UltraCare
10
•
you
have met all the terms and conditions of the
plan
and the
claim
is not
otherwise excluded;
•
you
have met the different terms and conditions that
we
would have
applied; and
•
it does not fall within any different exclusions that
we
would have applied.
If
we
would have provided
you
with cover under the
plan
at a higher premium,
the
benefits
payable on any
claim you
make shall be reduced proportionately
based on the amount of premium that
we
would have charged. For example, only
half of the
claim
will be paid
if
we
would have charged double the premium for
you
.
Group plans
If the
planholder
or
plan administrator
do not tell
us
all
material facts
or give
us
inaccurate or incomplete
material facts
,
we
can avoid the entire
plan
(treat it as
if it had not existed from the
start date
,
renewal date
or the date of any changes
that were made to the
plan
) if
we
would not have issued, renewed or made
changes to it, or would only have done so on different terms, if
we
had known all
of the
material facts
.
We
will not avoid the entire
plan
if
material facts
only relate to a group
plan
member
and:
•
the
planholder
or
plan administrator
had asked the
member
concerned
about these
material facts
before applying for, renewing or making
changes to the
plan
; and
•
to the best of the
planholder
or
plan administrator’s
knowledge or belief,
these
material facts
were accurate and complete.
We
will only avoid the part of the
plan
which provides
benefits
to
you
as a
member
, if
you
(or the
planholder
or
plan administrator
on
your
behalf):
•
deliberately or recklessly gave
us
inaccurate or incomplete
material facts
;
or
•
did not take reasonable care to give
us
accurate and complete
material
facts
and
we
would not have covered
you
under the
plan
at all had
we
known about such
material facts
.
We
will not avoid the part of the
plan
which provides
benefits
to
you
as a
member
, if
we
would have provided cover to
you
on different terms under the
plan
had
we
known about the
material facts
, but
we
may refuse to pay all or part
of any
claim you
make.
If
we
would have applied different terms, conditions and exclusions to
you
as a
member
, then the
plan
shall be treated as if it had contained such different terms,
conditions and exclusions and a
claim
will only be paid if:
•
you
have met all the terms and conditions of the
plan
and the
claim
is not
otherwise excluded;
•
you
have met the different terms and conditions that
we
would have
applied; and
•
it does not fall within any different exclusions that
we
would have applied.
If
we
would have provided
you
with cover under the
plan
at a higher premium,
the
benefits
payable on any
claim you
make shall be reduced proportionately
based on the amount of premium that
we
would have charged. For example, only
half of the
claim
will be paid
if
we
would have charged double the premium for
you
.
GC3
If
you
make a
claim
that
you
know is false or fraudulent,
we
will refuse the
claim
.
If any payment has already been made,
we
will recover any costs from the
planholder
.
We
will cancel cover from a date given by
us
.
GC4
We
will send all correspondence about a
plan
to the
planholder
.
GC5
When handling
your claim we
will always:
•
communicate directly with
you
if
you
are aged 18 or over;
•
communicate directly with the
main member
if
you
are under 18;
unless
you
or
your
personal representative give
us
explicit consent to contact any
other individual about
your claim
in accordance with
our
data protection policy.
GC6
If
you
need to make a
claim
,
you
must follow
your Claims
procedures and
send all the information
we
ask for as soon as possible.
GC7
If
we
ask for more information to support a
claim
, this must be provided or
your claim
may not be paid.
We
also have the right to instruct a
specialist
of
our
choice to examine
you
as often as
we
feel is necessary to support a
claim
.
GC8
If
we
reject a
claim
under a
plan
,
for any reason,
you
will have to prove that
the
claim
is covered under the
plan
.
GC9
I
f an eligible
claim
is
submitted at any time and it relates to a
plan year
for
which a no-
claims
discount was previously given, the no-
claims
discount amount
must be returned before
your claim
can be paid.
GC10
If
you
attend a
hospital
,
clinic or any other facility where direct billing or
cashless arrangements are in place, and the
claim
for this
is subsequently found
to be ineligible,
we
have the right to recover the full amount of the
claim
from
you
or the
planholder
. Payment of a
claim
is not an indication of
our
acceptance
of liability for the
claim
or confirmation that further costs for the same
medical
condition
or any
related medical condition
will be met.
GC11
If there are other insurance plans or policies that cover a
claim
, including
any reciprocal health insurance arrangements, and they have any of the same, or
equivalent
benefits
, only
our
share of the
claim
will be paid under
your plan
with
us
, after:
•
you
have paid any deductibles that apply on any of the other plans or
policies; and
•
you
have paid any
deductible
on
your plan
with
us
.
GC12
We
will not return the original
claim
documents to
you
after payment has
been made to
you
or the provider.
GC13
If more than one currency is shown on
your
Table of
benefits
, the
benefit
limit shown in the same currency as
your plans
will apply to
you
.
GC14
If the
country where you live
is in an area where
we
have to collect any
taxes,
we
will charge these on top of the premium due.
GC15
If
your area of cover
is Area 3 and
you
are a citizen of the USA,
we
will
cancel
your
cover
if
you
have spent more than 180 continuous days in the USA in
any one
plan year
.
GC16
We
can make an administration charge to replace or reissue
plan
documents or membership cards.
GC17
If there is a break in
your
cover with
us
,
for any reason,
we
can change any
plan
terms and apply any special conditions.
GC18
The
planholder
or
plan administrator
must tell
us
immediately in writing
by letter, fax or email about any proceedings or right of action against any other
party, due to any circumstances which led to a
claim
under a
plan
. The
planholder
or
plan administrator
must continue to keep
us
informed in writing and take all
steps
we
reasonably need, for
us
to take proceedings against the other party.
GC19
The
planholder
or
plan administrator
must tell
us
about any negotiations
or settlement discussions that
you
enter into with any other party about any
action which leads to a
claim
under a
plan
.
You
must not agree to a settlement
with any party before
we
give
our
written agreement.
GC20
We
are entitled to take proceedings in
your
name for
our
own benefit
to recover the costs of any eligible
claim
under a
plan
.
We
will decide how
we
handle any proceedings.
GC21
If
you
want to take legal action against
us
in respect of a
plan
,
you
must do
so within three years from the date the relevant event took place.
GC22
The
UltraCare plan
and add-on
plans
are governed by the laws of England
and Wales. Any disputes, including non-contractual disputes and claims, will be
dealt with by the exclusive jurisdiction of the courts of England and Wales.
GC23
Any translated versions of
our
documents that
we
issue are for
your
information only. In the case of any dispute or discrepancy of wording or
interpretation, the English version will apply.
Benefit conditions
BC1
All
treatment
must be given by
medical practitioners
,
specialists
,
nurses
or
therapists
with the aim to cure or substantially relieve
medical conditions
.
BC2
You
or
your
personal representative must request
pre-authorisation
for any
in-patient treatment
,
daycare treatment
, medical evacuation, compassionate
emergency
visit, or preparation or transportation of
your
body or mortal remains,
before it takes place. Once
you
or
your
personal representative have received
our
approval,
we
will settle all covered costs directly with the providers. If
you
or
your
personal representative do not receive
our
approval before it takes place,
we
will
only approve
the costs
we
would have negotiated if
we
had been involved and
given
our
approval.
BC3
Hospital
accommodation will be paid up to the cost of a standard single
room with a private bathroom. This will include
your hospital
meals.
BC4
If a local situation makes it impossible, dangerous or not practical to enter a
specific location or country,
we
may be unable to arrange a medical evacuation.
BC5
If
we
have not been given details of
your medical practitioner
on
your
