In this section, we will identify the different types of care and treatments that aren’t covered. We
describe these under two headings: Types of Care and My Body.
Health Cover for Me will not cover you for:
- Routine consultations at your GP, optician and dentist
- Preventative screening procedures & tests
- Emergency treatment in an Accident and Emergency department
- Conditions which are ongoing or long term (often known as chronic conditions)
- Pre-existing conditions that you had before joining Health Cover for Me and which have been excluded
- Treatment in a nursing home
- Treatment that has not been authorised
- Out-patient drugs & dressings.
Routine consultations with your GP, optician and dentist are those where you go for normal
consultations, check ups, get prescriptions, benefit from regular monitoring and screening which
are normally carried out by the NHS.
Preventive screening procedures, treatment and tests, including:
- Screening procedures as a result of poor personal or family history
- Cervical smears, mammograms, preventative cancer screening, osteoporosis screenings etc
- Well person health checks and screenings
- Vaccinations, immunisations.
Emergency treatment includes all treatment and immediate care in an Accident and Emergency
department. Once your condition has been stabilised and your consultant has agreed that you are
well enough, you may be able to transfer to private facilities or become a private patient within the
NHS, but please remember to contact us for authorisation beforehand.
Conditions which are ongoing or long term (often known as chronic conditions), include diseases,
illnesses or injuries such as diabetes, asthma, multiple sclerosis, which have at least one 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.
To Please note that we do not consider cancer to be a chronic condition and therefore there isn’t a time limit for cover. Please go to My Cancer cover.
Pre-existing conditions that you had before joining Health Cover for Me may be excluded from
your cover. We will advise you of your personal terms before you buy the policy so that you can
decide whether you believe that Health Cover for Me is right for you. Please go to My Application.
Treatment, including convalescence and/or rehabilitation, that takes place in a nursing home or
hospital, which has become a place of permanent residence. Important note - this does not apply
to cancer (please go to My Cancer Cover).
Treatment that has not been authorised is not covered by Health Cover for Me so please
remember that if you are being referred for treatment, you need to contact us before going ahead.
Out-patient drugs & dressings are not covered, other than those prescribed immediately following
an in-patient/day-patient stay in hospital or out-patient surgery. Important note - this does not
apply to cancer drugs (please go to My Cancer Cover).
There are some parts of your body and some treatments that we don’t cover under Health Cover
for Me. These are:
- Eyes, teeth and ears:
- We don’t cover preventative treatments for eyes, teeth and hearing
- This includes sight tests, regular check ups, spectacles, surgical treatment to correct long or
short sightedness, crowns, implants, bridges, dentures and treatment for deafness, hearing
aids, cochlear implants etc.
However, disease of these organs is covered so, for example, cataracts, corneal grafts & wisdom
teeth (if treatment takes place in hospital) are covered.
- Pregnancy and fertility treatment or investigations in connection with:
- Pregnancy or childbirth
- Abortion
- Any form of assisted reproduction such as in vitro fertilisation
- Infertility.
Important note - we do not consider pregnancy or childbirth to be illnesses and are therefore
not covered under Health Cover for Me. However, illnesses arising while pregnant or undergoing
childbirth would be covered.
- Transplants:
- Transplant operations
- Investigations done before a transplant operation, or treatment needed as a result of a transplant operation.
However, we do cover corneal and skin grafts. We also cover bone marrow & stem cell transplants
for cancer (go to My Cover).
-
Regular or long-term renal dialysis in chronic or end-stage kidney failure
-
Cosmetic and plastic surgery
-
Treatment required as a result of an injury sustained whilst training for or participating in,
sport for which you receive payment or sponsorship (other than travel costs)
- Mental and psychological treatment:
- For depression and/or
- For stress and/or
- For mental illness and/or
- For psychiatric disorders and/or
- For psychological disorders.
-
Complementary treatment, such as acupuncture, speech therapy, dietician, homeopathy and
pain clinics
Only physiotherapy, osteopathy, podiatry and chiropractic treatments are covered with Health Cover for Me.
National Institute for Health and Clinical Excellence (NICE) & experimental treatments.
It is also important to explain where we stand regarding the NICE guidelines, treatment or drug
therapy which is experimental and/or unproven, and what this means for your cover under
Health Cover for Me.
NICE is an internationally renowned, government funded body that is responsible for providing
national guidance on the promotion of good health and the prevention and treatment of ill health.
We use NICE approval as the main benchmark for experimental/unproven therapies. NICE have
two measures of approval; clinical effectiveness and cost effectiveness. Some treatments get clinical
approval but not cost effectiveness approval, i.e. they work but are too expensive for the NHS:
- Treatments which have been clinically approved are covered
- Even if the treatment does not carry a cost effectiveness approval, you are covered. For example, Avastin and Herceptin are both used for the treatment of cancer and are covered by us even though NICE classifies them as not being cost effective
- Treatments which have entered the NICE process but have not yet received a final decision are assessed by our medical advisers, but are usually covered. (Please check with us before proceeding with any treatment)
- If NICE do not approve a treatment for clinical effectiveness, it will not be covered.