Coverage

WHAT IS COVERED BY THE SCHEME

The Health Fund will normally consider benefit payments to members for the following, up to limits shown on the Discretionary Benefit Schedule, PROVIDING THE CLAIM HAS BEEN PRE-AUTHORISED.

  • Accommodation in the Preferred Provider Hospital € details of the Preferred Provider Hospitals in the Tricare scheme are available from the office.
  • Overnight parent accommodation can be claimed for up to ten days when children up to the age of twelve years are being treated.
  • Operating Theatre Charges
  • Drugs dressings and medicines prescribed for in-patient treatment.
  • Consultations, Pathology, X-Rays, ECG’s and other diagnostic procedures.
  • Special Hi-Tech procedures, to allow member access to the latest medical technology -CT Scans, MRI Scans, endo scopies etc., when requested by a consultant physician/surgeon.
  • Physiotherapy on referral by General Practitioner (GP).
  • Consultations in relation to a specific condition or complaint, when referred by a GP or GDP will be limited to 2 specialists per condition except at the discretion of the Directors.
  • Alternative Medical Treatment -Homeopathy, Chiropractic, Osteopathy and Acupuncture (when referred by a Specialist)
  • NHS Cash Benefit -Payable for each pre-authorised night spent in an NHS hospital without charge (for treatment of conditions that would otherwise be covered for private treatment). In the case of emergency admissions, NHS benefit may be payable for the fourth and subsequent nights of a continuous in-patient stay directly following on from an emergency admission.
  • Joint replacements are limited to one replacement per joint (no refashioning of a previously replaced joint). In the case of spinal surgery, this will be considered as joint replacement. The rule will apply to each of three regions of the spine € the cervical spine, the thoracic spine and the lumbo-sacral spine.

Please remember – ALWAYS CONTACT THE CLAIMS HELPLINE TO RESOLVE ANY DOUBTS OR CONCERN ABOUT TREATMENT. The discretionary benefits which are payable for various items of treatment are shown on the Discretionary Benefits Schedule. Check these limits carefully and if in doubt, contact the Claims Helpline Call Local Rate on 0845 6025013 / 01905 796682.

EMERGENCY TREATMENT IS NOT COVERED IN ANY CIRCUMSTANCES.

WHAT IS NOT COVERED BY THE SCHEME

The following will not be considered under the Medical Scheme Rules:

  • ANY EMERGENCY TREATMENT
  • Any treatment which has not been pre-authorised.
  • Any Medical condition existing prior to membership until 2 years of membership have passed without treatment.
  • Alcoholism or substance abuse or conditions arising as a result of alcoholism or substance abuse.
  • Accommodation or treatment received in Health Hydros, Nature Cure Clinics or similar establishments or private beds registered as a Nursing Home attached to such establishments.
  • Cosmetic treatment except where treatment is required as a direct result of bodily injury arising from a Police Officer’s duty.
  • Chronic conditions that require continuous, recurrent or ongoing treatment, e.g. asthma, diabetes, arthritis (this list is not exhaustive).
  • Drugs, medicines and dressings prescribed on an Out Patient basis, Surgical/Dental appliances, Spectacles, Contact Lenses or Hearing Aids, except where prescribed in the Discretionary Benefits Schedule.
  • Dental Treatment unless carried out as an Oro-Surgical procedure under general anaesthetic and with admission to hospital (This does not apply to Dental Cash Benefit claims).
  • Fertility, contraception, operations for sterilisation or reversal of sterilisation or procedures relating to such treatment.
  • General Practitioner or General Dental Practitioner services
  • Hormone replacement therapy unless performed immediately following or in conjunction with surgical procedure that is covered under the terms of the fund.
  • Nursing at Home or residential stay in a Private Hospital arranged wholly or partly for domestic reasons or which is not directly related to the treatment of a medical condition.
  • Organ transplants or any treatment prior to and following such transplants.
  • Personal expenses incurred in hospital such as telephone calls, guest meals and newspapers.
  • Pregnancy and childbirth or any treatment or investigations relating to pregnancy or childbirth.
  • Psychiatric treatment.
  • Sight testing or medical examination of a routine or preventative nature.
  • Supportive treatments of renal failure, including dialysis.
  • Transferred treatment. Treatment as an In-patient where the initial treatment was provided by the NHS and where the patient remains under NHS care.
  • Treatment received outside the UK unless specifically agreed by the Management Committee.
  • Treatment which in any way arises from, is attributable to, or is consequent upon any Human Immunodeficiency Virus (HIV) infection or related syndromes.
  • Expenditure arising from any consequence whether directly or indirectly as a result of nuclear or chemical contamination, war, invasion, act of foreign enemy, hostilities (whether war be declared or not), civil wars, riot, civil disturbance, rebellion, revolution, insurrection or military usurped power, other than arising directly from a Member’s employment as a Police Officer.
  • Treatment in non-Preferred Hospitals without the prior written agreement of the Fund Manager.
  • Iatrogenic conditions (that is where medical treatment for one condition has caused another) will only be treated at the discretion of the Directors.
  • Any condition where medical advice has not been followed by the claimant
  • Where emergency treatment on the NHS has been declined by the claimant.
  • Routine examinations, annual check ups or health screening.
  • Occupational Therapy.

APPEALS AGAINST THE APPLICATION OF THE RULES BY THE FUND MANAGER MUST BE MADE IN WRITING TO THE MANAGEMENT COMMITTEE. PERSONAL OR TELEPHONE APPEALS WILL NOT BE CONSIDERED.