UltraCare
16
Fraud is a crime
Examples of fraud include:
•
giving false or misleading information in order to obtain insurance or a
reduction in premium;
•
claiming for
treatments
or services not received;
•
altering or amending invoices or any other documents;
•
deliberately failing to disclose previous medical history when required;
•
falsifying diagnosis;
•
claiming from more than one insurer for the same
treatment
or service;
and
•
using somebody else’s insurance to obtain
treatments
or services.
Examples of maladministration include:
•
duplicate billing;
•
incorrect billing for
treatments
or services; and
•
providing unnecessary treatments or services.
Here are some simple steps you can take to help protect
yourself and keep premiums down:
•
Compare invoices with
your
records. Check the dates are correct and the
treatments
or services were actually provided to
you
.
•
Ask questions if
you
do not understand, or if there are any discrepancies.
•
Liaise closely with
us
in the event of a
claim
.
•
Contact
us
if
you
are concerned that
your medical practitioner
is
providing
treatment
that is not necessary for
you
.
•
Carefully complete any
Claim
forms. If there is anything
you
do not
understand or are unsure of, please ask
us
.
•
Look after
your
insurance details and documentation.
•
Make sure
you
understand any documentation before
you
sign.
•
Keep copies of any documentation and correspondence.
•
Report suspected fraud to
us
.
We
are committed to protecting
you
against fraud and also have statutory
responsibilities to prevent
our
products from being used as a vehicle for financial
crime.
We
operate strict controls to deter, prevent, detect and investigate fraud.
We work closely with others to prevent fraud
We
work in conjunction with other insurance providers and the following
organisations to prevent and detect fraud;
•
Health Insurance Counter Fraud Group (HICFG);
•
International Insurance bodies;
•
International Police and Investigative agencies; and
•
Governmental departments.
Suspect fraud?
Fraud and Investigation referrals:
Fraud and Investigation Confidential telephone line:
+44 (0)1252 745 990 (ext 5990)
We
are members of the
Definitions
Abuse
– the excessive use of alcohol, drugs or any other intoxicating substance.
This includes use of drugs in a manner or in quantities other than as directed or
prescribed on medical authority or for a reason other than that for which it was
originally prescribed.
Accident
– any involuntary, sudden or unexpected event resulting in a
bodily
injury
to
you
.
Acute
– a
medical condition
that responds to
treatment
, which aims to return
you
to
your
previous state of health or leads to
your
full recovery.
Area of cover
– the geographic area of the world in which
your plan
applies. This
is shown on
your
Certificate of Insurance.
Benefit
– the cover provided by
your plan
and any extensions or restrictions
shown in
your Plan
guide, Certificate of insurance or Table of
benefits
.
Birth defect
– any deformity, abnormality or disability caused during childbirth.
Bodily injury
– any physical harm or damage to
you
.
Business colleague
– an associate who is employed by the same company as
you
.
Card
– Visa debit, Visa credit or MasterCard.
Chronic
– a
medical condition
that has one or more of the following
characteristics:
•
needs ongoing or long-term monitoring through consultations,
examinations, checkups or tests;
•
needs ongoing or long-term control or relief of symptoms;
•
needs rehabilitation or special training to cope with it;
•
continues indefinitely;
•
has no known cure;
•
comes back or is likely to come back.
Claim
– when
you
or
your
agent, personal representative, assignee or trustee in
bankruptcy seek payment or settlement under the terms and conditions of the
plan
.
Close family member
– a son, daughter, stepson, stepdaughter, legally adopted
son, legally adopted daughter, husband, wife, partner, parent, step-parent, legally
adoptive parent, parent-in-law, grandparent, grandchild, brother, sister, brother-in-
law, sister-in-law, son-in-law, daughter-in-law or legal guardian.
Co-insurance
– the percentage of costs that
you
must pay for a covered
claim
.
Congenital abnormality
– a
medical condition
that is present at birth or is
believed to have been present since birth, whether it is
inherited
or caused by an
environmental factor.
Consequential loss
– any costs
you
must pay that may be associated with a
claim
, but are not covered under a
plan
.
For example, loss of earnings as a result
of a
medical condition
.
Continuation of Personal Medical Exclusions
– continuation of the same
underwriting terms, including any special exclusions, that applied to
you
with
a previous insurer. The underwriting terms with
us
can be
CPME previously
moratorium
or
CPME previously FMU
.
You
will not be subject to any new
personal underwriting terms. Cover will still be governed by the
benefits
, terms
and conditions of
your plan
with
us
. See the ‘Transfers’ or ‘Group member
transfers’ section and the
CPME previously moratorium
and
CPME previously
FMU
definitions in this
Plan
guide for more information.
Country where you live
,
country where a member lives
– the country
you
live in
for most of the time, usually for a period of at least six months during a
plan year
.
CPME
– see
Continuation of Personal Medical Exclusions
CPME previously FMU
– continuation of
your
full medical underwriting terms
with a previous insurer.
You
will not be subject to any new personal underwriting
terms. Cover will still be governed by the
benefits
, terms and conditions of
your
plan
with
us
, including
benefit
exclusion BE2.
Benefit
exclusion BE1 will not
apply.
CPME previously moratorium
– continuation of
your
moratorium start date if
you
had moratorium underwriting terms with a previous insurer.
You
will not
be subject to any new personal underwriting terms. Cover will still be governed
by the
benefits
, terms and conditions of
your plan
with
us
, including
benefit
exclusion BE1.
Benefit
exclusion BE2 will not apply.
Critical
– a
medical condition
that is unstable and serious, where the outcome
cannot be medically predicted, prognosis is uncertain and the person may die.
Curtailed
,
curtailment
–
you
abandon a
trip
.
