingdom
Waiting period
We, Us, Our
You, Your
Gender Dysphoria
Gender Incongruence
High-risk activities
Scheme
Pandemic
Epidemic
Neurodevelopmental disorders
Diagnostic
- outpatient and daycase tests or investigations used to reach a diagnosis of an illness or injury
Scheme year 2024
The below changes will come into effect for the new scheme year from 1st January 2024.
| Scheme Changes | ||
|
Dependant underwriting |
Underwriting with Bupa |
Underwriting with Healix Dependants' pre-existing medical conditions/symptoms, whether or not advice has been sought, are excluded from treatment for a period of two years after the date of joining the scheme. |
|
Excess |
Excess with Bupa Rolling excess All members and dependants are liable for an excess of £100. This is a rolling excess, which means it will apply once every twelve months. This is regardless of whether the treatment is for the same condition, a related condition, or for an entirely new condition. |
Excess with Healix Annual excess All members and dependants are liable for an excess of £100, which is payable once every scheme year, if you make an eligible claim. Your excess will be applied to the first eligible treatment that you receive in each scheme year. This is regardless of when the last excess payment was made and whether the treatment is for the same condition, a related condition, or for an entirely new condition. Please contact us before you receive any treatment, so that we can advise you on when your excess will apply. |
Section 9: Glossary
The words and phrases below have the following meanings. They will appear in bold in this guide, the list of 'How to Claim' in Section 4
Active treatment
Acute condition
Annual renewal date
Benefit
Benefits
Biological therapies
Cancer
Chronic condition
Complementary practitioner
- Acupuncture practitioners must be registered with the BMAS (British Medical Acupuncture Society), BacC (British Acupuncture Council), AACP (Acupuncture Association of Chartered Physiotherapists) or AAC (The Association of Acupuncture Clinicians)
- Osteopaths must be registered with the GOsC (General Osteopathic Council)
- Chiropractors must be registered with the GCC (General Chiropractic Council). <
Daycase
Dependant
- a member’s unmarried dependent children.
Dependants
- a member’s unmarried dependent children.
Dialysis
- haemodialysis, (through the use of a kidney machine or dialyser)
- peritoneal dialysis (by introducing fluid into the abdomen to act as a filter). <
Disorder
Emergency
Employer
End of life care
General practitioner
GP
High dependency unit
Home healthcare
Hospital
Private hospital - an independent hospital which can provide acute medical, surgical or psychiatric care. It must be registered under The Registered Homes Act (1984) and approved by the Healthcare Commission or any future law. It may also include a private bed in an NHS hospital.
Inpatient
Intensive care unit
Medical condition
Medically necessary
-
In accordance with professional standards of medical practice in the United Kingdom
-
Clinically appropriate, in terms of type, frequency, extent, site and duration of treatment
-
Required for reasons other than the comfort or convenience of the patient or specialist
-
Provided at an appropriate facility, in an appropriate setting and at an appropriate level of care for the treatment of the patient’s medical condition
-
Provided only for an appropriate duration of time
-
No more costly than an alternative treatment at least as likely to produce the same therapeutic or diagnostic results.
<
Member
Members
Mental health condition
Outpatient
Palliative care
Partner
Physiotherapist
Pre-existing condition
-
you have received medication, advice or treatment, or
-
you have experienced symptoms whether the condition was diagnosed or not.
<
Private ambulance
Prosthesis
Psychological therapist
-
a psychologist who is either:
-
Registered with the Health and Care Professions Council (HCPC)
-
Registered with the British Psychological Society (BPS) as a chartered Psychologist.
-
a therapist who is either:
-
An accredited member of the British Association of Counselling and Psychotherapy (BACP)
-
An Accredited Member of the British Association for Behavioural and Cognitive Psychotherapies (BABCP)
-
An Accredited Member of Scotland’s Professional Body for Counselling and Psychotherapy (COSCA)
-
A practitioner who is registered with the United Kingdom Council for Psychotherapy (UKCP).
Registered nurse
Related condition
Specialist
- a medical practitioner with full current registration with the General Medical Council
-
a dentist with full current registration with the General Dental Council.
and:
-
a specialist in the treatment you are referred for (this is applicable to all specialities including anaesthetics and psychiatry)
-
has a certificate of Higher Specialist Training in their specialty that is issued by the Higher Specialist Training Committee of the appropriate Royal College or Faculty
-
is or has been a National Health Service consultant or dentist
-
has been recognised for benefit purposes as a specialist by Healix.
<
Start date
Surgical appliance
The scheme
Practitioner
- an occupational therapist
- an orthoptist
- a podiatrist
- a speech and language therapist
- a dietician or;
- a nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number. <
Treatment
Treatments
Trust Deed
Trustee, Trustees
United Kingdom
Waiting period
We, Us, Our
You, Your
Gender Dysphoria
Gender Incongruence
High-risk activities
Scheme
Pandemic
Epidemic
Neurodevelopmental disorders
Diagnostic
- outpatient and daycase tests or investigations used to reach a diagnosis of an illness or injury