GUARDIAN HEALTH LETTERHEAD]
1. AIDS This POLICY does not cover MEDICAL TREATMENT
directly or indirectly related to Human
Immunodeficiency Virus (HIV) or Acquired
Immune Deficiency Syndrome (AIDS) or
any syndrome or condition of a similar kind
whatever it is called.
2. APPLIANCES This POLICY does not cover the provision of
surgical or medical appliances, aids or
equipment, including spectacles, contact
lenses, hearing aids, dentures or dental
3. CARE OF THE AGED This POLICY does not cover MEDICAL TREATMENT in
any establishment for care of the aged,
including the geriatric ward of a HOSPITAL.
4. CLAIM FORMS AND REPORTS This POLICY does not cover any charges or fees
for the completion of claim forms or for
medical reports needed on or before applying
for insurance under this POLICY or any other
insurance cover or enrolment in any insurance
5. COSMETIC TREATMENT This POLICY does not cover cosmetic treatment,
whether or not for psychological reasons,
unless necessary as a result of an accident
which happens while YOU are covered by this
6. DENTISTRY This POLICY does not cover dental, orthodontic
and periodontal treatment except SPECIFIED
OROSURGICAL PROCEDURES - see definitions.
7. DRUGS AND DRESSINGS This POLICY does not cover the cost of drugs
and dressings prescribed when YOU are receiving
MEDICAL TREATMENT as an OUT-PATIENT unless
used in the course of chemotherapy or
8. GP AND ROUTINE This POLICY does not cover the services of a GP,
EXAMINATIONS eye tests, hearing tests or medical
examinations of a routine or preventative
9. HEALTH-HYDROS AND This POLICY does not cover MEDICAL TREATMENT
NATURE CURE CLINICS in any health-hydro or nature cure clinic or
similar establishment, or occupying private
beds in a HOSPITAL attached to one of these
10. HOME NURSING This POLICY does not cover MEDICAL TREATMENT
CHARGES for home nursing for mental or
psychiatric illness or wholly or partly arranged
for domestic reasons.
11. HORMONE REPLACEMENT This POLICY does not cover Hormone Replacement
THERAPY Therapy (HRT) unless it follows the removal of
both ovaries, when the treatment will be
limited to a maximum of two years from
the date of removal.
12. KIDNEY FAILURE This POLICY does not cover supportive treatment
for renal failure including dialysis. YOU are
covered for dialysis immediately before and
after a kidney transplant or in connection
with acute secondary failure when the dialysis
is part of intensive care.
[GUARDIAN HEALTH LETTERHEAD]
EXCLUSIONS (continued)
13. MENTAL AND PSYCHIATRIC This POLICY does not cover MEDICAL TREATMENT as
ILLNESS, ALCOHOLISM, DRUG an IN-PATIENT or DAY-PATIENT for mental or
AND SUBSTANCE ABUSE psychiatric illness and for alcoholism, drug
or substance abuse or addiction or
conditions which may be directly attributed to
alcoholism or drug or substance abuse or
addiction for any period in excess of 28 days
per INSURED PERSON in any one POLICY YEAR.
14. ORGAN TRANSPLANT This POLICY does not cover any amount in EXCESS
of Pound 50,000 for each INSURED PERSON in a
POLICY YEAR relating to organ transplant. Any
MEDICAL TREATMENT CHARGES relating to a live
donor will be incorporated within this amount.
15. PREGNANCY a) This POLICY does not cover MEDICAL TREATMENT
for pregnancy or childbirth unless it
is either complicated by a MEDICAL
CONDITION needing MEDICAL TREATMENT during
the ante-natal stages of pregnancy or
needing a SPECIFIED OBSTETRIC PROCEDURE -
see definitions.
b) This POLICY does not cover intentional
termination of pregnancy unless medically
necessary during MEDICAL TREATMENT that is
insured under this POLICY.
c) This POLICY does not cover MEDICAL TREATMENT
for infertility or for inability to
conceive, other than investigations into
the cause of infertility, provided that YOU
and YOUR spouse:
i) have been insured by US under this
POLICY for a continuous period
of two years at the start of the
investigations and
ii) were unaware of YOUR infertility or
inability to conceive before
YOUR insurance started under this
d) This POLICY does not cover MEDICAL TREATMENT
related to any form of assisted reproduction
and/or any subsequent pregnancy,
delivery and, within three months of the
birth, post-natal care of the mother and
child or children.
e) This POLICY does not cover foetal surgery,
which is surgery performed on an unborn
child, or MEDICAL TREATMENT in connection
with such surgery whether undergone by the
mother or the unborn child.
16. RADIOACTIVITY This POLICY does not cover MEDICAL CONDITIONS
caused by, or attributed to radioactive
17. REFERRAL WITHIN PRACTICE This POLICY does not cover MEDICAL TREATMENT
from a chiropractor, osteopath or homeopath in
the same practice as the GP who referred YOU.
18. SELF-INFLICTED This POLICY does not cover intentional self-
CONDITIONS inflicted MEDICAL CONDITIONS.
19. SEX CHANGE This POLICY does not cover MEDICAL TREATMENT
in connection with sexual reassignment, whether
or not for psychological reasons.
20. SHORT-SIGHTEDNESS, This POLICY does not cover MEDICAL TREATMENT
LONG-SIGHTEDNESS for myopia (short-sightedness) or hyperopia
(long-sightedness).
[GUARDIAN HEALTH LETTERHEAD]
EXCLUSIONS (continued)
21. TREATMENT ABROAD This POLICY does not cover MEDICAL TREATMENT
outside the UK, if YOU are outside the UK
either against medical advice or specifically
to:
a) Obtain MEDICAL TREATMENT
b) Take up a permanent appointment to work
outside the UK
22. WAR This POLICY does not cover MEDICAL TREATMENT
for any MEDICAL CONDITIONS arising out of war,
invasion, act of foreign enemy, hostilities
(whether war is declared or not), civil war,
riot, civil commotion, acts of terrorism,
rebellion, revolution, insurrection, or
military or usurped power.
NOTE: THE HEADINGS USED IN THIS SECTION
OF THE POLICY ARE FOR CONVENIENCE OF REFERENCE
ONLY AND DO NOT AFFECT ITS CONSTRUCTION.
[GUARDIAN HEALTH LETTERHEAD]
1. CANCELLATION a) WE may cancel or alter the terms of this
POLICY for the following reasons after
giving seven days notice in writing to
the INSURED:
i) non-payment of the premium by the INSURED;
ii) the INSURED'S failure to observe the terms
of this POLICY or failure to act with
utmost good faith.
b) WE may cancel or alter the terms of cover for
an INSURED PERSON if the INSURED PERSON has:
i) mis-led US by mis-statement or concealment;
ii) agreed to any attempt by a third party to
obtain money unreasonably to OUR cost;
iii) failed to observe the terms of this POLICY
or failed to act with utmost good faith.
2. CHILDREN If a child is born during a POLICY YEAR and
YOU want him or her to qualify as an INSURED
PERSON without providing evidence of health,
YOU must ask US for this in writing within
three months of the birth.
3. CLAIMS If there is a claim under this POLICY, WE will
only pay BENEFIT if:
a) Written details on OUR claim form are sent
to US as soon as possible with original
bills or accounts (not copies). The claim
form must be sent no later than two months
after the start of the MEDICAL TREATMENT;
b) WE can ask for medical information from any
GP, SPECIALIST or other physician as often
as WE may reasonably require; and
c) WE are told as soon as reasonably possible
of any circumstances which may lead to a
claim against a third party; and
d) Premiums have been paid for the appropriate
POLICY YEAR; and
e) The MEDICAL TREATMENT takes place during
the POLICY YEAR.
4. FRAUD If there is or has been any fraud, hiding of
facts or untrue statement made whether before
the POLICY started or afterwards, WE will
cancel this POLICY. YOU must pay back any
BENEFIT we have already paid.
5. MATERIAL CHANGES WE must be informed as soon as possible of any
material change affecting the INSURED or an
INSURED PERSON. WE reserve the right to alter
the terms of the POLICY following a material
6. OTHER INSURANCE If MEDICAL TREATMENT CHARGES claimed under this
POLICY are or may be covered by any other
insurance or indemnity, WE will not pay BENEFIT
or contribute towards that claim. If the other
insurance or indemnity does not cover all of
the MEDICAL TREATMENT CHARGES, WE will pay the
balance, but only up to our limit of BENEFIT.
7. PAYMENT OF BENEFITS WE will pay the BENEFITS directly to the person
or organisation who provides the MEDICAL
For MEDICAL TREATMENT outside the UK WE will
pay all BENEFITS to YOU in Sterling at the
rate of exchange in use when the claim is
[GUARDIAN HEALTH LETTERHEAD]
8. PAYMENT OF PREMIUM Premium is payable in advance of any cover
being provided by this POLICY and must be paid
in the manner agreed by US.
9. SUBROGATION If YOU have a right to claim payment from
another person in respect of anything covered
by this POLICY WE may take over YOUR rights
against that person.
10. WAIVER OF TERMS If WE do not at any time apply or enforce any
of the terms of this POLICY this will not
prevent US from doing so at a later date.
NOTE: THE HEADINGS USED IN THIS SECTION OF THE
POLICY ARE FOR CONVENIENCE OF REFERENCE ONLY
AND DO NOT AFFECT ITS CONSTRUCTION.
[GUARDIAN HEALTH LETTERHEAD]
WHEN YOU REQUIRE TREATMENT
1. VISIT YOUR GP If your GP can provide treatment, YOU need not
inform us, as consultations and treatments
carried out by a GP are not covered under this
If YOUR GP recommends that YOU should see a
specialist, explain that YOU have private
health insurance with Guardian Health. YOUR GP
will pass YOUR details to a SPECIALIST in order
that an appointment can be made.
2. CALL THE GUARDIAN Before YOU go to see the SPECIALIST YOU must
HEALTH HELPLINE BEFORE YOU call the helpline. Either the member or the
SEE YOUR SPECIALIST patient may call, whichever YOU
prefer. The helpline will check the name and
address of the patient against OUR records
using the POLICY number. YOU will need to
provide the POLICY number which YOU will find
on YOUR certificate of insurance and membership
card. The helpline will already know the
details of the cover. YOU will then need to
supply details of the condition being treated
so that WE can check this information against
the cover provided.
3. TAKE YOUR YOU will be sent a claim form together with an
PRE-AUTHORISED CLAIM FORM explanatory letter by the helpline which will
TO THE SPECIALIST contain YOUR policy number, name and address
etc. Please check that this information is
correct and complete any missing details on the
front of the form, then sign and date the form.
The REVERSE of the form must be completed by
YOUR GP or the SPECIALIST in charge of
Please note: the GP signing the form can make
a small charge for this service which is not
covered by the POLICY.
4. WHEN AND WHERE TO SEND Once the form is fully completed PLEASE send it
YOUR CLAIM FORM to Guardian Health. The form should be sent to
US within two months of the start of the
5. WHEN YOU RECEIVE THE When YOU have received treatment and start to
ACCOUNTS receive the accounts, please check them
carefully and make sure YOU have received all
the treatments for which YOU are being charged.
Once YOU are happy with the bill, sign and
forward it to Guardian Health. WE will pay the
bill and send YOU a statement telling YOU what
payments have been made on YOUR behalf.
6. ADDITIONAL TREATMENT After the initial treatment YOU will probably
need to see YOUR SPECIALIST for a routine
post-treatment check-up. However, if YOUR
SPECIALIST recommends any additional treatment
call the Guardian Health helpline before going
for further treatment. They will help YOU and
advise whether an additional claim form needs
to be completed.
[GUARDIAN HEALTH LETTERHEAD]
7. ANY QUESTIONS? Remember the helpline is there for YOU. The
people who take YOUR call will understand YOUR
needs and be able to answer YOUR questions.
They are there for YOUR benefit to provide
advice, guidance and information, so do make
use of their experience. Using the helpline
will assist YOU to get the best value-for-money
treatment and consequently help to keep down
costs. Above all the helpline is completely
confidential so YOU can discuss YOUR needs
without reserve.
Our helpline number is 01303 853400.
[GUARDIAN HEALTH LETTERHEAD]
YOUR QUESTIONS ANSWERED
1. ARE THERE ANY FINANCIAl There is no overall maximum amount that YOU may
LIMITS TO THE AMOUNT I MAy claim in the UK. However, some parts of the
CLAIM? cover, such as private ambulance usage do have
a maximum amount which YOU may claim in any one
POLICY YEAR. Overseas treatment also has an
annual maximum amount that YOU may claim.
Please check YOUR table of benefits for further
2. CAN I SEE MY GP No. WE do not cover the costs of private
PRIVATELY? consultations or treatment with YOUR GP.
3. CAN I GO STRAIGHT TO a No. YOUR GP must refer YOU to the SPECIALIST.
SPECIALIST? If YOU go directly to a SPECIALIST without
referral from YOUR GP it will not be covered,
except in the case of an emergency.
4. WHICH HOSPITALS CAN I Go If YOU are covered on A scale you may use any
TO? HOSPITAL on the Hospital List. If you are
covered on the B scale YOU may use any
HOSPITAL on the Hospital List providing B or C
accommodation. If YOU ARE covered on C scale
YOU may only use A HOSPITAL providing C
accommodation. To ensure correct room
allocation and charges YOU must advise the
HOSPITAL of YOUR level of cover before
treatment. Should YOU wish to use a HOSPITAL
which is not on the Hospital List please
telephone OUR helpline on 01303 853400 who will
be able to advise YOU.
5. IS PREGNANCY COVERED? No. Pregnancy or childbirth is not covered
unless it is complicated by a MEDICAL CONDITION
requiring MEDICAL TREATMENT during pregnancy or
requiring a SPECIFIED OBSTETRIC PROCEDURE.
Details of SPECIFIED OBSTETRIC PROCEDURES may
be found in the definitions section of this
6. IS DENTAL TREATMENt Dental treatment is not covered. However,
COVERED? certain procedures, referred to as SPECIFIED
OROSURGICAL PROCEDURES, are covered. Details
of these may be found in the definitions
section of this documentation.
7. IS EYE TESTING COVERED? No. Eye testing of a routine or preventative
nature is not covered. Neither is the supply
of spectacles.
8. AS I AM COVERED By No. YOU do not lose the benefit of the NHS.
GUARDIAN HEALTH, DOES Indeed, if YOU ARE treated as an IN-PATIENT in
THIS MEAN I CANNOT BE a NHS HOSPITAL YOU will receive a cash benefit
TREATED UNDER THE NHS? for each night YOU stay.
9. IS PRIVATE NURSING At Yes. YOU can receive private nursing at home as
HOME COVERED? long as YOUR SPECIALIST considers it medically
necessary and it is not in any way for
domestic reasons or for mental or psychiatric
illness. It must be carried out by a QUALIFIED
NURSE. Where home nursing for more than 14 days
is required, we may need to request a medical
report from YOUR SPECIALIST to establish YOUR
entitlement to further nursing care.
[GUARDIAN HEALTH LETTERHEAD]
10. AM I COVERED WHILE I Yes. YOU are covered while YOU are abroad on
AM ABROAD? holiday or business. This cover applies in
every country in the world and in addition WE
provide an overseas helpline (details on YOUR
membership card) to help arrange emergency
treatment or repatriation where necessary.
REMEMBER, IF YOU HAVE ANY QUESTlONS PLEASE DO
NOT HESITATE TO CONTACT OUR HELPLINE ON 01303
[GUARDIAN HEALTH LETTERHEAD]
COMPLAINTS PROCEDURE
Any complaint you may have regarding
YOUR POLICY should be addressed in the first
instance, to the intermediary who arranged the
POLICY. If for any reason YOU are dissatisfied,
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