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Frequently asked questions – how to claim

 

Below, we've aimed to answer all your claiming questions. We want you to have a policy that meets your needs, so we recommend that you review your cover on a regular basis to make sure that it does. 

 

If you can't find the answer you're looking for and it's not in the product terms and conditions, as a business customer you can call us on 0800 980 7517 (Monday - Friday 9am - 5pm) or email us

How do I make a claim?

The first thing you need to do is pay for the costs of the treatment or service to the person providing them (for example, your optician). You then claim those costs back from us. It’s really easy to claim online. Please visit simplyhealth.co.uk/register and follow the simple registration process. If you’re unsure about how to claim online then please contact us.

What do you need to know to pay my claim?

Before we’re able to pay your claim, we need to be sure that the policy covers it. For example, we need to be sure that the person who receives the treatment or service is a member, and that there is not an exclusion that applies.

 

You’ll need to send a receipt that shows:

  • who the patient is 
  • who gave the treatment or service and how much they’ve charged 
  • the details and date of the treatment or service and 
  • the amount that you’ve paid. 

 

We don’t accept receipts that have been altered, or invoices, credit or debit card receipts, or bank statements. We are unable to return receipts. We won’t be able to pay a claim if you don’t send us everything that we need to assess it. 

What happens if you need more information to assess my claim?

We may need to ask the person who provided the service or treatment for more details.

We won’t pay if there’s a charge for this. We may ask for a second opinion but we’ll pay the cost for this.

Why is the claim I just made on SimplyPlan not visible on my online account or vice versa?

Submitted claims will appear on your online account (and the SimplyPlan app) once they are processed, which can take up to 3 working days. 

What can I claim - myWellbeing

We have a range of services and health-related information available to you. You can access these services through your online account. If you haven’t already registered please visit simplyhealth.co.uk/ register and follow our simple registration process. The information and services available on the myWellbeing website can change without notice from time to time.

 

Speak to a GP

The service is available 24 hours a day, 365 days a year by calling 0330 102 5443. Webcam appointments are also available from 8.30am to 6.30pm, Monday to Friday.

 

If the GP privately prescribes you some medication, they can arrange for the medication to be delivered to you at home or at work. The cost of the medication and delivery is not covered under this policy.

 

The policyholder or their partner will need to call on behalf of any children covered under this policy.

 

Telephone counselling

The service is available 24 hours a day, 7 days a week by calling 0800 975 3345. This service has some age restrictions, please see the myWellbeing website for more information.

 

Wellbeing and lifestyle guidance

This service is available 24 hours a day, 7 days a week by calling 0800 975 3345. This service has some age restrictions, please see the myWellbeing website for more information.

 

Some of the myWellbeing services are only available in the UK. The website will tell you which of the services this applies to.

What can I claim - Dental

This benefit is to help towards the costs when you see a qualified dental professional (for example a dentist or hygienist) in a dental surgery.

 

What the dental benefit covers 

  • dental check-ups 
  • treatment provided by a dentist, periodontist or orthodontist 
  • endodontic (root canal) treatment 
  • hygienists’ fees 
  • local anaesthetic fees and intravenous sedation 
  • dental brace or gum-shield provided by a dentist or orthodontist 
  • dental crowns, bridges and fillings
  • dentures 
  • laboratory fees and dental technician fees referred by a dentist or orthodontist 
  • dental X-rays 
  • denture repairs or replacements by a dental technician. 

 

What the dental benefit does not cover 

  • dental prescription charges 
  • dental consumables, for example toothbrushes, mouthwash and dental floss 
  • dental implants and bone augmentation procedures, for example sinus lift, bone graft 
  • cosmetic procedures, for example dental veneers, tooth whitening and the replacement of silver coloured fillings with white fillings 
  • laboratory fees not connected to dental treatment or performed by a dentist 
  • dental treatment provided at a hospital as a day-patient or in-patient 
  • general exclusions.

What can I claim - Optical

This benefit is to help towards the costs when you see a qualified optical professional (for example an optometrist or optician).

What the optical benefit covers

  • sight-test fees, scans or photos for an eye test 
  • fitting fees 
  • prescribed lenses and accompanying frames for: 
    • glasses 
    • sunglasses 
    • safety glasses 
    • swimming goggles 
  • adding new prescribed lenses to existing frames 
  • glasses frames 
  • contact lenses (including contact lenses paid for by instalment) 
  • consumables supplied as part of an optical prescription, for example solutions and tints 
  • repairs to glasses. 

 

What the optical benefit does not cover

  • eye surgery (for example laser eye surgery, lens replacement surgery or cataract surgery)
  • optical consumables, for example contact lens cases, glasses cases and glasses chains/cords, cleaning materials 
  • magnifying glasses 
  • eyewear that does not have prescription lenses 
  • ophthalmic consultant charges or tests related to an ophthalmic consultation 
  • general exclusions.

What can I claim - Physiotherapy, osteopathy, chiropractic, acupuncture, homeopathy (POCAH

Important: In order to be able to practise in the UK:

  • physiotherapists must be registered with the Health and Care Professions Council (HCPC) 
  • osteopaths must be registered with the General Osteopathic Council (GOsC) 
  • chiropractors must be registered with the General Chiropractic Council (GCC). 

 

We will not pay for treatment by someone who is not registered with the HCPC, GOsC or GCC (as appropriate).

 

What the POCAH benefit covers

  • physiotherapy 
  • osteopathy 
  • chiropractic 
  • acupuncture 
  • homeopathy and homeopathic medicines prescribed by and bought directly from a homeopath. 

 

What the POCAH benefit does not cover

  • any other treatments, for example reflexology, aromatherapy, herbalism, sports/remedial massage, Indian head massage, reiki, Alexander technique 
  • X-rays and scans 
  • appliances, for example lumbar roll, back support, TENS machine 
  • homeopathic medicines bought from a professional who is not a homeopath or bought from a chemist, health food shop, by mail order or over the internet 
  • general exclusions.

What can I claim - Chiropody/podiatry

Important: In order to be able to practise in the UK chiropodists / podiatrists must be registered with the Health and Care Professions Council (HCPC). We will not pay for treatment by someone who is not registered with the HCPC.

 

What the chiropody/podiatry benefit covers

  • treatment supplied by a chiropodist or podiatrist 
  • assessments, for example gait analysis, performed by a chiropodist or podiatrist 
  • consumables prescribed by and bought from the chiropodist or podiatrist at the time of treatment, for example orthoses, dressings 
  • consultations with a podiatric surgeon. 

 

What the chiropody/podiatry benefit does not cover 

  • cosmetic pedicures 
  • X-rays and scans 
  • consumables not bought from the chiropodist or podiatrist at the time of treatment, for example corn plasters bought from a pharmacy 
  • surgical footwear, for example corrective footwear 
  • general exclusions.

What can I claim - Diagnostic consultations

A diagnostic consultation is to find or to help to find the cause of your symptoms.

 

What the diagnostic consultation benefit covers 

  • the fees for a diagnostic consultation that you have as a private patient. The consultation must be with a medical professional who is (or has been) a consultant in an NHS hospital or the Armed Services. The consultant post must be a substantive appointment (that is to say not as a locum).

    In addition, the consultant must hold a current licence to practise and also be included on the: 
    • General Medical Council’s specialist register (please see www.gmc-uk.org) or 
    • General Dental Council’s dentist’s register (please see www.gdc-uk.org).
      If you have any questions as to whether your consultant meets these criteria then please contact Customer Services on 0370 908 3481. 
  • blood tests or visual field tests directly connected to a diagnostic consultation 
  • allergy tests performed by a GP or consultant (not tests or advice about nutrition or food intolerance). 

 

What the diagnostic consultation benefit does not cover 

  • follow-up consultations and check-ups after you have been diagnosed, for example cancer remission checks or management of a condition 
  • treatment charges, for example private hospital charges, operation fees, anaesthetic fees
  • consultations with a podiatric surgeon 
  • diagnostic tests and procedures, for example X-rays and scans, endoscopy, tests on body tissue samples, ECGs, health screening 
  • counselling, for example psychological counselling, speech therapy and dyslexia services 
  • assisted conception, fertility treatment or termination, pregnancy care 
  • general exclusions

What can I claim -Hospital

This benefit can help towards costs such as meals for visitors, telephone calls, travel costs or even hospital parking fees, if you are admitted to hospital.

 

To make an online claim for hospital cover you’ll need a copy of your discharge letter as evidence of your admission. If you do not have your discharge letter, you’ll need to get written confirmation of your hospital stay (for example a headed letter from the hospital).

 

What the benefit covers: 

  • an admission to hospital as a day-patient for tests or treatment.
    A day-patient is 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. If you are admitted as a day-patient and then stay overnight, we will pay one night’s hospital cover (not one day and one night) 
  • an overnight stay in a hospital as an in-patient for tests or treatment. An in-patient is a patient who is admitted to hospital and who occupies a bed overnight or longer for medical reasons 
  • out-patient cancer treatment, for example chemotherapy or radiotherapy 
  • an overnight stay in a hospital for one parent who has accompanied their child where the child is an in-patient for tests or treatment. Both the parent and child must be covered by the policy. 

 

What the benefit doesn’t cover: 

  • pre-existing conditions during the first 12 months that you are covered by the policy. We may ask for evidence that your condition is not pre-existing if you claim for this benefit during the first 12 months of cover. A pre-existing condition is any condition for which you: 
    • have been referred to a consultant or hospital for either tests or treatment before the date that you joined the policy or 
    • are receiving consultant or hospital tests or treatment before the date that you joined the policy or 
    • reasonably believe that you would be referred to a consultant or hospital for tests or treatment within 12 months of joining the policy. 
  • the first 14 nights of any stay in hospital during which you give birth 
  • out-patient visits, for example consultations, tests, scans 
  • out-patient treatment (although treatment for cancer is covered) 
  • day care, for example psychiatric, respite care (short term temporary relief for a carer of a family member), maternity care and care for the elderly 
  • permanent residence in a nursing home 
  • kidney dialysis 
  • attendance at an accident and emergency department, or treatment not in a hospital, for example operations carried out in a GP’s surgery or clinic 
  • pregnancy termination 
  • laser eye surgery 
  • cosmetic surgery 
  • hotel ward admission
  • ante or post-natal admission for a child registered on the policy 
  • a parent staying with their child during the postnatal period following the child's birth
  • general exclusions

What can I claim - New child payment

This benefit has a qualifying period of 12 months.

 

If, after the qualifying period, you have a baby or adopt a child we will pay new child payment for that baby or child. We only make one payment for each child no matter how many policies you or your partner are covered on. If you have more than one policy you will have to choose which one to claim the new child payment under.

 

We will also make a payment following a stillbirth of your child after 24 weeks of pregnancy.

 

To claim under this benefit we may ask you for supporting documents, for example a birth or stillbirth certificate, or adoption papers.

 

We will make a new child payment after:

  • the birth of your child 
  • the legal adoption of a child by you or your partner. However, we will not pay new child payment if that child is already related to either you or your partner (for example if you adopt your partner’s child) 
  • the stillbirth of your child after 24 weeks of pregnancy. 

 

We will not make a new child payment for: 

  • a miscarriage of up to 24 weeks’ gestation 
  • foster children 
  • a baby born to a child who is covered under the policy 
  • pregnancy termination 
  • a child born or adopted before or during the qualifying period

What isn't covered - General exclusions

This policy will not pay for: 

  • any benefit if your treatment date is before the date that your cover under the policy started 
  • any treatment or service that you receive from a:
    • member of your immediate family 
    • a parent, child, brother or sister, or your partner
    • business that you own 
  • any consultation with, or treatment by, a trainee (even if they are supervised by a qualified professional) 
  • any consultation which is not face to face, for example telephone, video or internet consultations (this exclusion does not apply to the services available through myWellbeing) 
  • insurance premiums for any goods or services, or payment for any type of extended warranty or guarantee for goods or services 
  • regular payment plans for treatment, for example dental practice plan payments 
  • postage and packing costs - administration or referral costs, joining fees or registration fees 
  • claims where you have paid costs with: 
    • discount vouchers or coupons 
    • any type of retail points scheme or loyalty scheme
  • fees or charges for: 
    • missing an appointment 
    • completing a claim form or providing a medical report
    • providing further information in support of a claim.

What is a 'member'?

Anyone who we have accepted for cover under this policy.

Who is my 'partner'?

Anyone in a relationship with, and who lives with, the policyholder. This could be their husband, wife, civil partner or unmarried partner.

Can I cover my partner or children?

If an employer chooses family cover this means employees can include their partner and any number of unmarried dependant children under the age of 21, or 24 if they are in full time education. Any family members included on the employee's policy must be resident in the UK, Channel Islands or Isle of Man.

I am leaving my workplace, what happens to my Simplyhealth policy?

If you are due to leave your group policy you may want to apply for a personal cash plan policy.