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Benefit Rules
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Administration ~ Notes on Benefits
Day Case Treatment: When the patient undergoes
surgical or medical procedures or complex medical tests or complex radiological
procedures requiring the patient to be in bed in hospital but not on an
overnight stay basis and the sole purpose of which is the cure or relief of
acute illness or injury.
In-Patient Treatment: When the patient remains overnight in hospital
for surgical or medical procedures the sole purpose of which is the cure or
relief of acute illness or injury.
Out-Patient Treatment: Private consultations with a Specialist or
treatment under a Specialist for the cure or relief of acute illness or injury
not received as In-Patient Treatment or Day Case Treatment.
General Practitioner: A registered medical practitioner in general
practice registered under the Medical Act 1983.
Physiotherapist: A practitioner of Physiotherapy whose qualification is
recognised by the Department of Health.
Osteopath: A practising Osteopath holding the MRO qualification who is
also a current member of the Register of Osteopaths.
Chiropractor: A practising Chiropractor holding the DC qualification
who is also a current member of the British Chiropractic Association.
Homeopathy: A practising Homeopath holding a recognised qualification
who is also a current member of the Register of Homeopaths.
Acupuncture: A practising Acupuncturist holding a recognised qualification
who is also a current member of the Register of Acupuncturists.
Qualified Nurse: A nurse whose name is currently on any register of
nurses maintained by any statutory nursing registration body within the United
Kingdom.
Specialist: A medical or dental practitioner who is registered under
the Medical Act 1983 or the Dentists Act 1984 (as appropriate) and holds or
has held a consultant appointment in an NHS Hospital or holds a certificate of
specialist accreditation from the appropriate Royal College. For the purpose of
out-patient treatment only, Physiotherapists, Osteopaths, Chiropractors,
Homeopaths, Acupuncturists, Orthoptists and Speech and Occupation therapists
shall be classed as Specialists in their own right.
CONDITIONS OF THE SCHEME
(i) Expressions defined on the Membership Agreement have the meanings ascribed. The following expressions have the following meanings:-
DATE OF REGISTRATION: The date specified on the
Membership Certificate.
ELIGIBLE DEPENDANTS: A subscriber’s spouse and unmarried children who
are minors on the relevant Renewal Date.
MEMBER: A person registered as a member of the Scheme.
RENEWAL DATE: 1st April each year or in accordance with the
Contract.
TRUSTEES: The Trustees nominated by the Employer to administer the
Scheme.
RHL: Revelation Healthcare Limited: The administrator of the Scheme
appointed by the Company.
(ii) The terms and conditions set out in this document constitute the entire agreement between the parties. No variation shall have effect unless in writing and signed on behalf of the Trustees and/or RHL. (iii) Any notice to be given by RHL may be effectively served by being sent to the Member’s last known home address, as notified to the Company by the Employer, or by being distributed by the Employer with the Member’s wage packet or notification of payment (in which event it shall be deemed served when such wage packet or notification is distributed).
(iv) This Agreement shall be governed by English Law.
2 REGISTRATION
(i) In consideration of the relevant Subscription Fee, RHL will provide Scheme Benefits to the Member and his registered Eligible Dependants. (ii) Any person employed by the Employer and resident in the United Kingdom or Channel Islands may apply to become a Member for himself and any Eligible Dependant by completing the form set out. Scheme Benefits are subject to restriction by reference to any existing condition(s) or complaint(s) and are discretionary. (iii) After initial registration, a Member may register Eligible Dependants by completing and forwarding to RHL a further membership application form. (iv) RHL reserves the right to refuse any application for membership without giving reason.
3 RENEWAL
(i) Membership of the Scheme runs initially until the next Renewal Date and thereafter from year to year or in accordance with the Contract. (ii) A Member may withdraw from the Scheme with effect from any Renewal Date by giving written notice to the Trustees. (iii) Not less than 28 days prior to each Renewal Date, RHL through the Employer, shall give notice to each member of the Subscription Fees applicable for the following year together with notice of the right of the Member to withdraw from the Scheme. If the Member does not give notice of withdrawal, his membership shall be automatically renewed for a further year.
(iv) Subscribers and/or registered Dependants who take up residence abroad shall cease from the next Renewal Date to be registered or entitled to participate under the Scheme.
(i) The Member shall pay Subscription Fees monthly in advance at RHL’s published rate for the Scheme by deduction from the preceding month’s payroll. (ii) Subscription Fees payable in respect of less than a full year shall be pro rated. (iii) If the Member shall cease to be employed by the Employer or shall die or if, for whatever reason, the Employer shall cease to employ the Scheme then, unless such cessation occurs by reason of a transfer of business and the Scheme shall be available through the new employer, RHL shall offer such Member (or his Dependants, as appropriate) the opportunity to participate in the Scheme as an individual upon its then current terms for Direct Subscription. If such terms are accepted within 28 days of the offer by RHL, the membership of the Scheme shall be deemed to have been continuous. (iv) If membership shall terminate by reason of circumstances beyond a Member’s control whilst he or a registered Dependant shall be undergoing a course of Treatment, Scheme Benefits will be continued for a maximum of 14 days at the disrection of the Trustees.
NOTE: Membership of the Companies Healthcare Trust Fund covers employees and their registered dependants only.
RHL have agreed to accept immediate benefit cover for all members of staff subject to agreement with the company with no restriction on benefits covered by the scheme in respect of conditions or treatment that may have arisen prior to joining the scheme.
New members joining the scheme who are not current members of a health insurance scheme will be required to meet the ‘Clear Zone’ qualification where existing medical conditions are excluded only for the first 18 months of membership or subject to the agreement by the company and RHL.
BENEFIT RULES
1 The rate of benefits shall be those prescribed by RHL
and may be altered from time to time. However any such alterations will only
apply to the enrolment with effect from the following annual renewal date.
2 Where maximum limits of benefit apply they are available for each person
included in the enrolment.
3 Except in an emergency all treatment for which benefit is claimed must be
arranged with the knowledge and approval of the patient’s General Practitioner
or of a Specialist to whom the patient has been referred by a General Practitioner.
Prior approval must in all cases be gained from RHL before receiving any form
of treatment.
4 The expenses of treatment for which benefit is claimed must in the opinion
of RHL be reasonable and necessarily incurred and be wholly and exclusively
for the purpose of curing an eligible medical condition and not for the
alleviation of long-term illness.
5 RHL may require full itemisation of any charges giving rise to a claim for
benefit.
6 RHL reserves the right to refuse to pay any part of the expenses of treatment
which are considered to be in excess of those customarily charged for the
provision of similar treatment in the United Kingdom.
7 Benefit is payable only in respect of services which are specified in the
schedule of benefits and which are actually rendered during a period for which
contributions have been paid.
8 Benefit in respect of private or NHS In-patient or Day-patient treatment
which is wholly or partly for any condition including psychiatric conditions
(other than those which are excluded in the Exclusion List) will be restricted
to a maximum of 28 days in the aggregate in any one year.
9 RHL will not accept liability unless the prescribed claim form is duly
completed and submitted to RHL within 6 months of the date of commencement of
treatment. All bills supporting a claim should be sent to us as soon as
possible.
10 In addition to the claim form RHL may require the submission of a Medical
Report. RHL do not meet fees for the completion of claim forms or medical
reports.
11 For the assessment of all In-patient claims the day of admission and
discharge shall count as one day.
12 Benefits will not be paid in excess of actual expenses incurred except by
payment of NHS Cash Benefit.
13 You must without delay notify and keep RHL informed about any claim or
right of action against any other party arising out of the circumstances
relating to a claim for benefit.
14 RHL may require you or any enrolled dependant to include (at no cost to
RHL) in any such claim against another party the amount of the benefits paid
with a view to reimbursing the outlay of the Trust Fund.
15 Surgical operations are classified in accordance with a Schedule of
Operations approved by RHL’s medical advisers. Complex major operations are
graded in the Schedule by degree of complexity.
ADMINISTRATION
1 The companies Healthcare Trust Fund will be administered
by RHL in accordance with the Agreement and our Memorandum and Articles of
Association, the Rules, the Schedule of Benefits and Contributions.
2 RHL will advise you of any alteration that we deem to be material, but any
accidental omission or failure to advise you shall not invalidate the alteration.
3 Any notice or correspondence to you shall be sent to the address in your
application for enrolment unless you have informed RHL in writing of a change
of address.
4 No agent of RHL’s is authorised to modify or waive all or any part of
these Rules. Any modification or waiver may only be made by RHL and the
Companies Healthcare Trust Fund.
5 No verbal communication can override or vary the written terms or conditions
of the Healthcare Scheme unless confirmed by RHL in writing and/or the Trustees.
NOTES ON BENEFITS
i) Benefit 1 is payable provided treatment is received in a Hospital room which is classified in the Register of RHL. ii) Benefit 2 is payable when a child under the age of 12, who is enrolled in their parents’ membership, is receiving In-patient treatment. The benefit is payable in respect of charges for one parent staying overnight in hospital with their child. iii) Benefit 5 is payable for each day that services are rendered by the Specialist during In-patient or Day-patient treatment. The Member must be under the regular care of a Specialist and, in respect of In-patient treatment, benefit would not normally be payable unless the Specialist attends the Member on at least 5 days each week. Benefit 5 is payable for up to 91 days in any one year. iv) Benefit 7 is payable if the Member needs a private ambulance to transport him to, from or between hospitals when the ambulance is required wholly out of medical necessity and in connection with eligible In-patient or Day-patient treatment. v) Benefit 8 is payable for each night of treatment as an In-patient free of charge under the NHS. Benefit 8 is payable for up to 35 nights in any one year. vi) Benefit is only applicable under the direction of a Specialist or Consultant and where in their opinion will aid recovery (applicable to acute conditions only).
vii) Benefit 11 is also payable for treatment given by an Acupuncturist, Homeopath, Chiropractor, or Osteopath when the patient has been specifically referred by a Specialist, but benefit will be limited to a maximum of £250 per person in any one year when the referral is made by a General Practitioner.
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