From 1 May 2007

THE WORLD OF BUPA

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BUPA
ClientChoice Plus,
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BUPA ClientChoice
providers may charge.
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BUPA ClientChoice
Essential
Membership
Guide
Cover is provided by BUPA Insurance Limited. Registered in England and Wales No 3956433#
#Authorised and regulated by the Financial Services Authority
Registered Office BUPA House 15-19 Bloomsbury Way London WC1A 2BA
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C LC / 5 2 1 0 / M AY 0 7 64223 UNI
 Contents
page

Your BUPA membership 2

Contacting us • About this guide
• What to do if you need treatment
If you have any questions about your membership or your cover please call
the helpline and we will be happy to help you. BUPA ClientChoice Plus, BUPA ClientChoice and
BUPA ClientChoice Essential
Call the helpline on 0845 60 09 673* † – your rules and benefits
(lines open 8am to 8pm, Monday to Friday and effective from 1 May 2007 6
9am to 1pm Saturday).
1 How your membership works 7
For those with hearing or speech difficulties who use a textphone, call our 1.1 The agreement between you and us 7
dedicated line on 0845 60 66 863* (lines open 9am to 5pm, Monday to 1.2 When your membership starts, renews and ends 8
Friday).
1.3 Paying subscriptions and other charges 11
1.4 Making changes 12
Or write to us at: BUPA, Staines, TW18 4XF
Or fax us on: 01784 465 232 1.5 General information 13
1.6 If you have cause for complaint 13
* BT landline calls to 0845 numbers will cost no more than 3 pence per minute. 2 What you are covered for 15
Charges from other providers may vary and calls made from mobiles usually cost more.
† Calls may be recorded and may be monitored. 2.1 Notes about your cover 15
• The type of treatment covered
• BUPA recognised medical practitioners and
treatment facilities
2.2 Summary of benefits table 18
2.3 Benefit notes 20
3 What is not covered 42
4 Claiming 56
4.1 Making a claim 56
4.2 How we will deal with your claim 58
4.3 If you want to withdraw a claim 59
4.4 If you have an excess 59
5 Glossary 61
6 Data Protection Notice 70
1

Your BUPA membership
We’d like to thank you for choosing BUPA.
Whether you’re new to BUPA or you’ve enjoyed the reassurance of BUPA private medical
insurance over the years, we’d like to remind you that your BUPA cover gives you access
to prompt private medical treatment that you can arrange at a time and place that suits
you. Above all you’ll enjoy the peace of mind of knowing that your health cover is in
safe hands.
About this guide
ClientChoice is based on BUPA’s LocalCare. This membership guide has been written to
take you through every aspect of your membership. It has been written in two parts. This
first part is designed to help you get the most from your membership. The second part
sets out the scheme rules and benefits which form part of the agreement between you
and us and they explain:
• how your membership works
• what you are and are not covered for
• about making a claim and how an excess works
• words and phrases that have a specific meaning under the scheme.
Please do not leave reading the rules and benefits until you need treatment. Although it
may seem a little daunting at first it is important that you understand how your cover
works should you need to arrange treatment at any time. If there is anything at all you
are unsure about when reading through this guide please call the helpline and we will be
happy to answer any queries you have. You’ll find the helpline number and other contact
details on the inside front cover.
We also recommend that you keep this guide, together with your membership
certificate, in a safe place as you may need to refer to them from time to time.
2 3
Your BUPA membership
What to do if you need treatment
We understand that it is only natural to feel anxious at a time of ill-health, so we will do
everything we can to help make arranging your treatment as simple and straightforward
as possible. You should always call us before arranging any consultation, diagnostic tests
or treatment; we can then explain the cover available to you and help you in arranging
your treatment.
Please refer to ‘Claiming’ in section 4 of ‘Your rules and benefits’ and then follow these
simple steps.
If you are a moratorium member – steps to making a claim
Please follow steps 1 and 2 below, then steps 3 to 7 on page 5.
1 If your GP refers you for a consultation or treatment
Before you arrange any consultations or treatment
• Explain to your GP that you are a BUPA member
• Call the helpline before you and/or your GP arrange any private consultations or treatment
• We will send you a pre-treatment form. You and your GP will need to complete the form in full and return it to us.
• Once we have received all the information we ask for we will contact you to confirm whether or not your proposed
treatment is covered under your moratorium membership and the benefits available to you.
Arranging your treatment
If we have confirmed your consultation, therapy or, for members whose scheme is BUPA ClientChoice Plus or BUPA
ClientChoice, complementary medicine treatment is covered you can go ahead and arrange your consultation or
treatment.
• If you need to see a consultant ask your GP to refer you to a BUPA recognised consultant who charges within
BUPA benefit limits and who has admitting rights to a BUPA partnership network hospital. The rules and benefits
explain about partnership consultants, non-partnership consultants and partnership network hospitals or you can
call the helpline and we will explain.
• If you need to see a therapist or, for members whose scheme is BUPA ClientChoice Plus or BUPA ClientChoice,
complementary medicine practitioner ask your GP to refer you to a BUPA recognised practitioner. The rules and
benefits explain why this is important for you or you can call the helpline and we will explain.
2 Call BUPA
When you call the helpline we will confirm whether your consultant, therapist or, for members whose scheme is BUPA
ClientChoice Plus or BUPA ClientChoice, complementary medicine practitioner is recognised by BUPA.
 Your BUPA membership Your BUPA membership

If you are an underwritten member – steps to making a claim For all members

3 When you see the consultant, therapist or, for members whose scheme is BUPA ClientChoice
Helping us to help you
Plus or BUPA ClientChoice, complementary medicine practitioner
So we can confirm whether your proposed treatment, diagnostics, healthcare Show them your membership certificate – and, if you are an underwritten member, your special condition
practitioner or facility is covered under the scheme we will need to ask you some supplement if you have one. See rule 1.1.a, ‘The agreement between you and us’ in ‘Your rules and benefits’.

questions. We will always ask you for your BUPA membership number. We will also ask
you some, or all, of the following so please have the information to hand when you call. 4a If your consultant recommends 4b If your consultant recommends day-patient or
• What condition are you suffering from? out-patient diagnostic tests or in-patient treatment
treatment Call the helpline and we will:
• When did your symptoms first begin? Call the helpline and we will confirm whether the • confirm whether your treatment is covered under your
tests and/or treatment are covered under your membership and the benefits available to you
• When did you first see your GP about them? membership and the benefits available to you.
• help you choose a partnership network hospital in
• What treatment has been recommended? your area.

• On what date will you receive the treatment?

5 When you go into hospital
• What is the name of the consultant or other healthcare practitioner?
Take your membership certificate with you – and, if you are an underwritten member, your special condition
• Where will your proposed treatment take place? supplement (if any).

• Will you need to stay in hospital? If so, for how long?

Please follow steps 1 and 2 below, then steps 3 to 7 on page 5. 6 When you leave hospital
• Settle any personal expenses such as newspapers, phone calls or guest meals.
1 If your GP refers you for a consultation or treatment • We will settle the medical and hospital bills covered under your membership.

Explain you are a BUPA member.

• If you need to see a consultant ask your GP to refer you to a BUPA recognised consultant who charges within 7 If your consultant recommends home nursing or out-patient treatment after your
BUPA benefit limits and who has admitting rights to a BUPA partnership network hospital. The rules and
benefits explain about partnership consultants, non-partnership consultants and partnership network hospitals hospital stay
or you can call the helpline and we will explain. Call the helpline and we will confirm your cover and the benefits available to you.
• If you need to see a therapist or, for members whose scheme is BUPA ClientChoice Plus or BUPA
ClientChoice, complementary medicine practitioner ask your GP to refer you to a BUPA recognised
practitioner. The rules and benefits explain why this is important for you or you can call the helpline and
we will explain.

2 Call BUPA
When you call the helpline we will confirm whether:
• your consultant, therapist or, for members whose scheme is BUPA ClientChoice Plus or BUPA ClientChoice,
complementary medicine practitioner is recognised by BUPA
• your proposed treatment is covered
• you need a claim form – in some cases you may not need to complete a claim form and we will tell you about this
when you call us.

4 5
 1

BUPA ClientChoice Plus, BUPA ClientChoice and How your membership works
BUPA ClientChoice Essential – your rules and
benefits 1.1 The agreement between you and us
In return for you, the main member, paying us subscriptions, we agree to provide you
effective from 1 May 2007
and your dependants (if any) with cover under the terms of our agreement.

These are the rules and benefits of the scheme and they form part of Only you and BUPA have legal rights under our agreement, although we will allow

our agreement. They apply to anyone joining the scheme or renewing anyone who is covered under your membership complete access to our complaints
process (see rule 1.6, ‘If you have cause for complaint’, in this section).
their membership on or after the ‘effective from’ date.
All the following make up our agreement and must be read together as they set out the
• For anyone joining the scheme they apply from their start date.
terms and conditions of your membership.
• For anyone renewing their membership of the scheme they apply for the period
• Your application for cover: this includes any quote request, applications for cover
from their first renewal date on or after the ‘effective from’ date.
for you and your dependants (if any) and the declarations that you made during
Please also see rule 1.4, ‘Making changes’ in section 1.
the application process
Words in bold and italic in these rules and benefits are defined terms which have a
• Your rules and benefits in the scheme Membership Guide: we pay for treatment
specific meaning. You should check their meaning in the glossary.
costs under the rules and benefits of the scheme that applied to you on the date
you received your treatment

• Your membership certificate: this shows your current membership details including:

• the scheme you are covered under, who is covered, the dates when the cover
started and when your membership is due for renewal

• the subscriptions you will be paying, the method of payment you have chosen
and your no claims discount level

• the excess amount you have chosen (if any)

• whether you have moratorium membership or underwritten membership

• if you are an underwritten member, any special conditions (you will only receive
a special condition supplement if there are any special conditions that apply to
you or anyone covered under your membership).

6 7
 How your membership works How your membership works

All membership documents and correspondence are sent to the main member.
We will only pay for treatment costs that are covered under the scheme. Treatment
costs that you incur that are not covered under the scheme are your sole responsibility.
1.2 When your membership starts, renews and ends
Renewing your membership
Our agreement is an annual one and your membership must be renewed each year on
your renewal date, subject to rule 1.4, ‘Making changes’ in this section. Your
membership will renew automatically as long as you continue to pay your subscriptions
and any other charges unless:

• you decide to end your membership, or

Starting membership
• we decide to end the scheme. If we decide to end the scheme we will write to let
Your membership starts on your start date.
you know at least 28 days before your renewal date.
Your dependants’ membership starts on their start date.

Covering your new born baby: you may apply to cover your new born baby under your How your membership can end

membership as one of your dependants, free of charge, until your first renewal date You can end your membership or the membership of any of your dependants at any
after their birth. time by writing to us. If your membership ends the membership of all your dependants

• if you are a moratorium member and have been a member of the scheme for at will also end.

least 12 months before the baby’s birth and you include the baby under your Your membership and that of your dependants will automatically end if:
membership before the baby is three months old we will not apply any • you do not renew your membership
moratorium conditions to the baby’s cover
• you do not pay your subscriptions, or any other payment you have to make in
• if you are an underwritten member and have been a member of the scheme for respect of the cover, on or before the date they are due
at least 12 months before the baby’s birth and you include the baby under your
• you stop living in the UK
membership before the baby is three months old we will not apply any special
• you die, or
conditions to the baby’s cover.
• we decide to end the scheme.
Please also see ‘Neo-natal treatment’ in section 3, ‘What is not covered’.
Your dependants’ membership will automatically end if:
Your right to cancel within 21 days of joining • your membership ends
You may cancel your membership for any reason by writing to us within 21 days of • you do not renew the membership of that dependant
receiving the first membership certificate we send you confirming your cover. As long as
• that dependant stops living in the UK
you have not made any claims we will refund all your subscriptions.
• that dependant dies, or
You may cancel any of your dependants’ membership for any reason by writing to us
• we decide to end the scheme.
within 21 days of receiving the first membership certificate we send you confirming their
cover. As long as no claims have been made in respect of their cover we will refund all
your subscriptions paid in respect of that dependant’s cover.

8 9
 How your membership works How your membership works

We can end a person’s membership if there is reasonable evidence that you or they 1.3 Paying subscriptions and other charges and your no claims discount
misled us or attempted to do so. By this we mean, giving false information or keeping
necessary information from us, either intentionally or carelessly, which may influence us Subscriptions and other charges
when deciding: You must pay subscriptions to us in advance for you and your dependants throughout

• whether or not we will provide cover for them
• what subscriptions should be paid for that person, or
• whether we have to pay any claim.
your membership. The amount you must pay and your method of payment is shown on
your membership certificate.
You must also pay to us the amount of any insurance premium tax (IPT) that is payable
in respect of the cover provided. You must also pay to us the amount of any other taxes,

Refund of subscriptions if your membership ends
If your membership ends for any reason we will refund any subscriptions you have paid
which relates to a period after your cover ends.
If your dependants’ membership ends for any reason we will refund any subscriptions
you have paid in respect of that dependant which relate to a period after their cover
ends.
Joining another BUPA scheme
If we decide to end the scheme we will offer you the opportunity to join the BUPA
private medical scheme that replaces this scheme on the basis of the terms and
conditions of the new scheme and:
• if you are a moratorium member we may assess your application and apply
special conditions to your cover and/or that of your dependants under the new
levies or charges that may be introduced which are payable in respect of the cover and
which either we or you have to pay by law. You must pay us these amounts when you
pay us your subscriptions unless otherwise required by law. The amount you have to
pay is shown on your membership certificate.
No claims discount
Your no claims discount level is based on your and your dependants’ (if any) claims
history during your claiming period.
• If, during your claiming period, we do not pay any claims for you or any of your
dependants we will increase your no claims discount by one level.
• If, during your claiming period, we do pay a claim for you or any of your
dependants we will reduce your no claims discount by two levels.
We apply your no claims discount to your net subscription rate (excluding IPT).

scheme No claims discount scale: this scale shows the amount of discount that applies for each

• if you are an underwritten member and you transfer within one month we will no claims discount level. Discount level 7 is the maximum discount level available.

not add any special conditions to your membership or that of any of your
dependants under the new scheme other than those that apply under this
Discount level you are on | 1 | 2 | 3 | 4 | 5 | 6 | 7

scheme. Discount you will receive | 0% | 5% | 10% | 15% | 20% | 25% | 30%

If your membership ends for any other reason you may apply to join another BUPA
private medical scheme. You may only do this as long as your membership didn’t end If you are unwell, you should not delay seeking treatment because of the impact it will

because you misled us or attempted to mislead us. We will consider your application at have on your no claims discount.

our sole discretion.

10 11
 How your membership works
1.4 Making changes
Changes we can make
We can change the terms and conditions of the membership at your renewal date.
These changes could affect:
• how we calculate subscriptions, the amount you have to pay, how often you pay
them, the method of payment and the no claims discount (the cost of
subscriptions has typically risen higher than the retail price index (RPI) over the
same period, but this does not mean that they will increase by the same rate in
the future)
• the amount and type of cover provided under the scheme.
If you are an underwritten member we will not add any special conditions to
someone’s cover for medical conditions that started after their start date provided they
gave us all the information we asked for before their start date.
We can, at any time, change the amount you have to pay us in respect of IPT or any
other taxes, levies or charges that may be introduced and which are payable in respect
of your cover if there is a change in the rate of IPT or if any such taxes, levies or charges
are introduced.
If we do make any changes to the terms and conditions of your membership we will
write to tell you at least 28 days before the change takes effect.
Changes you can make
At your renewal date you can apply to add, remove or change an excess under the
scheme. We will consider your application at our sole discretion. If you are an
underwritten member and apply to increase cover under the scheme we may ask you
to agree to special conditions before we accept your application.
Other parties
No other person is allowed to make or confirm any changes to the agreement on our
behalf or decide not to enforce any of our rights. Equally, no change to the agreement
will be valid unless it is confirmed by us in writing.
12
How your membership works
1.5 General information
Change of address
You should call or write to tell us if you change your address. If you do not contact us to
tell us you have changed your address and you pay your subscriptions by direct debit,
your membership of the scheme will automatically end on your next renewal date if we
cannot contact you.
Correspondence between us
Letters between us must be sent with the postage costs paid before posting. We can
each assume that the letter will be received three days after posting.
Documents you send to us
We cannot return original documents to you. However we will send you copies if you
ask us to do so at the time you give us the documents.
1.6 If you have cause for complaint
If something has gone wrong, we want to do everything we can to put it right. Here’s a
simple procedure to ensure your concerns are dealt with as quickly and effectively as
possible.
The helpline is always the first number to call if you have any complaints:
• Please call us on: 0845 60 09 673* † between 8am and 8pm, Monday to Friday and
9am to 1pm on Saturdays. Or write to us at: Envoy Team, BUPA, Staines TW18 4XF
or fax us on 01784 893 232.
• For members with special needs:
• for hearing and speech impaired members who have a textphone, please call us
on: 0845 60 66 863*, between 9am and 5pm Monday to Friday
• we can also offer a choice of Braille, large print or audio for correspondence.
Please let us know which you would prefer.
13
 How your membership works
If we have not been able to resolve the problem and you wish to take your
complaint further, you can contact our Customer Relations Department. Please call:
0845 60 66 726* † between 8:30am and 5:30pm, Monday to Friday. Or write to:
BUPA, Staines TW18 4XF.
It’s very rare that we can’t settle a complaint, but if this does happen, you may refer
your complaint to the Financial Ombudsman Service. You can write to them at:
South Quay Plaza, 183 Marsh Wall, London E14 9SR or call them on 0845 08 01 800*
between 9am and 5pm, Monday to Friday.
Please let us know if you want a full copy of our complaints procedure.
None of these procedures affect your legal rights.
Applicable law
The agreement between you and BUPA is governed by English law. Any dispute that
cannot otherwise be settled will be dealt with by the courts in the UK.
* BT landline calls to 0845 numbers will cost no more than 3 pence per
minute. Charges from other providers may vary and calls made from
mobiles usually cost more.
†Calls may be recorded and may be monitored.
14
2
What you are covered for
This section 2 should be read as a whole and sets out what you are covered for under
the scheme subject to the terms and conditions of the scheme including the exclusions
and any special conditions or moratorium conditions that may apply to you.
2.1 Notes about your cover
2.1.a The type of treatment covered
You are only covered for eligible treatment that is carried out in the UK. Your GP must
have initially referred you for the treatment. However for eligible day-patient
treatment or eligible in-patient treatment provided by a consultant such referral is not
required in the case of a medical emergency.
By eligible treatment we mean treatment of an acute condition together with the
products and equipment used as part of the treatment that:
• are consistent with generally accepted standards of medical practice and
representative of best practices in the medical profession in the UK
• are clinically appropriate in terms of type, frequency, extent, duration and the
facility or location where the services are provided
• are demonstrated through scientific evidence to be effective in improving health
outcomes, and
• are not provided or used primarily for the expediency of you or your consultant
or other health care professional
and the treatment, services or charges are not excluded under the terms and conditions
of the scheme.
There are certain treatments, services or charges that are not covered under the
scheme including treatment of chronic conditions. These are explained in section 3,
‘What is not covered’.
15
 What you are covered for How your membership works

2.1.b BUPA recognised medical practitioners and treatment facilities 2.1.c The type of membership you have
Your cover for eligible treatment costs depends on you using certain BUPA recognised There are two different types of membership under the scheme. These are moratorium
medical practitioners and treatment facilities as explained in the benefit notes. membership and underwritten membership. You and your dependants will have the

Please note:
• the medical practitioners, other health care professionals and treatment facilities
you use can affect the level of benefits we pay you
• certain medical practitioners, other health care professionals and treatment
facilities that we recognise may only be recognised by us for certain types of
treatment or certain levels of benefits
• the medical practitioners, other health care professionals and treatment facilities
that we recognise and the type of treatment and/or level of benefit that we
recognise them for can change from time to time.
You are not covered for treatment costs where:
same type of membership. The type of membership you have is shown on your
membership certificate.
Moratorium members
If you are a moratorium member, when you joined the scheme you agreed that you
and your dependants, if any, would not be covered for any moratorium conditions.
See ‘Moratorium conditions’ in section 3 for full details including details of other medical
conditions and treatments that are not covered under the scheme.
Underwritten members
If you are an underwritten member, when you joined the scheme you agreed that you

• the person who has overall responsibility for your treatment is not a consultant – and your dependants, if any, would not be covered for any pre-existing conditions.

the only exception to this is where your GP refers you for eligible out-patient See ‘Pre-existing conditions’ in section 3 for full details including details of other medical

treatment by a therapist or, for members whose scheme is BUPA ClientChoice conditions and treatments that are not covered under the scheme.

Plus or BUPA ClientChoice, complementary medicine practitioners as set out in

benefit note 2a

• the medical practitioner, other health care professional or treatment facility is not
recognised by BUPA for providing either the type of treatment you need or for
treating the medical condition you have.

You should always call us before arranging any treatment to check your cover and
whether your chosen medical practitioner, other health care professional or treatment
facility is recognised by us.

16 17
 What you are covered for What you are covered for

2.2 Summary of benefits table Type of eligible treatment costs covered

This table only shows the headings for the type of eligible treatment costs we will pay When you are admitted to hospital
for. Each heading refers to a benefit note. We only pay the eligible treatment costs we Consultants’ fees for medical and surgical hospital treatment benefit note 3
say we pay for in the benefit notes and only up to the limits set out in them, subject to Hospital charges benefit note 4
the rules and benefits of the scheme including the exclusions and any special
what we pay for hospital charges benefit note 4a
conditions that may apply to you.
out-patient surgical operations benefit note 4b
We do not pay for any charges or fees incurred for treatment that is not covered under day-patient and in-patient treatment
the scheme, including any costs for treatment, including consultations that take place
hospital accommodation benefit note 4c
after the date your membership ends. Any costs you incur that are not covered under
parent accommodation benefit note 4d
the scheme are your responsibility.
theatre charges, nursing care, drugs and surgical dressings benefit note 4e
intensive care benefit note 4f
pathology, radiology, diagnostic tests, MRI, CT and PET scans benefit note 4g
Type of eligible treatment costs covered
therapies, such as physiotherapy benefit note 4h
Reasonable and customary charges benefit note 1:
this note applies prostheses and appliances benefit note 4i
equally to all the
treatment at home benefit note 4j
other benefit notes
Additional benefits
When you are not admitted to hospital
Private ambulance charges benefit note 5a
Out-patient consultations, treatment and diagnostic tests
and investigations benefit note 2 Home nursing after private eligible in-patient treatment benefit note 5b
Out-patient consultations and therapies benefit note 2a Benefits for specific medical conditions
Out-patient consultations and treatment benefit note 2a(i) Cancer treatment benefit note 6a
for members whose scheme is BUPA ClientChoice Plus or
Psychiatric treatment for members whose scheme is
BUPA ClientChoice, out-patient consultations with a consultant
BUPA ClientChoice Plus benefit note 6b
and out-patient therapies and complementary medicine on GP or
consultant referral
Out-patient consultations and treatment for members benefit note 2a(ii)
whose scheme is BUPA ClientChoice Essential
out-patient consultations with a consultant and out-patient therapies
on GP or consultant referral – when following and directly related
to day-patient or in-patient treatment
Out-patient diagnostics
out-patient tests and investigations on consultant referral benefit note 2b
out-patient MRI, CT and PET scans on consultant referral benefit note 2c

18 19
 What you are covered for
2.3 Benefit notes
We pay the eligible treatment costs we say we pay for in these benefit notes subject to
the rules and benefits of the scheme including the exclusions and any special
conditions or moratorium conditions that may apply to you. The benefit notes set out
the type of treatment costs we pay for and how much we pay, which in most cases is in
a table within the relevant benefit note.
Benefit note 1 reasonable and customary charges
This benefit note 1 applies equally to benefit notes 2 to 6 and should be read in
conjunction with all those benefit notes.
We only pay eligible treatment charges that are reasonable and customary. This means
that the amount you are charged by medical practitioners, other health care
professionals and/or treatment facilities and what you are charged for have to be in line
with what the majority of our other members are charged for similar treatment or
services.
When you are not admitted to hospital
Benefit note 2 out-patient consultations, treatment and diagnostic tests
and investigations
Benefit notes 2a to 2c set out your cover for eligible out-patient treatment. Your
treatment must follow an initial referral from your GP.
benefit note 2a out-patient consultations and therapies
What we pay for out-patient consultations and therapies depends on the scheme that
you are covered under. If your scheme is:
• BUPA ClientChoice Plus you should read benefit note 2a(i)
• BUPA ClientChoice you should read benefit note 2a(i)
• BUPA ClientChoice Essential you should read benefit note 2a(ii).
20
What you are covered for
benefit note 2a(i) for members whose scheme is BUPA ClientChoice Plus or
BUPA ClientChoice:
out-patient consultations with a consultant and out-patient therapies and complementary
medicine treatment on GP or consultant referral
Consultations with a consultant
For members who scheme is BUPA ClientChoice Plus or BUPA ClientChoice we pay
consultants’ fees for out-patient consultations that are to assess your acute condition
when carried out as eligible out-patient treatment.
Consultants’ charges for the use of consulting rooms are not treated as consultants’
fees for a consultation. We may pay consultants’ charges for the use of consulting
rooms. Where we do agree we will treat the charge as falling under this benefit note 2a
and subject to the benefit limit in this benefit note.
We do not pay hospital charges for the use of a consulting room.
Therapies and complementary medicine treatment
For members who scheme is BUPA ClientChoice Plus or BUPA ClientChoice we pay
therapists’ fees and complementary medicine practitioners’ fees for eligible
out-patient treatment when you are referred for the treatment by your GP or
consultant.
Please note: for members whose scheme is BUPA ClientChoice Plus psychiatric
treatment provided by therapists and carried out as out-patient treatment is only paid
at our discretion. We will exercise our discretion as set out in benefit note 6b. You
should refer to that benefit note if you need that type of out-patient treatment.
If your consultant refers you to a medical or health practitioner who is not a BUPA
recognised therapist or complementary medicine practitioner, we may pay the
charges as if the practitioner were a therapist or complementary medicine practitioner
if all of the following apply:
• your consultant refers you to the practitioner before the eligible out-patient
treatment takes place and remains in overall charge of your care, and
• the practitioner has applied for BUPA recognition and we have not written to say
he/she is not recognised by BUPA.
21
 What you are covered for
consultants and therapists for members whose scheme is BUPA ClientChoice
Plus: we pay up to a total amount of £1,000 each
year for all such eligible out-patient treatment.
for members whose scheme is BUPA ClientChoice:
we pay up to a total amount of £500 each year for
all such eligible out-patient treatment.
These are the overall amounts we pay for all such
consultations and treatment and not for each type
of consultation or treatment individually.
complementary medicine You can use up to £250 of your available cover to
practitioners pay for eligible out-patient treatment provided by
complementary medicine practitioners.
benefit note 2a (ii) for members whose scheme is BUPA ClientChoice Essential:
out-patient consultations with a consultant and out-patient therapies on GP or consultant
referral – when following and directly related to day-patient or in-patient treatment
For members whose scheme is BUPA ClientChoice Essential we pay:
• consultants’ fees for out-patient consultations that are to assess your acute
condition when carried out as eligible out-patient treatment
• therapists’ fees for eligible out-patient treatment when you are referred for the
treatment by your GP or consultant
but we only pay when:
• the consultation or treatment follows and is directly related to eligible
day-patient treatment or eligible in-patient treatment
• is received within six months of the date you are discharged from the hospital
after the eligible day-patient treatment or eligible in-patient treatment it is
related to, and
• for consultations with a consultant we only pay for up to two such consultations
during the six months period.
22
What you are covered for
If your consultant refers you to a medical or health practitioner who is not a BUPA
recognised therapist, we may pay the charges as if the practitioner were a therapist if
all of the following apply:
• your consultant refers you to the practitioner before the eligible out-patient
treatment takes place and remains in overall charge of your care, and
• the practitioner has applied for BUPA recognition and we have not written to say
he/she is not recognised by BUPA.
Consultants’ charges for the use of consulting rooms are not treated as consultants’
fees for a consultation. We may pay consultants’ charges for the use of consulting
rooms. Where we do agree we will treat the charge as falling under this benefit note 2a
and subject to the benefit limit in this benefit note.
We do not pay hospital charges for the use of a consulting room.
consultants and therapists We pay up to a total amount of £500 each year for
all such eligible out-patient treatment. This is the
overall amount we pay for all such consultations
and treatment and not for each type of
consultation or treatment individually.
benefit note 2b out-patient tests and investigations on consultant referral
When requested by your consultant to help determine or assess your condition as part
of eligible out-patient treatment we pay hospital charges (including the charge for
interpretation of the results) for diagnostic tests. We do not pay charges for diagnostic
tests that are not from the hospital.
(MRI, CT and PET scans are not paid under this note – see benefit note 2c.)
hospital We pay in full
23
 What you are covered for What you are covered for

benefit note 2c out-patient MRI, CT and PET scans on consultant referral We do not have to pay your consultants’ fees if your eligible treatment is carried out in

When requested by your consultant to help determine or assess your condition as part a hospital that is not a partnership network hospital without our prior written approval.

of eligible out-patient treatment we pay imaging centre or hospital charges (including

Surgeons and anaesthetists
the charge for interpretation of the results), for:
We pay consultant surgeons’ fees and consultant anaesthetists’ fees for eligible
• MRI scans (magnetic resonance imaging)
surgical operations carried out in a partnership network hospital.
• CT scans (computed tomography)
Please note: the benefits available for consultant surgeons and consultant anaesthetists
• PET scans (positron emission tomography).
may differ for the same operation.
We do not pay charges for MRI, CT and PET scans that are not from the imaging centre
or hospital. partnership consultants We pay in full

Details of imaging centres and the type of scan we recognise them for are available on
request. consultants who are not We pay up to the benefit limits set out in the
partnership consultants consultant fees schedule based on:
imaging centre We pay in full • the type and complexity of the eligible surgical
operation carried out
• the BUPA recognition status of the consultant
hospital that is not an We pay up to £100 towards the total • where the eligible surgical operation is carried
imaging centre hospital charges out, both in terms of the hospital or facility and
the location.
The consultant fees schedule may change from
time to time. Details of the schedule are available on
When you are admitted to hospital request. Before receiving your treatment you are
advised to check with your consultant whether they
charge within the benefit limits set out in the
Benefit note 3 consultants’ fees for medical and surgical hospital consultant fees schedule.
treatment
We pay consultants’ fees for eligible treatment but the amount we will pay depends on:
Physicians
• whether your treatment is provided by a partnership consultant or a consultant
We pay consultant physicians’ fees for eligible day-patient treatment or eligible
who is not a partnership consultant, and
in-patient treatment in a partnership network hospital if the treatment does not
• where your treatment is carried out. include a surgical operation or cancer treatment.
If you need eligible cancer treatment this is dealt with separately under benefit note 6a If your treatment does include an eligible surgical operation we only pay consultant
and you should refer to that benefit note if you need that type of treatment. physicians’ fees if the attendance of a physician is medically necessary because of your
For members whose scheme is BUPA ClientChoice Plus if you need psychiatric eligible surgical operation.
treatment this is dealt with separately under benefit note 6b and you should refer to If your treatment does include eligible cancer treatment we only pay consultant
that benefit note if you need that type of treatment. physicians’ fees if the attendance of a consultant physician is medically necessary

24 25
 What you are covered for What you are covered for

because of your eligible cancer treatment, for example if you develop an infection that Day-patient and in-patient treatment
requires eligible in-patient treatment. We pay the type of hospital charges set out in benefit notes 4c to 4i for eligible
day-patient treatment and eligible in-patient treatment up to the amounts below.
partnership consultants We pay in full

partnership network hospital We pay in full

consultants who are not We pay up to £55 each day for eligible day-patient
partnership consultants treatment and for eligible in-patient treatment.
hospital that is not a We do not have to pay your claim for hospital
We pay up to an additional £80 each night for a partnership network hospital charges if you receive your treatment in a hospital
total of 14 nights each year for eligible in-patient that is not a partnership network hospital without
treatment for certain major medical illnesses as our prior written agreement.
classified in the consultant fees schedule.
If, for medical reasons, your proposed eligible
day-patient treatment or eligible in-patient
treatment cannot take place in a partnership
Benefit note 4 hospital charges network hospital we may agree to your treatment
being carried out in a hospital that is not a
partnership network hospital. We need full clinical
benefit note 4a what we pay for hospital charges
details from your consultant before we can give our
We pay hospital charges for eligible treatment. The hospital charges we pay for are set decision. If we do agree, we pay benefits for the
treatment as if the hospital had been a partnership
out in benefit notes 4b to 4i. The amount we pay for those hospital charges is explained network hospital. When you contact us we will
in this benefit note 4a and depends on where your treatment is carried out and whether check your cover and help you to find a suitable
alternative hospital. Please note, an en suite or
your treatment is out-patient, day-patient or in-patient treatment.
single room may not be available in a hospital that
is not a partnership network hospital.
Out-patient surgical operations
We pay the type of hospital charges set out in benefit note 4b for eligible surgical
operations carried out as eligible out-patient treatment up to the amounts below.
benefit note 4b out-patient surgical operations
We pay hospital charges for eligible surgical operations carried out as eligible
partnership network hospital We pay in full out-patient treatment. We pay for theatre use, including equipment, and drugs and
surgical dressings used during the surgical operation.

hospital that is not a
partnership network hospital
We pay up to a total amount of £100 for the
hospital charges. This is the total amount we pay
for all the hospital charges and not the amount we
pay for each type of service, charge or item
individually.
Please note: we do not have to pay your claim for
consultants’ fees if you use a hospital that is not a
partnership network hospital without our prior
written agreement.
benefit note 4c hospital accommodation
We pay hospital accommodation charges for eligible day-patient treatment or eligible
in-patient treatment including your own meals and refreshments while you are
receiving your treatment.
We do not pay for personal items such as telephone calls, newspapers, guest meals or
personal laundry.

26 27
 What you are covered for
We do not pay hospital charges for accommodation if:
• the charge is for an overnight stay for treatment that would normally be carried
out as out-patient treatment or day-patient treatment
• the charge is for use of a bed for treatment that would normally be carried out as
out-patient treatment.
benefit note 4d parent accommodation
We pay hospital accommodation charges for each night a parent needs to stay in the
hospital with their child. We only pay for one parent each night. The child must be:
• under 12
• a member under the scheme, and
• receiving eligible in-patient treatment.
This benefit applies to the child’s cover and any charges are payable from the child’s
benefits.
benefit note 4e theatre charges, nursing care, drugs and surgical dressings
We pay hospital charges for use of the operating theatre and for nursing care, drugs
and surgical dressings when needed as an essential part of your eligible day-patient
treatment or eligible in-patient treatment.
We do not pay for extra nursing services in addition to those that the hospital would
usually provide as part of normal patient care without making any extra charge.
We do not pay for drugs and surgical dressings used for out-patient treatment or for
you to use after your stay in hospital.
28
What you are covered for
benefit note 4f intensive care
We pay hospital charges for intensive care when needed as an essential part of your
eligible day-patient treatment or eligible in-patient treatment but we only pay if all
the following conditions are met:
• the intensive care is required routinely by patients undergoing the same type of
treatment as yours
• you are receiving private eligible treatment in a hospital equipped with a critical
care unit
• the intensive care is carried out in the critical care unit, and
• it follows your planned admission to the hospital for private treatment.
We also pay for intensive care for eligible day-patient treatment or eligible in-patient
treatment if unforeseen circumstances arise from a medical or surgical procedure which
does not routinely require intensive care as part of the treatment but only if:
• you are receiving private eligible treatment in a hospital equipped with a critical
care unit, and
• the intensive care is carried out in the critical care unit
in which case your consultant or hospital should contact us at the earliest opportunity.
We do not pay for any intensive care in any of the following circumstances:
• it follows an unplanned or an emergency admission to an NHS hospital or facility
• it follows a transfer (whether on an emergency basis or not) to an NHS hospital or
facility from a private hospital
• it is carried out in a unit or facility which is not a critical care unit.
Please also see ‘Intensive care’ in the ‘What is not covered’ section.
29
 What you are covered for What you are covered for

benefit note 4g pathology, radiology, diagnostic tests, MRI, CT and PET scans benefit note 4j treatment at home
When recommended by your consultant to help determine or assess your condition as We may, at our discretion, pay for you to receive eligible treatment at home. You must
part of eligible day-patient treatment or eligible in-patient treatment we pay hospital have our written agreement before the treatment starts and we need full clinical details
charges for: from your consultant before we can make our decision. We will only consider

• pathology (such as checking blood and urine samples) treatment at home in the following circumstances:

• radiology (such as X-rays) • your consultant has recommended that you receive the treatment at home and
remains in overall charge of your treatment
• diagnostic tests (such as ECGs)
• if you did not have the treatment at home then, for medical reasons, you would
• MRI scans (magnetic resonance imaging)
need to receive the treatment in a hospital, and
• CT scans (computed tomography), and
• the treatment is provided to you by a medical treatment provider.
• PET scans (positron emission tomography).

medical treatment provider If we agree to pay for eligible treatment at home

benefit note 4h therapies, such as physiotherapy we pay in full for the charges we agree to pay on
We pay hospital charges for eligible treatment provided by therapists (such as your behalf unless we tell you that a benefit limit
applies.
physiotherapy) when needed as part of your eligible day-patient treatment or eligible
We do not pay for any fees or charges for
in-patient treatment.
treatment at home that has not been provided to
you by the medical treatment provider.
benefit note 4i prostheses and appliances
We pay hospital charges for a prosthesis or appliance needed as part of your eligible
day-patient treatment or eligible in-patient treatment.

Please note: see the Glossary for the definitions of prosthesis and appliance as these set
out the extent of the cover.

We do not pay for any treatment which is for or associated with or related to a
prosthesis or appliance that we do not cover under the scheme.

30 31
 What you are covered for What you are covered for

Additional benefits Benefits for specific medical conditions

Benefit note 5a private ambulance charges
We pay for travel by private road ambulance if you need private eligible day-patient
treatment or eligible in-patient treatment, and it is medically necessary for you to
travel by ambulance:
• from your home or place of work to hospital
• between hospitals when you are discharged from one hospital and admitted to
another hospital for eligible in-patient treatment
• from hospital to home, or
• between an airport or seaport and hospital.
We pay up to £60 for each single trip up to an overall maximum amount of
£120 each year.
Benefit note 6a cancer treatment
This benefit note 6a sets out what we pay for:
• eligible cancer treatment carried out as eligible out-patient treatment,
• out-patient drugs for eligible cancer treatment,
• radiotherapy (the use of radiation to treat cancer) and chemotherapy (the use of
drugs to treat cancer), and
• day-patient treatment and in-patient treatment for eligible cancer treatment
that includes a bone marrow or stem cell transplant.
For all other eligible cancer treatment we pay on the same basis and up to the same
limits as we pay for other eligible treatment as set out in benefit note 1 and benefit
notes 3 to 5.

benefit note 6a(i).1 out-patient consultations for cancer with a consultant,

Benefit note 5b home nursing after private eligible in-patient treatment out-patient therapies for cancer on GP or consultant referral and out-patient
tests and investigations for cancer on consultant referral
We pay for home nursing immediately following private eligible in-patient treatment if
the home nursing:
Out-patient consultations for cancer with a consultant
• is for eligible treatment
We pay consultants’ fees for out-patient consultations that are to assess your acute
• is needed for medical reasons ie not domestic or social reasons condition of cancer when carried out as eligible out-patient treatment.
• is necessary ie without it you would have to remain in hospital
Out-patient therapies for cancer on GP or consultant referral
• starts immediately after you leave the hospital
We pay therapists’ fees for eligible out-patient treatment for cancer when you are
• is provided by a qualified nurse in your own home, and
referred for the treatment by your GP or consultant.
• is carried out under the supervision of your consultant.

We do not pay home nursing provided by a community psychiatric nurse.

If your home nursing is payable we pay up to £600 each year.

We may pay more than £600 for home nursing, but only if we have agreed this in advance.
We need full clinical details from your consultant before we can give our decision.

32 33
 What you are covered for What you are covered for

If your consultant refers you to a medical or health practitioner who is not a BUPA If your consultant refers you to a medical or health practitioner who is not a BUPA
recognised therapist, we may pay the charges as if the practitioner were a therapist if recognised complementary medicine practitioner, we may pay the charges as if the
all of the following apply: practitioner were a complementary medicine practitioner if all of the following apply:

• your consultant refers you to the practitioner before the eligible out-patient • your consultant refers you to the practitioner before the eligible out-patient
treatment takes place and remains in overall charge of your care, and treatment takes place and remains in overall charge of your care, and

• the practitioner has applied for BUPA recognition and we have not written to say • the practitioner has applied for BUPA recognition and we have not written to say
he/she is not recognised by BUPA. he/she is not recognised by BUPA.

Out-patient tests and investigations for cancer on consultant referral complementary medicine We pay up in full
When requested by your consultant to help determine or assess your condition as part practitioners

of eligible out-patient treatment for cancer we pay hospital charges (including the
charge for interpretation of the results) for diagnostic tests. We do not pay charges for
diagnostic tests that are not from the hospital.
(out-patient MRI, CT and PET scans for cancer are not paid under this benefit note – see
benefit note 6a(ii))
benefit note 6a(ii) out-patient MRI, CT and PET scans on consultant referral
When requested by your consultant to help determine or assess your condition as part
of eligible out-patient treatment for cancer we pay imaging centre or hospital charges
(including the charge for interpretation of the results), for:

• MRI scans (magnetic resonance imaging)

consultants, therapists, We pay up in full
and hospitals • CT scans (computed tomography)

• PET scans (positron emission tomography).

benefit note 6a(i).2 for members whose scheme is BUPA ClientChoice Plus or We do not pay charges for MRI, CT and PET scans that are not from the imaging centre

BUPA ClientChoice: out-patient complementary medicine for cancer on GP or or hospital.

consultant referral Details of imaging centres and the type of scan they are recognised for are available on

For members whose scheme is BUPA ClientChoice Plus or BUPA ClientChoice we pay request.

complementary medicine practitioners’ fees for eligible out-patient treatment for

cancer when you are referred for the treatment by your GP or consultant. imaging centre We pay in full

hospital that is not an We pay up to £100 towards the total hospital charges
imaging centre

34 35
 What you are covered for What you are covered for

benefit note 6a(iii) consultant oncologists’ fees for chemotherapy and

radiotherapy
We pay consultant oncologists’ fees for planning and carrying out eligible cancer
treatment in a partnership network hospital or, if your eligible cancer treatment
includes a bone marrow or stem cell transplant, in a specialist treatment centre.
We do not have to pay your consultant oncologists’ fees if:
• your eligible cancer treatment is carried out in a hospital that is not a
partnership network hospital, or
• your eligible cancer treatment includes a bone marrow or stem cell transplant
and is carried out in a hospital that is not a specialist treatment centre.
partnership consultants We pay in full
consultants who are not For radiotherapy treatment we only pay up to a
partnership consultants maximum of £380 for consultants’ fees for each course
of radiotherapy treatment. By a course of radiotherapy
treatment we mean up to 15 attendances for
radiotherapy.
For chemotherapy treatment we only pay consultants’
fees up to the amounts set out below according to your
‘Start Date’ (by Start Date we mean the date your
chemotherapy treatment begins, or we consider it
begins) and the date your treatment ends. For
treatment beginning on your Start Date and
continuing for:
continued
continued
• 1 week, we pay up to a maximum of £137;
• 2 weeks, we pay up to a maximum of £257;
• 3 weeks, we pay up to a maximum of £386; or
• 4 weeks, we pay up to a maximum of £515.
By 1 week we mean your Start Date to the 7th day
of treatment.
By 2 weeks we mean your Start Date to the 14th day
of treatment.
By 3 weeks we mean your Start Date to the 21st day
of treatment.
By 4 weeks we mean your Start Date to the 28th day
of treatment.
We do not pay each week of a course of chemotherapy
treatment separately when the treatment begins on
your Start Date and lasts more than one week. Twenty-
eight days after your Start Date, we will consider any
further costs you incur for chemotherapy treatment to
be new treatment for the purpose of the scheme and a
new Start Date will apply to your chemotherapy
treatment.
benefit note 6a(iv) out-patient cancer drugs
We pay hospital charges or specialist treatment centre charges for drugs (such as
cytotoxic drugs) that are related specifically to planning and carrying out eligible cancer
treatment which you receive as out-patient treatment.

hospital or specialist We pay in full

treatment centre

36 37
 What you are covered for What you are covered for

benefit note 6a(v) eligible cancer treatment that includes a bone marrow or stem
cell transplant
If your eligible cancer treatment includes a bone marrow or stem cell transplant and is
carried out as day-patient treatment or in-patient treatment what we pay for and how
much we pay is explained below.
Benefit note 6b for members whose scheme is BUPA ClientChoice Plus:
psychiatric treatment after two years’ membership
For members whose scheme is BUPA ClientChoice Plus we may, at our discretion, pay
for eligible treatment of a psychiatric condition (ie psychiatric treatment) that you
receive from a consultant or therapist. Before we will consider paying for psychiatric

In a specialist treatment centre treatment you must have been covered under BUPA ClientChoice Plus (or any BUPA
scheme which included cover for psychiatric treatment) for the whole of the two years

consultants We pay consultants’ fees on the same basis and up
to the same limits as consultants’ fees for other
eligible treatment carried out in a partnership
network hospital as set out in benefit note 3.
specialist treatment centre We pay the specialist treatment centre charges on
the same basis and up to the same limits as hospital
charges for other eligible treatment carried out in a
partnership network hospital as set out in benefit
note 4.
In a hospital that is not a specialist treatment centre
consultants We do not have to pay your consultants’ fees.
leading up to the psychiatric treatment. It is then at our discretion whether or not we
will pay. Before receiving any psychiatric treatment you must ask your consultant to
get our written agreement. Otherwise we will not be obliged to pay the consultants’ or
therapists’ fees, or the hospital charges or any other charges. We need full clinical
details from your consultant before we can give our decision.
Psychiatric treatment that is not covered
We do not pay for treatment of a psychiatric condition in the following circumstances:
• if you have received two episodes of treatment for that psychiatric condition or
any related psychiatric condition during your membership of the scheme (and
any other BUPA scheme which has cover for psychiatric treatment) whether your
membership is continuous or not. By an episode of treatment we mean:
– seven nights or more in-patient treatment, whether consecutive or not, or

– 20 or more separate attendances for out-patient treatment or day-patient

hospital We do not have to pay the hospital charges.
treatment in any 12 month period;

• if either before or during your membership of the scheme you suffer from any
psychiatric condition for a continuous period of two years or more which
requires any form of treatment at any time during that period. The treatment
need not be ongoing or continuous during the period of the psychiatric
condition.

38 39
 What you are covered for What you are covered for

What we will pay for psychiatric treatment • Consultants’ fees

If we agree to pay for psychiatric treatment we pay consultants’ and therapists’ fees If we agree we pay consultants’ fees for psychiatric treatment carried out as
and hospital charges as follows: day-patient treatment or in-patient treatment in a psychiatric network hospital.

Please note: we do not have to pay your claim for consultants’ fees if you use a hospital
Out-patient treatment
which is not a psychiatric network hospital.
If we agree to pay for psychiatric treatment carried out as out-patient treatment we
pay for: partnership consultants If we agree we pay in full.
• consultants’ fees for out-patient consultations to assess your psychiatric
condition consultants who are not If we agree we pay up to a maximum of £55 each
• psychiatric treatment provided by a consultant or therapist and carried out as partnership consultants day for day-patient treatment or in-patient
treatment.
out-patient treatment.

consultants and therapists
If we agree we pay in accordance with benefit note
2a(i) and subject to the overall limit set out in
benefit note 2a(i) for members whose scheme is
BUPA ClientChoice Plus
• Hospital charges
If we agree to pay for psychiatric treatment carried out as day-patient treatment or
in-patient treatment we pay the type of hospital charges we say we pay for in benefit
notes 4c to 4i.

Day-patient and in-patient treatment

psychiatric network hospital If we agree we pay in full
If we agree to pay for psychiatric treatment carried out as day-patient treatment or
in-patient treatment we may pay for up to a maximum of 28 days’ psychiatric
hospital that is not a If we agree we pay up to a total amount of:
treatment costs in total each year. This is the maximum number of days we may pay for
psychiatric network hospital
psychiatric treatment for all psychiatric conditions each year and not for each • £50 each day for day-patient treatment, or

psychiatric condition individually. If we agree to pay we pay consultants’ fees and • £80 each night for in-patient treatment.
hospital charges as set out below. This is the overall total amount we pay for the
hospital charges in these circumstances. It is not
the amount we pay for each type of service or item
individually.

Please also see ‘Chronic conditions’ in section 3, ‘What is not covered’.

40 41

3 Exception: We pay for eligible treatment for, or arising from AIDS or HIV if the person
What is not covered
This section explains the treatment, services and charges that are not covered under this
scheme. Part 1 sets out the general exclusions that apply to all BUPA personal schemes
including this scheme. Part 2 sets out the additional exclusions which apply to this
scheme.
The exclusions are grouped under headings and listed alphabetically. The headings are
just signposts, they are not part of the exclusion. If there is an exception to an exclusion
this is shown. Where we refer to specific treatments or medical conditions in the
exceptions these are examples only and not evidence of cover.
This section does not contain all the limits and exclusions to your cover. For example the
benefit notes in section 2 also describe some limitations and restrictions for particular
types of treatment, services and charges. Also, you may have special conditions or
moratorium conditions that limit or restrict your individual cover.
PART 1
Ageing, menopause and puberty
We do not pay for treatment to relieve symptoms commonly associated with any bodily
change arising from any physiological or natural cause such as ageing, menopause or
puberty and which is not due to any underlying disease, illness or injury.
AIDS/ HIV
We do not pay for treatment for, or arising from, AIDS or HIV, including any condition
which is related to, or results from, AIDS or HIV.
42
What is not covered
with AIDS or HIV became infected five years or more after their current continuous
membership began, or has been a member of this scheme (or any BUPA scheme which
included cover for this type of treatment) since at least July 1987 without a break in
their cover.
Allergies or allergic disorders
We do not pay for treatment to de-sensitise or neutralise any allergic condition or
disorder.
Birth control, conception, sexual problems and sex changes
We do not pay for treatment for any type of:
• contraception, sterilisation, termination of pregnancy
• sexual problems (including impotence, whatever the cause)
• assisted reproduction (eg IVF treatment), surrogacy, the harvesting of donor eggs
or donor insemination
• sex changes or gender reassignments
or treatment for or arising from any of these.
Exception: Where your consultant considers that there are symptoms and/or medical
evidence to suggest that you and/or your partner are infertile, we pay for eligible
treatment for either you and/or your partner (where your partner is a dependant
under this scheme) for reasonable investigations into the medical cause of infertility, if:
• neither you nor your partner had been aware of any such symptoms and/or
medical problems before joining, and
• you have both been members of the scheme (or any BUPA scheme which
included cover for this type of investigation) for a continuous period of two years
before receiving the treatment.
Once the cause is confirmed, no further payment is made for additional investigations or
treatment in the future.
Please also see ‘Pregnancy and childbirth’ in this section.
43
 What is not covered
Chronic conditions
We do not pay for treatment of chronic conditions. By this, we mean 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.
Exception: We pay for eligible treatment arising out of a chronic condition, or for
treatment of acute symptoms of a chronic condition that flare up. However, we only
pay if the treatment is likely to lead quickly to a complete recovery or to you being
restored fully to your previous state of health, without you having to receive prolonged
treatment. For example, we pay for treatment following a heart attack arising out of
chronic heart disease.
Please note: for members whose scheme is BUPA ClientChoice Plus this exception does
not apply to treatment of a psychiatric condition.
Please note: in some cases it might not be clear, at the time of treatment, that the
disease, illness or injury being treated is a chronic condition. We are not obliged to pay
the ongoing costs of continuing, or similar, treatment. This is the case even where we
have previously paid for this type of or similar treatment.
Please also see ‘Temporary relief of symptoms’ in this section.
Complications from excluded or restricted conditions/ treatment
We do not pay any treatment costs, including any increased treatment costs, you incur
because of complications caused by a disease, illness, injury or treatment for which
cover has been excluded or restricted from your membership. For example, if cover for
diabetes is excluded from your cover (either because it is a moratorium condition if you
are a moratorium member or is a special condition if you are an underwritten
member), and you have to spend any extra days in hospital after an operation because
you have diabetes, we would not pay for these extra days.
44
What is not covered
Contamination, wars, riots and terrorist acts
We do not pay for treatment for any disease, illness or injury resulting from nuclear or
chemical contamination, war, riot, revolution, terrorist act or any similar event.
Convalescence, rehabilitation and general nursing care
We do not pay for private hospital accommodation if it is primarily used for any of the
following purposes:
• convalescence, rehabilitation, supervision or any purpose other than receiving
eligible treatment
• receiving general nursing care or any other services which could have been
provided in a nursing home or in any other establishment which is not a hospital
• receiving services from a therapist.
Exception: We may, at our discretion, pay for eligible treatment for rehabilitation. By
rehabilitation we mean treatment which is aimed at restoring health or mobility or to
allow you to live an independent life, such as after a stroke. We will only consider cases
where the rehabilitation:
• is an integral part of eligible in-patient treatment
• starts within 42 days from and including the date you first receive that eligible
in-patient treatment, and
• takes place in a rehabilitation centre.
You must have our written agreement before the rehabilitation starts and we need full
clinical details from your consultant before we can give our decision. If we agree we pay
for up to a maximum of 21 consecutive days rehabilitation.
Cosmetic, reconstructive or weight loss treatment
We do not pay for treatment to change your appearance, such as a remodelled nose or
facelift whether or not it is needed for medical or psychological reasons.
We do not pay for breast enlargement or reduction or any other treatment or
procedure to change the shape or appearance of your breast(s) whether or not it is
needed for medical or psychological reasons, for example, for backache or
gynaecomastia (which is the enlargement of breasts in males).
45
 What is not covered What is not covered

We do not pay for any treatment, including surgery, Exception: We pay for an eligible surgical operation carried out by a consultant to:

• which is for or involves the removal of healthy tissue (ie tissue which is not • put a natural tooth back into a jaw bone after it is knocked out or dislodged in an
diseased), or the removal of surplus or fat tissue, or unexpected accidental injury

• where the intention of the treatment, whether directly or indirectly, is the • treat a jaw bone cyst, but not if it is related to a cyst or abscess on the tooth root
reduction or removal of surplus or fat tissue including weight loss (for example, or any other tooth or gum disease or damage
surgery related to obesity including morbid obesity) • surgically remove a complicated, buried or impacted tooth root, such as an
whether or not the treatment it is needed for medical or psychological reasons. impacted wisdom tooth, but not if the purpose is to facilitate dentures or the

We also do not pay for scar revision. acute condition relates to a pre-existing condition.

Exception: We pay for an eligible surgical operation to restore your appearance after
Dialysis
an accident, or as a direct result of surgery for cancer, if either of these takes place
during your current continuous membership of the scheme. We will only pay if this is We do not pay for treatment for or associated with kidney dialysis (haemodialysis),

part of the original eligible treatment resulting from the accident or cancer and you meaning the removal of waste matter from your blood by passing it through a kidney

have obtained our written agreement before receiving the treatment. machine or dialyser.

Please also see ‘Screening and preventive treatment’ in this section. We do not pay for treatment for or associated with peritoneal dialysis, meaning the
removal of waste matter from your blood by introducing fluid into your abdomen which

Deafness acts as a filter.

We do not pay for treatment for or arising from deafness caused by a congenital Exception: We pay for eligible treatment for short-term kidney dialysis or peritoneal

abnormality, maturing or ageing. dialysis if the dialysis is needed temporarily for sudden kidney failure resulting from a
disease, illness or injury affecting another part of your body.

Dental/oral treatment (such as fillings, gum disease, Please also see ‘Transplant surgery’ in this section.
jaw shrinkage, etc)
We do not pay for any dental or oral treatment. Drugs and dressings for out-patient or take-home use
We do not pay for the provision of dental implants or dentures, the repair or We do not pay for any drugs or surgical dressings provided or prescribed for out-patient

replacement of damaged teeth (including crowns, bridges, dentures, or any dental treatment or for you to take home with you on leaving hospital or a treatment facility.

prosthesis made by a laboratory technician). Exception: We pay for out-patient drugs (such as cytotoxic drugs) for eligible cancer

We do not pay for the management of, or any treatment related to, jaw shrinkage or treatment as set out in benefit note 6a, in section 2.

loss as a result of dental extractions or gum disease. Please also see ‘Experimental drugs and treatment’ in this section.

We also do not pay for surgical operations for the treatment of bone disease when
related to gum disease or tooth disease or damage.

46 47
 What is not covered
Experimental drugs and treatment
We do not pay for treatment or procedures which, in our reasonable opinion, are
experimental or unproved based on established medical practice in the United
Kingdom, such as drugs outside the terms of their licence or procedures which have not
been satisfactorily reviewed by NICE (National Institute for Clinical Excellence).
Exception: We may pay for this type of treatment of an acute condition. However, you
will need our written agreement before the treatment is received and we need full
clinical details from your consultant before we can give our decision.
Please also see ‘Drugs and dressings for out-patient or take-home use’ in this section.
Eyesight
We do not pay for treatment to correct your eyesight, for example for long or short
sight or failing eyesight due to ageing, including spectacles or contact lenses.
Exception: We pay for eligible treatment for your eyesight if it is needed as a result of
an injury or an acute condition, such as a detached retina.
HRT and bone densitometry
We do not pay for treatment for hormone replacement therapy (HRT) or bone densitometry.
Exception: We may pay for bone densitometry recommended by your consultant to
help determine or assess your condition as part of eligible treatment. However, we need
full clinical details from your consultant before we can give our decision. If we agree to
pay for bone densitometry we only pay for an initial bone densitometry scan and for
one follow-up scan if this is carried out:
• within three years of you starting treatment, and
• during your current continuous period of membership of the scheme.
Please also see ‘Ageing, menopause and puberty’ in this section.
48
What is not covered
Intensive care (other than routinely needed after private day-patient
treatment or in-patient treatment)
We do not pay for any intensive care if:
• it follows an unplanned or an emergency admission to an NHS hospital or facility
• it follows a transfer (whether on an emergency basis or not) to an NHS hospital or
facility from a private hospital
• it is carried out in a unit or facility which is not a critical care unit.
We do not pay for any intensive care, or any other treatment in a critical care unit, if it
is not routinely required as a medically essential part of the eligible treatment being
carried out.
Exception: We pay for eligible treatment for intensive care but only as set out in
benefit note 4, in section 2.
Learning difficulties, behavioural and developmental problems
We do not pay for treatment related to learning difficulties, such as dyslexia, or
behavioural problems, such as attention deficit hyperactivity disorder (ADHD), or
developmental problems, such as shortness of stature.
Overseas treatment and repatriation
We do not pay for treatment, including treatment for medical emergencies, that you
receive outside the UK or for repatriation to the UK.
Physical aids and devices
We do not pay for supplying or fitting physical aids and devices (eg hearing aids,
spectacles, contact lenses, crutches, walking sticks, etc).
Exception: We pay for prostheses and appliances as set out in benefit note 4, in
section 2.
49
 What is not covered
Pregnancy and childbirth
We do not pay for treatment for, or any condition arising from, pregnancy, childbirth or
termination of pregnancy. This includes:
• pre-eclampsia (a condition in which elevated blood pressure, fluid retention and
the presence of protein in urine occurs in late pregnancy)
• eclampsia (a seizure or coma during pregnancy)
• pregnancy induced hypertension (raised blood pressure during pregnancy)
• treatment of an embryo or foetus.
Exception 1: We pay for eligible treatment of the following conditions:
• miscarriage or when the foetus has died and remains with the placenta in the
womb
• still birth
• hydatidiform mole (abnormal cell growth in the womb)
• foetus growing outside the womb (ectopic pregnancy)
• heavy bleeding in the hours and days immediately after childbirth (post-partum
haemorrhage)
• afterbirth left in the womb after delivery of the baby (retained placental
membrane)
• complications following any of the above conditions.
Exception 2: We may pay for eligible treatment for delivering a baby by caesarean
section when the mother has been a member of the scheme for at least 12 months
before the delivery. However, we need full clinical details from your consultant before
we can give our decision.
Please also see ‘Birth control, conception, sexual problems and sex changes’ and
‘Neo-natal treatment’ in this section.
50
What is not covered
Screening and preventive treatment
We do not pay for:
• health screening, such as routine tests or health checks
• tests or procedures which, in our reasonable opinion based on established clinical
and medical practice, are carried out for screening or monitoring purposes, such
as endoscopies when no symptoms are present
• preventive treatment, procedures or medical services, for example, removing
breast tissue when there is no disease or tumour present.
Sleep problems and disorders
We do not pay for treatment for or arising from sleep problems or disorders such as
insomnia, snoring or sleep apnoea (temporarily stopping breathing during sleep).
Speech disorders
We do not pay for treatment for or relating to any speech disorder, for example
stammering.
Exception: We may at our discretion pay for eligible treatment for short-term speech
therapy which is part of eligible in-patient treatment. The speech therapy must take
place during and/or immediately following the eligible in-patient treatment and be
provided by a therapist who is a member of the Royal College of Speech and Language
Therapists.
Temporary relief of symptoms
We do not pay for treatment, the main purpose or effect of which is to provide
temporary relief of symptoms or which is for the ongoing management of a condition.
Exception: We may pay for this type of treatment if you need it to relieve the symptoms
of a terminal disease or illness.
51
 What is not covered What is not covered

Unrecognised providers or facilities that moratorium condition for a continuous period of two years after your start date of

We do not pay for any treatment where the consultant in overall charge of the the scheme (or your joining date of your previous ClientChoice scheme or, if your cover

treatment is not recognised by BUPA. under the scheme is arranged by your employer or membership association, your joining
date of the previous scheme ).
We do not pay for treatment provided by a consultant, therapist or other health care
professional who is not recognised by BUPA. Exception 2: We will not apply this exclusion to any baby of yours included under your
membership as a dependant if you have been a member of the scheme for at least 12
We do not pay for treatment in any hospital or by any other provider of services whom
months before the baby’s birth and you include the baby under your membership
we have not recognised or to whom we have sent a written notice saying that we no
before the baby is three months old.
longer recognise them for the purpose of our schemes.
Please also see ‘Covering your new-born baby’ in rule 1.2 in section 1.
BUPA does not recognise consultants, therapists or other health care professionals in the
following circumstances:
Pre-existing conditions
• where BUPA does not recognise them as having specialised knowledge of, or
For underwritten members we do not pay for treatment for a pre-existing condition,
expertise in, the treatment of the disease, illness or injury being treated
or a disease, illness or injury which results from or is related to a pre-existing condition.
• where BUPA does not recognise them as having specialised expertise and
Exception: We pay for eligible treatment of a pre-existing condition, or a disease,
ongoing experience in carrying out the type of treatment or procedure needed
illness or injury which results from or is related to a pre-existing condition, if all the
• where we have sent a written notice to them saying that we no longer recognise
following requirements have been met:
them for the purposes of our schemes.
• you have been sent your membership certificate which lists the person with the
pre-existing condition (whether this is you or one of your dependants)
PART 2
• you gave us all the information we asked you for, before we sent you your first
membership certificate listing the person with the pre-existing condition for their
Moratorium conditions
current continuous period of cover under the scheme
For moratorium members we do not pay for any treatment for any moratorium
• neither you nor the person with the pre-existing condition knew about it before we
conditions.
sent you your first membership certificate which lists the person with the pre-existing
Exception: We pay for treatment for a moratorium condition after two years continuous condition for their current continuous period of cover under the scheme, and
membership of the scheme from your start date (or your joining date of your previous
• we did not exclude cover (for example under a special condition) for the costs of
ClientChoice scheme or, if your cover under the scheme is arranged by your employer
the treatment, when we sent you your membership certificate.
or membership association, your joining date of the previous schem e ) if you have not:

• received any medication for,

• asked for or received any medical advice or treatment for, or

• experienced symptoms of

52 53
 What is not covered What is not covered

Special conditions Sexually transmitted diseases

For underwritten members we do not pay for treatment directly or indirectly relating to We do not pay for treatment for or arising from sexually transmitted diseases.
special conditions. Please also see ‘Birth control, conception, sexual problems and sex changes’ in this
We are willing, at your renewal date, to review certain special conditions. We will do this section.
if, in our opinion, no treatment is likely to be needed in the future, directly or indirectly,
relating to the disease, illness or injury referred to in the special condition or for a related Transplant surgery
disease, illness or injury. However, there are some special conditions which we do not We do not pay for treatment for any form of transplant surgery or any treatment
review. If you would like us to consider a review of your special conditions please call the related to or resulting from this type of surgery.
helpline prior to your renewal date. We will only determine whether a special condition
Exception: We pay for eligible cancer treatment for a bone marrow or stem cell
can be removed or not, once we have received full current clinical details from your GP or
transplant to the extent set out in benefit note 6a, in section 2.
consultant. If you incur costs for providing the clinical details to us you are responsible
for those costs, they are not covered under the scheme.
Treatment in a hospital that is not a partnership network hospital
Please also see ‘Covering your new-born baby’ in rule 1.2 in section 1.
We do not pay for day-patient treatment or in-patient treatment, including
consultants’ fees and hospital charges, which you receive in a hospital that is not a
Complementary medicine
partnership network hospital.
For members whose scheme is BUPA ClientChoice Essential we do not pay for any
Exception: We may pay consultants’ fees and hospital charges for eligible day-patient
complementary medicine treatment including but not limited to acupuncture,
treatment or eligible in-patient treatment in a hospital that is not a partnership
chiropractic, osteopathy and homeopathy.
network hospital when your proposed treatment cannot take place in a partnership
network hospital for medical reasons. However, you will need our written agreement
Neo-natal treatment
before the treatment is received and we need full clinical details from your consultant
We do not pay for any treatment that takes place within the first 28 days of birth before we can give our decision.
including but not limited to diagnostic tests, investigations and scans.
Please also see benefit notes 3 and 4, in section 2.
Please also see ‘Pregnancy and childbirth’ in this section.

Psychiatric treatment
For members whose scheme is BUPA ClientChoice or BUPA ClientChoice Essential we do
not pay for treatment for or arising from mental and/or addictive conditions or
problems, including but not limited to alcoholism, drug addiction and eating disorders.

54 55
 Claiming

4 If you do need to complete a claim form we will send you one. You will need to return
the fully completed claim form to us as soon as possible and in any event within six
months of receiving the treatment for which you are claiming unless this was not
reasonably possible.
Claiming 4.1.b for underwritten members – making a claim
When you call the helpline we will:
4.1 Making a claim
• confirm whether your proposed treatment, medical provider or treatment facility
Always call the helpline before arranging any treatment.
will be eligible for benefit under the scheme, and

4.1.a for moratorium members – making a claim • if you wish to make a claim, tell you whether you will need to complete a claim

When you joined the scheme you agreed that you would not be covered for any form.

moratorium conditions. Each time you make a claim you must provide to us If you do not need to complete a claim form, we will treat your call to us as your claim
information so we can confirm whether your proposed treatment is covered under your once we are notified that you have received your consultation or treatment. In most
membership. cases we will be notified that you have received your consultation or treatment by your

When you call the helpline we will send you a pre-treatment form to complete giving consultant or the provider of your treatment.

details of the history of the medical condition you are claiming for, including information If you do need to complete a claim form we will send you one. You will need to return
that you will need to ask your GP or consultant to provide to you, although you may the fully completed claim form to us as soon as possible and in any event within six
authorise us to do this on your behalf. Your GP or consultant may charge you a fee for months of receiving the treatment for which you are claiming unless this was not
providing a report which we do not pay. Each claim you make during your membership reasonably possible.
will be assessed on this information and any further information we ask you to provide
4.1.c for all members – making a claim
to us at the time you claim.
You must provide us with information to help us assess your claim if we make a
Once we receive all the information we ask you for we will:
reasonable request for you to do so. For example, we may ask you for one or more of
• confirm whether your proposed treatment, medical provider or treatment facility
the following:
will be eligible for benefit under the scheme, and
• medical reports and other information about the treatment for which you are
• if you wish to make a claim tell you whether you will need to complete a claim
claiming
form.
• the results of any independent medical examination which we may ask you to
If you do not need to complete a claim form, we will treat your submission of your
undergo at our expense
pre-treatment form to us as your claim once we are notified that you have received your
• original accounts and invoices in connection with your claim (including any related
consultation or treatment. In most cases we will be notified that you have received your
to treatment costs covered by your excess – if any) we cannot accept
consultation or treatment by your consultant or the provider of your treatment.
photocopies of accounts or invoices or originals that have had alterations made to
them.

56 57
 Claiming
If your treatment is needed as a result of somebody else’s fault you must write to tell
us as soon as possible, or complete the appropriate section on your claim form. For
example, treatment for an injury suffered in a road accident in which you are a victim. If
so, you must take any reasonable steps we ask of you to:
• recover from the person at fault the cost of the treatment paid for by BUPA
• claim interest if you are entitled to do so.
If you are able to recover the cost of any treatment or services that we have paid, you
must repay the amount and any interest to BUPA.
If you have other insurance cover for the cost of the treatment or services that you are
claiming from us you must write to tell us as soon as possible, or complete the
appropriate section on your claim form. If so, we will only pay our share of the cost of
the eligible treatment that you are claiming.
Unless we tell you otherwise, your claim form and proof to support your claim should be
sent to: Envoy Team, BUPA, Staines TW18 4XF.
4.2 How we will deal with your claim
In most cases we pay eligible claims direct to the provider of your treatment – such as
your hospital or consultant. Otherwise we will pay the main member. We will write to
tell the main member how we have dealt with any claim.
We pay claims under the rules and benefits of the scheme that applied to you on the
date you received your treatment.
We only pay costs for treatment that you receive while you are a member of the
scheme.
We only pay eligible costs and expenses actually incurred by you for treatment you
receive.
We do not have to pay a claim if you break any terms and conditions of your
membership.
We reserve the right to change the procedure for making a claim. If so, we will write and
tell you about any changes.
58
Claiming
Ex-gratia payments: If we agree to pay for the costs of treatment to which you are not
entitled under the terms of your cover, ie an ‘ex-gratia payment’, this payment will still
count towards the maximum amount we will pay under your cover. Making these
payments does not oblige us to make them in the future.
4.3 If you want to withdraw a claim
If, for any reason, you wish to withdraw your claim for the costs of treatment you have
received, you should call the helpline to tell us as soon as possible. You will be unable to
withdraw your claim if we have already paid your claim.
If you do withdraw your claim you will be responsible for paying the costs of that
treatment.
4.4 If you have an excess
If you have agreed with us that an excess shall apply to you and each of your
dependants the amount will be shown on your membership certificate.
How an excess works
Having an excess means that each year you have to pay the first part of any eligible
treatment costs that would otherwise be paid by us up to the amount of your excess.
By eligible treatment costs we mean costs that would have been payable under the
terms and conditions of the scheme if you had not had an excess.
The excess applies to you and each of your dependants individually.
The excess starts at the beginning of each new year even if treatment is ongoing. So,
the excess could apply twice to a single course of treatment if your treatment begins in
one year and continues into the next year.
We will write to the main member to tell them who you should pay the excess to, for
example, your consultant, therapist or hospital. The excess must be paid direct to them
– not to BUPA. We will also write to tell the main member the amount of the excess
that remains for the year (if any).
You should always make a claim for eligible treatment costs even if we will not pay the
claim because of your excess. Otherwise the amount will not be counted towards your
excess and you may lose out should you need to claim again during the year.
59
 Claiming

How the excess applies to your benefits

5
We apply the excess to your claims in the order in which we process those claims.

When you claim for eligible treatment costs under a benefit that has a benefit limit your
excess amount will count towards your total benefit limit for that benefit for the year.
Glossary
Example 1: How your excess affects your claims settlement and benefits with a monetary Words and phrases printed in bold and italic in these rules and benefits have the meanings set
limit, eg home nursing. (This example assumes you have a £100 excess and that all costs are out below.
eligible for benefit.)
Word / Phrase Meaning
Home nursing benefit limit for the year £600

You incur costs of home nursing £300 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
BUPA pays your qualified nurse £200 immediately before suffering the disease, illness or injury, or which

BUPA notifies you of excess amount which you pay direct leads to your full recovery.
to your qualified nurse £100 Agreement the agreement between the main member and us to provide cover for
you and your dependants (if any) under the terms and conditions set
Your home nursing benefit limit remaining for the rest
out in the documents referred to in rule 1.1, ‘The agreement between
of the year £300
you and us’ in section 1.

Appliance • a knee brace which is an essential part of a repair to a cruciate

Example 2: How your excess is affected when your claim for treatment costs is less than the (knee) ligament
amount of your excess. (This example assumes you have a £100 excess, all costs are eligible • a spinal support which is an essential part of surgery to the spine
for benefit and you are claiming for physiotherapy.)
• a hand splint which is an essential part of surgery to correct
Your excess for the year £100 Dupuytren’s contracture (thickening of the connective tissue of
the hand).
You incur costs of physiotherapy £70
BUPA BUPA Insurance Limited. Registered in England and Wales No
We pay your therapist £0 3956433. Registered office: BUPA House, 15-19 Bloomsbury Way,
London WC1A 2BA. BUPA provides your cover.
We notify you of excess amount you pay direct to
your therapist £70 Cancer a malignant tumour characterised by the uncontrolled growth and
spread of malignant cells and invasion of tissue.
Your remaining excess for the rest of the year £30

60 61
 Glossary Glossary

Chronic condition a disease, illness or injury which has at least one of the following Consultant fees the schedule used by BUPA for the purpose of the scheme which sets
characteristics: schedule out the benefit limits for consultants’ fees for surgical operations

• it continues indefinitely and has no known cure based on the type and complexity of the surgical operation carried
out, the BUPA recognition status of the consultant and where the
• it comes back or is likely to come back
surgical operation is carried out both in terms of the hospital or
• it is permanent facility and the location. The schedule may change from time to time.
• you need to be rehabilitated or specially trained to cope with it Details of the schedule are available on request.

• it needs long-term monitoring, consultations, check-ups, Critical care unit any intensive care unit, intensive therapy unit, high dependency unit,
examinations or tests. coronary care unit or progressive care unit which is in our list of critical
care units and recognised by us for the type of intensive care that you
Claiming period the first 10 months of your current year and the last two months of
require at the time you receive your treatment. The units on the list
your previous year (if any) making a 12 month period.
and the type of intensive care that we recognise each unit for may
Complementary an acupuncturist, chiropractor, homoeopath or osteopath who, at the
change from time to time. Details of these critical care units are
medicine practitioner time you receive your treatment is:
available on request.
• under age 70 and is recognised by us as a complementary
Day-patient treatment treatment which, for medical reasons, means you have to go into a
medicine practitioner for the purpose of the scheme, and
hospital or day-patient unit because you need a period of clinically-
• is recognised by us for providing the type of treatment supervised recovery but do not have to stay overnight.
you need.
Dependants your partner and any child of yours who is a member of the scheme
You can contact us to find out if a practitioner is recognised by us as a and named on your membership certificate.
complementary medicine practitioner and the type of complementary
Diagnostic tests investigations, such as X-rays or blood tests, to find or to help to find
medicine we recognise them for.
the cause of your symptoms.
Consultant a registered medical or dental practitioner who, at the time you receive
Eligible cancer eligible treatment of cancer.
your treatment:
treatment
• is under age 70, and
Eligible day-patient eligible treatment carried out as day-patient treatment.
• is recognised by BUPA as a consultant and has received written treatment
confirmation from us of this, unless we recognised him or her as
Eligible in-patient eligible treatment carried out as in-patient treatment.
being a consultant before 30 June 1996.
treatment
You can contact us to find out if a medical or dental practitioner is
Eligible out-patient eligible treatment carried out as out-patient treatment.
recognised by us as a consultant.
treatment

Eligible surgical eligible treatment carried out as a surgical operation.

operation

62 63
 Glossary
Eligible treatment treatment of an acute condition together with the products and
equipment used as part of the treatment that:
• are consistent with generally accepted standards of medical
practice and representative of best practices in the medical
profession in the UK
• are clinically appropriate in terms of type, frequency, extent,
duration and the facility or location where the services are
provided
• are demonstrated through scientific evidence to be effective in
improving health outcomes, and
• are not provided or used primarily for the expediency of you or
your consultant or other health care professional
and the treatment, services or charges are not excluded under the
terms and conditions of the scheme.
Excess the amount you have to pay towards the cost of the treatment that
you receive each year that would otherwise have been covered under
your membership. The amount of your excess is shown on your
membership certificate.
Home • the place where you normally live, or
• any other establishment, including a non-healthcare setting, which
we may decide to treat as a home for the purpose of the scheme.
Hospital this means any of the following at the time you receive your
treatment:
• a partnership network hospital, or
• any other establishment which we may decide to treat as a
hospital for the purpose of the scheme.
Imaging centre any facility which is in our list of imaging centres for carrying out either
MRI and/or CT and/or PET scans and is listed as an imaging centre for
the type of scan you need at the time you receive your treatment. The
imaging centres on the list and the type of scan we recognise them for
may change from time to time. Details of these imaging centres and
the type of scans we recognise them for are available on request.
64
Glossary
In-patient treatment treatment which, for medical reasons, means you have to stay in
hospital overnight or for longer.
Intensive care eligible treatment for intensive care, intensive therapy, high
dependency care, coronary care or progressive care.
Main member the person who has taken out the membership being the first person
named on the membership certificate.
Medical treatment a person or company who is recognised by us as a medical treatment
provider provider for the type of treatment at home that you need at the time
you receive your treatment. These medical treatment providers and
the type of treatment we recognise them for may change from time
to time. Details of these medical treatment providers and the type of
treatment we recognise them for are available on request.
Membership certificate the most recent membership certificate that we issue to you for your
current continuous period of membership of the scheme.
Moratorium condition any disease, illness or injury or related condition, whether diagnosed
or not, which you:
• received medication for,
• asked for, or received, medical advice or treatment for,
• experienced symptoms of, or
• were, to the best of your knowledge aware existed
in the five years before your start date (or your joining date of your
previous ClientChoice scheme).
Moratorium member/ a member who joined the scheme under a moratorium
membership application.
Out-patient treatment treatment given at a hospital, consulting room or out-patient clinic
where you do not go in for day-patient or in-patient treatment.
Partner your husband or wife, or the person you live with in a relationship
similar to that of a husband or wife, whether the same sex or not.
Partnership consultant a consultant who is recognised by us as a partnership consultant for
the purpose of the scheme at the time you receive your treatment.
You can contact us to find out if a consultant is a partnership
consultant.
65
 Glossary
Partnership network any hospital which is in our list of partnership network hospitals and is
hospital recognised by us for the type of treatment you need at the time you
receive your treatment. The hospitals on the list and the types of
treatment we recognise them for may change from time to time.
Details of these hospitals and the types of treatment we recognise
them for are available on request.
For a child under 16 years old, any hospital that we agree in writing
will be treated as a partnership network hospital in the case of
treatment for that child which is not carried out in a partnership
network hospital.
Pre-existing condition any disease, illness or injury for which:
• you have received medication, advice or treatment, or
• you have experienced symptoms
whether the condition was diagnosed or not before your start date.
Previous ClientChoice where applicable, the scheme that you were covered under
scheme immediately prior to your cover under the scheme without a break in
your cover and being either:
• the BUPA ClientChoice Plus scheme
• the BUPA ClientChoice scheme, or
• the BUPA ClientChoice Essential scheme.
Previous scheme if your cover under the scheme is arranged by your employer or
membership association and we notify you that your previous scheme
will be taken into account when we assess whether a claim is for a
moratorium condition, any other private medical insurance cover
arranged by that employer or membership association which you were
covered by without any break until becoming a member of the scheme.
66
Glossary
Prosthesis an artificial body part which is designed to form a permanent part of
your body and is surgically implanted for one or more of the following
purposes:
• to replace a joint or ligament
• to replace one or more heart valves
• to replace the aorta or an arterial blood vessel
• to replace a sphincter muscle
• to replace the lens or cornea of the eye
• to control urinary incontinence (bladder control)
• to act as a heart pacemaker
• to remove excess fluid from the brain
• to reconstruct a breast following surgery for cancer.
Psychiatric condition a mental or addictive condition, including alcoholism, drug addiction
and eating disorders.
Psychiatric network any hospital which is a registered mental nursing home and is in our
hospital list of participating hospitals as a psychiatric network hospital at the
time you receive your psychiatric treatment. The hospitals may
change from time to time. Details of these hospitals are available on
request.
Psychiatric treatment eligible treatment of a psychiatric condition.
Qualified nurse a nurse who is on the register of the United Kingdom Central Council
for Nursing, Midwifery and Health Visiting, and holds a valid UKCC
personal identification number.
Rehabilitation centre any rehabilitation centre which is in our list of rehabilitation centres at
the time you receive your treatment. The rehabilitation centres may
change from time to time. Details of these centres are available on
request.
67
 Glossary
Related condition any symptom, disease, illness or injury which reasonable medical
opinion considers to be associated with another symptom, disease,
illness or injury.
Renewal date • each anniversary of your start date, or
• if you are a member under a group scheme arrangement with a
common renewal date for all members of the group, your renewal
date will be the common renewal date for the group and you will
have been told about this when you joined.
Scheme the scheme that applies to your cover under our agreement being
either:
• the BUPA ClientChoice Plus scheme,
• the BUPA ClientChoice scheme, or
• the BUPA ClientChoice Essential scheme
as shown on your membership certificate.
Special condition any exclusions or restrictions to cover that are personal to an
individual based on the medical history given to us for that individual.
If special conditions apply to a person’s cover these are shown on the
special condition supplement attached to your membership
certificate. You will only receive a special condition supplement if
special conditions apply to you and/or any of your dependants.
Specialist treatment any hospital which is in our list of specialist treatment centres at the
centre time you receive your treatment. The hospitals on this list may change
from time to time. Details of these hospitals are available on request.
Start date for a main member: the ‘Your membership starts’ date shown on your
first membership certificate we sent you for your current continuous
period of cover under the scheme
for a dependant: the ‘Your membership starts’ date shown on your
first membership certificate we sent you which lists that dependant as
a member for their current continuous period of cover under the
scheme.
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Glossary
Surgical operation a surgical procedure or complex investigative/diagnostic procedure
including all medically necessary treatment related to the procedure
and all consultations carried out from the time you are admitted to
hospital until the time you are discharged, or if it is carried out as
out-patient treatment, all medically necessary treatment related to
the operation and any consultation on the same day which is integral
to the operation.
Therapist a practitioner who is:
• a chartered or state registered physiotherapist
• a state registered occupational therapist
• a state registered orthoptist
• a member of the Royal College of Speech and Language Therapists
• or, for members whose scheme is BUPA ClientChoice Plus only, a
Chartered Psychologist registered with the British Psychological
Society
who at the time you receive your treatment is under age 70 and is
recognised by us as a therapist for the purpose of the scheme
• any other practitioner who at the time you receive your treatment
is under age 70 and has written confirmation from us that we
recognise them as a therapist for the purpose of the scheme.
You can contact us to find out if a practitioner is recognised by us as a
therapist.
Treatment surgical or medical services (including diagnostic tests) that are
needed to diagnose, relieve or cure a disease, illness or injury.
Underwritten a member who joined the scheme under an underwritten application.
member/membership
United Kingdom/UK Great Britain, Northern Ireland, the Channel Islands and the
Isle of Man.
Year the period beginning on your start date or previous renewal date and
ending on the day before your next renewal date.
You/your this means the main member only.
We/our/us BUPA.
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 6

Data Protection Notice For your notes

Confidentiality: The confidentiality of patient and member information is of paramount concern to the companies
in the BUPA group. To this end, BUPA fully complies with Data Protection Legislation and Medical Confidentiality
Guidelines. BUPA sometimes uses third parties to process data on its behalf. Such processing, which may be outside
of the European Economic Area is subject to contractual restrictions with regard to confidentiality and security in
addition to the obligations imposed by the Data Protection Act.

Medical information: Medical information will be kept confidential. It will only be disclosed to those involved
with your treatment or care, including your GP, or to their agents, and, if applicable, to any person or
organisation who may be responsible for meeting your treatment expenses, or their agents.

Member details: All membership documents and confirmation of how we have dealt with any claim you may
make will be sent to the main member.

Telephone calls: In the interest of continuously improving our service to members, your call may be recorded
and may be monitored.

Research: Anonymised or aggregated data may be used by BUPA, or disclosed to others, for research or
statistical purposes.

Fraud: Information may be disclosed to others with a view to preventing fraudulent or improper claims.

Names and addresses: BUPA does not make the names and addresses of members or patients available to
other organisations.

Keeping you informed: BUPA would, on occasion, like to keep you informed of BUPA products and services
which it considers may be of interest to you.

Contact address: If you do not wish to receive information about BUPA’s products and services, or have any
other Data Protection queries please write to the BUPA Group Information Protection Manager, at BUPA House,
15-19 Bloomsbury Way, London WC1A 2BA or at DataProtection@BUPA.com.

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 For your notes For your notes

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