Intermediaries

Your questions answered

We've answered intermediaries' most common questions about our health insurance plans. Please refer your client to their policy document if their question isn't answered here. Documents for most of our health insurance plans can be downloaded here.

It bothers us if you still can't find what you're looking for. If this is the case, please call us on 0330 1025 337 - we're always happy to help. 


Applications and services

Changes to circumstances

Hospitals


Applications and services

How does my client apply?

It's no bother to apply for cover.

If you are applying for Simply Personal Health for an individual or family then you can ask your client to fill in an Application Form.

  1. Call our Helpline on 0330 1025 337 for a quotation and application pack
  2. Your client will need to decide which employees they want to cover and what scale of cover is suitable for them
  3. Your client then needs to fill in an Application Form for group cover and hand out Application Forms to employees who are joining. If your client is transferring from another insurer, employees may not need to complete individual forms
  4. Clients can send completed forms to us, or to you. No payment is needed at this stage
  5. When we receive the application, we'll confirm premiums and the individual terms of acceptance and your client can decide if they want to go ahead

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Who can apply?

  • There is no upper age limit for Simply Personal Health but applicants must be over 18
  • Unmarried dependent children can be included provided they are under the age of 21, or 24 if they are in full-time education
  • Occasionally, we may refuse to accept an application

Want to talk to someone about applying? Call 0330 1025 337

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How does my client switch?

Your client will need to complete an application form including these medical questions. When we have received these we will make an assessment about the application.

If we accept the application without an updated medical assessment, we would apply the same personal medical exclusions that your client, and any family members they wish to include in the policy, have with their current insurer. We'll also ask them to provide a membership certificate from the previous insurer.

Find out more about switching, or call our team on 0330 1025 337

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How does the excess work?

The excess applies once each policy year for each person included in the policy - and not for every claim made.

If the first claim is for less than the policy excess, the remainder will be carried over to the next claim, until the excess is reached.

Once this is paid there will be no further excess to pay on any subsequent claims for treatment received in the same polciy year. If your client is claiming for NHS cash benefit, they don't need to pay the excess.

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How does my client add their partner or dependants?

Unmarried dependent children may be included under the age of 21, or 24 if they are in full-time education. Family members must be resident in the UK, Channel Islands or Isle of Man.

If your client is a member of a group policy, they will need the agreement of their employer. Depending on their employer's arrangement with us, the cost of including dependants may have to be met by the individual, in which case payment must be made through the Group Secretary.

To add new dependants, at any time, simply complete an Application Form and forward it to us (via the Group Secretary if your client is part of a group). Once we receive the application we will confirm individual terms of acceptance and inclusion within the policy. Your client will need to decide which underwriting option they wish to be applied to their dependants. The options are explained on the Application Form.

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How does my client claim?

If your client needs treatment they must always call us on 0330 1025 337 before arranging any treatment. We will confirm whether their treatment is eligible and the claims process they need to follow.

For some policies it is mandatory for the claim to be authorised in advance and treatment to be arranged by Simplyhealth. If your client has an excess they will need to pay it when they call to authorise their claim. For full details of their claims process always refer your client to their Policy Document.

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How does my client make a complaint?

We aim to provide you with the very highest levels of customer service and care at all times. To maintain this service standard, we have a procedure you can use to raise any concern, complaint or recommendation you have by contacting Customer Services at our registered office address of Hambleden House, Waterloo Court, Andover, Hampshire SP10 1LQ.

We will investigate any complaint and issue a final response. If you are not satisfied with our response, or we have not replied within eight weeks, you have the right to refer your complaint to:

Financial Ombudsman Service
Exchange Tower
London
E14 9SR

Telephone: 0330 1025 337

The Financial Ombudsman Service will only consider your complaint if you have given us the opportunity to resolve the matter first. Making a complaint to the Ombudsman will not affect any legal rights that you may have. We will send you full details of our complaints procedure if you ask us for them.

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What is a chronic condition?

A chronic condition is a disease, illness, or injury that has one or more of the following characteristics:

  • It needs ongoing or long-term monitoring through consultations, examinations, check-ups, and/or tests
  • It needs ongoing or long-term control or relief of symptoms
  • It requires your rehabilitation or for you to be specially trained to cope with it
  • It continues indefinitely
  • It has no known cure
  • It comes back or is likely to come back

If your client's condition has or acquires one or more of the characteristics detailed above, we will not pay any benefit for this condition, unless agreed in advance by us in advance of the treatment. Even if we have paid for previous treatment, it does not mean that we will continue to cover that condition, if we think it has become chronic.

Examples of chronic conditions and an explanation of cover for chronic conditions can be found in the relevant policy document.

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Changes to circumstances

What happens if my client has an accident?

In many accidents, someone or something is at fault and the accident victims have a right to claim compensation. Simplyhealth has a legal right to recover any medical expenses if your client makes a claim for treatment resulting from an accident or illness which was someone else's fault.

When claiming for treatment your client must notify us that they have a personal injury claim against another party as a result of an accident. We will ask for their solicitor's details. Your client, or their solicitor, then need to keep us informed of the claim's progress.

Your client needs to:

  • Pursue their personal injury claim at their own personal expense
  • Tell their solicitor immediately that they are insured by Simplyhealth for medical expenses
  • Include all the medical expenses which they have claimed, or will claim from us, under their policy cover in their personal injury claim
  • Ask their solicitor to help us, in particular, ensure we can contact their solicitor and obtain copies of any pleadings, expert reports, witness statements, court documents or other legal documents concerning their personal injury. We will pay reasonable photocopying charges for any documents we ask to see
  • Ask their solicitor not to agree any final settlement of their claim or waive our right to recover expenses paid out for medical treatment without consulting us first
  • Ask their solicitor to repay their medical expenses direct to us from any settlement of their claim

If your client has other insurance policies

If your client is making a claim and they have insurance with another insurance company or provident association that covers them for any of the same benefits under their policy, they must tell us and provide us with this other company's details.

This additional cover might be in the form of travel insurance, home insurance or other types of insurance cover. We may well need to contact these other companies, since we will not be liable to pay more than our proportionate share when split between the various insurance companies.

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What happens if my client is diagnosed with cancer?

We know that when anyone finds out they have cancer it is a worrying time. We want to help your client understand how their policy can help them.

Cancers cannot be easily categorised as either acute conditions or chronic conditions. So, we want your client to be clear about what is covered and what is not covered for cancer treatment under their policy. Always refer your client to their policy document for full details of what is and isn't covered on their policy.

Care when you need it the most

If your client needs treatment for cancer, then they will have the personal support of their own Simplyhealth nurse adviser.

We will authorise eligible claims, guide them through their treatment programme and explain what treatment is covered under their policy.

Your client's nurse adviser will be there to support their care whether this is given privately or through the NHS. Remember, we are always here to help.

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What happens if my client leaves their group policy?

If your client leaves their group policy, due to retirement or leaving the company, they can apply for personal membership of Simplyhealth. For full details of the options available, leavers can call our Sales Helpline on 0330 1025 337.

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Hospitals

What happens if my client is treated in a hospital for which they are not covered?

For our Care for Corporate, Preferential, Accessible, Vital and Private Patients Scheme policies hospitals are classified by Simplyhealth in the Hospital Directory.  The Hospital Directory sets out the scale of cover required to use each hospital and your client needs to select a scale of cover that corresponds with the hospitals they are most likely to use should treatment be required. 

If your client receives treatment in a more expensive hospital than they are covered for (i.e. one which is a higher scale in the Hospital Directory), then they will be responsible for most of the expenses incurred. There will be a significant difference between the amount we agree to pay and the actual expenses incurred. Your client will be responsible for paying this difference to the treatment provider. We strongly recommend treatment at a hospital within their scale so that these additional expenses are avoided. For more information, please refer your client to 'Out of scale limits' in their Policy Document.

If your client is using Service+ as their claims process, we will select their treatment provider and will only pay for treatment authorised and arranged through the Service+ Helpline.

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What happens if my client needs dental treatment?

Although we don't cover routine treatment from the Dentist, we do cover a limited number of surgical treatments, subject to terms and conditions. These treatments must be carried out by an oral maxillofacial surgeon in a hospital. We will only pay for treatment that is normally provided under the NHS or approved by the National Institute of Health and Clinical Excellence (NICE).

We will pay for:

  • Surgical removal of impacted / buried or unerupted tooth / teeth
  • Surgical removal of complicated buried roots
  • Apicectomy of tooth or teeth (removal of the tip of the root)
  • Enucleation of cyst of jaw (surgical removal of cyst lining from the jaw bone)

Need help?

We know these medical terms sound complicated.  But we have to be precise about what is covered. So, if your client has any queries about the claims process or needs someone to explain what is covered under their policy, they should call us on 0330 1025 337.

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Need help?

If you would like more information please contact us on:

Health plans

0330 1025 337

Mon to Fri: 8am to 6pm

or email us.

Hospital locator

Find a hospital for treatment if you are a PMI customerGot a health insurance plan? Need treatment?

Find a hospital

Trouble logging in?

Email Intermediary Support for help.

Cancer treatment - what is covered?

Cancer as a condition does not fit easily into the acute and chronic definitions used to categorise other illnesses.

Find out more about what is covered in cancer treatment.