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Good4you Health Plan - Benefit rules

Full details of each benefit is listed on this page. Cover is subject to the General Terms and Conditions specified in the policy summary. Where words or phrases appear in bold type, they have the special meaning for the purposes of the plan.

If there is anything about these benefit rules that you don’t understand please contact our Customer Helpline on 0114 250 2000 and we will be happy to help.

OPTICAL

Your maximum benefit is available over a two year benefit period. You have a separate allowance for dependent children – the maximum benefit is available over a two year benefit period and is shared between all your dependent children.

When...

• you pay an Optician and
• you submit your claim in accordance with section 7, General Terms and Conditions

We will cover...

• 100% of the cost, up to the maximum for your plan level, see Table of Benefits
• eyesight tests
• prescription spectacles, sunglasses and/or contact lenses
• prescription lenses to an existing frame
• payments that you make for prescription contact lenses supplied under a monthly scheme, when you obtain an itemised receipt

We will not cover...

• repairs to frames
• frames purchased without prescription lenses
• non-prescription spectacles or sunglasses or contact lenses
• solutions for contact lenses
• any insurance or peace of mind guarantee
• sundry items
• missed appointment fees
• exclusions (see section 5, General Terms and Conditions)

DENTAL

Your maximum benefit is available over a one year benefit period. You have a separate allowance for dependent children – the maximum benefit is available over a one year benefit period and is shared between all your dependent children.

When...

• you pay a Dentist and
• you submit your claim in accordance with section 7, General Terms and Conditions

We will cover...

• 100% of the cost, up to the maximum for your plan level, see Table of Benefits
• dental treatment, full* or partial dentures and dental check-ups

We will not cover...

• insurance or dental care scheme premiums, registration or administration fees
• dental treatment as a result of an accident (see Dental Trauma benefit)
• teeth whitening
• prescription charges
• sundry items
• missed appointment fees
• exclusions (see section 5, General Terms and Conditions)

*Full Dentures

If you need full dentures (either a full upper set, full lower set or both) you can claim up to double the maximum Dental Benefit, but this allowance will be available over a two year benefit period. Your receipt must confirm that full dentures have been supplied. Once you have made a claim for full dentures, all subsequent benefit periods for dental or denture claims will then also be assessed over a two year benefit period. If you do not claim the maximum benefit on the first claim you submit for dentures, any remaining balance may be used, within the two year benefit period, for claims for either dental treatment or dentures.

DENTAL TRAUMA

Your maximum benefit is available over a one year benefit period. You have a separate allowance for dependent children – the maximum benefit is available over a one year benefit period and is shared between all your dependent children.

When...

• you pay a Dentist for treatment carried out as a result of accidental injury to teeth, caused by direct external impact to the head e.g. sports injuries, falls, or other accidents that cause injury by external force and
• the dentist’s receipt specifically confirms treatment is a consequence of an accidental injury and
• you give us details of the accident, which must have occurred after you applied for the plan and
• you submit your claim in accordance with section 7, General Terms and Conditions

We will cover...

• 100% of the cost, up to the maximum for your plan level, see Table of Benefits
• dental treatment directly related to the accidental injury

We will not cover...

• any payment made more than 24 months after the date of the accident
• any insurance or dental care scheme premiums
• prescription charges
• sundry items
• missed appointment fees
• exclusions (see section 5, General Terms and Conditions)

CONSULTATION

Your maximum benefit allowance is available over a one year benefit period. You can use your benefit allowance for yourself, your partner and/or your dependent children.

When...

• your GP recommends referral to a Consultant Physician or Consultant Surgeon and
• you pay a registered Consultant Physician or Consultant Surgeon, who holds an appropriate qualification (see Definitions section) and
• you submit your claim in accordance with section 7, General Terms and Conditions

We will cover...

• 100% of the cost on level 5 and 75% on levels 1,2,3 or 4, up to the maximum for your plan level, see Table of Benefits
• diagnostic consultations on all levels of the plan
• payments you make to a Consultant Physician or Consultant Surgeon for treatment on levels 3, 4 or 5 of the plan

We will not cover...

• treatment on levels 1 or 2 of the plan
• consultations or treatment relating to vasectomy or sterilisation (including reversal)
• consultation or treatment relating to cosmetic surgery
• medical examinations, consultations or reports for the purpose of your employment, legal, or insurance reasons
• room fees, nursing charges, prescription items/charges or sundry items
• missed appointment fees
• exclusions (see section 5, General Terms and Conditions)

PHYSIOTHERAPY, ACUPUNCTURE, OSTEOPATHY AND CHIROPRACTIC

Your maximum benefit allowance is available over a one year benefit period and represents the total for any one or combination of treatment types.

When...

• your GP or Consultant Physician/Consultant Surgeon recommends that you receive treatment. If requested at anytime, you must provide us with written evidence of this recommendation at your own expense and
• you receive and pay for treatment from a registered Physiotherapist or an Acupuncturist, Chiropractor or Osteopath who is a member of an approved professional organisation, relevant to the treatment that they are providing (see Definitions section) and
• you submit your claim in accordance with section 7, General Terms and Conditions

We will cover...

• 100% of the cost on level 5 and 75% on levels 1,2,3 or 4, up to the maximum for your plan level, see Table of Benefits
• physiotherapy, acupuncture, chiropractic, osteopathy treatment

We will not cover...

• any treatment that is not physiotherapy, acupuncture, chiropractic or osteopathy
• scans e.g. MRI. (See Consultation benefit)
• sundry items
• missed appointment fees
• herbs, herbal remedies, supplements or vitamins even if these have been recommended or supplied by your Physiotherapist, Acupuncturist, Chiropractor or Osteopath
• exclusions (see section 5, General Terms and Conditions)

HOMEOPATHY

Your maximum benefit allowance is available over a one year benefit period.

When...

• your GP or Consultant Physician/Consultant Surgeon recommends that you receive treatment and
• you receive and pay for treatment from a Homeopath who is a member of an approved professional organisation, relevant to the treatment that they are providing (see Definitions section) and
• you submit your claim in accordance with section 7, General Terms and Conditions

We will cover...

• 100% of the cost on level 5 and 75% on levels 1,2,3 or 4, up to the maximum for your plan level, see Table of Benefits
• homeopathic consultations and treatment
• homeopathic prescriptions supplied by a Homeopath as part of a consultation

We will not cover...

• any treatment that is not homeopathy
• herbs, herbal remedies, supplements or vitamins even if these have been recommended or supplied by your Homeopath
• sundry items
• missed appointment fees
• exclusions (see section 5, General Terms and Conditions)

CHIROPODY

Your maximum benefit allowance is available over a one year benefit period.

When...

• you receive and pay for treatment from a registered Chiropodist/Podiatrist (see Definitions section) and
• you submit your claim in accordance with section 7, General Terms and Conditions

We will cover...

• 100% of the cost on level 5 and 75% on levels 1,2,3 or 4, up to the maximum for your plan level, see Table of Benefits
• chiropody and podiatry consultations, assessments and treatment

We will not cover...

• any treatment that is not chiropody or podiatry
• sundry items
• missed appointment fees
• exclusions (see section 5, General Terms and Conditions)

HOME CARE

Your maximum benefit allowance is available over a one year benefit period. You can use your benefit allowance for yourself and/or your partner.

When...

• your local authority has carried out a full needs assessment and
• you are required to pay a contribution to your local authority towards the package of care that they have commissioned* and
• you provide us with evidence of this by sending us a copy of your current Care Plan and
• you submit your claim in accordance with section 7, General Terms and Conditions

We will cover...

• 100% of the cost on level 5 and 75% on levels 1,2,3 or 4, up to the maximum for your plan level, see Table of Benefits
• payments that you have made towards the Home Care detailed on your Care Plan

We will not cover...

• services or additional hours not detailed on your Care Plan
• exclusions (see section 5, General Terms and Conditions)

*If you have opted for Local Authority Direct Payment we will only pay you towards the contribution you are required to pay for the Home Care as detailed on your current Care Plan. You must provide us with a copy of your current Care Plan, proof of your assessed contribution, details of local authority payments to you and a fully itemised receipt from the service provider with each claim.

SURGICAL APPLIANCE

Your maximum benefit allowance is available over a one year benefit period.

When...

• you pay for an appliance prescribed by your GP, Consultant Physician/Consultant Surgeon, Chiropodist/ Podiatrist, Physiotherapist, Acupuncturist, Chiropractor or Osteopath and
• you provide us with evidence that the appliance was prescribed for your use and
• you submit your claim in accordance with section 7, General Terms and Conditions

We will cover...

• 100% of the cost on level 5 and 75% on levels 1,2,3 or 4, up to the maximum for your plan level, see Table of Benefits
• hearing aids (including repairs); surgical supports (including hosiery); surgical shoes (custom-made for your specific medical needs); orthotics; wigs; mastectomy bras

We will not cover...

• any item not specifically listed above
• hearing aid batteries
• exclusions (see section 5, General Terms and Conditions)

HEALTH SCREENING

Your maximum benefit allowance is available over a two year benefit period.

When...

• you pay for and receive a health screening check and
• the screening check is carried out by medically qualified staff and
• you submit your claim in accordance with section 7, General Terms and Conditions

We will cover...

• 100% of the cost on level 5 and 75% on level 4, up to the maximum for your plan level, see Table of Benefits
• full health screening; well-woman screening; well-man screening; breast screening; heart disease screening; bone density screening*

We will not cover...

• any other screening check or test not carried out as part of one of those listed above
• any health screening check, medical examination, consultation or report for the purpose of your employment, legal or insurance reasons
• missed appointment fees
• exclusions (see section 5, General Terms and Conditions)

* For a bone density screening check, you must supply evidence that it has been specifically recommended by your GP.

IN-PATIENT

Your benefit is payable for a maximum of 30 nights in a one year benefit period. Each of your dependent children has a maximum allowance of 30 nights in a one year benefit period.

When...

• you are admitted as an in-patient to an NHS or private hospital, registered treatment centre or hospice and
• you submit your claim in accordance with section 7, General Terms and Conditions

We will cover...

• you at the nightly rate for your plan level, see Table of Benefits
• overnight in-patient admissions for treatment, tests or investigations
• maternity related in-patient admissions, from the 11th night that you have been an in-patient. You must give us evidence of the first 10 nights that you have spent in hospital (these nights do not have to be consecutive)
• a dependent child required to remain in hospital following its birth, from the date that the mother is discharged
• claims submitted when the patient is discharged, or after 30 nights in-patient stay

We will not cover...

• maternity related admissions for the first ten nights
• any type of in-patient admission where the hospital could be regarded as your permanent residence
• admissions for rehabilitation, domestic reasons or respite care
• exclusions (see section 5, General Terms and Conditions)

RECUPERATION

Your benefit is payable once in a two year benefit period. Benefit is payable once per dependent child in a two year benefit period.

When...

• you are discharged following an in-patient stay of 14 or more consecutive nights and
• you are entitled to claim In-patient benefit for those nights and
• you submit your claim in accordance with section 7, General Terms and Conditions

We will cover...

• you at the rate for your plan level, see Table of Benefits
• you for Recuperation benefit in addition to In-patient Benefit

We will not cover...

• you if you are not discharged
• exclusions (see section 5, General Terms and Conditions)

DAY SURGERY

Your benefit is payable for a maximum of 10 days in a one year benefit period. Each of your dependent children has a maximum allowance of 10 days in a one year benefit period.

When...

• you are admitted to an NHS or private hospital or registered treatment centre as a day case patient and
• you are required to sign a consent form and are allocated a bed – the use of which is normally for a period of supervised recovery and
• you undergo a surgical procedure involving the use of theatre facilities and
• you submit your claim in accordance with section 7, General Terms and Conditions

We will cover...

• you at the daily rate for your plan level, see Table of Benefits

We will not cover...

• out-patient attendances, including procedures carried out in an out-patient setting
• tests or investigations e.g. biopsies and endoscopies carried out for investigative purposes only
• attendances at a GP or Dental surgery
• attendances immediately prior to or following an overnight stay for which a claim is payable under In-patient benefit
• exclusions (see section 5, General Terms and Conditions)

MATERNITY

Benefit(s) are payable once in a one year benefit period.

When...

• you are named as mother or father on the child’s full birth certificate, or you are named on the legal adoption papers and
• you submit your claim in accordance with section 7, General Terms and Conditions

We will cover...

• you at the rate for your plan level, see Table of Benefits
• single or multiple births, benefit is payable per child
• adoptions finalised before the child’s third birthday
• stillbirths when you send us the stillbirth certificate

We will not cover...

• exclusions (see section 5, General Terms and Conditions)

GP TELEPHONE CONSULTATION

Available on all levels of the plan.

The GP Telephone Consultation service is provided on behalf of Westfield Health by Medical Solutions UK Ltd., 44 Finchampstead Road, Wokingham, Berkshire RG40 2NN.

The GP Telephone Consultation service provides you and family members normally resident with you, with access to telephone consultations with a GP, 24 Hours a day – every day. By arrangement you will be telephoned by a qualified practising GP, at a time convenient to you. There is no limit to the duration of the telephone consultation or number of times that you can use the service.

The service gives you the reassurance of speedy access to completely confidential telephone advice from a GP whenever you need it. Because the consultation is carried out by a fully qualified GP, who will take into account your personal medical history, the Doctor will in many cases be able to provide a diagnosis of your symptoms and recommend an appropriate course of action. With your consent a report of the telephone consultation can be forwarded to your GP within 2 working days, if required. If you wish to seek further information about a medical condition or proposed course of treatment the GP can discuss all areas relating to health from surgical procedures, diseases, injuries and prescription medicines to new treatments, foreign travel, exercise and nutrition.

If you would like to arrange a telephone consultation, simply call the GP Telephone Consultation service on 08456 123 861* from the UK or if calling from overseas on 44 (0) 118 936 5633*. To confirm your eligibility to use the service you will be asked for the policyholder’s Westfield account number. An experienced healthcare operator will request some preliminary information regarding the nature of your enquiry before booking an appointment for a GP to call you back, even if you are temporarily outside the UK. You will only pay the cost of the initial telephone call to book the consultation.**

This is not an emergency service. The GP Telephone Consultation service is not intended to replace the personal care offered by your own Doctor and cannot be used to obtain a referral for treatment that can be claimed under the plan.

* For your protection calls will be recorded. Please be assured that all consultations remain confidential.

** Your network provider may charge for a call received to your mobile telephone while you are overseas.

HEALTH CLUB CONCESSION

For the policyholder on all levels of the plan.

This service is provided on behalf of Westfield Health by roadtohealth Ltd., PO Box 2877, Eastbourne, East Sussex BN22 0WD.

We believe in the importance of promoting good health and wellbeing. This service provides access to a national network of health clubs who will offer you membership at a concessionary rate. By constantly updating the offers available the service aims to find you the very best health club membership deal in your area. Even if there are presently no health clubs within 15 miles of your home or workplace able to offer you a concession, the service will endeavour to locate a club willing to participate in the scheme.

For information on the range of health club deals currently available to you log on to www.westfieldhealth.com and go to the policyholder section then simply follow the instructions on the screen. Alternatively you can telephone 0845 123 5327*.

Once you have selected your preferred deal a voucher, that contains all the necessary information for you to present to the health club of your choice, will be e-mailed to you immediately. If you choose to register by telephone the voucher will be posted to you.

*Available Monday to Friday 9.00am – 5.30pm (except public holidays).

24 HOUR COUNSELLING AND ADVICE LINE

Available on all levels of the plan.

The 24 Hour Counselling and Advice Line is provided on behalf of Westfield Health by First Assist Group Ltd., Wheatfield Way, Hinckley, Leicestershire LE10 1YG.

The 24 Hour Counselling and Advice Line provides around the clock access for you, and your family normally resident with you, to specialist teams of qualified and experienced counsellors, lawyers and medical staff.

A serious accident or ill health can result in problems such as stress, absence from work, debt, relationship difficulties, bereavement or coming to terms with a continuing disability. In addition the medical team can provide help and advice on a wide range of medical issues, problems or queries. The teams of counsellors, lawyers and medical staff are on hand to help you address both the emotional implications of such matters and also to advise you on any legal remedies you may have following an accident and any welfare benefits you may be entitled to. Whatever the problem you are free to talk to a counsellor, lawyer or medical advisor at any time of the day or night in complete confidence. No information relating to your call is released to any other person and you can remain anonymous when using the service. By prior arrangement the same counsellor, lawyer or medical advisor will speak with you on any subsequent occasion.

Please note, the Medical Helpline provides general guidance only and does not intend to detract from or substitute your normal personal medical care. This is not an emergency service and will not provide diagnosis or prescribe treatments.

To contact the 24 Hour Counselling and Advice Line, simply Freephone* 0800 092 0987. You will need to quote the special Scheme number supplied in the policyholder’s Welcome Pack, or that can be obtained from the Westfield Customer Helpline. This number confirms your eligibility to use the service and does not in any way identify you as an individual.

In addition, you can access a wide range of health information by logging on to the My Westfield section of our website and simply following the instructions on the screen to browse through our essential guide to everything you need to know about your health. Topics include an A-Z of medical conditions, first aid, diet and nutrition, health while travelling abroad and much more.

*Call charges may apply from some networks.

A-Z HEALTH SITE

The A-Z Health Site is provided on behalf of Westfield Health by Fist Assist Group Ltd, Wheatfield Way, Hinckley, Leicestershire, LE10 1YG.

You and your family normally resident with you, can access a wide range of health information at our A-Z Health Site by logging onto www.westfieldhealth.com. First go to the Policyholders section and simply click on A-Z Health Site, you will be asked to enter your name and Westfield Health account number.

PERSONAL ACCIDENT COVER

For the policyholder on levels 3,4 and 5 only.

For the Personal Accident cover, Westfield Contributory Health Scheme Ltd., Westfield House, 87 Division Street, Sheffield S1 1HT is an intermediary acting on your behalf dealing exclusively with ACE European Group Limited (ACE) – a provider of Accident and Health insurance, whose registered office is at ACE Building, 100 Leadenhall Street, London EC3A 3BP. Authorised and regulated by the Financial Services Authority (FSA). Registration number FRN202803.

Full details can be found on the FSA’s Register by visiting http://www.fsa.gov.uk/register or by contacting the FSA on 0845 606 1234.

If you suffer Bodily Injury as a direct result of an Accident which within twenty four months of the Accident results in death or disablement, benefit will be paid in accordance with the scale outlined below.

		LEVEL 5	LEVEL 4	LEVEL 3
1	Death as a result of an Accident	£50,000	£25,000	£15,000
2	Permanent Total Disablement	£50,000	£25,000	£15,000
3	Permanent and incurable paralysis of all limbs £	£50,000	£25,000	£15,000
4	Permanent and incurable insanity	£50,000	£25,000	£15,000
5	Total Loss of Sight in both eyes	£50,000	£25,000	£15,000
6	The permanent and total Loss of both hands or feet	£50,000	£25,000	£15,000
7	Total Loss of Sight in one eye	£25,000	£12,500	£7,500
8	Permanent and total Loss of one hand or one foot	£25,000	£12,500	£7,500
9	Permanent and total loss of hearing in: both ears one ear	£25,000 £7,500	£12,500 £3,75	£7,500 £2,250
10	Permanent and total loss of the lens of one eye	£12,500	£6,250	£3,750
11	Permanent and total Loss of four fingers and thumb of either hand	£20,000	£10,000	£6,000
12	Permanent and total Loss of four fingers of either hand	£10,000	£5,000	£3,000
13	Permanent and total Loss of one thumb of either hand: both joints one joint	£10,000 £5,000	£5,000 £2,500	£3,000 £1,500
14	Permanent and total Loss of fingers on either hand: three joints two joints one joint	£2,500 £1,750 £1,000	£1,250 £875 £500	£750 £525 £300
15	Permanent and total Loss of toes: all – one foot big – both joints big – one joint other than big, each toe	£7,500 £2,500 £1,000 £1,000	£3,750 £1,250 £500 £500	£2,250 £750 £300 £300
16	Established non-union of fractured leg or kneecap	£5,000	£2,500	£1,500
17	Shortening of leg by at least 5cm in full	£3,750	£1,875	£1,125

Note

1. ACE will not pay you more than the amounts shown in the table for Permanent Total Disablement as a result of any one Accident.
2. If ACE pay you compensation for permanent total Loss of use of a whole limb, then you cannot claim for parts of that limb.
3. ACE will not pay the Permanent Total Disablement benefit if you are 75 or over.
4. ACE will take account of any disability or condition you already had when they assess the amount of disablement benefit they will pay as a result of a subsequent Accident.
5. ACE will only pay the Personal Accident Benefit if at the time of the Accident you were registered as a current policyholder on levels 3,4 or 5.
6. This benefit does not apply to dependent children.
7. Payment for any Permanent Disability not shown in the table will be based on a medical assessment of your disability in relation to the table and not in relation to your ability to work.

Exclusions

ACE shall not be liable in respect of Bodily Injury resulting directly or indirectly from or contributed to by:

1. War, whether declared or not, between any of the following countries – France, United Kingdom, Peoples Republic of China, Former Constituents of the Union of Soviet Socialist Republics, and the United States of America, or war in Europe, whether declared or not (other than civil war, but including any enforcement action by or on behalf of the United Nations), in which any of those countries or armed forces thereof are engaged. This exclusion shall be inoperative in the event of war being declared whilst you are actually engaged on a journey outside your country of residence. ACE may cancel insurance hereunder in respect of war, invasion, act of foreign enemy, hostilities (whether war be declared or not), civil war, rebellion, insurrection, military or usurped power by sending 48 hours notice to Westfield at their last known address. Insurance in respect of a journey involving travel outside your country of residence which had been commenced before the expiry of such notice shall not be affected thereby.
2. Intentional self-injury, suicide or any attempt thereat.
3. Your engaging in any form of aerial flight other than as a passenger.
4. Your suffering from sickness or disease not resulting from Bodily Injury.

Termination of Cover

The Personal Accident Cover shall terminate immediately on the earliest of the following dates:

1. the date payment of benefit is made to you or your personal representative under any one of injuries 1 to 6 of the scale of benefits outlined on page 17.
2. the date you cease to be a current policyholder on Good4you Plan levels 3,4 or 5.