Terms & Conditions: Well Being Plans

Terms & Conditions of your LHF Well-being Plan

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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 health care 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 and the Table of Cover. 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. 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 the start of your policy, in which to change your mind and cancel your membership, 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 customers. We believe that everyone should benefit from sensible, everyday healthcare and we aim to help our members get the most out of our Well-being Plans. For most of our products we offer plans at the same price to 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, this means there is a requirement for you to use the Well-being Plan responsibly.

Well-being Plans 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 we 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 to see what level of cover you are entitled to. Pre-existing medical conditions are covered by these benefits.

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.
Treatment provided by a dental surgeon.
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

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.

There is 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 entitlement 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 optician.

There is no qualifying period. Time limit for claiming - 13 weeks from the date of treatment.

Physiotherapy, Acupuncture, Osteopathy, Chiropractic & Homeopathy Treatment

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

What is covered

Physiotherapy, Acupuncture, Osteopathic, Chiropractic or Homeopathy 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 – Registered with the General Osteopathic Council (GOsC).
Chiropractic – Registered with the General Chiropractic Council (GCC).
Acupuncture – Registered with the British Acupuncture Council (MBAcC) or The British Medical Acupuncture Society (BMAS) or The Modern Acupuncture Association.
Homeopathy - The Faculty of Homeopathy, International Guild of Professional Practitioners, the Society of Homeopaths, Alliance of Registered Homeopaths.

What is not covered

Any treatment supplied by a professional who is not registered with the appropriate professional body to provide Physiotherapy, Acupuncture, Osteopathic, Chiropractic, or Homeopathic 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.

There is no qualifying period. Time limit for claiming - 13 weeks from the date of treatment.

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.

There is no qualifying period. Time limit for claiming - 13 weeks from the date of consultation.

Comprehensive Employee Assistance Programme

Specially for our Members we provide access to helpline and counselling services as set out in the Summary of Cover up to your annual entitlement. FirstAssist provides these services on behalf of LHF.

What is covered

Unlimited access to a free confidential helpline, 24 hours a day 7 days a week, that can provide help and guidance in relation to a number of areas including legal, tax and medical issues.

What is not covered

Counselling services other than those arranged through the helpline.
Self-help or guidance products or services.

There is no qualifying period.

Additional Benefits

Face to Face Counselling

A specific number of face-to-face counselling sessions are available where it has been purchased by your participating employer. The counselling sessions are available with a qualified counsellor upon request via the helpline should this benefit apply to you.

Occupational Health

Occupational Health cover is available where it has been purchased by your participating employer. Your Human Resources department will be in contact with you to arrange an appointment, should this benefit apply to you.

Confidential Helpline

The LHF Well-being Plan Helpline is available 24 hours a day, 7 days a week, 365 days a year – just phone 0870 162 0392.

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 for 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 Helpline is provided by FirstAssist. There are stringent service level agreements in place and a number of calls are recorded to ensure quality standards are met so that complaints can be rectified accordingly. First Assist is IS09001:2000 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 Member.

SECTION ONE - HOW TO JOIN

1.1 You can become a Member if you are employed by a Participating Employer that has agreed to provide you with Cover under a Policy and you permanently reside in the United Kingdom.

1.2 All the information you give to us in relation to your membership, any claim under a Policy and your state of health 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 membership.

1.3 Cover under your membership is provided on a monthly basis and will commence from the date that we receive payment of Premium in relation to your membership and are notified of your details by a Participating Employer. Under these Terms and Conditions you consent to the renewal of Cover for further monthly periods and on a monthly continuous basis subject to the continued payment of Premiums by a Participating Employer.

SECTION TWO – UPGRADES, DEPENDENT CHILDREN AND PARTNERS

2.1 If you have chosen to upgrade your level beyond that provided by your participating employer, all cover except Employee Assistance Cover (face-to-face sessions) and Occupational Health, increase to the upgraded level.

2.2 You can increase your level once a year but you must stay on that level for a minimum of twelve months before you can decrease your level again.

2.3 Dependent children under the age of 17, residing at the same address as the Member, are covered for all benefits with the exception of the 24 hour helpline, Employee Assistance Programme and Occupational Health.

2.4 Dependent children must be listed on a Members policy in order to be entitled for cover.

2.5 We may refuse to allow a child to be added to the policy until you have provided information satisfactory to us about them including sight of birth certificate (or certified copy).

2.6 You can apply to include your partner (or another adult residing at the same address) on the Well-being Family Plan (thereby agreeing to pay the appropriate increased premium to cover him/her) if your partner is over the age of 17 but under 65 years of age.

SECTION THREE – PREMIUMS

3.1 The Premium level that a Participating Employer has chosen to pay determines the Cover available to you. The Cover applicable to the Policy is shown in the Summary of Cover, which accompanies this document.

3.2 The payment of Premiums on your behalf by a Participating Employer may mean that you incur income tax liabilities. You should consult with your employer’s Human Resources or Payroll department to confirm what these liabilities are.

3.3 Premiums must continue to be paid in order for you to be provided with Cover and to be entitled to claim. We reserve the right to cancel the Policy should the premiums fail to be kept up to date.

3.4 If a Participating Employer or Employee increases the Premium level, any claims paid in the Claiming Year under the previous Premium level will count towards the maximum entitlement available under the new Premium level.

3.5 Your Claiming Year will not change if a Participating Employer or Employee increases or decreases your Premium level during a Claiming Year.

3.6 Included as part of the Premium paid by a Participating Employer 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 the Premium to reflect this.

SECTION FOUR - 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. When you join you can claim straight away.

Employee assistance elements of Cover

4.1 The Confidential 24 hour helpline can be accessed by calling 0870 162 0392.

4.2 In order to access counselling services, you should call the helpline who will arrange counselling sessions.

4.3 The advice line provides general medical advice only and should not be used as a substitute for your normal personal medical care. It is not an emergency service and will not prescribe treatments or provide diagnostic services. Advice from this service is free but calls are charged at national rate.

Other elements of Cover

4.4 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 call Customer Services on 0800 056 0366, or log on to www.lhfhealthplan.co.uk to request one.

4.5 When making a claim you should 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 the treatment, a description of the treatment and the amount paid for the treatment. You should submit claims as soon as you can but no later than 13 weeks from the date treatment was supplied. We reserve the right to reject any claim, which is not sent to us within 13 weeks.

4.6 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.

4.7 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.

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

4.9 We do not pay any amounts you may be charged by a hospital or doctor or other person for completing your claim and/or for medical information requested by us in support of your claim. These charges will be your responsibility.

4.10 You can only claim for treatment you have received under one area of Cover.

4.11 We will cover you for business or holiday visits within the European Economic Area (EEA) of up to and including 28 days duration. Claims must be supported where necessary with a translation of the endorsement or relevant receipt, providing the details of the claim.

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

4.13 All outstanding claims must be submitted within one month if a Participating Employer increases or decreases the Premium level.

4.14 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.

4.15 If you have two or more LHF policies you can only claim once for each event, you will not be permitted to claim twice for the same treatment on different policies. You will be permitted to split your receipt over two plans (submitting two claim forms and one receipt) if the claim has resulted in you reaching your limit on one or more of the policies.

SECTION FIVE - HOW DOES COVER END

5.1 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:

a) 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.

b) 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

c) 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.

d) You breach the Terms and Conditions of this policy, for which we will give you not less than 30 days cover.

e) In the event of your death.

SECTION SIX - CUSTOMER CARE

6.1 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 concerns or complaints you may have. In the first instance you should write to LHF, Customer Services Team Leader, Riverside House, 7 Canal Wharf, Leeds, LS11 5WA, or contact Customer Services direct on 0800 056 0366 or email customer.services@lhfhealthplan.co.uk. 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 the Financial Ombudsman Service, South Key Plaza, 183 March Wall, London E14 9SR. Telephone: 0845 080 1800. Full details of our complaints procedure are available on request.

6.2 Changing your mind - You have 14 days from receipt of your welcome letter in which to change your mind and cancel your membership, provided no claims have been made. If you do change your mind, please call 0800 056 0366 or write to LHF, Riverside House, 7 Canal Wharf, Leeds, LS11 5WA and we will cancel your membership for you.

6.3 Changes to your details - You must inform us as soon as is reasonably possible of any changes to the information that you have given to us, including any change of address, or marital status or any other material change. Failure to do so may result in Cover being refused or cancelled or your membership being cancelled.

6.4 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.

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

SECTION SEVEN - WHAT HAPPENS IF WE CHANGE THE TERMS AND CONDITIONS OF YOUR PLAN

7.1 Before making such changes to the Terms and Conditions we will give a Participating Employer the following periods of notice:

a) In respect of any changes to the levels of cover, premiums or Terms and Conditions, at least one month’s prior notice in writing.

7.2 Where a Participating Employer has 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 EIGHT - Additional Information

8.1 Waiver - waiver by us of any Term or Condition of a Policy or these Terms and Conditions will not prevent us from relying on such Term or Condition thereafter.

8.2 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 a Policy. We will communicate with you in English.

8.3 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 (DPA). LHF and other companies within the Simplyhealth Group 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:

(a) Fraud prevention agencies and other organisations who may record, use and give out information to other insurers;

(b) People who provide a service to us or acting as agents on the understanding that they will keep the information confidential;

(d) 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.

8.4 Sensitive Data - in order to assess the terms of the insurance contract or administer claims 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.

8.5 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.

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

8.7 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 LHF 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 part of your claim that has been covered by us.

8.8 You may be covered under this Policy and a separate LHF Policy in relation to a particular element of Cover. However, you may only make one claim in relation to a single treatment under one Policy. Once you have reached the limit of Cover under this Policy you may then make a further claim for other treatments under the other Policy that you hold.

8.9 We do not cover any element of a claim that is insured under another insurance policy.

SECTION NINE - DEFINITIONS

Certain words in the policy have a special meaning. Whenever the following words and phrases appear in this Policy, they will always have these meanings.

Claiming Year - Your claiming year runs annually from the date of commencement of cover for the employees of a participating employer.

Cover - The range of Cover under your Plan as detailed in the Summary of Cover.

EEA - The countries of the European Union at the date of treatment or cost incurred, together with Iceland, Norway and Liechtenstein.

Member - An employee of a participating employer who is covered under a policy.

Membership - The provision of cover and other benefits to a member by us.

Participating Employer - An employer of a Member that has purchased cover under a plan on the Member’s behalf.

Partner - A spouse or a person who resides with you on a permanent basis as if your legal spouse regardless of gender.

Plan - The LHF product to which these Terms and Conditions apply.

Policy - Our contract of insurance with a Participating Employer.

Premium - The amount a Participating Employer has selected to pay, which determines the level of Cover available to you.

Specialist, Consultant or Surgeon - A medically qualified person who specialises in a specific field of medicine who may or may not hold a Consultant position in an NHS Hospital but who is a Member, Fellow or Licentiate of one of the Royal Colleges.

Summary of Cover - Details what level you are covered for.

Table of Cover - Shows the individual treatments you are entitled to claim for.

We/LHF – LHF is a trading division of Simplyhealth Access.

You - The Member.