4 Exclusions Booklet.pdf

Bupa By You – Eligible Treatment
Benefits Table
This Table sets out the type of Benefits
and charges we pay for Eligible
Treatment, what we do not cover and
some items where we have a discretion.
This Table forms part of the Bupa By You
Health Insurancew Agreement.
Some words and phrases we use are in
italics. These have technical meanings
which are set out in the glossary at the
end of the Bupa By You Health Insurance
Policy Terms.
Your Certificate sets out the details of the
cover you have chosen and we do not pay
for any Benefit [or Discretion] listed in
this Table unless it is included in your
Certificate.
We also only pay up to the limits stated in
your Certificate and subject to any excess
or co-insurance payments your Certificate
says you will make.
We do not pay for any Special Conditions
detailed in your Certificate, or any
Pre-existing Conditions or Moratorium
Conditions.
Although we advise that you should
always call us before arranging or
receiving treatment to check that you will
be covered, if your Certificate says that
Open Referral applies, you must call us
first.
Even if we have already paid for some
treatment, if it becomes clear that your
treatment is not what we consider to be
Eligible Treatment, we can refuse to pay
for any new or continuing treatment.
All treatment must be carried out in a
Recognised Facility in the UK and
provided by a Consultant, Medical
Practitioner or Healthcare Professional we
recognise, unless we specifically authorise
otherwise in a particular case. We will tell
you whether we recognise a facility or
practitioner or you can access these
details at finder.bupa.co.uk
There must be a Consultant with overall
responsibility for your treatment, unless
your GP or Consultant refers you, or we
authorise, Outpatient treatment by a
Mental Health and Wellbeing Practitioner
or Complementary Medicine Practitioner
we recognise.
Where additional items such as Diagnostic
Tests are included in a Benefit, they are
covered up to the limit for that Benefit.
Some additional items are covered by a
separate Benefit – in which case that
Benefit must be included in your
Certificate.

Benefit B1 outpatient treatment
Benefit B1.1 Outpatient Consultations & Treatment
Included Eligible Treatment – What we pay for
Consultants’ fees to assess an acute condition.
While we do not pay for treatment of Chronic Conditions, we will pay for Eligible Treatment
for a flare-up of acute symptoms of a Chronic Condition (except a Mental Health Condition),
if the treatment is likely to lead quickly to a complete recovery rather than prolonged
treatment.
Remote consultations by telephone or via any other remote medium with a Consultant are
only covered if the Consultant is at the time of your Treatment recognised by us to carry out
remote consultations 1
[We pay other charges for Outpatient treatment if they are related to and an integral part of
your treatment.] 3
Excluded Eligible Treatment – What we do not pay for
See General Exclusion [GE6] Chronic Conditions
Discretion D1.1 Outpatient Consultations & Treatment
[We may pay a Consultant or recognised facility charge for the use of a consulting room for
the consultation.] 2
In some cases, where it is not clear that treatment is of a Chronic Condition, we may pay,
but that does not mean that we will continue paying when we have more information which
confirms that it is a Chronic Condition being treated.
Benefit B1.2 Outpatient Therapies
Included Eligible Treatment – What we pay for
Therapist fees for Outpatient treatment.
Remote consultations by telephone or via any other remote medium with a Therapist, Mental
Health and Wellbeing Therapist or any other Healthcare Professional, are only covered if the
Healthcare Professional is at the time of your Treatment recognised by us to carry out remote
consultations. 4
Discretion D1.2 Outpatient Therapies
If your Consultant refers you to a practitioner who is not a Therapist, we may pay where the
Consultant remains in overall charge of your care and the practitioner has applied for Bupa
recognition, which we have not yet accepted or rejected.
Benefit B1.3 Outpatient Complementary Medicine
Included Eligible Treatment – What we pay for
Complementary Medicine Practitioner’s fees for Outpatient treatment.
Excluded EB1.3 Outpatient Complementary Medicines / alternative products
Complementary or alternative products, preparations or remedies.
Bupa By You – Eligible Treatment Page 17

Benefit B1.4 Diagnostic Tests, MRI / CT & PET Scans
Included Eligible Treatment – What we pay for
When requested by your Consultant as part of Outpatient treatment, Recognised Facility
charges for diagnostic tests and their interpretation.
[Where additional items such as Diagnostic Tests are included in a Benefit, they are covered
up to the limit for that Benefit.] 5
Benefits 2 – B12 treatment in hospital
Benefit B2.1 Surgeons and Anaesthetists
Included Eligible Treatment – What we pay for
Consultant Surgeons and Consultant Anaesthetists fees for Eligible Surgical Operations.
While we do not pay for treatment of Chronic Conditions, we will pay for Eligible Surgical
Operations for a flare-up of acute symptoms of a Chronic Condition, if the treatment is likely
to lead quickly to a complete recovery rather than prolonged treatment.6
Although we do not generally pay for Cosmetic surgery, we do pay for an Eligible Surgical
Operation required to restore your appearance as a direct result of an accident or Cancer
surgery so long as the accident or the Cancer surgery was during your current continuous
period of cover under this Agreement or under any other Bupa medical insurance provided
without a break in your cover. You must have our consent before receiving the treatment.
But if your Treatment includes an Eligible Surgical Operation, we only pay Consultant
Physician’s fees if the attendance of the physician is medically necessary for the operation.
Where the Treatment is Eligible Cancer Treatment, your Certificate must state that Cancer
treatment is included.
Excluded Eligible Treatment – What we do not pay for
See General Exclusion [GE6] Chronic Conditions
See General Exclusion [GE10]
Benefit B2.2 Dental/Oral Surgical Treatment 7
Included Eligible Treatment – What we pay for
An Eligible Surgical Operation carried out by a Consultant to:
JJ
JJ
JJ
put a natural tooth back into a jawbone after it is knocked out or dislodged in an unexpected
accidental injury.
treat a jawbone cyst, but not if it is related to a cyst or abscess on the tooth root or any other
tooth or gum disease or damage.
remove a complicated, buried or impacted tooth root, e.g. an impacted wisdom tooth, but not
if the purpose is to facilitate dentures.
Excluded Eligible Treatment – What we do not pay for
See General Exclusion [GE12] Dental/Oral Treatment

Benefit B2.3 Dialysis 8
Included Eligible Treatment – What we pay for
JJ
Eligible treatment for short-term kidney dialysis or peritoneal dialysis if:
JJ
the dialysis is needed temporarily for sudden kidney failure resulting from a disease, illness or
injury affecting another part of your body.
JJ
you need this immediately before or after a kidney transplant.
Excluded Eligible Treatment – What we do not pay for
See General Exclusion [GE13] Dialysis
Benefit B2.4 Eyesight9
Included Eligible Treatment – What 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.
Excluded Eligible Treatment – What we do not pay for
See General Exclusion [GE17] Eyesight
Benefit B2.5 Pregnancy and
Childbirth10
Included Eligible Treatment – What we pay for
Eligible treatment of the following conditions:
JJ
miscarriage or when the foetus has died and remains with the placenta in the womb.
JJ
still birth
JJ
hydatidiform mole (abnormal cell growth in the womb).
JJ
foetus growing outside the womb (ectopic pregnancy).
JJ
heavy bleeding in the hours and days immediately after childbirth (post-partum
haemorrhage).
JJ
afterbirth left in the womb after delivery of the baby (retained placental membrane).
JJ
complications following any of the above conditions.
JJ
Eligible treatment of an Acute Condition of the member (mother) that relates to pregnancy or
childbirth but only if:
JJ
the Treatment is required due to a flare-up of the medical condition, and
JJ
the Treatment is likely to lead quickly to a complete recovery or to you being restored fully to
your state of health prior to the flare-up of the condition without you needing to receive
prolonged Treatment.
Excluded Eligible Treatment – What we do not pay for
See General Exclusion [GE24] Pregnancy and Childbirth
Discretion D2.5 Caesarean Section
We may pay for the delivery of a baby by caesarean section only when the life of the
member (mother) is in immediate danger or would be put at direct risk by vaginal delivery.
We need full clinical details from your Consultant before we can give our decision.11
Bupa By You – Eligible Treatment Page 19

Benefit B3 – recognised facility charges
Benefit B3.1 Outpatient Surgical Operations
Included Eligible Treatment – What we pay for
Recognised Facility charges for Outpatient Eligible Surgical Operations.
This includes theatre use, equipment, Common Drugs, advanced therapies, specialist drugs
and surgical dressings used during the operation.
Discretion D3 Unrecognised Facility
We may pay Consultants’ fees and facility charges for Eligible treatment in a treatment
facility that is not a Recognised Facility when your proposed Treatment cannot take place in
a Recognised Facility for medical reasons. However, you will need our agreement12 before
the Treatment is received and we need full clinical details from your Consultant before we
can give our decision.
Benefit B3.2 Day Patient and In-Patient Treatment
Included Eligible Treatment – What we pay for
Recognised Facility charges for Day patient and In-patient treatment including Eligible
Surgical Operations.
Listed in Benefits B3.2.1 to B3.2.7 are the charges we pay, but note that some Facilities have
categories of accommodation (A, B or C) and your Certificate will show the relevant scale of
cover we pay14.
Discretion D3.2 Non-Recognised Facilities
If your Treatment cannot take place in a Recognised Facility for medical reasons,13 we may
agree to your treatment being carried out other than in a Recognised Facility, but we need
full clinical details from your Consultant before we can make that decision.
If we do agree, we pay the same benefits as if the facility was a Recognised Facility

Benefit B3.2.1 Accommodation
Included Eligible Treatment – What we pay for
Recognised Facility Accommodation including your meals and refreshments while you are
receiving treatment.
Excluded Eligible Treatment – What we do not pay for
JJ
Accommodation charges for an overnight stay or a bed if:
JJ
The charge is for an overnight stay for treatment that would normally be carried out as
Out-patient or Day-patient treatment.
JJ
The charge is for the use of a bed for treatment that would normally be Out-patient
treatment.
JJ
The accommodation itself is primarily used for:
––
Convalescence, rehabilitation, supervision or other purposes which are not Eligible
Treatment.
––
general nursing care or other services which could be provided in a nursing home or other
establishment which is not a Recognised Facility.
––
services from a Therapist or Complementary Medicine Practitioner.
Benefit B3.2.2 Parent Accommodation
Included Eligible Treatment – What we pay for
Accommodation for one parent, each night they need to stay in the Recognised Facility with
their child.
The child must be a Member receiving in-patient treatment and the amount will count
towards any limits applicable to the child’s relevant benefit. 16
Excluded Eligible Treatment – What we do not pay for
Excluded EB3.2.2 Parent Accommodation
We do not pay if the child is over the age limit shown against parent accommodation on the
Certificate detailing the child’s cover.15
Benefit B3.2.3 Theatre Charges, Nursing Care, Drugs and Surgical Dressings
When essential for Day-patient treatment or In-patient treatment, operating theatre and
nursing care charges, common drugs, advance therapies, specialist drugs and surgical
dressings.
Excluded Eligible Treatment – What we do not pay for
Excluded EB3.2.3 Extra Nursing Services
We do not pay for extra nursing services in addition to those that the Recognised Facility
would usually provide for normal patient care, without extra charge.
Bupa By You – Eligible Treatment Page 21