Terms & Conditions: Dental Plans

These Terms and Conditions set out the way in which we provide you with cover under your plan. As a member, they bind you whether or not you have signed the 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 294 6792.

Definitions

To avoid repetition, the following words or expressions, wherever used in these terms and conditions, have the specific meanings given below.

To assist you in identifying the defined words or expressions these are shown in bold print throughout these terms and conditions.

• Accident

  A sudden identifiable violent external blow to the mouth that happens by chance and which could not be expected.

• Call-out fee

  The amount charged by a dentist or specialist, when an appointment occurs outside of the dentist's or specialist's normal opening hours. This appointment must be to provide temporary treatment for a dental emergency.

• Dependent child/children

  Natural, legally adopted or legally fostered dependant children of you or your partner under the age of 18 (extended to under the age of 24 for children in full-time education) who permanently live with you.

• Claiming year

  Your claiming year runs annually from your registration date.

• Cover

  The range of cover under your plan applicable to you.

• Dangerous sports

  Sports or activities such as, but not limited to:

  • Hockey, including ice hockey;
  • Boxing, judo or martial arts of any kind;
  • Mountain biking, motor cycle racing;
  • Rugby.

• Dental emergency

  Treatment urgently required for the relief of severe pain, trauma, inability to eat, the control of acute infection, swelling, haemorrhage or which causes a severe threat to your general health. Any subsequent treatment required after the emergency is specifically excluded.

• Dentist

  A dental surgeon who is registered with the General Dental Council and engaged in general dental practice.

  The dentist must practise in the United Kingdom.

• Level

  The level determines the maximum amount of annual cover available to you.

• Member

  A policyholder, who may or may not be a constitutional member of LHF.

• Mouth cancer

  A diagnosis of cancer of the lips, tongue, major salivary glands, gums, mouth or pharynx or the oral cavity from the lips to pharynx substantiated by a specialist's letter and histology.

• Partner

  A spouse or civil partner under the Civil Partnership Act 2004 or a person who resides with you on a permanent basis as is your legal spouse or civil partner.

• Permanent treatment

  Treatment that is clinically necessary to secure and maintain oral health.

• Plan

  The LHF product to which these terms and conditions applies.

• Policy

  Our contract of insurance with you.

• Terms and conditions

  The full Terms and Conditions that relate to your policy.

• Premium

  The amount you pay to us for cover.

• Qualifying period

  A period of time during which premiums must be continuously paid by you but you cannot make claims.

• Registration date

  The date the policy begins, as shown in your welcome letter.

• Review date

  The annual anniversary of the registration date.

• Specialist

  A dentist who is included in the specialists list on distinctive branches of dentistry within the dentists' register, as defined by the General Dental Council (Distinctive Branches of Dentistry) Regulations 1998; a dentist who has additional specialist or further qualifications in a particular speciality, or whose practice is limited to such a speciality. The specialist must practise in the United Kingdom. For claims for mouth cancer, a registered medical practitioner who holds or has held an appointment as a consultant in a National Health Service hospital or has a certificate of Higher Specialist Training from the appropriate Royal College.

• Table of Cover

  A table (current at the date of treatment or cost incurred) issued by us giving the levels of cover applicable to each of the premium levels of your plan.

• Temporary treatment

  Such care and treatment that is immediately and necessarily required to stabilise the oral condition pending further definitive treatment. Such treatment would include, but is not limited to:

  • Temporary filling, crown or bridge
  • Temporary denture
  • Removal of pulpal tissue.

• We/our/us

  Simplyhealth Access trading as LHF, a company incorporated in England and Wales.

• You/your

  The member and where applicable, any partner or dependants covered under your policy.

Details of cover under this plan

Dental accident cover

We will pay you, 100% of the total cost you pay directly to the dentist or specialist for treatment covered by this policy resulting from an accident which occurs after your registration date, up to the appropriate maximum entitlement available in your claiming year under your chosen level.

What is covered

• Permanent treatment or temporary treatment required as a result of an accident

What is not covered

• General exclusions
• Treatment required as a result of participating in a dangerous sport where appropriate mouth protection has not been worn
• Any permanent treatment or temporary treatment required which is not as a result of an accident

Dental emergency cover

We will pay you, 100% of the total cost you pay directly to the dentist or specialist for temporary treatment covered by this policy resulting from a dental emergency, up to the appropriate maximum entitlement available in your claiming year under your chosen level.

What is covered

• Temporary treatment urgently required for the relief of severe pain, trauma, inability to eat, the control of acute infection, swelling, haemorrhage or which causes a severe threat to your general health.
• Temporary treatment required as a result of injury caused by foodstuffs or foreign bodies in the course of consumption
• Call-out fees

What is not covered

• General exclusions
• Permanent treatment
• Any subsequent temporary treatment required after the emergency
• Permanent treatment or temporary treatment required as a result of an accident.

Maintenance

We will pay you, 100% of the total cost you pay directly to the dentist or specialist for dental maintenance covered by this policy, up to the appropriate maximum entitlement available in your claiming year.

What is covered

• Dental check-ups, examinations or investigations
• Simple scaling
• Hygienist fees
• X-rays

What is not covered

• General exclusions

Mouth cancer cover

We will pay you, one payment to the maximum shown in the Table of Cover under your chosen level, where you are diagnosed by a specialist with mouth cancer. Mouth cancer cover is a one off payment, payable once per member, for as long as mouth cancer cover is offered under the terms of this plan by us.

What is covered

Benefit will be paid when you have been diagnosed by a specialist with cancer of the; lips, tongue, major salivary glands, gums, mouth, or pharynx or the oral cavity from lips to pharynx

What is not covered

• General exclusions
• Costs of any diagnostic or exploratory tests
• Benefit will not be paid if you are diagnosed with mouth cancer within the six-month qualifying period which commences on your registration date
• This cover is not payable if you have ever been diagnosed with mouth cancer or have been referred by your dentist or GP for diagnostic or exploratory tests of the area of the oral cavity from the lips to pharynx prior to your registration date

Treatment

We will pay you, 75% of the total cost you pay directly to the dentist or specialist for dental treatment covered by this policy, up to the appropriate maximum entitlement available in your claiming year.

What is covered

Treatment required after a three-month qualifying period which commences on your registration date, including:

• Permanent treatment or temporary treatment provided by a dentist or specialist
• Anaesthetic fees, including intravenous sedation
• Gum-shields provided by a dentist or specialist
• Dental crowns, bridges and white fillings
• Dentures
• Laboratory fees and Dental Technician fees referred by a dentist or specialist

What is not covered

• General exclusions
• Any treatment required within a three-month qualifying period which commences on your registration date
• Unnecessary treatment
• Dental implants

General exclusions

We will not provide cover for:

• Charges made by a dentist, specialist, doctor or other professional for completing the claim form
• Dental consumables, including but not limited to toothbrushes, mouthwash and dental floss
• Dental practice plan premiums and dental insurance premiums
• Joining fees
• Missed appointment fees and administration fees
• Dental prescription charges
• Laboratory fees and dental technician fees in isolation
• Claims relating to treatment carried out outside of a normal dental surgery, including but not limited to removal of impacted teeth carried out in a hospital
• Orthodontic treatment
• Cosmetic procedures
• Dental veneers
• Tooth whitening, including but not limited to laser whitening
• Claims relating to treatment arising directly or indirectly from
  • You participating in a criminal act
  • Your abuse of alcohol or drugs
  • Deliberate self-inflicted injury
  • Damage to dentures whilst not being worn
  • Treatment required as a result of war or terrorist activity

Terms and Conditions

Section one — how to join

1.1 You can apply to join if you are 18 years of age and over but 69 years of age or younger on the date that we receive your properly completed application form. You must be permanently resident in the United Kingdom. We do not have to accept your application.

1.2 You can apply to include your partner on your policy (thereby agreeing to pay the appropriate increased premium to cover him / her) if your partner is 18 years of age and over but 69 years of age or younger and permanently resides at your address in the United Kingdom. You can also apply to include your unmarried dependent children or your partner's unmarried dependent children (thereby agreeing to pay the appropriate increased premium to cover them) if the children permanently reside with you at the date we receive a notice to include them. When your children cease to be covered by your policy they can apply to become a member in their own right. We may refuse to allow a person to be added to your policy until you have provided information satisfactory to us about the person, including in the case of a child, a copy of their Birth Certificate.

1.3 If you move outside of the United Kingdom, whether permanently or temporarily, you may still remain a member, providing you continue to pay your premiums in sterling, provide us with an address in the United Kingdom for correspondence, and return to the United Kingdom for treatment by a dentist or specialist.

1.4 All the information you give to us on or in relation to your application form, your state of health, any notice to add another person to your policy and any claims must be accurate, true and complete to the best of your knowledge and belief. If you fail to provide information to us in accordance with this obligation, we reserve the right to cancel your policy.

1.5 Your policy shall be for one year and will commence from your registration date. It will continue from year to year until it is cancelled, terminated by us on notice or otherwise comes to an end.

Section two — renewal and premiums

2.1 Your premium is payable for 12 months from your registration date, and then 12 months from each subsequent review date. You may not cancel your policy midway through your claiming year.

2.2 Your policy will continue subject to the terms in force at the time of each review date where this policy cover is still offered by us. On this basis you agree that we may at our option renew your policy automatically on the terms in force at each review date, that we may continue to collect your premium at the rate in force and that we need not obtain your request to do so for each renewal. We will notify you of any changes to premium or policy terms prior to each review date and you may then notify us should you not wish to renew.

2.3 All premiums are payable by direct debit in advance of any cover under your policy being provided.

2.4 Each monthly premium relates to one month's cover. You must continue to pay your monthly premiums to be entitled to claim and we reserve the right to cancel your policy should you fail to keep up to date with your premiums.

2.5 Any change we make to your monthly premiums will come into effect on your next review date.

2.6 You may increase your level once a year but you must stay on that level for a minimum of 12 months before you can increase your level again.

2.7 If you increase your level any claims paid in your claiming year under the previous level will count towards the maximum entitlement available under your new level.

2.8 You may decrease your level at any time, providing you have been on your current level for a minimum of 12 months.

2.9 Where applicable, included as part of your premium is Insurance Premium Tax (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.

Section three — how to claim

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.

3.1 You have to have received and paid for treatment before we will pay your claims. Claims will be offset against the claiming year in which treatment was received. You must use the claim form we provide for making claims. If you do not have a claim form please visit www.lhfhealthplan.co.uk or call Customer Services on 0800 294 6792.

3.2 When making a claim you need to send a fully completed claim form and original receipt for any bill that you are seeking reimbursement for. The original receipt and/or bill must be on official headed paper and must show the name of the patient, the name, address and qualifications of the person providing treatment, a description of the treatment and the amount paid for that treatment. You should submit claims as soon as you can but no later than 13 weeks from the date treatment was supplied.

3.3 You must provide us with any information or proof 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.

3.4 We reserve the right to request a second opinion from a dentist or specialist appointed by us.

3.5 We do not accept original receipts that have been altered, nor do we accept invoices, credit card receipts or photocopies of any accounts. We do not return any receipts or invoices.

3.6 We will not pay any claim while you are in breach of these Terms and Conditions.

3.7 We do not pay any amounts you may be charged by a dentist, specialist 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.

3.8 You can only claim for treatment you have received under one area of cover.

3.9 If there is any other insurance covering any of the same benefits, you must disclose to us and we shall not be liable to pay or contribute more than our reasonable proportion.

3.10 We will cover you for business or holiday visits anywhere in the world of up to and including 28 days duration.

We will not provide cover where the purpose of the trip is to receive dental treatment outside of the United Kingdom.

Claims must be supported where necessary with a translation of the invoice and relevant receipt, providing details of the claim. The dentist or specialist must hold comparable qualifications to a dentist or specialist who practises in the United Kingdom.

3.11 Cover will not be provided in respect of any treatment provided by a member of your family to you.

3.12 We reserve the right to recover any overpayment of claims from any sums payable to you and/or to recover any such overpayments directly from you.

3.13 You must give us written notification of any claim or right of action against any party arising out of any circumstances which gave rise to the claim under this policy, and must continue to keep us informed in writing and take all steps we reasonably require in making a claim upon that party.

We shall be entitled to prosecute in your name for our benefit any claim for indemnity or damages or otherwise which relates to any benefits and costs payable under this policy.

Section four — how does cover end

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

a) You decide to cancel your policy, by giving us notice in writing (which will take effect on your next review date). We will not refund any of your monthly premiums that have already been paid and you will not be able to rejoin any plan for a period of three years from the date that cancellation of your policy takes effect.

b) You, or any third party who is paying your premiums on your behalf, miss paying three consecutive monthly premiums. We may at our discretion cancel your cover earlier in accordance with 2.4 if you fail to pay premiums. We may reinstate that cover if each outstanding premium is paid within one month of its due date.

c) You die. Cover can be transferred to your partner provided that within three months of death they agree to pay the premiums.

d) We exercise our right to cancel your policy at any time (with retrospective effect where appropriate) if you:

• misled us by mis-statement or concealment;
• knowingly claimed benefits for any purpose other than as are provided for under this policy;
• agreed to any attempt by a third party to obtain an unreasonable pecuniary advantage to our detriment;
• otherwise failed to observe the Terms and Conditions of this policy or failed to act with utmost good faith.

4.2 All cover under this policy in respect of a partner or child included on your policy will end when he/she dies or he/she ceases to satisfy the criteria in 1.2.

Section five — customer care

5.1 Putting things right — 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 complaints you may have. In the first instance you should write to Customer Services, LHF Healthplan, Riverside House, 7 Canal Wharf, Leeds LS11 5WA.

Or contact Customer Services direct on 0800 294 6792. 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 dissatisfied with our final response, you have the right to refer your complaint to: Financial Ombudsman Service, South Quay Plaza, 183 Marsh Wall, London E14 9SR. Telephone: 0845 080 1800.

Full details of our complaints procedures are available on request.

5.2 Changing your mind — you have 14 days from receipt of your welcome letter in which to change your mind and receive a full refund of any premiums you have paid, providing no claims have been made. If you change your mind, please call 0800 294 6792 or write to Customer Services, LHF Healthplan, Riverside House, 7 Canal Wharf, Leeds LS11 5WA.

And we will cancel your policy for you.

5.3 Changes to your details — you must inform us as soon as reasonably possible of any changes to the information that you have given to us, including any change of address, marital status or any other material change. Failure to do so may result in cover being refused or cancelled or your policy being cancelled.

5.4 Making information about us accessible — 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.

5.5 You are protected by the Financial Services Compensation Scheme (FSCS) — in the unlikely event that we go out of business or into liquidation the FSCS protects you. Should this happen then any valid outstanding claims you have at this point will be paid by the scheme. Cover is limited to 100% of the first £2,000 and 90% of the remainder of the claim, without any upper limit. For more details on the scheme please visit www.fscs.org.uk or contact the FSCS direct on 020 7892 7300.

Section six — what happens if we change the Terms and Conditions of your plan

6.1 We have the absolute right to change any of the Terms and Conditions relating to the plan at any review date.

6.2 We have the absolute right to change the premium at any review date.

6.3 We will notify you at your home address giving one month's notice in writing of any such changes. We will not be responsible if such notification, for any reason, fails to come to your attention. You may cancel your policy in accordance with 4.1 if you do not like the changes we have made.

6.4 Where you have been notified of a change to the Terms and Conditions, claims will be paid in accordance with the Terms and Conditions in operation at the time treatment was supplied.

Section seven — The legal bits

7.1 Waiver — waiver by us of any Term or Condition of the policy will not prevent us from relying on such Term or Condition thereafter.

7.2 Enforcement — no term of this policy or any part of it, is enforceable under the Contracts (Rights of Third Parties) Act 1999 by a person who is not party to it. Your partner or children are not party to the policy.

7.3 Choice of law — the parties to insurance contracts in the United Kingdom may choose which law will apply. Unless we agree otherwise, English law will be applied to your policy.

7.4 Language — we will communicate with you in English.

7.5 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 1998.

We and other Simplyhealth 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, LHF, 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:

• (1) Fraud prevention agencies and other organizations who may record, use and give out information to other insurers;
• (2) People who provide a service to us or acting as agents on the understanding that they will keep the information confidential;
• (3) Anyone to whom we may transfer our rights and duties under this agreement;
• (4) 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.

7.6 Sensitive Data — in order to assess the terms of the insurance contract or administer claims we may collect data, which the Data Protection Act 1998 defines as sensitive. By agreeing to these Terms and Conditions you consent to this data being processed by us.

7.7 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, LHF, Hambleden House, Waterloo Court, Andover, Hampshire SP10 1LQ.

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

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

7.10 Claims you may have against third parties — if you are bringing or are entitled to bring a legal compensation claim against a third party, which would cover claims met under your policy, 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.

7.11 You and anyone included on your policy may only hold, or be covered under, one policy. We reserve the right to determine which policy will apply to a person who is registered with us on more than one policy.

7.12 We may not cover the total claim of any amount which is insured under another insurance policy.

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.