WHA Healthcare Benefit & General Conditions
“We, us or our” means Welsh Hospitals & Health Services Association trading as WHA.
“You or your” means the person paying regular subscriptions for WHA.
“Group members” means members whose subscriptions are deducted from pay or pension.
“Direct members” means members who pay their subscriptions directly to WHA.
We will pay benefit at the rate applicable to your subscription and membership choice as indicated in the table of benefits, provided that your claim complies with the appropriate conditions as stated in the following paragraphs.
1 HOSPITAL INPATIENT
1.1 We will pay benefit at the daily rate for each completed period of 24 hours a patient stays in a recognised hospital receiving treatment as an inpatient.
1.2 When we calculate the benefit payable, we count the day of admission but not the day of discharge.
1.3 We will pay up to the maximum benefit shown in the table of benefits once in a period of two years. The period of two years is calculated from the date of admission to hospital.
1.4 If a patient is admitted for psychiatric or geriatric treatment, the maximum benefit payable is restricted to one half of the maximum benefit shown in the table of benefits.
1.5 If a patient dies while in hospital and if there is a surviving spouse, we will pay a minimum of ten days hospital inpatient benefit, subject to the maximum benefit stated in paragraph 1.3 of the conditions.
1.6 If a patient is in hospital continuously for more than two years, when the maximum hospital inpatient benefit has been paid once, we will not pay any further hospital inpatient benefit unless the patient is discharged from hospital and is then readmitted to hospital for a different medical condition.
1.7 If a parent is required to stay with a child under the age of 16 years who has been admitted to hospital, in addition to child hospital inpatient benefit we will also pay the daily rate of adult hospital inpatient benefit for one parent only for each completed period of 24 hours during which the child is accompanied. Claims must be supported by written confirmation from the hospital authorities of the period that the parent accompanied the child.
2 HOSPITAL OUTPATIENT
2.1 We will pay benefit when the patient has attended as a National Health Service outpatient or day patient on at least four occasions in a continuous period of six months.
2.2 We will pay the maximum benefit shown in the table of benefits once in a period of two years. The period of two years is calculated from the date of the first attendance certified.
2.3 We will not pay benefit for outpatient or day patient attendances required because of pregnancy.
2.4 We will not pay benefit for outpatient or day patient attendances required because of psychiatric or geriatric conditions.
3.1 We will pay maternity benefit when a child is born either in hospital or at home.
3.2 The maternity benefit shown in the table of benefits includes up to seven days in hospital before or after the birth. If the mother is in hospital for a total of more than seven days, from the eighth day onwards we will pay benefit at the hospital inpatient rate for each completed period of 24 hours spent in hospital, up to the maximum hospital inpatient benefit.
3.3 We will only pay maternity benefit to one parent.
3.4 We will pay hospital inpatient benefit at the child rates shown in the table of benefits if a child remains as a hospital inpatient after the mother has been discharged from hospital. We will calculate the benefit payable from the date of the mother’s discharge from hospital.
3.5 We will not pay child hospital inpatient benefit for the period commencing with the date of birth while the mother also remains in the same hospital.
4 CONVALESCENT HOMES SERVICE
4.1 We can arrange for an admission to a Convalescent Home if a patient’s general practitioner recommends convalescence to aid recovery from illness or injury. We can only arrange an admission if the patient has been in hospital for a continuous period of at least 14 days in the three month period before an application for this service is submitted. When we have arranged an admission to a convalescent home for a patient, we will only arrange a further admission for that patient after a period of three years has elapsed.
4.2 We will not pay benefit for any fees incurred by the patient for admission to a convalescent, residential, nursing or respite home.
5.1 We will pay up to the maximum benefit for fees incurred and paid for new spectacles, lenses or contact lenses prescribed by a qualified optical practitioner registered with the General Optical Council.
5.2 We will pay the maximum benefit shown in the table of benefits once in a period of two years. The period of two years is calculated from the date on which spectacles, lenses or contact lenses are supplied.
5.3 We may deduct the value of any NHS vouchers from the total fees incurred when calculating the benefit payable.
5.4 We will not pay benefit for any optical care plans, contact lens solutions, repairs nor for the supply of new spectacle frames only.
6.1 We will pay up to the maximum benefit for fees incurred and paid for treatment by a qualified dental practitioner registered with the General Dental Council.
6.2 We will pay the maximum benefit shown in the table of benefits once in a period of two years. The period of two years is calculated from the date certified on the receipt submitted.
6.3 We will not pay benefit for payments made directly to a dental technician.
6.4 We will not pay benefit for regular payments made for any dental maintenance plans such as Denplan.
7 PERSONAL ACCIDENT BENEFIT
7.1 We will cover subscribers to certain schemes for death, disablement or for injuries suffered as a result of an accident. We will send you full details of personal accident benefit on request.
8 COMPLEMENTARY TREATMENT
8.1 Complementary treatments are Physiotherapy, Osteopathy, Acupuncture, Chiropractic and Chiropody.
8.2 We will pay up to the maximum benefit for 75 per cent of fees incurred and paid for treatment by a practitioner with an appropriate qualification or registration. Patients should ensure that the practitioner is properly qualified and has appropriate insurance cover.
8.3 We will pay the appropriate maximum benefit as shown in the table of benefits once in a period of two years. The period of two years is calculated from the date certified on the receipt submitted.
8.4 We will only pay benefit for treatment received because of illness or injury or to relieve pain.
9 SPECIALIST CONSULTATION
9.1 We will pay up to the maximum benefit as shown in the table of benefits for fees incurred and paid for the first consultation for a medical or surgical condition with a specialist holding consultant status in the National Health Service, including fees incurred and paid for x-rays or tests required as part of the first consultation.
9.2 We will pay up to the maximum benefit shown in the table of benefits once in a period of two years. The period of two years is calculated from the date certified on the receipt submitted.
9.3 We will not pay benefit for follow-up consultations, consultations for pension, insurance or emigration matters, legal or industrial actions, medical examinations, maternity, family planning, cosmetic surgery or health screening.
9.4 We will not pay benefit for fees for injections or for any treatment.
9.5 We will not pay hospital outpatient benefit for appointments which qualify for specialist consultation benefit.
10.1 When you enrol or increase your subscriptions, you must be under 65 years of age. If you are enrolling as a member of a Partners scheme or if you are a member of a Partners scheme and wish to increase your subscriptions, your partner must also be under 65 years of age.
10.2 Personal scheme membership covers the subscriber for all benefits and any child dependants under the age of 18 years for hospital inpatient, hospital outpatient and specialist consultation benefits at special rates.
10.3 Partners scheme membership covers the subscriber and spouse for all benefits and any child dependants under the age of 18 years for hospital inpatient, hospital outpatient and specialist consultation benefits at special rates.
10.4 Single subscribers can choose Partners scheme membership if they nominate a partner to be regarded as a spouse. Your partner is the person to whom you are married or the person with whom you live as if you were married. Your partner's full name must be registered with us before you can make a claim and you cannot claim for more than one partner.
10.5 If partners both pay a valid subscription, they will both be regarded as Personal scheme members.
10.6 We reserve the right to impose special conditions for certain membership options or to decline certain membership options.
11.1 Your claims must be submitted on a properly completed and certified benefit claim form which you can obtain from group representatives, pay, pension, personnel and welfare offices or from WHA's office.
11.2 Direct Members should obtain benefit claim forms from WHA's office.
11.3 We will not pay benefit if the date of the treatment or service received or the date of hospital inpatient discharge or the fourth hospital attendance is more than six months before the date on which the claim is submitted to our Cardiff office.
11.4 We will not pay benefit for claims arising out of any medical condition which existed on enrolment. We will not pay benefit at higher rates if the medical condition existed when subscriptions were increased. In order to assess eligibility for benefit, we reserve the right to request the patient to provide further information about any medical condition from his or her general practitioner.
11.5 We will consider your claims in accordance with the benefit scale and conditions which applied at the commencement of the treatment or on the date that the service was received, as appropriate.
11.6 When we calculate the maximum benefit payable, all relevant benefits paid in the two year period prior to the date on which the treatment commenced or on which the service was received are taken into consideration.
11.7 We will not pay benefit for treatment or services which are received or which commence before the date on which the subscriber enrolled. We will not pay benefit for hospital admissions or attendances which occurred or commenced before the date on which the subscriber enrolled.
11.8 We will not pay benefit for illness or injury which may be self-inflicted or arising out of riot, civil commotion, terrorism or act of war.
11.9 We require an original, dated receipt showing the name of the patient and the fee incurred for claims for optical, dental, complementary treatment and specialist consultation benefits. We will not accept photocopied or altered receipts or certifications or receipts or certifications made out in joint names. You must pay for any treatment or services received before you submit a claim. We will not pay practitioners directly for any fees you have incurred.
12 Qualifying Periods
12.1 When you enrol as a subscriber or increase your subscriptions, you will have to serve a qualifying period for benefits. Qualifying periods apply to all persons covered for benefit whether on enrolling or increasing subscriptions, unless any special arrangements have been agreed. Qualifying periods also apply to partners and child dependants.
12.2 The qualifying period for Group Members and Direct Members paying by direct debit is three months for all benefits except maternity benefit.
12.3 For all other members, the qualifying period is six months for all benefits except maternity benefit.
12.4 For all members, the qualifying period for maternity benefit is 12 months.
12.5 There is no qualifying period if a hospital admission or hospital attendance is required as a result of an accident.
12.6 Qualifying periods commence on the date of enrolment or on the date on which subscriptions are increased. Claims for treatment or services received before or which commence before the appropriate qualifying period has ended are not eligible for benefit or, if subscriptions have been increased, are not eligible for benefit at the higher rate.
13.1 Your subscriptions must be paid continuously at a valid rate. Past subscriptions cannot be refunded. It is your responsibility to ensure that your subscriptions are paid at the correct amount and at the correct frequency. Membership is continuous provided that subscriptions are paid at the correct rate and frequency. You can cancel your membership by giving us one week’s notice, in writing. If you cancel your membership, we will refund any advance subscriptions you may have paid for the period after the date of cancellation.
13.2 Your subscriptions must be paid up to date before a claim can be considered. If your subscriptions are more than three months in arrears for any reason other than illness or redundancy, your membership will be terminated and you will no longer be eligible to claim benefits. Although we are not obliged to do so, we will make every effort to inform you if we are no longer receiving your subscriptions.
13.3 If your subscriptions are in arrears because of illness (excluding maternity) or redundancy your membership will not be terminated until your subscriptions are more than twelve months in arrears. But you should make arrangements for payment of subscriptions to us as soon as possible. If you owe us any arrears of subscription, they must be paid before you can submit a claim for benefit.
14.1 When you pay a valid subscription to us, you will be subject to the Benefit and General Conditions for the time being in force, copies of which are available from our Cardiff office.
14.2 We may change the rates of subscription and any or all of the benefits and conditions. We will give you one month's notice by post at your address as shown in our records of any changes to the rates of subscription, the benefits or conditions.
14.3 We reserve the right to make special conditions of membership or to decline applications for membership. We also reserve the right to terminate membership by giving one month’s notice, in writing.
14.4 Children under the age of 18 years are covered by one parent's subscriptions for hospital inpatient, hospital outpatient and specialist consultation benefits at special rates. Persons over the age of 16 years can be covered for adult benefits provided that the appropriate subscription is paid, in which case the child benefits cease to apply.
14.5 Benefits are payable for treatment and services received anywhere in the United Kingdom. Hospital inpatient and hospital outpatient benefits are also applicable for emergency treatment during temporary absence abroad.
14.6 We will not pay benefit for fees incurred for private hospital treatment, prescription charges or surgical appliances.
14.7 We will not reimburse any fees incurred for completion of benefit claim forms.
15.1 Should you find it necessary to complain about any aspect of our service, you can telephone us on 029 2048 5461 or you can write to us at
Welsh Hospitals & Health Services Association, 60 Newport Road, Cardiff, CF24 0YG.
15.2 Complaints we cannot settle may be referred to the Financial Ombudsman Service.
A. For security purposes, we will pay your benefits to you by crossed cheque. We will not pay benefit where the amount payable is less than £1.00.
B. Once you are a member, your membership may continue up to any age.
C. Your subscription includes Insurance Premium Tax at the rate applicable.
D. We reserve the right to recover any overpayments of benefit made to you from any future benefits payable to you
E. To protect all members, we will always take legal action against anyone who makes a dishonest, false or fraudulent claim.
Revised 1 January 2005
WHA is a trading name of Welsh Hospitals & Health Services Association, a limited company registered in Wales No 515135.
Welsh Hospitals & Health Services Association
60 Newport Road,
Telephone 029 2048 5461
Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.