Yourpolicy
benefitsandterms
Bupa By You health insurance
Full terms and conditions of everything covered
under our health insurance options
Page 2
How to use this booklet
There are a number of dierent cover options
available with Bupa By You health insurance and
this booklet includes full details of them all.
To understand your personal cover, you should read this booklet alongside your
Membership Certificate which is unique to you and anyone else covered by your policy,
and any Confirmation of Special Conditions. We will send a Confirmation of Special
Conditions for anyone to whom a Special Condition applies which forms part of our
Agreement with you.
Bupa By You: Policy Benefits and Terms
Eective from 1 January 2023
These are the Policy Benefits and Terms of Bupa By You. They apply to any Main Member
whose Cover Start Date is on or after the ‘Eective from date’ and to any Dependants
included in their policy from that Dependant’s Cover Start Date.
Words in italics
Wherever you see words or phrases in italics, these have technical meanings which are
set out in the glossary towards the end of this booklet.
How do I make a claim?
We have included a ‘Step by step guide to making a claim’ in Section 2 of this booklet.
You can also call us on 0345 609 0777* and we can talk you through the process.
*We may record or monitor our calls.
^ Bupa Anytime HealthLine and Family Mental HealthLine are not regulated by the Financial Conduct Authority
or the Prudential Regulation Authority.
#
Calls may be recorded and to maintain the quality of our service a nursing manager may monitor some calls
always respecting the confidentiality of the call.
†Telephone support between 8am to 6pm Monday to Friday.
Bupa Anytime HealthLine^
If you have any questions or worries about your health call our confidential Bupa Anytime
HealthLine on 0345 601 3216
#
. Our qualified nursing team is on hand 24 hours a day, so
whatever your health question or concern, they have the skills and practical, professional
experience to help.
Family Mental HealthLine^
If you are a parent or care for a young person, and have concerns about their mental
wellbeing, our Family Mental HealthLine is available to provide advice, guidance and
support. A trained adviser and/or mental health nurse will listen to what your family
is experiencing and give you advice about what to do next. Call our Family Mental
HealthLine on 0345 266 7938
#
†. The young person does not have to be covered
under your policy for you to be able to use this service.
Page 3
How do I contact Bupa?
We are always on hand to help.
Call
For any queries about your cover
please call us on 0345 609 0777.
We may record or monitor our calls.
Webchat
You can now chat with us either
using your Bupa digital account, or
by visiting bupa.co.uk. You can use
this service to ask general queries
and authorise treatment. We may ask
you to call us based on your needs.
If you have diculties
For those with hearing or speech
diculties you can use the Relay UK
service on your smartphone or
textphone. For further information
visit www.relayuk.bt.com. We also
oer documents in Braille, large print
or audio.
Bupa digital account
Creating an account provides on the
go access to your Bupa policy. Giving
you a comprehensive, personalised
view of your cover in one place, visit
bupa.co.uk to create an account or
download the Bupa Touch App. From
here you can call or use webchat to
get in touch, which is the quickest
way of reaching us.
Write
You can also write to us at Bupa, Bupa Place, 102 The Quays, Salford M50 3SP
Page 4
Get started
Section one:
Eligible treatment, benefits and limitations
5
Benefits Table 5
General Exclusions: What is not covered 24
Section two:
Policy terms
31
1. Cover for you and your dependants 31
2. Claiming 35
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Step by step guide to making a claim 35
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General information on claiming 37
3. Paying a claim 40
4. Changes to lists 42
5. Glossary 43
Section three:
Protecting your information and rights
50
1. Status disclosure 50
2. Cancellation 50
3. Statement of demands and needs 51
4. Privacy notice – in brief 52
5. Making a complaint 54
6. The Financial Services Compensation Scheme (FSCS) 55
7. Financial crime and sanctions 55
Section one: Eligible treatment, benefits and limitations Page 5
Section one:
Eligible treatment, benefits and limitations
Benefits Table
This Benefits Table sets out the type of Benefits and charges we pay for Eligible
Treatment, and what we do not cover in relation to any particular Benefit. The General
Exclusions section sets out the areas we do not cover and in some cases the related
exceptional circumstances in which we do provide cover. This Table forms part of the
Bupa By You Health Insurance Agreement.
Important Information
1. At the Cover Start Date you must have been registered continuously with a GP for
a period of at least six months, or have access to and be able to provide your full
medical records in English.
2. Your Membership Certificate sets out the details of the cover you have chosen. We do
not pay for any Benefit listed in this Table unless it is included on your Membership
Certificate. We also do not pay for any personal travel and/or accommodation costs
which are not expressly set out in your Benefits.
3. We only pay up to the limits stated on your Membership Certificate and subject to
any excess stated on your Certificate. The limits may aect how much we pay for
particular Benefits or to particular Treatment providers.
4. If your underwriting method shown on your Membership Certificate is:
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Underwritten: we do not pay for Treatment for any Special Conditions detailed
on your Confirmation of Special Conditions or any Pre-existing Conditions,
see your Membership Certificate for more details including what we mean by
Special Conditions. We will send a Confirmation of Special Conditions for anyone
to whom a Special Condition applies.
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Moratorium: we do not pay for Treatment for Moratorium Conditions, see
your Membership Certificate for more details including what we mean by
Moratorium Conditions.
5. You should always call us before arranging or receiving Treatment to check that you
will be covered. The number to call us on can be found on your Membership Certificate.
6. All Treatment must be carried out in a Recognised Facility in the UK, and provided by a
Consultant, medical practitioner or healthcare professional who is recognised by us for
the Treatment you need on the date you receive that Treatment, unless we specifically
authorise otherwise in a particular case. For example we may pay Consultants’ fees
for Eligible Treatment in a treatment facility that is not recognised by us when your
proposed Treatment cannot take place in a Recognised Facility for medical reasons.
However, you will need our agreement before the Treatment is received and we need
full details from your Consultant before we can give our decision.
Page 6 Section one: Eligible treatment, benefits and limitations
You can ask us whether at the time of your Treatment:
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a facility is a Recognised Facility
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a practitioner is a Recognised Practitioner
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a Consultant, medical practitioner or healthcare professional is recognised by us
for remote consultations.
You can also access these details at finder.bupa.co.uk
7. If the Treatment you need is not available in the UK and would have been Eligible
Treatment except for it not being available in the UK, we will pay you a contribution
up to the cost that we would have paid to you to have the standard alternative
Treatment available in the UK. Before the Treatment starts you must have our written
confirmation that these criteria have been met and we need full clinical details from
your Consultant, including confirmation that the Treatment is not available in the
UK, before we can determine this. You will need to settle the claim direct to the
medical provider or treatment facility yourself and submit your receipts to us before
we reimburse you up to the level of the standard Treatment available in the UK.
(See General Exclusion GE14 Experimental Drugs and Treatment.)
8. There must be a Consultant with overall responsibility for your Treatment, unless you
are referred by:
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a Consultant
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our Direct Access service (see paragraph 2.2 in the Claiming section of this
booklet for details of the Direct Access service)
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a GP (including via a digital GP service), or
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another healthcare practitioner (the situations in which we will accept such
a referral are set out on bupa.co.uk/referrals)
for Out-patient Treatment carried out by a Consultant, Therapist, Mental Health and
Wellbeing Therapist or other Recognised Practitioner.
9. We do not pay for Treatment of Chronic Conditions. However, we will pay for
Eligible Treatment for an unexpected flare-up of acute symptoms of a Chronic
Condition if the Treatment is likely to lead quickly to a complete recovery rather than
prolonged Treatment. We do not pay for Treatment required due to the expected
deterioration or flare up of a Chronic Condition. This includes conditions which have
a relapsing-remitting nature and require management of recurrent flare-ups, for
example, inflammatory bowel disease. In such cases, the flare-ups are an expected
part of the normal course of the illness and therefore we do not consider them as
acute complications of the disease.
See General Exclusion GE5 Chronic Conditions.
10. Information about cover for children aged 17 or under: Some private hospitals do
not provide services for children or have restricted services available for children,
so Treatment may be oered at an NHS hospital. You can ask us about Recognised
Facilities where paediatric services are available or you can find them on
finder.bupa.co.uk
Where In-patient or Day-patient Eligible Treatment is required, children are likely to
be treated in a general children’s ward. This is in line with good paediatric practice.
Section one: Eligible treatment, benefits and limitations Page 7
Benefit B1 Out-patient Treatment
This benefit B1 explains the type of charges we pay for Out-patient Treatment.
We will pay for Out-patient Treatment at home when recommended by your treatment
provider or oered by us. We only pay if your treatment provider is recognised by us for
Treatment at home.
Benefit B1.1 Out-patient Consultations
Included Eligible Treatment
Consultants’ fees for Out-patient consultations as part of Eligible Treatment.
Remote consultations by telephone or via any other remote medium with a Consultant recognised by us to
carry out remote consultations.
Excluded Treatment
See General Exclusion GE5 Chronic Conditions
Benefit B1.2 Out-patient Therapies
Included Eligible Treatment
Therapists’ fees for Out-patient Eligible Treatment.
Remote consultations by telephone or via any other remote medium with a Therapist or Recognised
Practitioner, recognised by us to carry out remote consultations.
Provider charges for Out-patient Treatment which is related to and is an integral part of your Out-patient
Treatment including Recognised Facility charges for Prostheses or Appliances needed as part of that
Out-patient Treatment. We treat these charges as falling under this Benefit B1.2.
Therapists’ fees for Out-patient Eligible Treatment for short-term speech therapy when it is part of Eligible
Treatment, eg after a stroke and takes place during or immediately following the Eligible Treatment.
The speech therapy must be provided by a Therapist who is a member of the Royal College of Speech
and Language Therapists.
Excluded Treatment
See General Exclusion GE23 Speech Disorders
Benefit B1.3 Out-patient Diagnostic Tests
Included Eligible Treatment
When requested by a GP or Consultant as part of Out-patient Eligible Treatment, Recognised Facility charges
or charges from Consultants recognised to carry out Out-patient diagnostic tests and their interpretation.
Benefit B1.4 Out-patient MRI, CT and PET Scans
When requested by your Consultant to help assess your Acute Condition, Recognised Facility charges for
MRI, CT and PET scans and their interpretation.
Page 8 Section one: Eligible treatment, benefits and limitations
Benefit B1.5 Out-patient Complementary Medicine
Included Eligible Treatment
We pay Complementary Medicine Practitioners’ fees up to the maximum annual benefit limit shown on
your Membership Certificate.
Excluded Treatment
We do not pay for any complementary or alternative products, preparations or remedies.
See General Exclusion GE13 Drugs and Dressings for Out-patient or Take-Home Use and Complementary
and Alternative Products.
Benefit B2 Treatment In Hospital
Benefit B2.1 Consultants’ Fees for Day-patient and In-patient Treatment and Out-patient
Surgical Operations
Included Eligible Treatment
Consultant surgeons’ and Consultant anaesthetists’ fees for Eligible Surgical Operations. Consultant
physicians’ fees for Eligible Treatment that does not include a Surgical Operation or Cancer Treatment.
Consultant physicians’ fees for the supervision of Chemotherapy or radiotherapy.
While we do not pay for Treatment of Chronic Conditions, we will pay for Eligible Surgical Operations for an
unexpected flare-up of acute symptoms of a Chronic Condition, if the Treatment is likely to lead quickly to a
complete recovery rather than prolonged Treatment.
If your Treatment includes an Eligible Surgical Operation, we only pay Consultant physician’s fees if the
attendance of the physician is medically necessary for the operation.
Where the Treatment is Eligible Treatment for Cancer, your Membership Certificate must state that Eligible
Treatment for Cancer is included.
Excluded Treatment
See General Exclusion GE5 Chronic Conditions
See General Exclusion GE9 Cosmetic, Reconstructive or Weight Loss Treatment
Benefit B2.2 Dental/Oral Surgical Treatment
This benefit cannot be claimed at the same time as Benefit A4.1
Included Eligible Treatment
An Eligible Surgical Operation carried out by a Consultant to:
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treat a jaw bone cyst, but not if it is related to a cyst or abscess on the tooth root or any other tooth or gum
disease or damage
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remove a complicated, buried or impacted tooth root, which is causing infection or pain eg an impacted
wisdom tooth, but not if the purpose is to facilitate dentures.
When this benefit is payable we pay on the same basis and up to the same limits as for other Eligible
Treatment under Benefits B1, B2, B3, B6 and B7.
Excluded Treatment
See General Exclusion GE11 Dental/Oral Treatment
Section one: Eligible treatment, benefits and limitations Page 9
Benefit B2.3 Dialysis
Included Eligible Treatment
Eligible Treatment for short-term kidney dialysis or peritoneal dialysis:
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if the dialysis is needed temporarily for sudden kidney failure resulting from a disease, illness or injury
aecting another part of your body, or
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you need this immediately before or after a kidney transplant.
When this benefit is payable we pay on the same basis and up to the same limits as for other Eligible
Treatment under Benefits B1, B2, B3, B6 and B7.
Excluded Treatment
See General Exclusion GE12 Dialysis
Benefit B2.4 Eyesight
Included Eligible Treatment
Eligible Treatment for your eyesight if it is needed as a result of an injury or an Acute Condition, such as a
detached retina.
Eligible Treatment for cataract surgery using ultrasonic emulsification.
When this benefit is payable we pay on the same basis and up to the same limits as for other Eligible
Treatment under Benefits B1, B2, B3, B6 and B7.
Excluded Treatment
See General Exclusion GE15 Eyesight
Benefit B2.5 Pregnancy and Childbirth
Included Eligible Treatment
Eligible Treatment of the following conditions:
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miscarriage or when the foetus has died and remains with the placenta in the womb
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stillbirth
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hydatidiform mole (abnormal cell growth in the womb)
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foetus growing outside the womb (ectopic pregnancy)
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heavy bleeding in the hours and days immediately after childbirth (post-partum haemorrhage)
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afterbirth left in the womb after delivery of the baby (retained placental membrane)
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complications following any of the above conditions.
Eligible Treatment of the member (mother) that relates to pregnancy or childbirth but only if:
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the Treatment is required due to a flare-up of the medical condition, and
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the Treatment is likely to lead quickly to a complete recovery or to you being restored fully to your state of
health prior to the flare-up of the condition without you needing to receive prolonged Treatment.
When this benefit is payable we pay on the same basis and up to the same limits as for other Eligible
Treatment under Benefits B1, B2, B3, B6 and B7.
Excluded Treatment
See General Exclusion GE20 Pregnancy and Childbirth
Page 10 Section one: Eligible treatment, benefits and limitations
Benefit B2.6 Cosmetic or Reconstructive Treatment
Included Eligible Treatment
An Eligible Surgical Operation for an excision of a lesion if any of the following criteria are met:
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a biopsy or clinical appearance indicates that disease is present
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the lesion obstructs one of your special senses (vision/ smell/ hearing) or causes pressure on other organs, or
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the lesion stops you from performing the Activities of Daily Living.
Before any Treatment starts you must have our confirmation that one of the above criteria has been met
and we need full clinical details from your Consultant before we can determine this. If benefits are payable
they are dealt with in the same way as for other Eligible Treatment under Benefits B1, B2, B3, B6 and B7.
Eligible Surgical Operations to restore the appearance of the specific part of your body that has
been aected:
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by an accident, or
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if your Benefits include cover for Cancer Treatment, as a direct result of surgery for Cancer, or eligible
prophylactic surgery (as explained in Benefit B4.1.3 Out-patient Diagnostic Tests for Cancer).
When both of the following apply:
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it is part of the original Eligible Treatment resulting from the accident, Cancer surgery or prophylactic surgery,
(as explained in Benefit B4.1.3 Out-patient Diagnostic Tests for Cancer)
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the accident, Cancer surgery or the prophylactic surgery took place during your current continuous period
under a Bupa scheme that includes Benefits for this type of Treatment
– the current continuous period may include being a member of another Bupa scheme and/or a beneficiary
of a trust administered by Bupa, as long as there has been no break in your cover.
Eligible Surgical Operations to restore appearance include those for the purposes of symmetry (eg surgery
to a healthy breast to make it match a breast reconstructed following cancer surgery). Once the initial
Eligible Treatment to restore your appearance is complete (including delayed surgery, such as delayed
breast reconstructions) we do not pay for repeat surgeries or reconstructions, or further Treatment to
restore or amend your appearance.
Before any Treatment starts you must have our confirmation that the above criteria have been met and we
need full clinical details from your Consultant before we can determine this. When this benefit is payable
we pay on the same basis and up to the same limits as for other Eligible Treatment under Benefits B1, B2,
B3, B6 and B7 and for Cancer Treatment B4.
We do not pay for more than the one course/one set of Eligible Surgical Operations or for repeat
cosmetic procedures.
Excluded Treatment
See General Exclusion GE9 Cosmetic, Reconstructive or Weight Loss Treatment
Benefit B3 Recognised Facility Charges
Benefit B3.1 Out-patient Surgical Operations
Included Eligible Treatment
Recognised Facility charges for Out-patient Eligible Surgical Operations.
This includes theatre use, equipment, Common Drugs, Advanced Therapies, Specialist Drugs and surgical
dressings used during the operation.
Section one: Eligible treatment, benefits and limitations Page 11
Benefit B3.2 Day-patient and In-patient Treatment
Included Eligible Treatment
Recognised Facility charges for Day-patient and In-patient Treatment including Eligible Surgical Operations.
Benefit B3.2.1 Accommodation
Included Eligible Treatment
Recognised Facility accommodation including your meals and refreshments while you are receiving
Eligible Treatment.
Excluded Treatment
Exclusion of Accommodation
We do not pay for:
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personal items such as telephone calls, newspapers, personal laundry, or guest meals and refreshments
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accommodation charges for an overnight stay or a bed if:
– the charge is for an overnight stay for Treatment that would normally be carried out as Out-patient or
Day-patient Treatment
– the charge is for the use of a bed for Treatment that would normally be Out-patient Treatment
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the accommodation itself if it is primarily used for:
– convalescence, rehabilitation, supervision or other purposes which are not Eligible Treatment
– general nursing care or other services which could be provided in a nursing home or other establishment
which is not a Recognised Facility
– services from a Therapist, Complementary Medicine Practitioner or Mental Health and Wellbeing Therapist.
Benefit B3.2.2 Parent Accommodation
Included Eligible Treatment
Accommodation for one parent, each night they need to stay in the Recognised Facility with their child.
The child must be a member receiving In-patient Eligible Treatment and the amount will count towards any
limits applicable to the child’s relevant Benefit.
Excluded Treatment
Exclusion of Parent Accommodation
We do not pay if the child is aged 18 or over.
Benefit B3.2.3 Theatre Charges, Nursing Care, Drugs and Surgical Dressings
Included Eligible Treatment
When essential for Day-patient Treatment or In-patient Treatment, operating theatre and nursing care
charges, Common Drugs, Advanced Therapies, Specialist Drugs and surgical dressings.
Excluded Treatment
Exclusion of Extra Nursing Services
We do not pay for extra nursing services in addition to those that the Recognised Facility would usually
provide for normal patient care, without extra charge.
Page 12 Section one: Eligible treatment, benefits and limitations
Benefit B3.2.4 Intensive Care
Included Eligible Treatment
Intensive care needed as an essential part of your private Eligible Treatment when it is required routinely by
patients undergoing the same type of Treatment as yours and:
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you are receiving your Eligible Treatment in a Recognised Facility equipped with a Critical Care Unit, and
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the intensive care is carried out in that Critical Care Unit.
Intensive care needed as part of your Eligible Treatment when unforeseen circumstances arise from
a medical or surgical procedure that does not routinely require intensive care is only covered when you
are receiving your Eligible Treatment in a Recognised Facility and either:
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the Recognised Facility is equipped with a Critical Care Unit, and your intensive care is carried out in that
Critical Care Unit, or
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the Recognised Facility is not equipped with a Critical Care Unit but has a prior agreement with us to follow
an emergency protocol agreed with another Recognised Facility that is equipped with a Critical Care Unit,
which is either adjacent or is part of the same group of companies, and you are transferred under that prior
emergency protocol and your intensive care is carried out in that Critical Care Unit.
In these circumstances your Consultant or Recognised Facility should contact us at the earliest opportunity.
If you want to transfer your care from an NHS hospital, or a self-funded stay, to a private Recognised Facility,
we only pay if all of the following conditions are met:
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you have been discharged from a critical care unit to a general ward for more than 24 hours, and
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it is agreed by both your referring and receiving consultants that it is clinically safe and appropriate to
transfer your care, and
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we have confirmed that your Treatment is Eligible Treatment.
We need full clinical details from your Consultant before we can give our decision.
Excluded Treatment
See General Exclusion GE17 Intensive Care
Benefit B3.2.5 Diagnostic Tests and MRI, CT and PET Scans
Included Eligible Treatment
When recommended by your Consultant as part of Day-patient or In-patient Treatment, we pay Recognised
Facility charges for:
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diagnostic tests
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MRI, CT and PET Scans.
Section one: Eligible treatment, benefits and limitations Page 13
Benefit B3.2.6 Therapies
Included Eligible Treatment
Recognised Facility charges for Eligible Treatment provided by Therapists, when necessary as part of your
Day-patient or In-patient Treatment.
Recognised Facility charges for short-term speech therapy when it is part of Eligible Treatment, eg after a
stroke and takes place during or immediately following the Eligible Treatment. The speech therapy must be
provided by a Therapist who is a member of the Royal College of Speech and Language Therapists.
Excluded Treatment
See General Exclusion GE23 Speech Disorders
Benefit B3.2.7 Prostheses and Appliances
Included Eligible Treatment
Recognised Facility charges for the provision of Prostheses or Appliances reasonably necessary as part of
Eligible Treatment as a Day-patient or In-patient.
By Prostheses and Appliances we mean any of those on our lists of prostheses and appliances for the
relevant Benefit and type of Treatment at the time of the Eligible Treatment. The lists will change from time
to time. Details are available on request or at bupa.co.uk/prostheses-and-appliances
Excluded Treatment
Exclusion of Prostheses and Appliances
We do not pay for any further Treatment which is associated with or related to Prostheses or Appliances
such as maintenance, refitting or replacement when you do not have acute symptoms that are directly
related to that Prosthesis or Appliance.
See General Exclusion GE19 Physical aids and Devices
Benefit B4 Cancer Treatment
Benefit B4.1 Cancer Cover
You are only covered for this benefit after a diagnosis of Cancer has been confirmed.
In addition to Benefits B4.1.1 to B4.1.5, fees and charges for Eligible Treatment for Cancer are paid on the
same basis as Eligible Treatment for other conditions as set out in Benefits B1.4, B2, B3, B6 and B7.
Benefit B4.1.1 Out-patient Consultations for Cancer
Included Eligible Treatment
Consultants’ fees for Out-patient consultations as part of Eligible Treatment for Cancer.
Remote consultations by telephone or via any other remote medium with a Consultant recognised by us to
carry out remote consultations.
Recognised Practitioner charges for clinical reviews we may request to establish the eligibility of Treatment.
Page 14 Section one: Eligible treatment, benefits and limitations
Benefit B4.1.2 Out-patient Therapies and Treatment for Cancer
Included Eligible Treatment
Therapists’ fees for Out-patient Eligible Treatment for Cancer.
Remote consultations by telephone or via any other remote medium with a Therapist or Recognised
Practitioner recognised by us to carry out remote consultations.
Benefit B4.1.3 Out-patient Diagnostic Tests for Cancer
Included Eligible Treatment
When requested by a GP or Consultant as part of Out-patient Eligible Treatment for Cancer, we pay
Recognised Facility charges or charges from Consultants recognised to carry out Out-patient diagnostic
tests and their interpretation.
If you are being treated for Cancer and have a strong direct family history of Cancer, we pay for a
genetically-based test to evaluate future risk of developing further cancers, if recommended by your
Consultant. If the test shows you are at high risk of developing further cancers we pay for prophylactic
surgery, if recommended by your Consultant. We will pay for reconstructive surgery following eligible
prophylactic surgery as set out in Benefit B2.6 Cosmetic or Reconstructive Treatment.
Before you have any tests, procedures or Treatment you must have our written confirmation that the above
criteria have been met and we will need full clinical details from your Consultant before we can determine this.
Excluded Treatment
See General Exclusion GE21 Screening, Monitoring and Preventive Treatment
Benefit B4.1.4 Out-patient Cancer Drugs
Included Eligible Treatment
We pay Recognised Facility charges for Common Drugs, Advanced Therapies and Specialist Drugs, related
specifically to planning and providing Out-patient Eligible Treatment for Cancer either:
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when they can only be dispensed by a hospital and are not available from a GP, or
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when they are available from a GP and you are prescribed an initial small supply on discharge from the
Recognised Facility to enable you to start your Treatment straight away.
Excluded Treatment
We do not pay for any Common Drugs, Advanced Therapies and Specialist Drugs that are otherwise
available from a GP or are available to purchase without a prescription. We do not pay for any
complementary, homeopathic or alternative products, preparations or remedies for Treatment of Cancer.
See General Exclusions GE13 Drugs and Dressings for Out-patient or Take-Home Use and Complementary
and Alternative Products and GE14 Experimental Drugs and Treatment
Section one: Eligible treatment, benefits and limitations Page 15
Benefit B4.1.5 Experimental Drug Treatment for Cancer
Included Eligible Treatment
We pay for experimental drug Treatment for Cancer subject to the following criteria:
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the use of this drug Treatment follows an unsuccessful initial licensed Treatment where available, and
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you speak regularly to our nurse, as we may reasonably require in order to allow us to eectively monitor
your Treatment and provide support, and
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the drug Treatment has been agreed by a multidisciplinary team that meets the NHS Cancer Action Team
standards defined in The Characteristics of an Eective Multidisciplinary Team (MDT), and
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for the proposed Treatment we are provided with an MDT report, which includes one of the following:
– evidence that the drug Treatment has been found to have likely benefit on your condition through a
predictive genetic test where appropriate/available, or
– evidence that the drug has had a health technology assessment with a positive outcome and there is
a European Medicines Agency (EMA) licence for the drug with the drug being used within its licensed
protocol, or
– evidence that at least one NHS/National Comprehensive Cancer Network (NCCN)/European Society for
Medical Oncology (ESMO) protocol exists, with supporting phase III clinical trial evidence, for your exact
condition (ie the specific indication including tumour type, staging and phase of Treatment if relevant), or
– evidence that the drug Treatment has published phase III clinical trial results showing that it is safe and
eective for your condition.
Before starting this type of Treatment you must have our confirmation that the above criteria have been
met and we need full clinical details from your Consultant before we can determine this.
Excluded Treatment
See General Exclusion GE14 Experimental Drugs and Treatment
Benefit B4.1.6 Out-patient Complementary Medicine Treatment for Cancer
Included Eligible Treatment
We pay Complementary Medicine Practitioners’ fees for Out-patient Treatment for Cancer when you are
referred for the Treatment by a GP or Consultant.
Excluded Treatment
We do not pay for any complementary or alternative products, preparations or remedies.
See General Exclusion GE13 Drugs and Dressings for Out-patient or Take-Home Use and Complementary
and Alternative Products
Page 16 Section one: Eligible treatment, benefits and limitations
Benefit B4.2 NHS Cancer Cover Plus
Included Eligible Treatment
We pay for Eligible Treatment for Cancer if:
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the radiotherapy, Chemotherapy, drug therapy or Surgical Operation you need to treat your Cancer is not
available to you from the NHS, and
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what is not available to you from the NHS does not consist solely of supportive medicines for Cancer or
diagnostic tests or investigations, and
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you receive your Treatment for Cancer in a Recognised Facility.
Where the conditions set out above do apply, we pay for your Eligible Treatment for Cancer as set out in
Benefit B4.1 and cash benefits CB2.4 and CB2.5.
If you have cover for NHS Cash benefits CB2.1, CB2.2 and CB2.3
If the above criteria apply and you have Eligible Treatment for Cancer as set out in benefit 4.1 but have part
of your Cancer Treatment provided under the NHS we pay NHS Cash Benefits as set out in benefit CB2.1,
CB2.2 and CB2.3 for that part of your Cancer Treatment received in the NHS if it would otherwise have been
covered under your Benefits for private Treatment.
Benefit B5 Mental Health Treatment
We pay for Mental Health Treatment as set out in this Benefit B5. Your Mental Health
Treatment must be provided by a Consultant psychiatrist or a Mental Health and
Wellbeing Therapist.
We do not pay for Treatment of dementia, behavioural or developmental conditions.
Cover is subject to the limits shown on your Membership Certificate.
Benefit B5.1 Out-patient Mental Health Treatment
Included Eligible Treatment
We pay Consultant psychiatrists’ and Mental Health and Wellbeing Therapists’ fees and Recognised Facility
charges for Mental Health Treatment as listed.
Benefit B5.1.1 Out-patient Consultations and Treatment for Mental Health Conditions
Included Eligible Treatment
Consultant psychiatrists’ fees for Out-patient consultations as part of Eligible Treatment of a Mental Health
Condition and for Out-patient Mental Health Treatment.
Remote consultations by telephone or via any other remote medium with a Consultant psychiatrist
recognised by us to carry out remote consultations.
Section one: Eligible treatment, benefits and limitations Page 17
Benefit B5.1.2 Out-patient Mental Health and Wellbeing Therapies
Included Eligible Treatment
Mental Health and Wellbeing Therapists’ fees for Out-patient Eligible Treatment for a mental health condition.
Access to an online supported therapy programme/service. The online therapy is based on guided self-help
and you must use the online programme/service we direct you to.
Remote consultations by telephone or via any other remote medium with a Mental Health and Wellbeing
Therapist recognised by us to carry out remote consultations.
Benefit B5.1.3 Out-patient Diagnostic Tests for Mental Health Conditions
Included Eligible Treatment
When requested by a GP or Consultant to help determine or assess your condition as part of Out-patient
Mental Health Treatment, Recognised Facility charges for diagnostic tests and interpretation of the results.
We pay for eligible diagnostic tests to rule out attention deficit hyperactivity disorder (ADHD) and autistic
spectrum disorder (ASD) when a Mental Health Condition is suspected. You must have our confirmation
before any diagnostic tests are carried out that the above criterion has been met and we need full clinical
details from your Consultant before we can determine this.
Excluded Treatment
MRI, CT and PET Scans are not paid under this Benefit – see Benefit B1.4
See General Exclusion GE18 Learning Diculties, Behavioural and Developmental Conditions
Benefit B5.2 Day-patient and In-patient Mental Health Treatment
Included Eligible Treatment
Consultant psychiatrists’ fees and Recognised Facility charges for Mental Health Day-patient Treatment and
In-patient Mental Health Treatment.
We pay the type of Recognised Facility charges referred to in Benefit B3.2.
Your Membership Certificate shows the maximum number of days that we will pay for in relation to Mental
Health Day-patient Treatment and In-patient Mental Health Treatment.
We only pay for one addiction Treatment programme in your lifetime of being covered under a Bupa
health insurance policy and/or a beneficiary of a Bupa administered trust. This applies to all Bupa health
insurance policies and/or Bupa administered trusts that you have been covered under and/or a beneficiary
of in the past or may be in the future, whether your being covered under a health insurance policy and/or
your being a beneficiary under a trust is continuous or not. By addiction Treatment programme we mean
a period of Eligible Treatment carried out as In-patient Mental Health Treatment and/or Mental Health
Day-patient Treatment for the Treatment of substance related addictions or substance misuse, including
detoxification programmes.
Page 18 Section one: Eligible treatment, benefits and limitations
Benefit B5.3 Treatment otherwise excluded by General Exclusions
We pay for Mental Health Treatment of mental health symptoms related to or arising from a condition for
which Treatment is otherwise excluded by the following General Exclusions in the ‘General Exclusions:
What is not covered’ section of this membership guide:
General Exclusion GE1 Ageing, Menopause and Puberty
General Exclusion GE2 Accident and Emergency Treatment
General Exclusion GE3 Allergies, Allergic Disorders or Food Intolerances
General Exclusion GE4 Birth Control, Conception and Sexual Problems
General Exclusion GE5 Chronic Conditions
General Exclusion GE9 Cosmetic, Reconstructive or Weight Loss Treatment
General Exclusion GE10 Deafness
General Exclusion GE12 Dialysis
General Exclusion GE15 Eyesight
General Exclusion GE18 Learning Diculties, Behavioural and Developmental Conditions
General Exclusion GE20 Pregnancy and Childbirth
General Exclusion GE21 Screening, Monitoring and Preventive Treatment
General Exclusion GE22 Sleep Problems and Disorders
General Exclusion GE23 Speech Disorders
General Exclusion GE26 Gender Dysphoria or Gender Armation
General Exclusion GE27 Varicose Veins of the Legs
Benefit B6 Home Nursing after Private Eligible Treatment as an In-Patient
Benefit B6 Home Nursing after Private Eligible Treatment as an In-patient
Included Eligible Treatment
Home nursing where:
J
it is Eligible Treatment
J
it is needed for medical reasons and not domestic or social reasons
J
it starts immediately after you leave a Recognised Facility
J
it is necessary so that without it you would have to remain in the Recognised Facility
J
it is provided by a nurse in your own home, and
J
it is carried out under the supervision of your Consultant.
The nurse must be a qualified nurse on the register of the Nursing and Midwifery Council.
You must have our written confirmation before the home nursing starts that the above criteria have been
met and we need full clinical details from your Consultant before we can determine this.
Excluded Treatment
Exclusion of Home Nursing
We do not pay for home nursing provided by a community psychiatric nurse.
Section one: Eligible treatment, benefits and limitations Page 19
Benefit B7 Private Ambulance Charges
Benefit B7 Private Ambulance Charges
Included Eligible Treatment
Travel by private road ambulance if you need private Day-patient or In-patient Eligible Treatment and an
ambulance is medically necessary for travel:
J
from your home, place of work, or an airport or sea port, to a Recognised Facility
J
between Recognised Facilities if you are moved for In-patient Treatment
J
from a Recognised Facility to home.
Benefit B8 Treatment at Home
Benefit B8 Treatment at Home
This benefit applies when you receive Eligible Treatment at home where this would otherwise require
In-patient Treatment or Day-patient Treatment or Chemotherapy as an Out-patient. We will only consider
Treatment at home if all the following apply:
J
your Consultant has recommended that you receive the Treatment at home and remains in overall charge of
your Treatment
J
if you did not have the Treatment at home then, for medical reasons, you would need to receive In-patient
Treatment or Day-patient Treatment or Chemotherapy as an Out-patient and
J
the Treatment is provided to you by a Medical Treatment Provider on our list for the type of Treatment at
home you need. These providers and the type of Treatment we recognise them for may change from time to
time. You can ask us whether a Treatment provider is on our list and the type of Treatment we recognise
them for or you can access these details at finder.bupa.co.uk
Before your Treatment at home starts you must have our confirmation that the above criteria have been
met and we need full details from your Consultant before we can determine this.
We do not pay for any fees or charges for Treatment at home that has not been provided to you by the
Medical Treatment Provider. You are covered on the same basis as set out in benefits 2 and 3. This benefit
does not apply to Out-patient Treatment which takes place at home as explained in benefit 1.
Benefit B9 Active Cover/Fit And Active Cover
Benefit B9 Active Cover/Fit and Active Cover
Included Eligible Treatment
You should contact us to find out if your condition is a muscle, joint or bone condition.
We pay for Eligible Treatment you require after your muscle, joint or bone condition has been diagnosed
and that is for or related to the diagnosed muscle, joint or bone condition.
We pay for Eligible Treatment for a muscle, joint or bone condition on the same basis as set out in Benefits
B1, B2, B3, B6, B7 and CB1 for Acute Conditions.
Excluded Treatment
We do not pay for any Treatment that is not related to a muscle, joint or bone condition under this benefit.
Page 20 Section one: Eligible treatment, benefits and limitations
Benefit B10 Fitness Check
Benefit B10 Fitness Check
Included Eligible Treatment
We will pay for one Fitness Check to be undertaken at a Bupa Health Centre for you each Year.
The Fitness Check is an assessment of cardiovascular fitness, including a:
J
range of tests
J
fitness consultation with an exercise physiologist
J
cardio-respiratory report, and
J
health and fitness report with action plan.
Further details are available from us on request.
Please note: A Fitness Check is not appropriate for people with certain medical conditions or who are
currently taking particular medications. You should contact us before booking a Fitness Check to confirm
that you are able to undergo it. We can provide information about those people who should not undergo a
Fitness Check.
Benefits CB Cash Benefits
Benefit CB1 NHS Cash Benefits for NHS In-patient Treatment
Included Eligible Treatment
If you receive free NHS In-patient Treatment which we would have covered for private In-patient Treatment,
we pay NHS Cash Benefit for each night you are in the NHS hospital.
Excluded Treatment
We do not pay this NHS Cash Benefit when your admission and discharge occur on the same date.
We do not pay for any additional charges by the hospital (eg for amenities) where your Treatment is
provided free under the NHS.
Except for NHS Cash Benefit for oral drug Treatment for Cancer in Benefit CB2.3 we do not pay this
Benefit CB1 at the same time as any other NHS Cash Benefit for NHS In-patient Treatment.
Benefit CB2.1 NHS Cash Benefit for NHS In-patient Cancer Treatment
Included Eligible Treatment
We pay NHS Cash Benefit for each night you receive NHS In-patient Treatment for Cancer when it includes
one of the following:
J
radiotherapy
J
Chemotherapy
J
a surgical operation
J
a blood transfusion
J
a bone marrow or stem cell transplant.
We only pay if your Treatment would otherwise have been covered for private In-patient Treatment under
your Benefits and is provided to you free under the NHS.
Excluded Treatment
We do not pay for any additional charges by the hospital (eg for amenities) where your Treatment is
provided free under the NHS.
Except for NHS Cash Benefit for oral drug Treatment for Cancer in Benefit CB2.3 we do not pay this
Benefit CB2.1 at the same time as any other NHS Cash Benefit for NHS In-patient Treatment.
Section one: Eligible treatment, benefits and limitations Page 21
Benefit CB2.2 NHS Cash Benefit for NHS Out-patient, Day-patient and Home Cancer Treatment
Included Eligible Treatment
If you receive free NHS Cancer Treatment carried out as Out-Patient Treatment, Day-Patient Treatment or in
your home which we would have covered for private Out-Patient or Day-Patient Treatment or Treatment at
home we pay this NHS Cash Benefit for:
J
each day you receive radiotherapy including proton beam therapy in a hospital setting
J
each day you receive Chemotherapy, other than Oral Chemotherapy
J
the day on which you undergo a Surgical Operation that is Eligible Treatment for Cancer.
Excluded Treatment
Except for NHS Cash Benefit for oral drug treatment for Cancer as set out in CB2.3 this benefit CB2.2 is:
J
not payable at the same time as any other NHS Cash Benefit for NHS Treatment and
J
only payable once, even if you have more than one Eligible Treatment on the same day.
Benefit CB2.3 NHS Cash Benefit for Oral Drug Treatment for Cancer
Included Eligible Treatment
We pay NHS Cash Benefit for each three-weekly interval, or part thereof, during which to take:
J
Oral Chemotherapy, or
J
oral anti-hormone therapy that is not available from a GP.
We pay this benefit CB2.3 at the same time as another NHS Cash Benefit you may be eligible for under
your Benefits on the same day.
We only pay if your Treatment would otherwise have been covered for private treatment under your Benefits
and is provided to you free under the NHS.
Benefit CB2.4 Cash Benefit for Wigs or Hairpieces
Included Eligible Treatment
We pay this cash benefit for a wig or hairpiece if you experience hair loss during Eligible Treatment for
Cancer. This benefit is paid once per Cancer occurrence.
If benefit B4.2 NHS Cancer Cover Plus applies to your Benefits, we pay this cash benefit as set out in
benefit B4.2.
Benefit CB2.5 Cash Benefit for Mastectomy Bras
Included Eligible Treatment
We pay this cash benefit for mastectomy bras and prostheses following an Eligible Surgical Operation
involving a mastectomy procedure where a reconstruction is not performed at the same time. This benefit
is paid once per mastectomy surgery.
If benefit B4.2 NHS Cancer Cover Plus applies to your Benefits, we pay this cash benefit as set out in
benefit B4.2.
Page 22 Section one: Eligible treatment, benefits and limitations
Benefit CB3 Procedure Specific NHS Cash Benefit
Included Eligible Treatment
We pay Procedure Specific NHS Cash Benefit in relation to certain specific Treatment provided to you
free of charge under the NHS. We only pay Procedure Specific NHS Cash Benefit if your Treatment would
otherwise have been covered for private Treatment under your Benefits. We pay your Procedure Specific
NHS Cash Benefit directly to the Main Member. For information on Procedure Specific NHS Cash Benefits
please contact us or go to bupa.co.uk/pscb. These cash benefits may change from time to time.
Excluded Treatment
We do not pay for any additional charges by the hospital (eg for amenities) where your Treatment is
provided free under the NHS.
Except for NHS Cash Benefit for oral drug Treatment for Cancer as set out in CB2.3 we do not pay this
Benefit CB3 at the same time as any other NHS Cash Benefit for NHS In-patient Treatment.
Benefits A Add-ons
At renewal if these Add-ons no longer meet your current needs, you can change or
cancel them without cancelling your main product. If you do change or cancel any of
these benefits your ability to claim for them will also change. It may also change your
total monthly and annual payment for cover.
Benefits A1, A2 and A3 do not apply to your cover
Benefit A4 Dental Cover
Included Eligible Treatment
Your Membership Certificate shows if you have Dental Cover 20.
Excluded Treatment
We do not pay for:
J
any Pre-existing Condition
J
Orthodontic Treatment
J
Surgical Implants or any Dental Treatment involving or making use of or in any way related
to Surgical Implants
J
mouthguards
J
any Dental Treatment not normally provided by Dental Professionals in the UK
J
the replacement of a prosthetic appliance (any artificial aid used to restore dentition):
– which has been lost or stolen
– which could have been repaired according to generally accepted dental standards (except dentures)
– within five years of it having been fitted
J
any Dental Treatment resulting from or related to any injury sustained whilst participating in a physical
contact sport such as rugby or boxing
J
any Dental Treatment or care resulting from or related to a deliberately self-inflicted injury
J
self-administered drugs such as antibiotics and painkillers or prescription charges.
Section one: Eligible treatment, benefits and limitations Page 23
Benefit A4.1 Dental Cover 20
This benefit cannot be claimed at the same time as Benefit B2.2 for the same Treatment
Included Eligible Treatment
We pay the proportion shown on your Membership Certificate of the amount you pay (up to the maximum
annual benefit limit also shown on your Membership Certificate) for:
J
Dental Treatment
J
Dental Injury Treatment
J
Emergency Dental Treatment
J
Routine Dental Treatment
which you receive in a Year.
We pay for Emergency Dental Treatment:
J
carried out during your initial appointment for the dental emergency, and
J
for the same dental emergency carried out at one subsequent appointment, but we only pay if the Treatment
is medically essential in order to complete the Emergency Dental Treatment started in the initial appointment.
Excluded Treatment
We do not pay for any Dental Injury Treatment arising as a direct or indirect result of an external impact
which occurred before the date you started your current continuous period of cover for this Benefit A4.1
or outside the UK.
Benefit A4.2 does not apply to your cover
Benefit A4.3 Oral Cancer Treatment for Dental Cover 20 only
Included Eligible Treatment
For Oral Cancer Treatment we pay on the same basis as set out in Benefit 4.1.
Excluded Treatment
We do not pay for any Oral Cancer Treatment received by you if the oral Cancer was diagnosed before the
date you started your current continuous period of cover for this Benefit A4.3 (or any Bupa dental scheme
which included cover for those types of Treatment).
Page 24 Section one: Eligible treatment, benefits and limitations
General Exclusions: What is not covered
General Exclusion GE1 Ageing, Menopause and Puberty
Excluded Treatment
Treatment to relieve symptoms commonly associated with any bodily change arising from a physiological or
natural cause, such as ageing, menopause or puberty and not due to any underlying disease, illness or injury.
For example, we do not pay for the Treatment of acne arising from natural hormonal changes.
Exception
We pay for Eligible Treatment of an Acute Condition that you develop during menopause, such as heavy
bleeding (menorrhagia) or urinary incontinence subject to the other policy terms.
General Exclusion GE2 Accident and Emergency Treatment
Excluded Treatment
J
Treatment, including immediate care, received during a visit to an NHS or private accident and emergency
(A&E) department, urgent care centre or walk in clinic.
J
Treatment received following an admission via an NHS or private A&E department, urgent care centre
or walk-in clinic until after you are referred by a Consultant for Eligible Treatment in a Recognised Facility.
In these circumstances, before you receive any Treatment, you should contact us as soon as reasonably
possible to confirm whether your Treatment is covered under your Benefits as you are responsible for any
costs you incur that are not covered under your Benefits.
Please also see ‘Benefit 3.2.4 Intensive Care’ in the section Benefits and ‘Exclusion GE17 Intensive Care
(other than routinely needed after private day-patient or in-patient treatment’) in this section.
General Exclusion GE3 Allergies, Allergic Disorders or Food Intolerances
Excluded Treatment
Treatment:
J
to de-sensitise or neutralise any allergic condition or disorder, or
J
of any food intolerance.
Once a diagnosis of an allergic condition or disorder or food intolerance has been confirmed we do not
pay for any further Treatment, including diagnostic tests, to identify the precise allergen(s) or foodstu(s)
involved – this means, for example, if you are diagnosed with a tree nut allergy we will not pay for further
investigations into which specific nut(s) you are allergic to.
General Exclusion GE4 Birth Control, Conception and Sexual Problems
Excluded Treatment
Treatment for or arising from:
J
any type of contraception, sterilisation, termination of pregnancy
J
any other type of sexual problem including impotence, whatever the cause
J
assisted reproduction (eg IVF investigations or Treatment), surrogacy, harvesting donor eggs or
donor insemination
J
solely, the Treatment of infertility
or any condition arising from any of these. Also see General Exclusion GE20 Pregnancy and Childbirth.
Section one: Eligible treatment, benefits and limitations Page 25
General Exclusion GE5 Chronic Conditions
Excluded Treatment
Treatment of Chronic Conditions.
Where it is not clear that a condition is a Chronic Condition and we have paid for its Treatment, that does
not mean that we will continue paying when we have more information which, in our reasonable view,
confirms that it is a Chronic Condition. You can ask us if a condition is covered.
When you are receiving In-patient Treatment, in making our decision on whether your condition is, or has
become, a Chronic Condition, we will consider the period of days during which there has been no change
in your clinical condition or change in your Treatment.
We do not consider Cancer as a Chronic Condition. We explain what we pay for Eligible Treatment of
Cancer in Benefit B4 Cancer Treatment in the Benefits Table section of this booklet.
We do not consider a Mental Health Condition as a Chronic Condition. We explain what we pay for Eligible
Treatment of Mental Health Conditions in Benefit 5 Mental Health Treatment in the Benefits Table section
of this booklet.
Also see General Exclusion GE24 Temporary Relief of Symptoms.
General Exclusion GE6 Complications from Excluded Conditions/Treatment and Experimental Treatment
Excluded Treatment
Treatment or increased Treatment costs arising from complications caused by a condition which is not
covered under your Benefits.
Treatment costs arising from complications caused by experimental Treatment or Treatment required as a
result of experimental Treatment.
General Exclusion GE7 Contamination, Wars, Riots and Terrorist Acts
Excluded Treatment
Treatment for any condition arising directly or indirectly from:
J
war, riots, terrorist acts causing chemical, biological, radioactive or nuclear contamination, civil disturbances,
acts against any foreign hostility where war has not been declared, or any similar cause, or
J
chemical, biological, radioactive or nuclear contamination, or combustion of chemicals or nuclear fuel or any
similar event.
General Exclusion GE8 Convalescence, Rehabilitation and General Nursing Care
Excluded Treatment
Accommodation if its usual primary use is for:
J
convalescence, rehabilitation, supervision or any purpose other than providing Eligible Treatment
J
general nursing care or other services which could be provided in a nursing home or any other establishment
which is not a Recognised Facility
J
services from a Therapist, Complementary Medicine Practitioner or Mental Health and Wellbeing Therapist.
This does not apply to addiction treatment programmes if they are covered by your policy under
Benefit B5 Mental Health Treatment.
Page 26 Section one: Eligible treatment, benefits and limitations
General Exclusion GE9 Cosmetic, Reconstructive or Weight Loss Treatment
Excluded Treatment
Treatment to change your appearance, whether or not it is needed for medical or psychological reasons,
such as:
J
breast enlargement, reduction or other Treatment to change the shape or appearance of breasts, including
gynaecomastia (the enlargement of breasts in males)
J
any Treatment or surgery for or with the intention, directly or indirectly, of removing healthy tissue or surplus
or fat tissue, including surgery related to obesity/morbid obesity
J
scar revision or Treatment of keloid scars.
Also see General Exclusion GE21 Screening, Monitoring and Preventive Treatment.
Exception
See Benefit B2.6 Cosmetic or Reconstructive Treatment
General Exclusion GE10 Deafness
Excluded Treatment
Treatment for or arising from deafness caused by congenital abnormality, maturing or ageing.
General Exclusion GE11 Dental/Oral Treatment
Dental or oral Treatment including:
J
routine examinations
J
dental implants or dentures, the repair or replacement of damaged teeth, including crowns, bridges, dentures
or other dental prosthesis
J
management of, or any Treatment relating to, jaw shrinkage or loss, as a result of dental extractions or
gum disease
J
bone disease when related to gum disease or tooth disease or damage
J
fillings (amalgam, composite anterior, composite posterior)
J
X-rays
J
scale and polish and chronic periodontal Treatment
J
root canal Treatment
J
surgical Treatment (extraction, surgical, extraction flap raised apicectomy, incising of abscess,
simple gingivectomy)
J
crowns and bridges (inlay/onlay, veneer, full gold crown, porcelain crown, porcelain bonded to metal crown,
bridge, adhesive bridge, cast post and core, pre-fabricated post and core, re-fix or re-cement of existing
crown, re-cement of adhesive bridge, re-cement of any other bridge)
J
dentures – acrylic/metal; partial/full; upper/lower (reline denture, addition of tooth, repair denture,
occlusal splint).
Please note: this General Exclusion GE11 does not apply to Add-on Benefit A4 Dental Cover.
Exception
See Benefit B2.2 Dental/Oral Surgical Treatment
Section one: Eligible treatment, benefits and limitations Page 27
General Exclusion GE12 Dialysis
Excluded Treatment
Treatment for or associated with kidney dialysis (haemodialysis), meaning the removal of waste matter
from your blood by passing it through a kidney machine or dialyser. Treatment for or associated with
peritoneal dialysis, meaning the removal of waste matter from your blood by introducing fluid into your
abdomen which acts as a filter.
Exception
See Benefit B2.3 Dialysis
General Exclusion GE13 Drugs and Dressings for Out-patient or Take-Home Use and Complementary and
Alternative Products
Excluded Treatment
Any drugs or surgical dressings provided or prescribed for Out-patient Treatment or for you to take home
with you on leaving hospital or a treatment facility.
Any complementary or alternative therapy products or preparations, including but not limited to
homeopathic remedies or substances, regardless of who prescribed or provided them or the type of
Treatment or medical condition they are used or prescribed for.
Also see General Exclusion GE14 Experimental drugs and Treatment.
Exception
See Benefit B4.1.4 Out-patient Cancer Drugs
General Exclusion GE14 Experimental Drugs and Treatment
Excluded Treatment
Treatment or procedures which we reasonably consider to be experimental or unproved based on
established medical practice in the United Kingdom, such as drugs outside the terms of their licence
or procedures which have not been satisfactorily reviewed by NICE (National Institute for Health and
Care Excellence). Licensed gene therapy, somatic-cell therapy or tissue engineered medicines for conditions
other than Cancer that have not been tested in phase III clinical trials will be considered experimental.
Exception
See Benefit B4.1.5 Experimental Drug Treatment for Cancer
General Exclusion GE15 Eyesight
Excluded Treatment
Treatment to correct your eyesight, for example, for long or short sight or failing eyesight due to ageing,
including spectacles or contact lenses.
Treatment for laser-assisted cataract surgery.
Exception
See Benefit B2.4 Eyesight
Page 28 Section one: Eligible treatment, benefits and limitations
General Exclusion GE16 Epidemic/Pandemic
Excluded Treatment
Treatment for or arising from any epidemic disease and/or pandemic disease.
An epidemic is the occurrence in a community or region of cases of an illness, specific health-related
behaviour, or other health-related events materially in excess of normal expectancy, or as otherwise
defined by the World Health Organisation (WHO). A pandemic is the worldwide spread of a disease with
epidemics occurring in many countries and most regions of the world.
General Exclusion GE17 Intensive Care
Excluded Treatment
Intensive care carried out in a unit or facility which is not a Critical Care Unit, or any intensive care following:
J
direct admission into a Critical Care Unit at the point of admission, such as following:
– an NHS transfer to a Recognised Facility
– an Out-patient consultation
– a GP referral
– repatriation
– private facility to private facility transfer
J
a transfer (whether as an emergency or not) to an NHS hospital or facility even if from a private
Recognised Facility
J
a transfer from an NHS Critical Care Unit to a private Critical Care Unit.
Exception
See Benefit B3.2.4 Intensive Care
General Exclusion GE18 Learning Diculties, Behavioural and Developmental Conditions
Excluded Treatment
Treatment related to learning diculties, such as dyslexia, or behavioural conditions, such as attention
deficit hyperactivity disorder (ADHD) and Autistic Spectrum Disorder (ASD), or developmental conditions,
such as shortness of stature.
Exception
See Benefit B5.1.3 Diagnostic Tests (in relation to mental health conditions).
General Exclusion GE19 Physical Aids and Devices
Excluded Treatment
We do not pay for supplying or fitting physical aids and devices (eg hearing aids, crutches, walking sticks, etc).
Exception
See Benefits B1.2 Out-patient Therapies and B3.2.7 Prostheses and Appliances
Section one: Eligible treatment, benefits and limitations Page 29
General Exclusion GE20 Pregnancy and Childbirth
Excluded Treatment
Treatment for:
J
pregnancy, including Treatment of an embryo or foetus
J
childbirth and delivery of a baby
J
termination of pregnancy, or any condition arising from termination of pregnancy.
Also see General Exclusions GE4 Birth Control, Conception and Sexual Problems, GE21 Screening,
Monitoring and Preventive Treatment and GE5 Chronic Conditions.
Exception
See Benefit B2.5 Pregnancy and Childbirth
General Exclusion GE21 Screening, Monitoring and Preventive Treatment
Excluded Treatment
Health checks or health screening. Health screening is where you may or may not be aware you are at risk
of, or are aected by, a disease or its complications but are asked questions or have tests, which may lead
to your needing further tests or Treatment. Routine tests, or monitoring of medical conditions, including:
J
routine antenatal care or screening for and monitoring of medical conditions of the mother or foetus during
pregnancy
J
routine checks or monitoring of Chronic Conditions such as diabetes mellitus or hypertension
J
tests or procedures which, in our reasonable opinion based on established clinical and medical practice, are
carried out for screening or monitoring purposes, such as endoscopies when no symptoms are present
J
preventive Treatment, procedures or medical services (including vaccinations)
J
medication reviews and appointments where you have had no change in your usual symptoms.
Also see General Exclusions GE5 Chronic Conditions and GE20 Pregnancy and Childbirth.
Exception
See Benefit B4.1.1 Out-patient Consultations for Cancer and Benefit B4.1.3 Out-patient Diagnostic Tests
for Cancer
General Exclusion GE22 Sleep Problems and Disorders
Excluded Treatment
Treatment for or arising from sleep problems or disorders such as insomnia, snoring or sleep apnoea
(temporarily stopping breathing during sleep).
General Exclusion GE23 Speech Disorders
Excluded Treatment
Treatment for or relating to any speech disorder, such as stammering.
Exception
See Benefit B3.2.6 Therapies
Page 30 Section one: Eligible treatment, benefits and limitations
General Exclusion GE24 Temporary Relief of Symptoms
Excluded Treatment
Treatment, the main purpose or eect of which is to provide temporary relief of symptoms or which is for
the continuing management of a condition.
Exception
We pay for Treatment to manage the symptoms of a terminal illness or disease from the date on which
your Consultant tells you that your ongoing Treatment will be to support your end of life care only and you
will not receive Treatment that is intended to halt or improve the terminal illness or disease itself. We then
pay all charges and fees for the Treatment you need in accordance with, and on the same basis as, your
other Benefits (including Benefit B8 Treatment at Home), for a maximum period of 21 consecutive days.
We only pay for this once in your lifetime.
General Exclusion GE25 Advanced Therapies and Specialist Drugs
Excluded Treatment
We do not pay for:
J
any gene therapy, somatic-cell therapy or tissue engineered medicines that are not on the list of Advanced
Therapies that applies to your Benefits
J
any drugs or medicines that are neither Common Drugs nor Specialist Drugs for which a separate charge is
made by your Recognised Facility.
General Exclusion GE26 Gender Dysphoria or Gender Armation
Excluded Treatment
Treatment for Gender Dysphoria or gender armation.
General Exclusion GE27 Varicose Veins of the Legs
Excluded Treatment
Treatment of varicose veins of the legs.
Exception: We pay for one Eligible Surgical Operation for varicose veins per leg in your lifetime of being
covered under a Bupa health insurance policy and/or a beneficiary of a Bupa administered trust. This
applies to all Bupa insurance schemes and/or Bupa administered trusts you may be a member and/or
beneficiary of in the future, whether your being a member and/or beneficiary is continuous or not.
Both legs being treated on the same day is considered one Surgical Operation on each leg.
We also pay:
J
any eligible consultations and diagnostic tests needed for your Surgical Operation
J
a single sclerotherapy Treatment within six months of an original Surgical Operation if there are
remaining symptoms.
Section two: Policy terms Page 31
Section two:
Policy Terms
Bupa By You Health Insurance
We are Bupa Insurance Limited and you are the Main Member named on the
Membership Certificate we provide which refers to these Policy Terms.
Your Membership Certificate (which is personal to you and your Dependants), the
Benefits Table and these Policy Terms (including the Glossary) and any Confirmation of
Special Conditions we send for anyone to whom a Special Condition applies, together
form our Bupa By You Health Insurance Agreement with you. If you have purchased the
Guided Care option, the Addendum we sent you separately, which explains the Guided
Care option, also forms part of our Agreement with you.
Some words and phrases we use are in italics. These have technical meanings which are
set out in the glossary at the end of these Terms.
Eligibility
To be eligible for this cover the Main Member and Dependants must:
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be Resident in the UK
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at the Cover Start Date have been registered continuously with a GP for a period of
at least six months, or have access to and be able to provide their full medical records
in English, and
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not receive payment for taking part in sports.
1. Cover for you and your dependants
1.1.1 Only you as the Bupa Main Member have legal rights under this Agreement,
although your Dependants also have access to our complaints process (please
see ‘Making a complaint’ in the ‘Protecting your information and rights’ section of
this booklet).
1.1.2 Your Membership Certificate names any Dependants you have asked us to cover.
Where we refer to “you” in these Terms, Benefits Table and on your Membership
Certificate in relation to the cover or a claim that will include your Dependants,
where relevant.
1.1.3 The details of the cover you have chosen, whether Cash Benefits apply, any
personal restrictions or exclusions, excess payments, and your Cover Start Date
and Cover End Date, are listed on your Membership Certificate and also any
Confirmation of Special Conditions we send for anyone to whom a Special
Condition applies.
1.1.4 The Benefits we provide and some requirements are described in our Benefits
Table. Benefits mentioned in these Terms or the Benefits Table, but not listed on
your Membership Certificate, do not apply to you or your Dependants.
Page 32 Section two: Policy terms
1.1.5 The Benefits Table also details conditions, Treatment, charges and costs we do
not cover and in some cases the related exceptional circumstances in which we
do provide cover.
1.1.6 Your Membership Certificate will state whether your cover is Underwritten or
Moratorium (and explain what that means).
1.1.7 You must pay subscriptions (including Insurance Premium Tax (IPT)) in advance
throughout your membership. Bupa Insurance Services Limited acts as our agent
for arranging and administering your policy. Subscriptions are collected by Bupa
Insurance Services Limited as our agent for the purpose of receiving, holding and
refunding subscriptions and claims monies. If the IPT rate changes or any new
taxes or charges are introduced, we will change the amount of the subscriptions
you have to pay.
1.2 You will have a contract with the Consultant/medical practitioner/ healthcare
professional and/or clinic/hospital for private medical Treatment and you are
responsible for paying for them. If your Treatment is covered, we will pay the
amount covered. We usually pay direct although occasionally we may pay you.
Any amount not covered is your responsibility. We will write to tell the Main
Member or Dependant having Treatment (when aged 16 and over) when there is
an amount for them to pay in relation to any claim (for example, if they have an
excess amount to pay) and who payment should be made to.
1.3 We only pay Benefits for Treatment you receive while you are covered under the
policy and we only pay Benefits in accordance with the cover that applies to you
on the date the Treatment takes place. We do not pay for any Treatment, including
any Treatment we have pre-authorised, that takes place on or after the date your
cover ends.
1.4 We do not have to pay a claim if you or a Dependant break any of the terms and
conditions of membership, which are related to the claim. If there is reasonable
evidence that you or a Dependant did not take reasonable care in answering our
questions (by this we mean giving false information or keeping necessary
information from us) then if this was:
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intentional, we may treat your or (if applicable) your Dependant’s cover as if it
never existed and refuse to pay all claims
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careless, then depending on what we would have done if you or they had
answered our questions correctly, we may treat your or (if applicable) your
Dependant’s cover as if it never existed and refuse to pay all claims (in which
case you may need to repay any claims we have paid and we will return any
subscriptions you have paid in respect of your or (if applicable) your Dependant’s
cover), change your or their cover, or we could reduce any claim payment.
1.5 Your agreement is for one year’s insurance. However, your cover will renew
automatically each Year, subject to 1.6.1 to 1.6.4 below, as long as you continue to
pay your subscriptions and any other charges, unless we decide to close Bupa By
You Health Insurance.
If this applies, we will write to tell you at least 28 days before your Renewal Date.
Section two: Policy terms Page 33
1.6.1 You can end your cover (which will also end the cover for your Dependants) or the
inclusion of any of your Dependants at any time by calling us on 0345 609 0777 (we
may record or monitor our calls) or writing to us: Bupa, Bupa Place, 102 The Quays,
Salford M50 3SP. We will refund any subscriptions which relate to a period after the
cover ends.
1.6.2 Your cover, and that of all your Dependants, will automatically end if
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you do not pay your subscriptions, or any other payment you have to make in
respect of the cover, on or before the date they are due. In the event of your
membership terminating as a result of your failing to pay subscriptions in
respect of your membership, on the due date, we may at our sole discretion
permit your membership and that of your Dependants to continue, on condition
that the overdue subscriptions payable in respect of your membership are
received by us within 30 days of the due date
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you stop being Resident in the UK, or
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we do not have the correct address for you, and we are unable to confirm your
correct address after using reasonable eorts to do so, then we will cancel
your policy at renewal as we will not be able to confirm that you still require
cover
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you die.
1.6.3 A Dependant’s individual cover will automatically end if:
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you tell us not to renew the cover of that Dependant
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the Dependant stops being Resident in the UK
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the Dependant dies.
It is your responsibility to tell us if any of these happen.
1.6.4 We can end a person’s membership in the circumstances set out in 1.4 above.
1.6.5 We can cancel or refuse to renew a Main Member’s or a Dependant’s cover if, in
our reasonable opinion, our relationship with that Main Member or Dependant has
broken down. Such circumstances include but are not limited to:
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being abusive to our sta or providers
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issuing court proceedings entirely without merit
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any action which leads us to believe the member will not act in good faith in
their dealings with us.
1.7 We can change these Terms, the amount of your subscriptions, any discount or
preferential rates and the cover available to you and your Dependants or other
terms of your membership, at your Renewal Date.
If your ‘Underwriting method’ on your Membership Certificate is ‘Underwritten’
we will not add any personal exclusions or restrictions to your cover for medical
conditions that:
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start after your Eective Underwriting Date, so long as you gave us all the
information we asked for before the Eective Underwriting Date
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start before your Eective Underwriting Date, where you gave us all the
information we asked for and we accepted the condition.
Page 34 Section two: Policy terms
If your ‘Underwriting method’ on your Membership Certificate is ‘Moratorium’
we will not add any personal exclusions or restrictions to your cover for medical
conditions that start before your Moratorium Start Date where the requirements
specified on your Membership Certificate have been met for that condition to
be covered.
If we do make any changes, we will write to tell you at least 28 days before the
Renewal Date. If you do not accept any of the changes you can cancel your Bupa
By You health insurance policy within the later of:
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28 days of the date on which the change takes eect, or
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28 days of Bupa telling you about the change.
If you do end your membership within the 28 days we will treat the changes as not
having been made.
1.8 At your Renewal Date you can ask us to:
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add, remove or change an excess, as explained on your Membership Certificate
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remove any Add-ons you have chosen
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change any of your cover options.
You may add Dependants to your cover at any time.
We will consider your request and we may not agree or, for an increase in cover, we
may add restrictions before we agree. These changes may aect the subscriptions
you have to pay.
Changes are not eective until we have confirmed them in writing.
You may tell us that you want your partner to have the authority to ask us to
make changes.
1.9 You must call or write to tell us if you change your address or you stop (or any of
your Dependants stops) being Resident in the UK.
1.10 Membership documents are sent to the Main Member. However, a Confirmation of
Special Conditions will be sent, for anyone to whom a Special Condition applies, to
the Main Member or to the Dependant when they are aged 16 or over. All claims
correspondence is sent to the Main Member, or to the Dependant having the
Treatment when they are aged 16 and over. When you send us documents, we
cannot return the originals to you. However, we will send you copies if you ask us
to do so at the time you give us the documents.
1.11.1 We may post any ocial communication (a notice) to you under your Agreement
at the contact details we hold. Our communication will be eective on the second
business day after posting.
1.11.2 Any ocial communication or request you send to us will only be eective when
we receive it. We may agree that you can send us ocial communications or
requests by email.
1.11.3 When you or any Dependant over 16 provides us with an email address, we will
invite you or your Dependant by email to create a Bupa digital account.
1.12 This Agreement is governed by English law.
Section two: Policy terms Page 35
1.13 This Agreement is, and our marketing and other communications will be, in English.
We will communicate with you in English throughout the period of the Agreement.
1.14 Private Healthcare Information Network
You can find independent information about the quality and cost of private
treatment available from doctors and hospitals from the Private Healthcare
Information Network: www.phin.org.uk
2. Claiming
2.1 Step by step guide to making a claim
Being referred for treatment
Your consultation or Treatment must follow an initial referral by:
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our Direct Access service. For details about cover for Direct Access and how it
works see 2.2 Direct Access service in this section
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a GP (including via a digital GP service), or
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another healthcare practitioner. The situations in which we will accept such a
referral are set out on bupa.co.uk/referrals
Step 1 Find out if the Direct Access service is available to you
It’s available for certain medical conditions and has two parts to it:
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first you can contact us directly without consulting a GP for a remote
assessment with a trained advisor, Therapist, Mental Health and Wellbeing
Therapist or other clinician who specialises in your condition. This may lead to
a referral for a consultation or Treatment
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second, if you already have a GP referral, you may also be oered the option to
speak to a Therapist, practitioner or other clinician who specialises in your
condition to explore all of your Treatment options.
For details about cover for the Direct Access service and how it works please see
paragraph 2.2 Direct Access service on page 36.
Step 2 If Direct Access is not available (or if you prefer) – consult a GP
for an open referral
Sometimes, when you have had a consultation with another healthcare practitioner
before consulting a GP and they believe referral to a Consultant is appropriate,
a GP appointment may not be clinically necessary. The situations in which we will
accept such a referral are set out on bupa.co.uk/referrals or you can call us.
The GP will assess if you need to go to see a Consultant. If they decide that you
do and:
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your Benefits include cover for Out-patient consultations, diagnostic tests and
therapies before hospital Treatment, ask the GP for an ‘open referral’ (unless a
paediatric referral is required – see ‘Referrals for children’ below). This allows us
to oer you a choice of nearby Recognised Practitioners covered under your
Benefits. Some GPs may prefer to give a ‘named referral’ to a certain Consultant,
however, you should call us before you make an appointment to confirm that
we recognise them under your cover, to avoid your being liable to pay
Page 36 Section two: Policy terms
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your Benefits do not cover Out-patient consultations, diagnostic tests or
therapies before a diagnosis of your condition and hospital Treatment, you will
need to choose whether to pay yourself for a private Out-patient consultation,
diagnostic test or therapy or use the NHS. If you decide to pay yourself call
us and we can talk through your options and help you find a Recognised
Practitioner covered under your Benefits in case you should go on to need
hospital Treatment.
Referrals for children aged 17 or under: It is not always possible for us to find you
a paediatric Consultant so when a paediatric referral is required we ask that you
obtain a named referral from a GP.
Step 3 Contact us
You can call us on 0345 609 0777* and we will talk you through your options.
Alternatively, you can contact us via our webchat service or complete the online
request for treatment form. We will explain which nearby Consultants, facilities and
healthcare professionals are covered under your Benefits and provide you with a
pre-authorisation number so your healthcare provider can send the bill directly to us.
If your Consultant recommends further tests or Treatment, it is important you
check back with us to obtain further pre-authorisation.
We strongly advise you to call us before arranging or receiving any Treatment to
pre-authorise it, as you will be responsible for paying any fees or charges that are
not covered under your Benefits.
Claims checklist
To help us make the claims process as simple and swift as possible, please have
the following information close to hand when you contact us:
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your Bupa membership number
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details of the condition you are suering from
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details of when your symptoms first began
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details of when you first consulted a GP about your condition
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details of the Treatment that has been recommended.
2.2 Direct Access service
Our Direct Access service applies only to certain medical conditions and has two
parts to it:
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first, it can help provide a fast and convenient way for you to access Eligible
Treatment without the need for a GP referral, and
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second, if you already have a GP referral, you may also be oered the option to
speak to a Therapist, practitioner or other clinician who specialises in your
condition to explore all of your Treatment options.
Age limits apply to who can use the service. Further details about the
Direct Access service, including the age limits that apply, can be found on
bupa.co.uk/direct-access or you can contact us.
*We may record or monitor our calls.
Section two: Policy terms Page 37
Please note:
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if your Membership Certificate shows your underwriting method as
‘Underwritten’, you have access to the Direct Access service. If the Direct
Access service refers you for a consultation or Treatment and you want to
make a claim you may need to provide us with certain information to establish
that your condition is not a Pre-existing Condition – please see paragraph 2.5
and 2.6 on pages 38 and 39 for full details
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if your Membership Certificate shows your underwriting method as
‘Moratorium’, you have access to the Direct Access service. If the Direct Access
service refers you for a consultation or Treatment and you want to make a
claim you will need to follow the standard process for claiming to establish that
your condition is not a moratorium condition – please see paragraphs 2.4 and
2.6 on pages 38 and 39 for full details
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you can use the Direct Access service when your medical condition is not
covered by your Benefits. For example, if you have a Pre-existing Condition or
general exclusion the Direct Access service will still be available to you for a
remote assessment. Any Out-patient consultations, therapies or Treatment
that’s recommended by the Direct Access service for those conditions would
not be covered under your Benefits
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if an individual Out-patient limit applies to your cover as shown on your
Membership Certificate and you have used all your Out-patient limit for the
Year, you can still use the Direct Access service but any Out-patient
consultations, diagnostic tests or therapies you are referred for would not be
covered under your Benefits
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if your Benefits do not cover Out-patient consultations, diagnostic tests and
therapies before diagnosis of your condition and hospital Treatment, you can
still use the Direct Access service, but any Out-patient consultations or
therapies the Direct Access service may refer you for would not be covered
under your Benefits.
The charge for any remote assessments required as part of our Direct Access
process will not:
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erode your Out-patient benefit limit if you have one, nor
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be subject to your excess if one applies to your cover.
If you go on to receive and claim for Eligible Treatment following referral by our
Direct Access service, that Treatment will be treated as a normal claim under
your cover.
General information on claiming
2.3.1 Treatment costs are only covered when:
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the person with responsibility is a Consultant. The only exception to this is
where a GP, Consultant or our Direct Access service refers you for Out-patient
Treatment by a Therapist, Mental Health and Wellbeing Therapist or
Complementary Medicine Practitioner
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on the date you receive Treatment the Consultant, medical practitioner or
other healthcare professional and the facility where the Treatment is given, are
recognised by us for treating the condition you have and for providing the type
of Treatment you need.
Page 38 Section two: Policy terms
2.3.2 Any Treatment must be provided in the UK.
2.4 If you need to make a claim and your Membership Certificate says that your
underwriting method is ‘Moratorium’: before you arrange any consultation or
Treatment you must call us and we will send you a pre-treatment form to complete
with details of the history of the relevant medical condition including information
you will need to get from a GP or Consultant. They may charge you a fee for this
which we do not pay. Once we receive all the information we need, we will say
whether your proposed Treatment, medical provider, healthcare professional or
treatment facility will be eligible under your cover.
If you wish to make a claim, we will tell you whether you will need to complete
a claim form.
2.4.1 If you do not need to complete a claim form, we will treat your submission of your
pre-treatment form to us as your claim once we are notified that you have received
your consultation or Treatment. In most cases we will be notified that you have
received your consultation or Treatment by your Consultant or the provider of
your Treatment.
2.4.2 If you do need to complete a claim form, you will need to return the fully completed
claim form to us as soon as possible and, in any event, within six months of receiving
the Treatment for which you are claiming unless this was not reasonably possible.
2.5 If you need to make a claim and your Membership Certificate shows your
underwriting method is ‘Underwritten’: it is important that you complete and send
us the Application Form for you and/or for your Dependants if your Membership
Certificate states that we require your medical history. Until you have completed this
we won’t be able to confirm exactly what your policy covers you and/or your
Dependants for, meaning your claims might take longer for us to process or you
might not be eligible to claim for Treatment you need.
2.5.1 When you call your helpline to pre-authorise your Treatment we will confirm if the
Treatment is eligible under your cover and if so the Benefits available to you and,
if you wish to make a claim, tell you whether you need to complete a claim form.
2.5.2 If you do not need to complete a claim form, we will treat your call to us as your
claim once we are notified that you have received your consultation or Treatment.
In most cases we will be notified that you have received your consultation or
Treatment by your Consultant or the provider of your Treatment.
2.5.3 If you do need to complete a claim form, you will need to return the fully completed
claim form to us as soon as possible and, in any event, within six months of receiving
the Treatment for which you are claiming unless this was not reasonably possible.
2.6 Providing us with information
You must provide us with the information we reasonably need to assess your
claim. For example, we may ask you for:
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medical reports and other information about the proposed Treatment
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an independent medical examination, at our expense
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original accounts and invoices in connection with your claim (including any
related to Treatment costs covered by your excess – if any). We cannot accept
photocopies of accounts or invoices or originals that have been altered.
Section two: Policy terms Page 39
You can, of course, refuse to supply any of this material, but if you do not provide
us with information we reasonably request, we will be unable to assess or pay
your claim.
Medical reports – when we need more information from your doctor
2.6.1 When we need to ask your doctor for more information, in writing about your
consultation, tests or treatment for insurance purposes, we will need your
permission. The Access to Medical Reports Act 1988 or the Access to Personal
Files and Medical Reports (NI) Order 1991 give you certain rights, which are:
1. you can give permission for your doctor to send us a medical report without
asking to see it before they send it to us.
2. you can give permission for your doctor to send us a medical report and ask to
see it before they send it to us.
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you will have 21 days from the date we ask your doctor for your medical
report to contact them and arrange to see it
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if you don’t contact your doctor within 21 days we will ask them to send the
report straight to us
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you can ask your doctor to change the report if you think it’s inaccurate or
misleading. If they refuse, you can insist on adding your own comments to
the report before they send it to us
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once you’ve seen the report, it won’t be sent to us unless you give your
doctor permission to do so.
3. you can withhold your permission for your doctor to send us a medical report.
If you do, we will be unable to see whether the consultation, test or treatment
is covered by your policy, and we won’t be able to give you a pre-authorisation
number or confirm whether we can contribute to the costs.
In any event you also have the right to ask your doctor to let you see a copy of your
medical report within six months of it being sent to us.
Your doctor can withhold some or all the information in the report if, in their view,
the information:
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might cause physical or mental harm to you or someone else or
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would reveal someone else’s identity without their permission (unless the
person is a healthcare professional and the information is about your care
provided by that person)
We may be able to pay towards the cost of a medical report. We will let you know
when we ask for your permission to request the report from your doctor. If we can
pay towards it, you will need to pay any remaining amount.
2.7 Claiming for Cash Benefits: If your Membership Certificate says you are entitled to
cash benefits, call the helpline to check your Benefits. We will confirm your Benefits
and tell you whether you need to complete a claim form. You must send us either:
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your completed claim form if you need to complete one – please note that for
NHS Cash Benefit you will need to take your claim form with you to the hospital
and ask them to complete the hospital sections, or
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if you do not need a claim form, a covering letter giving your name, address
and membership number together with your original invoices and receipts.
Page 40 Section two: Policy terms
2.8 When you claim for Treatment you need because of an injury or medical condition
that was caused by or was the fault of someone else (a ‘third party’) it is your
responsibility to notify us as soon as reasonably possible and ensure our interests
are protected in any legal action required so that we are able to recover any costs
that we have paid for your Treatment. This includes:
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notifying us as soon as you become aware that you require (or may require)
Treatment that was caused by or was otherwise the fault of a third party. You
can contact us with this information on 0800 028 6850* or email
infothirdparty@bupa.com^
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taking steps we ask of you to recover from the third party the cost of the
Treatment paid for by us. This includes ensuring that we are able to liaise with
you and your legal representative (if you appoint one) in relation to this and
that you or your legal representative regularly keep us updated as to progress
with any recovery action
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ensuring that where you agree settlement with a third party, the settlement
includes the cost of Treatment that we have paid for you in full, and that you
pay such sum (and applicable interest) to us as soon as reasonably possible.
2.9 Please note: you can only claim for eligible private medical costs once. This means
if you have two policies that provide private medical cover, the cost of your Eligible
Treatment may be split between Bupa and the other insurance company. You will
be asked to provide us with full details of any other insurance policy at the time
of claim.
2.10 Case Management: If we believe you are having Eligible Treatment that could
benefit from our case management support we will provide a case manager to help
you navigate through your healthcare experience. Your case manager will contact
you by phone and will work with you to understand your individual needs and the
best way to help you. This can include discussing options available to you, liaising
with healthcare professionals and helping you get the most from your policy.
3. Paying a claim
3.1 Usually, we will pay the providers of your Treatment directly. Otherwise we will pay
the Main Member. We will pay claims for cash benefits to the Main Member.
3.2 If you wish to withdraw your claim, you should call the helpline to tell us as soon as
possible. You will be unable to withdraw if we have already paid the claim. If you do
withdraw your claim you will be responsible for paying the costs of that Treatment.
3.3 When you receive private medical treatment you have a contract with the providers
of your Treatment. Any costs that are not covered under your Benefits you are
responsible for paying.
*We may record or monitor our calls.
^If you need to send us sensitive information you can email us securely using Egress. For more information
and to sign up for a free Egress account, go to https://switch.egress.com. You will not be charged for sending
secure emails to a Bupa email address using the Egress service.
Section two: Policy terms Page 41
3.4 Other than in relation to the reimbursement of Eligible Treatment costs, there is no
contract between you and us in respect of any private medical treatment or any
other clinical services that you receive under your policy. We are not the provider
of these things and this means that we are not responsible for the delivery of your
private medical treatment or other clinical services.
3.5.1 Your Membership Certificate will say if you have agreed with us an excess payment.
3.5.2 Having an excess means that you have to pay part of any Treatment costs that we
would otherwise pay. An excess applies to the first amount of any claim.
3.5.3 Any excess applies per person per policy Year. It resets at each Renewal Date even
if your Treatment is continuing. So your excess could apply twice to a single course
of Treatment if the Treatment begins in one Year and continues into the next.
You are responsible for paying any excess. We will write to the Main Member or
Dependant having Treatment (when aged 16 and over) to say who they should pay.
3.5.4 You should always make a claim for Treatment costs even if we will not pay the
claim because of your excess. Otherwise the amount will not be counted towards
your excess and you may lose out should you need to claim next time.
3.5.5 Unless we say otherwise on your Membership Certificate:
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we apply the excess limits in the order in which we process claims
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the excess does not apply to cash benefits
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when you claim for Treatment costs where a benefit limit applies, your excess
payment will not count towards your total benefit limit for that Benefit.
3.5.6 Example of how an annual fixed excess works
Check your Membership Certificate to see if an excess applies to your Benefits.
The following is an example only and assumes that all costs are Eligible Treatment
costs and:
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an excess of £100 a Year
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an Out-patient benefit limit of £500 a Year.
Example
Out-patient benefit limit for the Year £500
You incur costs for Out-patient physiotherapy £250
We pay your Therapist £150
We notify you of excess amount you pay direct to your Therapist £100
Your remaining Out-patient benefit limit for the rest of the Year £350
Your remaining excess for the rest of the Year £0
Page 42 Section two: Policy terms
4. Changes to lists
Where we refer to a list that we can change, it will be for one of the following reasons:
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where we are required to by any industry code, law or regulation
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where a contract ends or is amended by a third party for any reason
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where we elect to terminate or amend a contract. For example: because of quality
concerns or changes in the provision of facilities and/or specialist services
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where the geographic balance of the service we provide is to be maintained
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where eectiveness and/or costs are no longer in line with similar Treatments or
services or accepted standards of medical practise, or
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where a new service, Treatment or facility is available.
The lists we apply these criteria to include the following:
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Advanced Therapies
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Appliances
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Consultant Fees Schedule
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Critical Care Units
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Fee-Assured Consultants
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Medical Treatment providers
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Prostheses
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Recognised Facilities
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Recognised Practitioners
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Schedule of Procedures
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Specialist Drugs.
Please note that we cannot guarantee the availability of any facility, practitioner
or Treatment.
Section two: Policy terms Page 43
5. Glossary
In this glossary we define the words and phrases which are in italics in the Bupa By You
Health Insurance Policy Terms, the Benefits Table and your Membership Certificate
and any Confirmation of Special Conditions we send for anyone to whom a Special
Condition applies.
Word/phrase Meaning
Activities of
Daily Living
functional mobility, bathing/showering, dressing, self-feeding, personal hygiene/
grooming, fulfilment of work or educational responsibilities.
Acute Condition a disease, illness or injury that is likely to respond quickly to Treatment which
aims to return you to the state of health you were in immediately before
suering the disease, illness or injury, or which leads to your full recovery.
Advanced Therapies gene therapy, somatic-cell therapy or tissue engineered medicines classified as
Advanced Therapy Medicinal Products (ATMPs) by the UK medicines regulator
to be used as part of your Eligible Treatment and which are, at the time of your
Eligible Treatment, included (with the medical condition(s) for which we pay for
them) on our list of Advanced Therapies that applies to your Benefits. The list is
available at bupa.co.uk/policyinformation or you can contact us.
The Advanced Therapies on the list will change from time to time.
Application form the questionnaire we provide to you when you and/or your Dependants first
take out or are added as a Dependant to a policy with us which requires you
and/or your Dependants to disclose details of your/their health, medical history
and lifestyle.
If you no longer have the application form, you may contact us to request
a replacement.
Benefits the Benefits explained in the Bupa Benefits Table.
The Benefits which relate to your cover are those specified on your Membership
Certificate for which you are individually entitled.
Bupa Bupa Insurance Limited. Registered in England and Wales No. 3956433.
Registered oce: Bupa, 1 Angel Court, London EC2R 7HJ. Bupa provides
the cover.
Cancer a malignant tumour, tissues or cells characterised by the uncontrolled growth
and spread of malignant cells and invasion of tissue.
Chemotherapy Systemic Anti-Cancer Therapies (SACT), excluding anti-hormone therapies. SACT
are therapies used to destroy or prevent growth of cancerous cells.
Chronic Condition a disease, illness or injury which has one or more of the following characteristics:
J
it needs ongoing or long-term monitoring through consultations, examinations,
check-ups and/or tests
J
it needs ongoing or long-term control or relief of symptoms
J
it requires your rehabilitation or for you to be specially trained to cope with it
J
it continues indefinitely
J
it has no known cure
J
it comes back or is likely to come back.
Page 44 Section two: Policy terms
Word/phrase Meaning
Common Drugs commonly used medicines, such as antibiotics and painkillers that, in our
reasonable opinion based on established clinical and medical practice, should be
included as an integral part of your Eligible Treatment.
Complementary
Medicine Practitioner
an acupuncturist, chiropractor or osteopath who is on our Recognised
Practitioner list. The practitioners on the list will change from time to time.
You can ask us if a practitioner is a Recognised Practitioner and the type of
Treatment we recognise them for.
Confirmation of
Special Conditions
the most recent confirmation of special conditions that we issue for any member
to whom Special Conditions apply, for your current continuous period of cover
under the policy.
Consultant a registered medical or dental practitioner who, at the time you receive your
Treatment is on our recognised consultant list for the relevant Benefit and type
of Treatment.
The practitioners on the list will change from time to time. You can ask us
whether a medical or dental practitioner is on our list and the type of Treatment
we recognise them for or you can access these details at finder.bupa.co.uk
Consultant fees
schedule
the schedule we use for providing Benefits setting out the benefit limits for
Consultants’ fees based on:
J
the type of Treatment carried out
J
for Surgical Operations, the type and complexity of the Surgical Operation
according to the Schedule of Procedures – the benefits available for Consultant
surgeons and Consultant anaesthetists may dier for the same Surgical Operation
J
the recognition status of the Consultant, and
J
where the Treatment is carried out both in terms of the treatment facility and
the location.
The schedule will change from time to time. Details of the schedule can be found
at bupa.co.uk/codes
Cover End Date the date on which your current period of cover under the policy ends, shown as
‘Cover end date’ on your Membership Certificate.
Cover Start Date the date on which your current period of cover under the policy starts, shown as
‘Cover start date’ on your Membership Certificate.
Critical Care Unit any intensive care unit, intensive therapy unit, high dependency unit, coronary
care unit or progressive care unit which is on our list of Critical Care Units and
recognised by us for the type of intensive care that you require at the time you
receive your Treatment. The units on the list and the type of intensive care that
we recognise a unit for will change from time to time. You can ask us whether
a Critical Care Unit is on our list and the type of Treatment we recognise it for.
Day-patient a patient who is admitted to a hospital or day-patient unit because they need
a period of medically supervised recovery but does not occupy a bed overnight.
Dental Injury Treatment Dental Treatment required as a direct result of injury caused by an external impact.
Dental Professional a Dental Professional who is registered with the General Dental Council.
Section two: Policy terms Page 45
Word/phrase Meaning
Dental Treatment the following Dental Treatment carried out by a Dental Professional:
J
fillings (amalgam, composite anterior, composite posterior)
J
root canal Treatment
J
surgical Treatment (extraction, surgical extraction (flap raised), apicectomy,
incising of abscess, simple gingivectomy)
J
crowns and bridges (inlay/onlay, veneer, full gold crown, porcelain crown,
porcelain bonded to metal crown, bridge, adhesive bridge, cast post and core,
pre-fabricated post and core, re-fix or re-cement of existing crown, re-cement of
adhesive bridge, re-cement of any other bridge)
J
dentures – acrylic/metal; partial/full; upper/lower (reline denture, addition of
tooth, repair denture, occlusal splint), including in each case anaesthetics fees.
Dependant your partner and any child for whom you or your partner hold responsibility and
who is named on your Membership Certificate. Your partner can be your husband
or wife, civil partner, or the person you live with in a relationship similar to that of
a marriage or civil partnership.
Eective
Underwriting Date
the date you/your Dependant started your/their continuous period of cover
under the policy, shown as your/their ‘Date of underwriting’ on your
Membership Certificate.
This may be the date you/they originally joined Bupa or, if you/they transferred
your/their cover from a Previous Policy the date of underwriting by the insurer or
administrator for your/their Previous Policy.
Eligible Surgical
Operation
Eligible Treatment carried out as a Surgical Operation.
Eligible Treatment Treatment of:
J
an Acute Condition or
J
a Mental Health Condition
together with the products and equipment used as part of the Treatment that:
J
are consistent with generally accepted standards of medical practice and
representative of best practice in the medical profession in the UK
J
are clinically appropriate in terms of type, frequency, extent, duration and the
facility or location where the services are provided
J
are demonstrated through scientific evidence to be eective in improving health
outcomes, and
J
are not provided or used primarily for the expediency of you or your Consultant
or other healthcare professional
and the Treatment, services or charges are not excluded under your Benefits.
Page 46 Section two: Policy terms
Word/phrase Meaning
Emergency Dental
Treatment
the following temporary Dental Treatment carried out by a Dental Professional,
where urgently required to alleviate pain, an inability to eat or any acute dental
condition which presents an immediate and serious threat to general health:
J
examinations
J
X-rays
J
extractions
J
root canal extirpation
J
initial relief Treatment of dental or gingival infection
J
temporary filling, or provision of permanent filling if a temporary filling is
not required
J
construction of temporary crown/bridge/veneer
J
re-cement of crown/inlay/bridge/veneer
J
temporary post and core, repair or replacement of orthodontic appliance
J
repair or adjustment to denture
J
other temporary emergency dental treatment as determined by the Dental
Professional eg stopping bleeding, re-fixing orthodontic retainer wire.
Fee-Assured
Consultants
a Consultant who, at the time you receive your Treatment, is recognised by us
as a fee-assured consultant. You can contact us to find out if a Consultant is
a fee-assured consultant or use finder.bupa.co.uk
Gender Dysphoria a condition where a person experiences discomfort or distress because there is
a mismatch between their biological sex and gender identity, sometimes known
as gender identity disorder, gender incongruence or transgenderism.
GP a doctor who, at the time he/she refers you for your consultation or Treatment,
is on the UK General Medical Council’s General Practitioner Register.
In-patient a patient who is admitted to hospital and who occupies a bed overnight or
longer, for medical reasons.
Main Member the person named as the Main Member on the Membership Certificate who is
eligible to be covered in his or her own right rather than as a Dependant.
Membership
Certificate
the most recent membership certificate that we issue to the Main Member for
your/your Dependant(s) (if any) current continuous period of cover under
the policy.
Mental Health and
Wellbeing Therapist
J
a psychologist registered with the Health and Care Professions Council
J
a psychotherapist accredited with the UK Council for Psychotherapy, the
British Association for Counselling and Psychotherapy or the British
Psychoanalytical Council
J
a counsellor accredited with the British Association for Counselling and Psychotherapy
J
a cognitive behavioural therapist accredited with the British Association for
Behavioural and Cognitive Psychotherapies,
who is on our Recognised Practitioner list. The practitioners on the list will
change from time to time. You can ask us whether a practitioner is on our list and
the type of Treatment we recognise them for or you can access these details at
finder.bupa.co.uk
Section two: Policy terms Page 47
Word/phrase Meaning
Mental Health
Condition
a condition which is a mental health condition according to a reasonable body
of medical opinion, and/or which is diagnosed and treated and managed as
a mental health condition by a Consultant psychiatrist or a Mental Health and
Wellbeing Therapist. We do not pay for Treatment of dementia, behavioural or
developmental conditions once diagnosed.
Mental Health
Day-patient Treatment
Mental Health Treatment which for medical reasons means a patient has
to be admitted to a Recognised Facility because they need a period of
clinically-supervised Mental Health Treatment as a day case but does not have
to occupy a bed overnight and the Mental Health Treatment is provided on either
an individual or group basis.
Mental Health
Treatment
Eligible Treatment of a Mental Health Condition as set out in Benefit B5 Mental
Health Treatment.
Moratorium Start Date the date you/your Dependant started your/their continuous period of
cover under the policy, shown as your/their ‘Moratorium start date’ on your
Membership Certificate.
This may be the date you/they originally joined Bupa or, if you/they transferred
your/their cover to Bupa from a Previous Policy the date identified by the insurer
or administrator of your/their Previous Policy for determining moratorium
conditions under your/their Previous Policy.
NHS
J
the National Health Service operated in Great Britain and Northern Ireland, or
J
the healthcare scheme that is operated by the relevant authorities of the
Channel Islands, or
J
the healthcare scheme that is operated by the relevant authorities of the Isle of Man.
NHS Band any of bands 1, 2 or 3 specified by the NHS in England in relation to the
classification of, and fees payable for, dental services provided to NHS patients
in England.
NHS Cash Benefit the cash payment we may make if you or a Dependant have received free NHS
Treatment which could have been covered by us as private Treatment.
Optician an ophthalmic Optician or optometrist registered with the General Optical Council.
Oral Cancer Treatment Treatment for Cancer of the oral cavity, lips, tongue and/or pharynx provided by
a Consultant.
Oral Chemotherapy Chemotherapy which is taken by mouth.
Orthodontic
Treatment
Dental Treatment provided for the correction or prevention of malocclusion or
any other irregular alignment or positioning of teeth.
Out-patient a patient who attends a hospital, consulting room or out-patient clinic and is not
admitted as a Day-patient or an In-patient.
Page 48 Section two: Policy terms
Word/phrase Meaning
Pre-existing Condition any disease, illness or injury for which in the seven years before your Eective
Underwriting Date:
J
you have received medication, advice or Treatment, or
J
you have experienced symptoms,
whether the condition was diagnosed or not.
Previous Policy
J
another Bupa private medical insurance policy or Bupa administered
healthcare trust
J
a private medical insurance policy or medical healthcare trust provided or
administered by another insurer
that we specifically agree will be treated as a previous policy for the purpose of
assessing your Moratorium Start Date, Eective Underwriting Date or continuous
periods of cover as applicable, provided that:
J
you have provided us with evidence of your continuous cover under the previous
policy, and
J
there is no break in your cover between the previous policy and this policy.
Recognised Facility the hospitals or Treatment facilities, centres or units that are:
J
on our list for the medical condition you have
J
carrying out the type of Treatment you need, and
J
covered by your Membership Certificate.
You can ask us whether a hospital, facility, centre or unit is on our list and the
type(s) of Treatment we recognise them for or you can access these details at
finder.bupa.co.uk
Recognised
practitioner
a healthcare practitioner who at the time of your Treatment:
J
is recognised by us for the purpose of our private medical insurance schemes for
treating the medical condition you have and for providing the type of Treatment
you need, and
J
is in our list of recognised practitioners that applies to your Benefits.
You can ask us if a practitioner is a Recognised Practitioner and the type
of Treatment we recognise them for or you can access these details
at finder.bupa.co.uk
Renewal Date
J
each anniversary of your Cover Start Date, or
J
common renewal date. Cover is generally renewed annually. Depending on the
month in which you first join the scheme, your initial period of cover may not be
a full 12 months and your Benefits and your subscriptions may change at the
common renewal date.
If you are unsure which applies to you, you can contact us or look in your
eligibility information leaflet.
Resident where your current, permanent address is.
Routine Dental
Treatment
the following dental services carried out by a Dental Professional:
J
routine examination/check-up
J
X-rays
J
scale and polish consultations, including simple scale and polish and chronic
periodontal Treatment.
Section two: Policy terms Page 49
Word/phrase Meaning
Schedule of
Procedures
the schedule we use for providing Benefits which classifies Surgical Operations
according to their type and complexity. The schedule will change from time to
time. Not all procedures listed in the schedule are covered under Bupa schemes.
Further information on the schedule is available on request.
Specialist Drugs drugs and medicines to be used as part of your Eligible Treatment, which are
not Common Drugs and are at the time of your Treatment included on our
list of Specialist Drugs that applies to your Benefits. The list is available at
bupa.co.uk/policyinformation or you can contact us. The specialist drugs on
the list will change from time to time.
Surgical Implant any implant inserted into the jaw bone for the support or retention of crowns,
bridges or dentures.
Surgical Operation a surgical procedure or complex investigative/diagnostic procedure. This
includes, if it is carried out as In-patient Treatment:
J
all medically necessary Treatment related to the procedure
J
all consultations carried out from the time you are admitted to a facility until the
time you are discharged, or
if it is carried out as Out-patient Treatment, the following if it is integral to
the operation:
J
all medically necessary Treatment related to the operation
J
any consultation on the same day.
Therapist
J
a chartered physiotherapist
J
a British Association of Occupational Therapists registered occupational therapist
J
a British and Irish Orthoptic Society registered orthoptist
J
a Royal College of Speech and Language Therapists registered speech and
language therapist
J
a Society of Chiropodists and Podiatrists registered podiatrist, or
J
a British Dietetic Association registered dietitian
who is Health and Care Professions Council registered and is on our list of
Recognised Practitioners.
The therapists on the list will change from time to time. You can ask us whether
a therapist is a Recognised Practitioner and the type of Treatment we recognise
them for or you can access these details at finder.bupa.co.uk
Treatment surgical or medical services (including diagnostic tests) that are needed to
diagnose, relieve or cure a disease, illness or injury.
UK/United Kingdom Great Britain, Northern Ireland, the Channel Islands and the Isle of Man.
We/our/us Bupa.
Year for each period of your cover, the period beginning on your Cover Start Date and
ending on your Cover End Date.
If your Renewal Date is a common renewal date or if you are a Dependant joining
an existing policy then depending on the month in which you first join the policy,
your initial period of cover may not be a full 12 months and your cover and your
subscriptions may change at the Renewal Date.
Page 50 Section three: Protecting your information and rights
Section three:
Protecting your information and rights
1. Status disclosure
Private health insurance and dental insurance are provided by Bupa Insurance Limited
and arranged and administered by Bupa Insurance Services Limited as an agent of Bupa
Insurance Limited. Subscriptions are collected by Bupa Insurance Services Limited as an
agent of Bupa Insurance Limited for the purpose of receiving, holding and refunding
subscriptions and claims monies. These companies (using the trading name Bupa) are
wholly owned subsidiaries of the British United Provident Association Limited.
Bupa Insurance Limited is authorised by the Prudential Regulation Authority and
regulated by the Financial Conduct Authority and the Prudential Regulation Authority.
Bupa Insurance Services Limited is authorised and regulated by the Financial Conduct
Authority. The firm reference numbers are 203332 and 312526 respectively. This
information can be checked by visiting the Financial Conduct Authority website
www.fca.org.uk
Bupa Insurance Limited is registered in England and Wales with company registration
No. 3956433 and Bupa Insurance Services Limited is registered in England and
Wales with company registration No. 3829851. They have the same registered oce:
1 Angel Court, London EC2R 7HJ
Getting in touch
The Bupa helpline is always the first number to call if you need help or support.
You can call us on 0345 609 0777*.
The Sta at Bupa are trained and supervised to provide our customers and members
with information only on Bupa’s own insurance products and health related services.
2. Cancellation
You may cancel your membership for any reason by calling us on 0800 010 383*, writing
to us, or emailing us at consumer.canc[email protected]^ within the later of 21 days of
receipt of your policy documents (including your Membership Certificate) we send you
confirming your cover, or your Cover Start Date. During this period, if you have not made
any claims, we will refund all of your subscriptions paid for that Year. After this period of
time you can end your cover at anytime, we will refund any subscriptions you have paid
relating to the period after your cover ends.
^If you need to send us sensitive information you can email us securely using Egress. For more information
and to sign up for a free Egress account, go to https://switch.egress.com. You will not be charged for sending
secure emails to a Bupa email address using the Egress service.
*We may record or monitor our calls.
Section three: Protecting your information and rights Page 51
You may cancel any of your Dependants’ membership for any reason by calling us on
0800 010 383*, writing to us, or emailing us at consumer.cancella[email protected]^
within the later of 21 days of receipt of your policy documents (including your
Membership Certificate) we send you confirming their cover, or their Cover Start Date.
During this period, as long as no claims have been made in respect of their cover, we will
refund all of your subscriptions paid in respect of that dependant’s cover for that Year.
After this period of time you can end their cover at anytime, we will refund any
subscriptions you have paid relating to the period after their cover ends.
Please note: cancelling or ending your and/or any Dependant’s membership will also
cancel or end your and/or their cover for Benefit A4 Dental Cover if you mor they have
cover for it.
Benefit A4 Dental Cover
You may cancel your and/or any of your Dependants’ cover for Benefit A4 Dental Cover
for any reason by calling us on 0800 010 383*, writing to us, or emailing us at
consumer.cancella[email protected]^ within the later of 21 days of:
J
receipt of your policy documents (including your Membership Certificate) we send
you confirming your and/or their cover for Benefit A4 Dental Cover or
J
your and/or their Cover Start Date for Benefit A4 Dental Cover.
During this period, as long as no claims have been made in respect of your and/or their
cover for Benefit A4 Dental Cover, we will refund all of your subscriptions paid in respect
of your and/or their cover for that Year that relate to that Benefit. After this period of
time you can end your and/or their cover for Benefit A4 Dental Cover at any time, we will
refund any subscriptions you have paid that relate to your and/or their cover for the
period after your and/or their cover for that Benefit ends.
Please also refer to section 2, sub sections 1.6.2 and 1.6.3.
3. Statement of demands and needs
This policy is generally suitable for someone who is looking to cover the cost of a range
of health expenses. We have not provided you with any advice regarding this policy.
If you have purchased through a non-Bupa financial adviser then please refer to the
demands and needs statement that they have provided you with.
Please read your Membership Certificate and this Policy Benefits and Terms booklet,
and any Confirmation of Special Conditions we send for anyone to whom a Special
Condition applies, to ensure this policy meets your needs (including the needs of
anyone else covered).
^If you need to send us sensitive information you can email us securely using Egress. For more information
and to sign up for a free Egress account, go to https://switch.egress.com. You will not be charged for sending
secure emails to a Bupa email address using the Egress service.
*We may record or monitor our calls.
Page 52 Section three: Protecting your information and rights
4. Privacy notice – in brief
We are committed to protecting your privacy when dealing with your personal
information. This privacy notice provides an overview of the information we collect about
you, how we use it and how we protect it. It also provides information about your rights.
The information we process about you, and our reasons for processing it, depends on
the products and services you use. You can find more details in our full privacy notice
available at bupa.co.uk/privacy. If you do not have access to the internet and would like
a paper copy, please write to Bupa Data Protection, Willow House, 4 Pine Trees,
Chertsey Lane, Staines-upon-Thames, Middlesex TW18 3DZ. If you have any questions
about how we handle your information, please contact us at datapr[email protected]om
Information about us
In this privacy notice, references to ‘we’, ‘us’ or ‘our’ are to Bupa. Bupa is registered with
the Information Commissioner’s Oce, registration number Z6831692. Bupa is made up
of a number of trading companies, many of which also have their own data-protection
registrations. For company contact details, visit bupa.co.uk/legal-notices
1. Scope of our privacy notice
This privacy notice applies to anyone who interacts with us about our products and
services (‘you’, ‘your’), in any way (for example, email, website, phone, app and so on).
2. How we collect personal information
We collect personal information from you and from certain other organisations (those
acting on your behalf, for example, brokers, health-care providers and so on). If you give
us information about other people, you must make sure that they have seen a copy of
this privacy notice and are comfortable with you giving us their information.
3. Categories of personal information
We process the following categories of personal information about you and, if it applies,
your dependants. This is standard personal information (for example, information we
use to contact you, identify you or manage our relationship with you), special categories
of information (for example, health information, information about race, ethnic origin
and religion that allows us to tailor your care), and information about any criminal
convictions and oences (we may get this information when carrying out anti-fraud
or anti-money-laundering checks, or other background screening activity).
4. Purposes and legal grounds for processing personal information
We process your personal information for the purposes set out in our full privacy notice,
including to deal with our relationship with you (including for claims and handling
complaints), for research and analysis, to monitor our expectations of performance
(including of health providers relevant to you) and to protect our rights, property,
or safety, or that of our customers, or others. The legal reason we process personal
information depends on what category of personal information we process. We normally
process standard personal information on the basis that it is necessary so we can perform
a contract, for our or others’ legitimate interests or it is needed or allowed by law.
We process special categories of information because it is necessary for an insurance
purpose, because we have your permission or as described in our full privacy notice.
We may process information about your criminal convictions and oences (if any) if this
is necessary to prevent or detect a crime.
Section three: Protecting your information and rights Page 53
5. Marketing and preferences
We may use your personal information to send you marketing by post, phone, social
media, email and text. We only use your personal information to send you marketing
if we have either your permission or a legitimate interest. If you don’t want to receive
personalised marketing about similar products and services that we think are relevant
to you, please contact us at optmeout@bupa.com or write to Bupa Data Protection,
Willow House, 4 Pine Trees, Chertsey Lane, Staines-upon-Thames, Middlesex TW18 3DZ
6. Processing for profiling and automated decision-making
Like many businesses, we sometimes use automation to provide you with a quicker,
better, more consistent and fair service, as well as with marketing information we think
will interest you (including discounts on our products and services). This may involve
evaluating information about you and, in limited cases, using technology to provide you
with automatic responses or decisions. You can read more about this in our full privacy
notice. You have the right to object to direct marketing and profiling relating to direct
marketing. You may also have rights to object to other types of profiling and automated
decision-making.
7. Sharing your information
We share your information within the Bupa group of companies, with relevant policyholders
(including your employer if you are covered under a group scheme), with funders who
arrange services on your behalf, those acting on your behalf (for example, brokers and
other intermediaries) and with others who help us provide services to you (for example,
health-care providers) or who we need information from to handle or check claims or
entitlements (for example, professional associations). We also share your information
in line with the law. You can read more about what information may be shared in what
circumstances in our full privacy notice.
8. International transfers
We work with companies that we partner with, or that provide services to us (such as
health-care providers, other Bupa companies and IT providers) that are located in, or run
their services from, countries across the world. As a result, we transfer your personal
information to dierent countries including transfers from within the UK to outside the
UK, and from within the EEA (the EU member states plus Norway, Liechtenstein and
Iceland) to outside the EEA, for the purposes set out in this privacy notice. We take steps
to make sure that when we transfer your personal information to another country,
appropriate protection is in place, in line with global data-protection laws.
9. How long we keep your personal information
We keep your personal information in line with periods we work out using the criteria
shown in the full privacy notice available on our website.
10. Your rights
You have rights to have access to your information and to ask us to correct, erase and
restrict use of your information. You also have rights to object to your information being
used; to ask us to transfer information you have made available to us; to withdraw
your permission for us to use your information; and to ask us not to make automated
decisions which produce legal eects concerning you or significantly aect you. Please
contact us if you would like to exercise any of your rights.
Page 54 Section three: Protecting your information and rights
11. Data-protection contacts
If you have any questions, comments, complaints or suggestions about this notice,
or any other concerns about the way in which we process information about you, please
contact us at datapr[email protected]om. You can also use this address to contact our
Data Protection Ocer.
You also have a right to make a complaint to your local privacy supervisory authority.
Our main oce is in the UK, where the local supervisory authority is the Information
Commissioner, who can be contacted at: Information Commissioner’s Oce,
Wyclie House, Water Lane, Wilmslow, Cheshire SK9 5AF, United Kingdom.
Phone: 0303 123 1113 (local rate).
5. Making a complaint
We are sorry if you need to complain. We will do our best to understand what has
happened and put things right.
Ways to get in touch
J
Call us: 0345 609 0777*
J
Chat to us online: bupa.co.uk/complaints
J
Email us: customerr[email protected]om
If you need to send us sensitive information you can email us securely using Egress.
For more information and to sign up for a free Egress account, go to
https://switch.egress.com
You will not be charged for sending secure emails to a Bupa email address using the
Egress service.
J
Write to us: Customer Relations, Bupa, Bupa Place, 102 The Quays, Salford M50 3SP
What happens with my complaint?
We will carefully consider your complaint and do our best to resolve it quickly. If we can’t
resolve it straight away, we will email or write to you within five business days to explain
the next steps.
We will keep you updated on our progress and once we have fully investigated your
complaint, we will email or write to you to explain our decision. If we have not resolved it
within eight weeks we will write to you and explain the reasons for the delay.
If we have not resolved your complaint within eight weeks, or if you are unhappy with our
decision, you may be able to refer your complaint to the Financial Ombudsman Service
for an independent review. The service they provide is free and impartial. You can visit
their website, financial-ombudsman.org.uk, or:
J
call them on 0800 023 4567
J
submit a complaint online at financial-ombudsman.org.uk/contact-us/complain-online
J
email them at complaint.info@financial-ombudsman.org.uk
J
write to them at the Financial Ombudsman Service, Exchange Tower, London E14 9SR
If you refer your complaint to the Financial Ombudsman Service, they will ask for your
permission to access information about you and your complaint. We will only give them
what is necessary to investigate your complaint and this may include medical information.
If you are concerned about this, please contact us.
*We may record or monitor our calls.
Section three: Protecting your information and rights Page 55
6. The Financial Services
Compensation Scheme (FSCS)
In the unlikely event that we cannot meet our financial obligations, you may be entitled
to compensation from the Financial Services Compensation Scheme. This will depend
on the type of business and the circumstances of your claim. The FSCS may arrange
to transfer your policy to another insurer, provide a new policy or, where appropriate,
provide compensation. Further information about compensation scheme arrangements
is available from the FSCS on 0800 678 1100 or 020 7741 4100 or on its website at:
www.fscs.org.uk
7. Financial crime and sanctions
Financial crime
You agree to comply with all applicable UK legislation relating to the detection and
prevention of financial crime (including, without limitation, the Bribery Act 2010 and the
Proceeds of Crime Act 2002).
Sanctions
We will not provide cover and we shall not be liable to pay any claim or provide any
benefit to the extent that such cover, payment of a claim(s) or benefits would:
J
be in contravention of any United Nations resolution or the trade or economic
sanctions, laws or regulations of any jurisdiction to which we are subject (which may
include without limitation those of the European Union, the United Kingdom, and/or
the United States of America); and/or
J
expose us to the risk of being sanctioned by any relevant authority or competent
body; and/or
J
expose us to the risk of being involved in conduct (either directly or indirectly) which
any relevant authority, banks we transact through, or competent body would
consider to be prohibited.
Where any resolutions, sanctions, laws or regulations referred to in this clause are, or
become applicable, we reserve all of our rights to take all and any such actions as may
be deemed necessary in our absolute discretion, to ensure that we continue to be
compliant. You acknowledge that this may restrict, delay or terminate our obligations
and we may not be able to pay any claim(s) in the event of a sanctions-related concern.
bupa.co.uk
BBY/1124/JAN23 BINS 09441
UNI-106037
Bupa Health Assessments, Bupa Anytime
HealthLine and Family Mental HealthLine are not
regulated by the Financial Conduct Authority or
the Prudential Regulation Authority.
Bupa Health Assessments and Bupa Anytime
HealthLine are provided by:
Bupa Occupational Health Limited. Registered
in England and Wales No. 631336.
Registered office: 1 Angel Court,
London EC2R 7HJ
Bupa health insurance is provided by:
Bupa Insurance Limited. Registered in England
and Wales No. 3956433. Bupa Insurance
Limited is authorised by the Prudential
Regulation Authority and regulated by the
Financial Conduct Authority and the Prudential
Regulation Authority. Financial Services
Register No. 203332.
Bupa insurance policies are arranged and
administered by:
Bupa Insurance Services Limited. Registered
in England and Wales No. 3829851. Bupa
Insurance Services Limited is authorised and
regulated by the Financial Conduct Authority.
Financial Services Register No. 312526.
You can check the Financial Services Register
by visiting: https://register.fca.org.uk or by
contacting the Financial Conduct Authority
on 0800 111 6768.
Registered office: 1 Angel Court,
London EC2R 7HJ
© Bupa 2023
