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WHA Direct

WHA Direct Benefit & General Conditions

DEFINITIONS

"We, Us or Our" means Welsh Hospitals & Health Services Association trading as WHA Direct.

"You or Your" means the person who is registered as being covered for benefits by regular subscription payments applicable to a personal or partners’ scheme.

“Enrolment Date” means the date on which cover starts, whether enrolling for the first time or changing to a new cover option with higher maximum benefits.

“Claim Date” means the date from which the maximum benefit payable is calculated and is:

  • the date of admission to hospital for hospital inpatient benefit, or
  • the date of the first attendance for hospital outpatient benefit, or
  • the date of the consultation for specialist consultation benefit, or
  • the date on which new spectacles, lenses or contact lenses are supplied for optical benefit, or
  • the date on which treatment ends for all other benefits.

BENEFIT CONDITIONS

We will pay benefit at the rate applicable to Your subscription and scheme option as indicated in the table of benefits, provided that Your claim complies with the appropriate conditions as stated in the following paragraphs.

1. HOSPITAL INPATIENT

1.1 We will pay benefit at the daily rate for each day spent in a recognised hospital as a formally admitted inpatient.

1.2 When We calculate the benefit payable, We count the day of admission but not the day of discharge. In order to qualify for benefit, there must be at least one overnight stay in hospital.

1.3 We will pay up to the maximum benefit shown in the table of benefits once in a period of two years, calculated from the Claim Date.

1.4 If a patient is in hospital continuously for more than two years, when the maximum hospital inpatient benefit has been paid once, We will not pay any further hospital inpatient benefit unless the patient is discharged from hospital and is then readmitted to hospital for a different medical condition.

2. HOSPITAL OUTPATIENT

2.1 We will pay benefit when the patient has attended as a National Health Service outpatient or day patient on at least three occasions in a continuous period of six months.

2.2 We will pay the maximum benefit shown in the table of benefits once in a period of two years, calculated from the Claim Date.

2.3 We will not pay benefit for outpatient or day patient attendances required because of pregnancy.

2.4 We will not pay benefit for outpatient or day patient attendances required because of psychiatric or geriatric conditions.

3. PERSONAL ACCIDENT BENEFIT

3.1 We will cover You and Your registered partner for death, disablement or for certain injuries suffered as a result of an accident. We will send You full details of personal accident benefit on request.

4. COUNSELLING

4.1 We will pay up to the maximum benefit for fees incurred and paid for appointments with a practitioner who is registered with at least one of the following organisations:

British Association for Counselling and Psychotherapy

British Psychological Society

National Counselling Society

United Kingdom Council for Psychotherapy

4.2 We will pay up to the maximum benefit shown in the table of benefits once in a period of two years, calculated from the Claim Date.

5. OPTICAL

5.1 We will pay up to the maximum benefit for fees incurred and paid for new spectacles, lenses or contact lenses prescribed by a qualified optical practitioner registered with the General Optical Council.

5.2 We will pay the maximum benefit shown in the table of benefits once in a period of two years, calculated from the Claim Date.

5.3 We may deduct the value of any NHS vouchers from the total fees incurred when calculating the benefit payable.

5.4 We will not pay benefit for any optical care plans, contact lens solutions, repairs or for the supply of new spectacle frames only.

6. DENTAL

6.1 We will pay up to the maximum benefit for fees incurred and paid for treatment by a qualified dental practitioner registered with the General Dental Council.

6.2 We will pay the maximum benefit shown in the table of benefits once in a period of two years, calculated from the Claim Date.

6.3 We will not pay benefit for regular payments made for any dental maintenance plans such as Denplan.

7. ALTERNATIVE THERAPIES

7.1 We will pay up to the maximum benefit for fees incurred and paid for Acupuncture, Alexander Technique, Bowen Therapy and Sports Therapy/Massage by a duly qualified and registered practitioner.

7.2 We will pay up to the maximum benefit shown in the table of benefits once in a period of two years, calculated from the Claim Date. The maximum benefit represents the total for any one or a combination of the treatment types.

7.3 We will only pay benefit for treatment received because of illness or injury or to relieve pain.

8. COMPLEMENTARY TREATMENT

8.1 We will pay up to the maximum benefit for fees incurred and paid for treatment by a duly qualified and registered Physiotherapist, Osteopath, Chiropractor or Chiropodist/Podiatrist.

8.2 We will pay the appropriate maximum benefit as shown in the table of benefits once in a period of two years, calculated from the Claim Date.

8.3 We will not pay benefit for any fees incurred in relation to the supply of orthotics/orthoses, equipment or for any items purchased.

9. SPECIALIST CONSULTATION

9.1 We will pay up to the maximum benefit as shown in the table of benefits for fees incurred and paid for a consultation for a medical or surgical condition with a doctor registered in the Specialist Register of the General Medical Council. In addition to the consultation fee, benefit is also payable for fees incurred and paid for the following:

x-rays, scans or tests

one follow-up consultation

minor treatment or injection fees not exceeding £100

9.2 We will pay up to the maximum benefit shown once in a period of two years, calculated from the Claim Date.

9.3 We will not pay benefit for more than one follow-up consultation. Benefit is not payable for consultations for pension, insurance or emigration matters, legal or industrial actions, medical examinations, pregnancy, family planning, cosmetic surgery or health screening.

GENERAL CONDITIONS

10. COVER OPTIONS

10.1 When You enrol or increase Your subscriptions, You must be under 70 years of age. If You are enrolling for partners’ scheme cover or if You have partners’ scheme cover and wish to increase Your subscription, Your partner must also be under 70 years of age.

10.2 Personal scheme options cover You for all benefits.

10.3 Partners’ scheme options cover You and Your partner for all benefits.

10.4 For partners’ scheme cover, Your partner is the person to whom You are married, Your civil partner or the person with whom You live as if You were married. You must live permanently at the same address as Your partner. Your partner's full name and date of birth must be registered with Us before You can make a claim. You must let Us know immediately if You change Your partner. Benefit is not payable in respect of a partner who is not registered with Us.

11. CLAIMS

11.1 You must submit Your claims on a properly completed and certified benefit claim form. Where fees have been incurred and paid, We require an original, dated receipt showing the name of the patient and the total fee incurred and paid. We will not accept photocopied or altered receipts or certifications. We will not accept receipts or certifications made out in joint names. You must pay for any treatment or services received before You submit a claim. We will not pay practitioners directly for any fees incurred.

11.2 We will consider Your claims in accordance with the benefit scale and conditions which applied at the date of hospital admission, the first hospital outpatient appointment, the start of the treatment or on the date that the service was received, as appropriate.

11.3 We will not pay benefit if You submit a claim to Our Cardiff office more than six months after the date of the treatment or service received, the date of hospital inpatient discharge or the date of the third hospital attendance, as appropriate.

11.4 We will not pay benefit for claims arising out of any medical condition which existed before Your Enrolment Date. If You increase Your subscriptions for higher benefit cover, We will not pay benefit at higher rates if the medical condition existed before Your Enrolment Date. In order to assess eligibility for benefit, We reserve the right to request the patient to provide further information about any medical condition from his or her general practitioner.

11.5 When We calculate the benefit payable for a claim, all relevant benefits paid in the two year period before the Claim Date are deducted from the relevant maximum benefit.

11.6 We will not pay benefit for treatment or services which are received or which start before Your Enrolment Date. We will not pay benefit for hospital admissions or attendances which occurred or started before Your Enrolment Date.

11.7 We will not pay benefit for illness or injury which may be self-inflicted or arising out of riot, civil commotion, terrorism or act of war.

12. QUALIFYING PERIODS

12.1 When You enrol or increase Your subscription, a qualifying period for benefits will be applicable. Qualifying periods apply to all persons covered for benefit whether on enrolling or increasing subscriptions, unless any special arrangements are applicable.

12.2 The qualifying period is three months for all benefits except for hospital admissions relating to pregnancy/childbirth.

12.3 The qualifying period for hospital admissions relating to pregnancy/childbirth is 12 months.

12.4 There is no qualifying period for personal accident benefit or if a hospital admission or hospital attendance is required as a result of an accident.

12.5 Qualifying periods start on the Enrolment Date. Claims for treatment or services received before or which start before the qualifying period has ended are not eligible for benefit or, if subscriptions have been increased, are not eligible for benefit at the higher rate. Benefit is not payable for any treatment or services which are received before or which start before the Enrolment Date. Personal accident benefit is not payable for any accident which occurs before the Enrolment Date.

13. SUBSCRIPTIONS

13.1 Your subscriptions must be paid continuously at a valid rate. Past subscriptions cannot be refunded. It is Your responsibility to ensure that Your subscriptions are paid at the correct amount and at the correct frequency. Cover is continuous provided that You pay Your subscriptions at the correct amount and frequency. You may cancel Your cover by giving Us one month’s notice, in writing. If You cancel Your cover, We will refund any advance subscriptions You may have paid for the period after the date of cancellation.

13.2 Your subscriptions must be paid up to date before a claim can be considered. When Your subscriptions are more than three months in arrears, Your cover will be terminated and You will no longer be eligible to claim benefits.

13.3 You must pay Us any arrears of subscription before You can submit a claim for benefit. The maximum amount of arrears which We can accept is three months subscriptions.

14. GENERAL

14.1 When You pay a valid subscription to Us, You will be subject to the Benefit and General Conditions for the time being in force, copies of which are available from Our Cardiff office and from www.whadirect.co.uk.

14.2 We may change the rates of subscription and any or all of the benefits and conditions. We will give You at least one month's notice by post at Your address, as notified to Us, of any changes to the rates of subscription , the benefits or the Benefit & General Conditions.

14.3 We reserve the right to make special conditions in relation to applications for cover or to decline applications for cover. We also reserve the right to terminate cover by giving at least one month’s notice, in writing, to the address notified to Us.

14.4 Benefits are payable for treatment and services received anywhere in the United Kingdom. Hospital inpatient and hospital outpatient benefits are also applicable for emergency treatment during temporary absence abroad. Personal accident benefit is also applicable during temporary absence abroad. No other benefits are applicable during temporary absence abroad.

14.5 We will not pay benefit for fees incurred for prescription charges, surgical appliances, equipment, items supplied or for private hospital treatment which cannot be classified as minor treatment.

14.6 We will not reimburse any fees incurred for completion of benefit claim forms.

14.7 For security purposes, We will pay Your benefits to You by crossed cheque. We will not pay benefit where the amount payable is less than £1.00.

14.8. We reserve the right to recover any overpayments of benefit made to You from any future benefits payable to You.

15. COMPLAINTS

15.1 Should You find it necessary to complain about any aspect of Our service, You can telephone Us on 029 2048 5461 or You can write to Us at Welsh Hospitals & Health Services Association, 60 Newport Road, Cardiff, CF24 0YG.

15.2 You may refer any complaints We cannot settle to the Financial Ombudsman Service.

Benefit & General Conditions Issue 1 dated 1 September 2015

WHA Direct is a trading name of Welsh Hospitals & Health Services Association, a limited company registered in Wales No 515135.

Welsh Hospitals & Health Services Association, 60 Newport Road, Cardiff, CF24 0YG

Telephone 029 2048 5461. Email mail@whadirect.co.uk

Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services Register number 202605.

Your subscription includes Insurance Premium Tax at the rate applicable.

Once You have enrolled, You can continue being covered for benefits to any age, without limit.

We will always take legal and/or police action against anyone who makes a dishonest, false or fraudulent claim.