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A
Accidental Injury
Injury to the body caused solely through external, violent and accidental means. Accidental injury does not include sickness, disease, or any naturally occurring, or deteriorating condition.
Accommodation Charges
Charges made for your hospital room, meals and nursing directly related to your treatment whilst you are an In-Patient or Day Case Patient.
Acupuncture
A Chinese medical treatment involving the insertion of very fine sterile needles into the body at specific points according to a mapping of "energy pathways.". Acupuncture is used to control pain and to treat other conditions such as allergies or addiction withdrawal. See Alternative Medicine.
Acute Condition
A disease, illness or injury that is likely to respond quickly to treatment which aims to return you to the state of health you were in immediately before suffering the disease, illness or injury or which leads you to full recovery.
Age Bands
The process used by Insurers on some group schemes to .
Age limit for Children
Refers to the maximum age which dependant children are allowed to be covered, under a "family" policy. This is variable between Insurers and may depend on the educational status of the child.
Alcoholism
A mental and/or physical condition, which is wholly or mostly due to alcohol abuse.
Alternative Medicine
Refers to treatments such as chiropractic, acupuncture, homeopathy, osteopathy and other complimentary treatments and practices.
Anaesthetist
A medical specialist practiced in the administration of anaesthetic, which blocks the perception of pain and other sensations. This allows patients to undergo surgery and other procedures without the distress and pain they would otherwise experience.
Ancillary Charges
Charges made by the Hospital for the use of the operating theatre, admission, resident medical staff, drugs, dressings and surgical appliances used during your treatment.
B
Banding
The process of applying catergories, bands or levels to hospitals, which enable Insurers to reflect the accommodation charges and thereby the premium charged. Please note that banding does not attempt to classify or in any way reflect the standard of medical care likely to be received, it merely demonstrates the cost that the hospital charges.
Benefits
The cash amount payable in respect of a claim.
Benefits table
The table/ list of benefits applicable to any policy, showing the maximum benefits payable.
Built-In Travel Cover
Refers to the option of inclusive or additional cost Travel Cover offered under a PMI policy (offering additional medical expenses cover, personal liability. personal accident, loss of deposits, cancellation, curtailment, baggage and personal effects, personal money and delayed departure etc) Please also see overseas emergency cover and repatriation which is included in some PMI policies.
C
Cash Benefit
A cash payment made to the policyholder. Normally payable when a policyholder or member stays in overnight or longer in a non-fee paying NHS hospital.
Cash Plan
Cash plans pay out cash benefits in set amounts when medical treatment is received. They are not designed to cover, or indeed nor do they need to, pay either in part or full for the costs of private medical treatment.
Chemotherapy
Although all treatment using drugs can be termed chemotherapy, the word is most often used to describe treatment by strong Cytotoxic drugs for serious diseases such as cancer.
Chiropractors / Osteopathy
Chiropractors specialise in using manual methods (working using their hands) to diagnose, treat and prevent mechanical disorders of the spine, joints and muscles. Osteopathy is an established, recognised system of diagnosis and treatment, which focuses on the structural and functional integrity of the body. It is distinctive because it recognises that much of the pain and disability that we suffer stems from abnormalities in the function of the body structure as well as damage caused to it by disease.
Chronic Condition
A disease, illness or injury which has at least one of the following characteristics:
- it continues indefinitely and has no known cure
- it comes back or is likely to come back
- it is permanent
- you need to be rehabilitated or specially trained to cope with it
- it needs long-term monitoring, consultations, check-ups, examinations or tests.
Claim
The amount of benefit paid (after deduction of any monetary excess) for providing treatment for a medical condition.
Claims Experience
An aggregate figure of the total amount claimed over a period of a policy year. This can be either represented as claims paid, or claims incurred and paid during this period. The figure is expressed in pounds (L).
Computerised Tomography
A CT scan, sometimes also called a CAT scan, takes pictures of the body and uses a computer to put them together. CT stands for computerised tomography and is a painless procedure. A series of X-rays are taken of the body at slightly different angles, to produce very detailed images of the inside of the body.
Condition
Definition.
Consultant
See "Specialist".
Continuation Option
Refers to the availability of Continuation Options to an individual when leaving a Group scheme (ie: when member wishes to transfer from Group cover to an Individual scheme).
Critical Illness Benefit
A benefit payable to a policyholder upon diagnosis of a critical illness (e.g.: cancer, heart attack, coronary artery disease, stroke or multiple sclerosis etc). Medical treatment for a critical illness is usually covered by PMI. - Please be aware that this is not usually an integral part of most PMI policies.
CT Scans
See Computerised Tomography.
Cytotoxic Drugs
Cytotoxic drugs are used in the treatment of many forms of cancer.
D
Day-Case Treatment
Treatment which, for medical reasons, means that you have to go into a hospital or day-patient unit because you need a period of clinically-supervised recovery but are not required to stay over night.
Dental Cover
Routine dentistry (such as check-ups and fillings etc) is not normally covered by a standard PMI policy conditions are generally only covered where a policy provides treatment for Oral Surgery. See under Oral Surgery.
If cover is not offered under the PMI policy, separate Dental Cover policies are available for this purpose.
Dependants / Family member
The policyholders partner and his/her unmarried children (or those of his/her partner) living with the policyholder. Partner means the the husband or wife or the person (whether or not of the same sex) the policyholder lives with permanently in a similar relationship.
Diagnostic Tests
Investigations, such as X-rays, scans or blood tests designed to find or to help the find the cause of your symptoms.
Disclosure
The process of providing information (usually via an application form) to an insurer for underwriting purposes (e.g.: details of an applicants medical history).
Discount
Refers to discount or reward offered by insurer for policyholder remaining loyal to the provider (ie: to encourage the policyholder to remain with the insurer instead of stopping the cover or switching to another provider). Some insurers off a special "age-capping" facility where you are locked in to the age at which you join. You are looked upon as being that age forever more.
E
ECG
Electrocardiagram - a device used to measure and record the electrical activity of the heart.
Elective Treatment
Medical treatment, which can be foreseen as being required and which is pre-arranged at the time of admission to hospital.
Endorsement
A policy amendment or restriction, that appears on your individual policy schedule. An endorsement may well take the form of an exclusion for a pre-existing medical condition. This is usually in addition to the main policy document.
Episode
The period for which a medical condition requires treatment.
Excess
A set amount of money, which forms a compulsory part of / or you voluntarily (usually in order to obtain a premium discount) agree to pay towards your claim. This may apply to each and every claim, or may be payable only on the first claim in any period of insurance.
Exclusion
All Policies contain standard exclusions (e.g. No cover available for Chronic Conditions) these can relate to a number of areas and may vary between Insurers. In addition A medical condition, which your policy will not cover.
F
Financial Services Authority (FSA)
Regulator of all providers of financial services in the UK.
Full Refund, Full Cover or Paid in Full
A term applied in relation to payment of benefits. Means that an insurer will pay out on a claim in full (i.e. in theory this means no shortfalls). However, in general, most insurers will make sure that any bills settled are not more than what is regarded as "customary and reasonable" for the procedure/treatment. Some insurers maintain their own fee guidelines and will pay bills "in full" but only up to their guideline maxima.
Full Medical Underwriting
The term Full Medical Underwriting is used to describe the detailed examination and assessment by insurers, of all information directly relating to the health of each new applicant. Generally, any condition which existed, or of which the applicant was aware prior to joining a scheme, will be excluded from benefit, unless such a condition has been declared on an Application Form and accepted by the insurer.
G
General Practitioner
A medical or dental practitioner registered in the UK for general practice.
H
Home Nursing
Refers to nursing received at home by a qualified nurse for medical reasons. The benefit is usually payable after an in-patient stay and on the recommendation of the Specialist. (See also under Nursing at Home)
Hormone Replacement Therapy (HRT)
Hormone Replacement Therapy (HRT) is the use of hormones to treat a hormone deficiency. Most commonly, this is used in the treatment of symptoms accompanying the menopause.
Hospital
a) A private hospital in the UK which is registered in accordance with UK legislation and which has specialist facilities for carrying out major surgical operations.
b) Pay-Beds in an NHS hospital.
I
In-Patient Treatment
Treatment which, for medical reasons, means you have to stay in hospital overnight or for longer.
Drugs & Dressing
Drugs and dressings used during the course of an in-patient stay in hospital.
Inception Date
The date on which your PMI policy starts.
Insurance Premium Tax
Tax levied on general insurance premiums currently payable at 5%
Insurers Review Guide
For the purposes of this publication the "Rev the insurer usually reviews the plan benefits ~ Insurers Review Guide" refers to the time (or times) of year when and/or premium rates.
Invasive Procedure
Medical procedure which involves inserting an instrument into the human body.
L
Loss Ratio
Definition
Low or No Claiming Discount schemes
Refers to GROUP SCHEMES and is the equivalent to the No Claims Discount facility available with some individual PMI plans. The main difference is that a group will generally experience at least one claim or a number of claims each year. Depending on the premium paid it may still be possible to have a discount applied to the premium if the overall claims are considered by the provider to be low.
M
Maternity Cash Benefit
Refers to the benefit payable on the birth of a child. Insurers will usually stipulate that a mother should have been covered for at least 10 continuous months under the policy.
Medical Declaration
The process of providing details of medical history for underwriting purposes. See also under Underwriting and Disclosure.
Medical History
Your medical history (usually going back 5 years prior to taking out the policy). This takes the form of any medical treatment or advice you have previously had from your GP or Specialist. This is required by some insurers for the purposes of underwriting. See also Underwriting.
Medical History Disregarded
Applicants may be accepted by an Insurer without the need for any medical declarations and will be accepted for all pre - existing conditions irrespective of the nature of these items, (provided they are covered under the terms on the policy).
Medical Inflation
The rate of increase in the cost of healthcare treatment per year. It is expressed as a percentage for the year. It is usually higher than the RPI (Retail Prices Index).
Moratorium
The clause excludes cover during an initial period (usually 2 years) of membership for any conditions or related condition for which medical treatment was received, advised on or was known about during a time period (usually 5 years) prior to cover commencing. However after completing the initial period, all pre-existing conditions then become eligible for benefit (provided that at the time of receiving treatment the member has been free from treatment and advice for that condition during the period).
MRI Scan
Head and bodily screening using a magnetic resonance imaging (MRI) scanner.
N
NHS
National Health Service.
NHS Cash Benefit
Refers to the benefit paid should a member have to receive treatment in an NHS hospital as an in patient (in a non-fee paying part of an NHS hospital).
NHS Hospital
A hospital in the UK run under the National Health Service with specialist facilities for treatment
No Claims Discount Facility
Refers to the "no claims discount" offered by a provider when the policyholder has made no claims during a cover year.
This is an alternative method disclose evidence of medical mechanics are essentially as of dealing with pre-existing conditions which removes the need to history. In effect, it is a blanket pre-existing condition clause.
No Worse Terms Switch Facility / CPME (Continued Personal Medical Underwriting)
Refers to the medical underwriting of an existing group scheme. The term applies to situations where a change of insurer (or change in policy) is under consideration; Members are covered with an alternative insurer using the previous medical underwriting status applicable to their old policy (i.e.: no worse medical underwriting terms are applied to the new one). It does act mean that the scheme benefits are replicated. The term can also be referred to as Continued Personal Medical Exclusions (CPME) or simply CME. However, it is usually difficult to find an insurer offering "no worse terms" to individual policyholders - unless the policyholder is changing cover from a group to individual basis with the same insurer.
Nursing at Home
When a qualified nurse takes care of you at home (usually only on the recommendation of your specialist and as a consequence of in-patient or day-case treatment). See also under Home Nursing.
O
Oncology
Refers to research into tumours.
Optical Cover / Routine Sight or Vision Testing
Routine eye treatment is not normally covered by all PMI policies (e.g.: check-ups and spectacles etc). However, medical treatment required in a hospital is normally covered.
Oral Surgery (Oro-Surgical Procedure / Operation)
A dental procedure classified under a schedule of oro-surgical operations published by an insurer (i.e.: those covered by the policy). These procedures refer to specific procedures relating to teeth, jaws and other parts of the mouth or face. Should not be confused with routine dentistry, which is not normally covered by PMI.
Osteopathy
The practice of treating medical conditions through the science of the bone. Treatment is designed to cure a disease usually caused by deformation of the spine through manipulation The treatment is not always related to the spine and can take different forms of manipulation of different parts of the body.
Out-Of-Band Benefit
Refers to the benefit payable per night/day in respect of the cost of hospital accommodation. The benefit ceiling paid is dependant on the scale of cover chosen (e.g.: if a member is covered for a "C" scale hospital but needs to attend a "B" scale hospital for treatment then the maximum benefit an insurer would pay is that of the "C" scale limit).
Out-Patient
When you receive treatment at a hospital or at the specialists consulting rooms or other facility, and you do not remain there over night (i.e.: you do not need to sign an admission form)
Out-Patient Services / Treatment
Refers to the services received or eligible as an out-patient (e.g.: for physiotherapy, radiology or pathology). These can take the form of both treatment and consultations. Out-patient treatment is that given at a hospital, consulting room or out-patient clinic where you do not go in for day-patient or in-patient treatment.
Overall Annual Limits Payable
Refers to the overall annual limit of benefits payable by an insurer in a contract year.
Overseas Emergency Cover
Definition
P
Parental Accommodation
Refers to a parent being allowed to stay with their child during a stay in hospital. The benefit is usually paid if there is a medical reason and is restricted to the child age.
Pathology
Refers to tests for the cause of bodily diseases.
Pay-Bed
An NHS hospital bed for use by paying private patients.
Period of Cover
The period of your insurance commencing with the Inception Date and finishing at the Renewal Date.
Physiotherapy
Refers to treatment of disease or injury by massage. heat and exercises using ultra-sound machines and lasers amongst other media.
Pre-existing condition
Any disease, illness or injury for which: a) you have received medication, advice or treatment; orb) you have experienced symptoms: whether the condition has been diagnosed or not (usually in the 2 years before the start date of the cover - this period can vary between insurers).
Private Ambulance
Refers to the benefit payable for the use of a private ambulance.
Primary Care
Treatment given by your GP (not normally covered under a standard PMI policy).
Prosthesis
An artificial body, part, which is designed to form a permanent part of the body. Some policies do not pay for this and some only pay for certain prosthesis on a published list.
Pre-existing Condition
Definition.
Psychiatric Cover
Insurance against the cost of treating a mental disease. Psychiatric cover can be applied to inpatient and out-patient treatment. Some insurers specifically exclude psychiatric cover on PMI policies.
Q
Qualified Nurse
A nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number. Radiolology Refers to X-Rays relevant to a situation. Radiotherapy Refers to treatment of cells by radioactive means. Renewal Date The annual anniversary of your policy when you are required to renew your cover.
R
Repatriation
The process of returning the policyholder or member to their home land in an emergency.
S
Six Week NHS Policies
Six Week NHS policies are commonly referred to as budget schemes. These policies operate on the basis of the NHS waiting list in your area for a required operation or treatment, if the operation or treatment is available on the NHS in your area within a 6-week period. from the date of seeing your Specialist, you are obliged to have that operation/treatment on the NHS - If it is established that the waiting list is over 6 weeks then you get immediate access to private treatment, Most 6 week plans apply the rule to in-patient and out-patient treatment but sometimes you might find an insurer who only applies the rule to in-patient treatment (i.e.: all out-patient treatment is available immediately irrespective of the NHS waiting list).
Specialist
A medical or dental practitioner registered under the Medical Acts who is or has been a Consultant in an NHS hospital or who holds a Certificate of Higher Specialist Training.
Surgeon/Anaesthetist Fees
Fees charged in respect of the surgeon and anaesthetist for an operation. Insurers who do not ~ provide full refunds in respect of these fees usually provide cover up to the limits suggested by the BMA guidelines. Most insurers (both those providing "full refund" cover or cover up to "foe guidelines") will generally ensure that fees paid are not above what is considered customary and reasonable for the procedure.
T
Table of Benefits
A document, which sets out the benefits payable under a PMI policy.
Third Party Administrators
Organisations, which provide claims administration services independently from PMI providers. These may typically be used when a group scheme is written under trust or as a straightforward alternative to the administration services offered by a PMI provider. Please refer to Contents page for a list of Third Party Administrators.
Treatment
Surgical or medical services (including diagnostic tests) that are needed to diagnose, relieve or cure a disease. Illness or injury.
An NHS hospital operating an independent, private unit
U
Underwriting
The assessment and agreement of an insurance risk. The process involves the disclosure of medical history, which enables the insurer to assess your risk. Once the assessment is complete you will be notified of any special terms (e.g.: exclusions) and given the opportunity to agree these terms.
Underwritten By
This refers to the organisation actually underwriting the policies. This is provided as some prospective clients (and indeed yourselves) prefer to have a deeper knowledge of the scheme and the "backing behind the organisation".
Update: 29 Aug 2005
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