Terms & Conditions: Company Plans

No nonsense Terms & Conditions of your Company LHF Healthplan.

General enquiries

0800 056 0366

We aim to make information about us accessible to you, whatever your needs. Information is available in large print or audio. Please call us if we can help in any other way.

It's just common sense.

LHF helps you get money back towards everyday healthcare treatments. This document lays out the terms and conditions of your plan. As a Member they bind you whether or not you have signed an application form or other document.

Please read them carefully and keep them in a safe place for future reference. If you have any questions about these terms and conditions, please contact Customer Services on 0800 056 0366.

The individual treatments you are entitled to claim for and the level of Cover you can receive are shown on your Summary of Cover leaflet.

Please make sure you check this table when you make a claim. Remember you can claim as many times each year as you need, up to the maximum yearly level for each treatment.

Plus, there is no need to wait. You can claim straight away for treatments (with the exception of Maternity and Funeral Cover which carry a 50 week qualifying period).

If you have any questions about your plan, treatments that are Covered, or the amounts you can claim, just call us on the number above.

Changing Your Mind

You have 14 days from receipt of your welcome letter, which confirms commencement of your policy, in which to change your mind and receive a full refund of any premiums you have paid, provided no claims have been made. If you do change your mind, please call 0800 056 0366 or write to the Customer Services Team Leader at LHF, Riverside House, 7 Canal Wharf, Leeds, LS11 5WA and we will cancel your policy for you.

A Fair Approach

LHF has no shareholders and exists solely for the benefit of our Members. We believe that everyone should benefit from sensible, everyday healthcare and we aim to help our Members get the most out of our healthplans.

For most of our products LHF offers healthplans at the same price for all of our Members, regardless of their age or individual circumstances. To make sure that we can continue to keep our prices affordable and maximise the level of Cover, LHF must always consider how we can best serve all of our Members. To remain strong for our Members now and in the future, there is a requirement for you to use the healthplan responsibly.

Healthplans are designed to help you pay for the costs of routine check ups, treatments and to regain good health. They are not intended to be used as a source of income and Members must not make fraudulent or unnecessary claims, as this will reduce what we are able to pay out for those in genuine need. We want to establish an honest, open and sustainable relationship with all of our Members that is regarded as fair.

This means that periodically LHF will review our claims records, to identify Members whose claims are much higher than usual or where we suspect fraudulent or inappropriate behaviours. This may necessitate a request for further information from these Members. Having taken this information into account, we may decide to offer an alternative plan or not to continue providing Cover. Such a decision will only be made where we believe that it is in the best interests of the majority of our Members to do so. Where we take such action we will ensure Members receive at least one month's notice.

Please check your Summary of Cover leaflet to see what Cover you are entitled to.

Pre-existing medical conditions are not covered by these benefits, this applies to all benefits excluding Dental and Optical.

Dental

We will pay you the full cost of dental treatment fees that are paid by you directly to the Dental Professional, up to the appropriate maximum entitlement of your plan.

What is Covered

Treatment provided by a Dental Professional registered with the General Dental Council (GDC)
Dental check—up.
Hygienist fees.
Fees paid to dentists for private treatment including dental crowns, dentures, bridges and white fillings, braces etc.
X—rays.

What is not Covered

Treatment provided by Dental Professionals not registered with the General Dental Council (GDC)
Dental prescription charges.
Sundry items including toothbrushes, mouthwash, dental floss etc.
Dental Insurance Premiums or dental care schemes.
Dental veneers.
Missed appointment fees or administration fees.
No qualifying period. Time limit for claiming — 13 weeks from the date of treatment.

Optical

We will pay you the full cost of optical treatment fees that are paid by you directly to the Optician, up to the appropriate maximum entitlement of your plan.

What is Covered

Treatment by a qualified optician.
Sight tests.
Prescribed glasses including frames and prescribed lenses.
Addition of new prescribed lenses to existing frames.
Fitting fees.
Eye laser surgery (excludes consultation).
New spectacle frames/repairs to frames.
Contact lenses including those paid by instalment (please submit your claim when the total fees are equal to the maximum benefit offered).
Sunglasses, safety spectacles and swimming goggles with prescription lenses.

What is not Covered

Optical sundry items i.e. solutions, tints, spectacle cases, spectacle chains/cords etc.
Non—prescription glasses.
Lenses supplied under an optical insurance plan.
Contact lens replacement insurance premiums.
Optician's insurance premiums.
Visual field tests, retinal scans and glaucoma tests.
Dyslexia and colour blindness tests.
Frames which have not been purchased from an opticians.
No qualifying period. Time limit for claiming — 13 weeks from the date of treatment.

Physiotherapy, Acupuncture, Osteopathy, Chiropractic Treatment

We will pay you up to the appropriate maximum entitlement of your plan for treatment you receive directly from a Physiotherapist, Acupuncturist, Osteopath or Chiropractor.

What is Covered

Physiotherapy, Acupuncture, Osteopathic or Chiropractic treatment supplied by a professional registered with an organisation recognised by LHF, which includes those as detailed below:
Physiotherapy — Registered with the Health Professionals Council (HPC).
Osteopathy — General Osteopathic Council (GOsC).
Chiropractic — General Chiropractic Council (GCC).
Acupuncture — British Acupuncture Council (MBAcC) or The British Medical Acupuncture Society (BMAS) or The Modern Acupuncture Association.

What is not Covered

Any treatment supplied by a professional who is not registered with the appropriate professional body to provide Physiotherapy, Acupuncture, Osteopathic or Chiropractic treatment.
All other treatments i.e. Aromatherapy, Herbalism, Sports Massage, Indian Head Massage, Reiki, Alexander Technique, Cranial—Sacro Therapy etc.
MRI Scan, CT Scan etc.
Appliances such as lumber roll, spinal pillows/cushions, "self—help" books, flexiband, tape etc.
No qualifying period. Time limit for claiming — 13 weeks from the date of treatment.

Chiropody, Podiatry Treatment

We will pay you up to the appropriate maximum entitlement of your plan for treatment you receive directly from a Chiropodist or Podiatrist.

What is Covered

Treatment supplied by a professional Chiropodist or Podiatrist registered with the Health Professionals Council (HPC).

What is not Covered

Cosmetic pedicures.
X—rays.
Sundry items i.e. corn plasters, insoles, dressings etc.
Assessments e.g. gait analysis.
Chiropody or Podiatric consultations where treatment is not provided.
No qualifying period. Time limit for claiming — 13 weeks from the date of treatment.

Maternity/Paternity and Adoption Grant

We will pay you a single payment at the appropriate rate under your chosen plan in respect of each child born to or adopted by the member providing that the 50 week qualifying period has been completed.

What is Covered

The birth of a child to the member (upon production of a copy of a Birth Certificate).
The birth of a child stillborn after 24 weeks gestation (upon submission of a stillbirth certificate).
Adoption of a child (upon submission of relevant supporting documentation) who is under the age of 5.

What is not Covered

A miscarriage of up to 24 weeks gestation.
Foster children.
Pregnancy termination.
A baby born to a child Covered under your plan.

Qualifying Period — 50 Weeks. Time limit for claiming — 13 weeks from child's/children's date of birth or issue of adoption papers

Family Plan — This benefit is only paid on the first named person on the policy

Health Screening

We will pay you up to the appropriate maximum entitlement of your plan for health screening services.

What is Covered

Full body health screening undertaken for prevention purposes by medically qualified staff at a hospital or registered health screening clinic.

What is not Covered

Medical examinations.
Medical and radiological tests in isolation including but not limited to X—rays, scans, ultrasounds, cholesterol and blood tests, diagnostic procedures and tests.
Home testing kits.
Medical screening for employment purposes.

No qualifying period. Time limit for claiming — 13 weeks from the date of screening.

Consultation Fees

We will pay you up to the appropriate maximum entitlement of your plan in respect of the fee for a diagnostic consultation, which you have paid directly to a medically qualified Specialist, Consultant or Surgeon.

What is Covered

A diagnostic consultation undertaken by a Physician or Surgeon with consultancy status at a hospital, including follow—up tests by a medically qualified specialist that has been recommended at the consultation.
IVF consultation.

What is not Covered

Tests and treatment charges in isolation.
Operation fees and fixed price medical procedures.
Medical examinations and reports.
Private hospital charges including room fees etc.
Laser eye consultations.
Visits to clinics.
X—rays including mammograms, CT scans, ultrasounds and MRI scans etc.
Fees for investigative procedures i.e. colonoscopy, laparoscopy, colposcopy, sigmoidoscopy etc.
Pathology and biopsy.
Haematology and biochemistry directly connected to a diagnostic consultation.
Medical tests for example ECG, EEG, lung function test etc.
Anaesthetic fees.
Dietician/nutritional services.
Speech therapy and dyslexia services.

No qualifying period. Time limit for claiming — 13 weeks from the date of final consultation.

X—ray/Scan

We will pay you up to the appropriate maximum entitlement of your plan for X—ray/Scan services.

What is Covered

X—ray and Scanner examinations that have been undertaken following a referral of a Consultant.

What is not Covered

Dental X—rays (as these are covered under the Dental Benefit).
MRI, PET & CT Scans.

No qualifying period. Time limit for claiming — 13 weeks from the date of X—ray/Scan.

Hospital in—Patient

We will pay you at the appropriate rate under your plan for each overnight stay when you are admitted for in—patient treatment in an NHS hospital or private hospital offering the same facilities. (See additional notes below).

What is Covered

Any period of overnight stay in an NHS or private hospital for treatment or investigation of an acute or chronic medical condition, which developed since you joined LHF.
Any overnight stay where you are admitted for in—patient treatment in an NHS hospital or private hospital offering the same facilities after an emergency accident admission.

What is not Covered

Any period of overnight stay in an NHS or private hospital for treatment of a Pre-existing condition.
Any Maternity related admissions do not attract payment for the first 5 nights.
Respite care.
Private nursing/residential homes.
Out—patient treatment.
Attendance at an Accident and Emergency Department.
Hospital Day Case admission (see Day Surgery).
Your partner if they are not a member.

No qualifying period. Time limit for claiming — 13 weeks from the date of discharge.

Additional Notes — Hospital Related Benefits

1. There is a maximum number of nights (see Summary of Cover leaflet for maximum number of nights) in the claiming year which applies to any combination of the following benefits; Hospital in—Patient and Hospital Accident Admission benefit.
2. Your claim form must be completed by the hospital with details of your admission and authorised by a hospital officer.

Day Surgery

We will pay you at the appropriate rate under your plan when you are admitted as a Day Case patient for treatment in an NHS hospital or private hospital offering the same facilities.

What is Covered

Admission as a day patient to an NHS or private hospital for either scheduled surgery or invasive investigative procedures, classified on the claim form by the Hospital Authority.

What is not Covered

The period immediately prior to or following an overnight in—patient stay for which payment has been made under Hospital in—Patient Benefit.
Out—patient appointments including treatment for chemotherapy, radiotherapy, oncology and kidney dialysis.
Out—patient treatment for day care, including psychiatric care, respite care, care for the elderly and maternity.
Cancelled operations.
Minor operations carried out in a GP's Surgery or Clinic.
Attendance at an Accident and Emergency Department.
No qualifying period. Time limit for claiming — 13 weeks from the date of discharge.

Parental Stay

We will pay for one parent only at the appropriate nightly rate when you have accompanied your Child (who is covered under your policy) who has been admitted as an in—patient overnight in an NHS hospital or private hospital offering the same facilities.

What is Covered

Any period of overnight stay in a NHS or Private Hospital from 1 to 10 nights where one parent has accompanied their Child.
Adoptive parent accompanying their Child (where the Child is registered under the policy).

What is not Covered

More than one parent accompanying their Child.
A grandparent or other relative accompanying the Child.
The Post Natal period following the birth of a Child.

No qualifying period. Time limit for claiming — 13 weeks from the date of discharge.

Your claim form must be completed by the hospital with details of your child's admission and authorised by a hospital officer.

Funeral Expenses (One Adult policies only — not applicable to the Family Plan)

We will pay up to the appropriate maximum entitlement of your plan towards funeral costs.

What is Covered

Cremation fees.
Medical certificates.
Fees of officiating Ministers for the service, Cremation or Burial.
Hearse or funeral car(s).
Coffin with fittings.
Preparation of the deceased for Cremation or Burial.
Services of the Funeral Directors' staff.

What is not Covered

Funeral charges that have been fully Covered by a pre—paid funeral plan, bond or specific saving plan.
Headstones.
Notice of death placed in the press.
Catering costs.
Floral tributes.

How to claim the funeral expenses grant

Contact LHF by telephoning 0800 056 0366 to request a claim form.
Return the completed claim form with an original certified copy of the Death Certificate and Funeral Director's account to: LHF, Riverside House, 7 Canal Wharf, Leeds, LS11 5WA.
On receipt of all documentation, and with payment approved, a cheque will normally be sent within 2 weeks.
All claims will be paid by cheque to the Executor of the estate or next of kin, if applicable. The Funeral Expenses benefit will terminate on the earlier of the following dates: (a) The date a policy holder ceases to be fully paid—up (b) The date the Board of Directors decide to end the provision of this benefit.

Qualifying period — 50 weeks. Time limit for claiming — 13 weeks from the date of death.

Medical Apparel

We will pay you up to the appropriate maximum entitlement of your plan for the purchase of medical apparel.

What is Covered

Surgical shoes.
Mastectomy items.
Prosthetic, back support, truss items.
Repairs to medical apparel.
Arch supports and orthotic insoles.
Surgical hosiery, when supplied through a medical prescription.
Wigs, when supplied through a medical prescription.
Hearing Aids.

What is not Covered

More than 2 items of medical apparel or repairs in a claiming year.
Invalid Equipment.
Medical Equipment, e.g. wheelchair etc.
Batteries.

No qualifying period. Time limit for claiming — 13 weeks from the date of supply.

Worldwide Cover

Cover is extended to business trips or holidays abroad of up to and including 28 days duration. Claims submitted are subject to the rules as detailed in your Summary of Cover leaflet and must be supported where necessary with a translation of the details to English.

Qualifying period — as per applicable benefit. Time limit for claiming — as per applicable benefit.

Homeopathy, Reflexology Treatment

We will pay you up to the appropriate maximum entitlement of your plan for the cost of treatment you receive directly from a Homeopath or Reflexologist.

What is Covered

Treatment supplied by a professional Homeopath or Reflexologist registered with an organisation recognised by LHF, which includes those as detailed below:

Homeopath — Member of either:
- The Faculty of Homeopathy
- International Guild of Professional Practitioners
- The Society of Homeopaths
- Alliance of Registered Homeopaths

Reflexologist — Member of either:
- The Federation of Holistic Therapists
- British Reflexology Association
- Association of Reflexologists
- International Institute of Reflexologists
- International Guild of Professional Practitioners.

What is not Covered

Any treatment supplied by a professional from an organisation not recognised by LHF for Homeopathy or Reflexology treatment.
Homeopathic medicines purchased in isolation for example from a chemist, health food shop, by mail order or over the internet.

No qualifying period. Time limit for claiming — 13 weeks from the date of treatment.

Personal Accident Protection

Subject to the provisions stated in the Personal Accident Protection policy, the amount of benefit payable under the Personal Accident Protection shall be considered if bodily injury results in death or permanent disability within one year following the date of accident. Personal Accident Protection Cover is provided by UK Underwriting Ltd on behalf of AXA Insurance UK plc. Please contact LHF by telephoning 0800 056 0366 for details of how to claim.

Personal Accident Protection Policy Details

This element of Your Plan is provided by UK Underwriting Ltd on behalf of AXA Insurance UK plc, Registered Office: 5 Old Broad Street, London EC2N 1AD, Registered in England No. 78950.

The terms and conditions detailed on the following pages apply to the Personal Accident cover only.

LHF is a trading division of Simplyhealth Access, UK Underwriting Limited, and AXA Insurance UK plc are authorised and regulated by the Financial Services Authority. This can be checked on the FSA's register by visiting the FSA's website at www.fsa.gov.uk/register or by contacting them on 0845 606 1234.

Personal Accident Protection

Subject to the Personal Accident section applying to your plan and subject to the provisions stated in the Personal Accident Protection Policy, the amount of benefit payable under the Personal Accident Protection shall be considered if Bodily Injury results in death or Permanent Total Disablement within one year following the date of Accident.

Schedule of Cover

If an insured member, because of Accidental Bodily Injury or sickness which occurred after the inception of this policy, suffers disability or loss of limb (as certified by a doctor) the following benefits will apply subject to the terms and conditions of the Policy.

Death as a result of an accident £15,000
Permanent total disablement £15,000
Permanent and incurable paralysis of all limbs £15,000
Permanent or incurable insanity £15,000
Loss of entire sight in both eyes £15,000
The permanent total loss of use of both hands or both feet £15,000
Loss of entire sight of one eye £ 7,500
The permanent total loss of one hand or one foot £ 7,500
Permanent loss of hearing in
1. Both ears: £7,500
2. One ear: £2,250
Permanent total loss of the lens of one eye £3,750
The permanent total loss of use of four fingers and thumb of either hand £6,000
The permanent total loss of use of four fingers of either hand £3,000
The permanent total loss of one thumb on either hand
1. both joints £3,000
2. one joint £1,500
The permanent total loss of use of fingers on either hand
1. a. three joints £750
2. two joints £525
3. 0ne joint £300
The permanent total loss of use of toes
1. a. all one foot £2,250
2. big both joints £750
3. big one joint £300
4. other than big, each toe £300
Shortening of leg by at least 5cm £1,125

The Sum Insured shall be limited to:

Members under 16 and over 65 years of age £5,000.
Members between 16 and 65 years of age £15,000.

When more than one injury arises from one accident the benefits are added together but shall not exceed the sum insured, no sum payable under the policy shall carry interest.

Period of Cover

The benefits of Your policy shall apply for the duration of your membership of the LHF Healthplan.

Definitions — relating to Personal Accident Protection only

Acceptable Sports & Leisure Activities — The following amateur activities are automatically included within the cover: Archery, if adequately supervised, Angling, Athletics, Aviation (as a fare paying passenger in a duly certified passenger—carrying aircraft), Badminton, Ballooning (which has been organised in the UK prior to departure), Baseball, Basketball, Beach Games, Boating (within 12 miles), Canoeing (to Grade 3), Clay Pigeon Shooting, Cricket (amateur), Croquet, Cycling, Dry Skiing, Fell Walking, Fencing, Fishing, Football, Golf, Go Carting, Gymnastics, Handball, Horse Riding (up to 7 days), Jet Skiing or Boating, Jogging, Kite Buggying, Kayaking (to Grade 3) Motor Cycling or Quad Biking up to 125cc, Netball, Non Manual Work, Orienteering, Outward Bound, Parascending (over water), Pony Trekking, Racquetball, Rambling, Roller Skating or Roller Blading, Rounders, Rowing, Running (sprinting or long distance), Safari (which has been organised in the UK prior to departure), Sail Boarding, Sailing (within 12 miles), Scuba Diving (max 90ft/30 metres) if adequately supervised, Shooting, Skate Boarding, Squash, Snorkelling, Softball, Street Hockey, Surfing, Swimming, Tennis, Trekking/Hiking (under 2000 metres), Triathlon, Volleyball, Water Polo, Water Skiing, White Water Rafting (to Grade 3), Windsurfing, Yachting or Dinghy Sailing (within 12 miles).
Accident / Accidental — shall mean a sudden, unexpected, unusual, specific event, which occurs at an identifiable time and place.
Administrator — LHF Healthplan of Your Personal Accident Protection Policy and the providers of Your Plan.
Bodily Injury / Injury — shall mean accidental bodily injury resulting solely and independently of all other causes in Your death or disablement and does not include any condition, which results due to a gradually operating cause.
Children/Child — means each of the Insured's children or legally adopted children
Duration — Your cover is valid for as long as you maintain your monthly premium payments under your Plan. Your policy is automatically renewed at the end of each complete calendar month after the Start date.
Loss — used with reference to hand, foot, thumb, finger or toe shall mean the loss by physical severance or the total and permanent loss of use of said member.
Loss of eye — shall mean the total and irrecoverable loss of sight.
Loss of hearing — shall mean the permanent loss of hearing recognised by a certified medical practitioner.
Partner — means a person who is either a spouse of the Insured or a person who has lived with the Insured permanently for 6 months or more
Permanent Total Disablement — shall mean disablement which in all probability will continue for the remainder of life, other than as specified by injuries 3 — 16 of the schedule of benefits and which entirely prevents you from engaging in or giving in or giving attention to any occupation.
Plan — Level of cover subscribed to under the Simplyhealth scheme including the benefits of the Personal Accident cover
Pre-existing Medical Condition — Any ongoing medical condition, or condition which has or will require medical treatment, including consultations or advice, within the last or next 12 months.
Sum Insured — The maximum amount payable under the terms and conditions of Your policy.
We / Us / Our / Company / Insurer — shall mean UK Underwriting Limited on behalf of AXA Insurance UK plc
You / Your / Member / Insured — shall mean the person in whose name the plan is recorded.

Extensions

Disappearance — In the event of Your disappearance, if after 12 months from the date of disappearance it is reasonable to believe that you have died as a result of an Accident the death benefit shall be payable. In the event of this belief being incorrect the benefits paid shall be repaid to Us.
Exposure — Death or Permanent Total Disablement as a direct result of exposure shall be deemed to have been caused by Bodily Injury.

Governing Law

This Policy shall be governed by and construed in accordance with the Law of England and Wales unless the Certificate holder's habitual residence (in the case of an individual) or central administration and/or place of establishment is located in Scotland in which case the law of Scotland shall apply. In the event of the place of establishment being situated in the Channel Islands the relevant law governing the Channel Islands shall apply.

Cancellation

We hope You are happy with the cover this policy provides. However, if after reading this Policy, this insurance does not meet with Your requirements, please return it to the Administrator, within 14 fourteen days of issue we will refund Your premium in full in connection with your Personal Accident cover.

The Insurer shall not be bound to accept renewal of any Insurance and may at any time cancel any insurance document by sending 14 days notice to the Insured at his last known address. Provided the premium has been paid in full the Insured shall be entitled to a proportionate rebate of premium in respect of the unexpired period showing on the Insurance.

Termination

Your cover shall terminate on the earliest of the following:

The Insured dies
The Insured reaches 75 Yrs
On the date we receive notification of cancellation from You under the terms of your policy.
At our discretion if You fail to pay the Premium on the due date or automatically 60 days after the due date if by the end of that period You have not paid the Premium due.
Insurers issuing notice of cancellation under the terms of the Policy
On the date the payment of benefit is made to You under any one of the injuries 1 — 6 of the Schedule of Cover.
If You have Individual & Partner, Individual & Children or Individual, Partner & Children cover Your protection will also end if:—
1. You are a Partner of the Insured when You reach 75 years old;
2. You are a Child of the Insured when You reach 16 years old or, if You are still in full—time education, You reach 21 years old;

Conditions

Any word or expression to which a specific meaning has been attached in any part of this Policy shall bear such meaning wherever it may appear
This insurance is not assignable. Benefits shall be payable only to You or Your legal representative whose receipt shall effectively discharge the Company.
Notice must be given to Administrator in writing as soon as practicable and in any case within thirteen weeks of any occurrence which may give rise to a claim under this Policy, notice of death must be given fore with and the Company shall have the right to have a postmortem examination of the body.
All documents, information and evidence required by the Company shall be supplied in the form prescribed and without expense to the Company.
You shall submit to medical examination on behalf of and at the expense of the Company as often as required in connection with any claim.
The liability of the Company under this Policy shall be conditional on Your observance of the terms and conditions and endorsements herein and on the truth of all statements made to the company by You.
Words in the masculine gender shall include the femine.
Any fraud, mis—statement or concealment either in the application on which this insurance is based, or in relation to any other matter affecting this insurance, or in connection with the making of any claim, shall render this insurance null and void and any benefits paid under a claim are to be returned to Us.
The Insurer may vary or amend the terms and conditions of Your policy at any time provided at least 30 days written notice is given to You prior to any alteration taking effect.
If Your activity does not appear on the list of Acceptable Sports & Leisure Activities, it is not covered.

Exclusions

The Company shall not be liable for any claim resulting from or contributed to by:
War, whether declared or not. This exclusion shall be inoperative in the event of war being declared whilst Your actually engaged on a journey outside their country of residence. The Company may cancel insurance hereunder in respect of war, invasion, act of foreign enemy hostilities (whether war be declared or not), terrorism, civil war, rebellion, insurrection, military or usurped power by sending 48 hours notice to You at Your 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 effected hereby.
Intentional self—injury, suicide or any attempt thereat.
Your suffering from sickness or disease not resulting from Bodily Injury
Any claim as a result of a Pre-existing medical condition.
Any claim arising out of either directly or indirectly as a result of alcohol or drugs unless under the advice of a doctor for a condition other than alcohol or drug addiction
Any claim occasioned or occurring whilst You are in a state of insanity, temporary or otherwise.
Any claim arising out of any condition caused by prolonged or aggravated by a psychiatric, mental or nervous disorder, including anxiety and or depression.
Whilst you are taking part in Military, Air force or naval service or operations (other than reserve or volunteer training).
Any activity not listed under Acceptable Sports & Leisure Activities as defined.

Claims Procedure

Should You suffer a loss covered under the terms of your policy please contact Customer Services on 0800 056 0366 to request a claim form.

UK Underwriting Ltd are an insurers agent and in the matters of a claim act on behalf of the insurer.

Helpline

Specially for our Members, we provide a Helpline, which offers an immediate source of counselling and straightforward advice, entirely free. The LHF Healthplan Helpline is available 24 hours a day, 7 days a week, 365 days a year — just phone 0870 608 9832. Calls will be charged at National rate.

Counselling

Just pick up the phone and speak directly to a fully trained counsellor. Typical problems we can help with include stress, relationships, bereavement, and family issues. We can also provide planned (weekly) telephone counselling sessions and onward referral to self—help groups in your area.

UK Tax Advice

Discuss personal taxation problems with tax experts. Typical issues we Cover are advice on self—assessment forms, PAYE, National Insurance and company benefits.

Travel Advice

You can get advice on inoculations, current medications, currency, local health issues, visa requirements and even equipping a first aid kit.

Legal Advice

Discuss personal legal problems with solicitors and legal experts. We can advise on consumer problems, wills, motoring, employment problems, probate, property buying or selling and accident or injury claims.

Health & Fitness Information

Just call for help with nutritional assessments, complementary health, giving up smoking and sports injuries.

Medical Advice Line

The Medical team can provide advice and information on a wide range of issues including all medical and surgical conditions, pre and post treatment advice, hospital procedures and details of local and national help and support groups.

Parental Advice

Call the Helpline if you could do with guidance on childminders, nursery places in your local area and advice on changing schools. We can also help with general paediatric issues, details of paediatric experts in your local area and with the sorts of communication issues that arise from time to time, especially with teenagers. The Helplines are provided by First Assist. There are stringent service level agreements in place and a number of the Helplines are recorded to ensure quality standards are met and so that complaints can be rectified accordingly. First Assist is IS09002 compliant and provides us with management information on a monthly basis.

This service is provided as an initial source of advice. Any costs incurred following advice must be borne by the policyholder.

Terms and Conditions

1. Introduction

1.1 Terms

LHF will notify you at your home address giving one month's notice in writing of any changes in the premium level rate and any other changes material to you as a member. Any changes to your premium will take effect from your next monthly premium following expiry of the notice period. LHF will not be responsible if such notification, for any reason, fails to come to your attention. Whilst LHF reserves the right to make material changes to the LHF Healthplan, any decision to withdraw maternity/adoption Cover will be subject to 12 months' notice. You may cancel your policy if you do not like the changes we make.

If your plan changes, claims will be paid on the plan amounts applicable at the date of treatment.

1.2 Governing Law

United Kingdom law allows you and LHF to choose the law which will apply to the Contract. Unless we make a written agreement saying otherwise before the start of this Contract, English law will apply to this Contract. We will communicate with you in English.

1.3 How to Join

You can apply to join if you are 16 years of age and over but under 65 years of age on the date that LHF receives your completed application form. You must also permanently reside within the United Kingdom.

1.4 Customer's Undertaking

All the information you give to us in relation to your application form, your state of health and any claims must be accurate to the best of your knowledge and belief. It is your responsibility to keep us informed about any changes in any of the information you have provided to us as soon as they take place.

By enrolling you undertake to abide by the Terms and Conditions set out within this policy document and policy schedule.

1.5 Commencement

This agreement shall take effect from the date that you enrol. Where you pay via a payroll deduction, commencement of your Cover will depend upon your preference at time of applying. Where you have opted for it to do so, Cover will start at the beginning of the pay period in which the first deduction was made.

1.6 How Your Cover Ends

All Cover under this policy will end automatically and you will not be Covered for claims not yet submitted in respect of you and all other persons included on your policy when:

You decide to cancel your Policy, by giving Us 30 days' notice in writing (which will take effect immediately on receipt by Us). We will not refund any of your monthly Premiums that have already been paid. Where Your Premiums are paid through your Employer via payroll deduction, You must notify your payroll department to avoid further premiums being deducted.
You become more than 30 days behind with the payment of your Premiums. At our discretion We may reinstate that Cover once outstanding Premiums have been paid
You mislead Us by providing incomplete or untruthful information to Us or knowingly claim Cover for any purpose other than is provided for under this Policy.
You breach the terms and conditions of this policy, for which we will give you not less than 30 days' written notice.
You die. Cover can be transferred to your Partner subject to the continued payment of Premiums.

1.7 Contract Between Us

Only you or LHF may enforce the contract between us or any part of it, no other insured person or third party may do so, and no term of this agreement shall be enforceable in accordance with Contracts (Rights of Third Parties) Act 1999.

1.8 Waiver

Waiver by us of any term and condition of this policy will not prevent us from relying on such term or condition thereafter.

2 Cover

2.1 Reviews

LHF Healthplan Cover is monthly and continues from month to month until it is cancelled or otherwise come to an end. The product is constantly reviewed to ensure it meets future needs.

2.2 Qualifying Periods

The qualifying period for the Maternity/Paternity and Adoption Grant and for Funeral Expenses is 50 weeks from the date of your registration before you become eligible to make a claim. There are no qualifying periods for any other benefits.

2.3 Dependent Children Membership

This Covers dependent children residing at the same address as the member up to their 17th birthday or until they commence paid employment whichever is the sooner.

On reaching the age of 17, children may register as a member in their own right and immediate Cover will be given with exception of the Maternity/Paternity and Adoption Grant (50 week qualifying period). Either paying parent, but not both, can submit claims for dependent children. If the dependent child does not bear the same surname as the member then proof of relationship must be provided. Where dependent children are entitled to Cover the same terms and conditions will apply.

LHF reserves the right to request a copy of a birth certificate of a dependent child before a claim is paid.

2.4 Family Plan

This covers 2 adults living at the same address and up to 6 dependent children.

2.5 Exclusions

Pre-existing medical conditions — A member or dependent child will not be entitled to benefit in respect of any ailment or health condition, which arose prior to enrolment with LHF or during the relevant qualifying period, regardless of when any treatment or service was given. This exclusion does not apply to the Optical or Dental benefits.

Any treatment, which is not related to the relief of illness or pain (pain is defined as bodily suffering caused by injury, pressure etc. Illness is defined as disease or other health problem etc).

Any benefit claim, which is insured through another insurance policy.

3. Premiums

3.1 Premium Level

The premium level you have chosen to pay determines the Cover available to you. The Cover applicable to your premium level is shown in the Summary of Cover leaflet.
Premiums are due on a continuous basis, in advance, according to your authorised payment frequency and are not refundable. You are not Covered unless payments are paid up to date.
If you increase your premium level any claims paid in your claiming year under the previous premium level will count towards the maximum available under the new premium level.
Your claiming year will not change if you increase or decrease your premium rate.
You may decrease your premium level at any time, providing that you have been on your current premium level for a minimum of twelve months.
If you increase your premium level to a plan which has additional Cover to your current plan, the normal qualifying periods will apply as specified within the plan.
You will only be allowed one premium level increase after your 65th birthday.
Each monthly premium relates to one month's Cover. If you pay premiums more than one month in advance, such payments will be applied on a monthly basis as premiums fall due.
LHF reserves the right to limit back dating the refund of any over payment made by a member to a maximum of three years.

3.2 Double Payroll Deductions — Employee and Partner

Where double payroll deductions are made for employee and partner, partner is defined as the first person permanently residing with the employee at the same address whose name has been notified in writing to LHF Healthplan.

3.3 Insurance Premium Tax (IPT)

Included as part of your premium is IPT, a tax levied by the government. Should the government announce an increase in IPT it may be necessary for us to amend your premium to reflect this. We will notify you of this change separately.

4. Claiming

4.1 How to Claim

You have to have received and paid for treatment before we will pay your claims. You can only claim for treatment you have received under one area of Cover. You must use the Claim Form we provide for making claims. If you do not have a Claim Form please call Customer Services on 0800 056 0366 or alternatively request a claim form from our website within the 'Contact Us' section www.lhfhealthplan.co.uk. When making a claim you need to send a fully completed Claim Form and original detailed receipt (see section 4.4) for any bill that you are seeking reimbursement for. You must provide us with any information to support your claim if we make a reasonable request for you to do so. We may seek written consent for medical information relating to a claim to be disclosed to an LHF medical practitioner. If you do not agree to this, we may not be able to pay your claim.

4.2 Payment

Payment will be by Direct Credit directly into your bank account or cheque (if requested) posted to your home address.

4.3 Time Limit for Claiming

All claims must be received within 13 weeks of either: — (a) date of hospital discharge, if applicable (b) child's birth/date of adoption, if applicable (c) date of practitioners treatment, if applicable (d) date of death (Funeral Expenses), if applicable.

4.4 Receipts (Proof of payment)

Receipts must reflect the amount paid in respect of the claimant or entitled child (joint receipts are not acceptable). The practitioners / consultants qualifications must also appear on the receipt. Till receipts, credit sales vouchers, photocopied or altered receipts are not acceptable. Payment will only be made on receipt of a final receipted account where all treatment has been completed. LHF will not return any receipts or invoices.

Maternity/adoption claims must be supported by a copy of the birth certificate or legal adoption papers. Hospital in—patient claims must be completed by the hospital and endorsed with an official hospital stamp.

4.5 Claiming Year

If you joined LHF before the 28th October 2002 or you joined LHF as an ASDA employee, your claiming year will operate from the 1st January to 31st December. If you joined LHF after the 28th October 2002 your claiming year will operate annually from your date of enrolment.

For the purpose of claiming years, a claim will be registered and set against the claiming year on the date treatment is given.

4.6 Overpayment

LHF reserves the right to recover any overpayments from either: —

any future claims payable to you and/or
to recover overpayments directly from you.

4.7 Fraudulent Claims

Submission of a receipt, which has been altered in any way, will be regarded as a fraudulent claim, your claim will not be paid and legal action may be taken against you.

4.8 Claims you may have against third parties

If you are bringing or entitled to bring a legal compensation claim against a third party, which would Cover claims met under your LHF plan, you must tell us about this as we may have the right to recover these sums from that third party. To enable us to do this, you must notify us of the claim, keep us informed of its progress, and act in accordance with our instructions. Alternatively, we may take over or bring a claim in your name in relation to the LHF element.

4.9 Charges Made by Healthcare Practitioners

LHF will not pay any amounts you may be charged by a Hospital or Doctor or other person for completing your claim form and/or for medical information requested by us in support of your claim. These charges will be your responsibility. Payment will not be made in respect of any treatment provided by a professional to a Member of their family.

4.10 Reviews

We continually review our claims procedures to make them as simple as possible and may introduce improvements in the future. Should this happen, We will notify you in advance.

5. Customer Care

5.1 Putting things right

At LHF we aim to provide you with the very highest levels of customer service and care at all times. In order to maintain this service standard, we encourage feedback from our Members and have put in place a procedure that you can use to raise any concern or complaint you may have. In the first instance you should write to the Customer Service Team Leader at LHF Healthplan, Riverside House, 7 Canal Wharf, Leeds, LS11 5WA or contact Customer Services direct on 0800 056 0366. If you are unhappy with the response you receive then we will refer your complaint to the Simplyhealth Group Quality Assurance Team for a final decision. Should you remain unhappy with our final response, you have the right to refer your complaint to the Financial Ombudsman Service, South Quay Plaza, 183 Marsh Wall, London E14 9SR. Tel: 0845 080 1800. Full details of our complaints procedure are available on request.

5.2 How we use information about you

As the Data Controller, we will store and process your personal data in accordance with the Data Protection Act (DPA) 1998. LHF and other Simplyhealth Group companies will use your information to provide our services, for assessment and analysis, for underwriting and claims handling, to improve our services, and to protect our interests.

We may use your information to keep you informed by post, telephone, e—mail or other means about products and services, which may be of interest to you. If you do not wish your information to be used for these purposes please write to The Data Controller, Simplyhealth Group, Hambleden House, Waterloo Court, Andover, Hampshire SP10 1LQ.

We will keep information about you confidential. However, we may give information about you and how you use our products to the following:

Fraud prevention agencies and other organisations who may record, use and give out information to other insurers;
People who provide a service to us or acting as agents on the understanding that they will keep the information confidential;
Anyone to whom we may transfer our rights and duties under this agreement;
We may also give out information about you if we have a duty to do so (such as to regulatory bodies), or if the law allows us to do so or if the person requesting the information has in our opinion, a legitimate interest in the disclosure.

Sensitive Data — In order to assess the terms of the insurance contract or administer claims, which arise, we may collect data, which the DPA defines as sensitive. By agreeing to these terms and conditions you consent to this data being processed by us. You have the right to see personal information, which is held by us. There may be a charge if you want to do this. For more details write to: The Data Controller, Simplyhealth Group, Hambleden House, Waterloo Court, Andover, Hampshire SP10 1LQ.

You are declaring that you have a right to give us information about your Partner and anyone else referred to by you.

To make sure we maintain a high quality service, we may monitor or record phone calls.

5.3 Financial Services Compensation Scheme (FSCS)

In the unlikely event that we go out of business or into liquidation, all of our Members are protected by the Financial Services Compensation Scheme. This means that any valid outstanding claims you have at this point will be paid by this scheme. Note that this Cover is limited to the first £2,000 of the outstanding claim, plus 90% of any amount above this. For more details on this scheme please visit www.fscs.org.uk or contact the FSCS direct on 020 7892 7300.

LHF, Riverside House, 7 Canal Wharf, Leeds, LS11 5WA

www.lhfhealthplan.co.uk

Part of the Simplyhealth Group. LHF Healthplan, Riverside House, 7 Canal Wharf, Leeds, LS11 5WA. LHF is a trading division of Simplyhealth Access, which is authorised and regulated by the Financial Services Authority. Simplyhealth Access is registered and incorporated in England and Wales, registered no. 183035. Its registered office is at Hambleden House, Waterloo Court, Andover, Hampshire, SP10 1LQ. Your calls may be recorded and monitored for training and quality assurance purposes.