ARMOR HEALTH - Health Insurance, Medicare & Dental Insurance
Dental insurance policy document - Aons/Dental...By membership rules, we mean this dental insurance...
Transcript of Dental insurance policy document - Aons/Dental...By membership rules, we mean this dental insurance...
Dental insurance policy document
Page 1 of 4NDP176 11/2016
020 7488 9880 www.unum.co.uk/dental
Your insurance explained
What we will cover
1. We will cover the member (and dependants if applicable)
set out in this policy document, the policy schedule and the
benefits schedule - as amended from time to time.
By member, we mean each of those individual employees
who have applied for cover and been accepted by Unum
Dental on behalf of the underwriters.
By dependant, we mean a member’s spouse, civil partner
or a member’s unmarried child under the age of ,
unless otherwise agreed with the employer.
2. We will pay for any dental expenses following treatment that
members and dependants are entitled to under this policy.
By treatment, we mean any dental procedure carried out
while the member or dependant is covered by this policy
(including a preventative or diagnostic procedure) which
is necessary for continued dental good health, including
treatment as a result of an accident. Reconstructive facial
plastic surgery following treatment of mouth cancer is also
considered as treatment for the purposes of this policy.
By accident, we mean a sudden and unexpected event which
causes injury to a member or dependant, including accidents
involving a vehicle in which the member or a dependant is
travelling, and accidental sports injuries.
By mouth cancer, we mean a malignant tumour, tissue or
cells, primarily in the oral cavity, lips, tongue or pharynx,
characterised by the uncontrolled growth and spread of
malignant cells and the invasion of tissue.
3. Following treatment, we will reimburse a member’s or
dependant’s dental expenses up to the sum set out in the
benefit schedule for the relevant treatment.
4. The total sum payable to a member or dependant during any
one insurance period cannot exceed the annual maximum
amount shown in the benefit schedule.
5. Where a member or dependant receives treatment abroad
and dental expenses are incurred in a foreign currency, we
will pay the claim in sterling at the exchange rate prevailing
on the day we agree to pay the claim.
What we won’t cover
6. We will not pay any claim made for:
a) Dental expenses directly or indirectly resulting from mouth
cancer conditions which existed before the start of the
member’s or dependant’s current continuous period of
cover under this policy
b) Any dental procedure which is purely cosmetic and not
necessary for continued dental good health
c) Benefits for overnight hospital stays in the Republic of
Ireland (ROI)
By period of cover, we mean the 12-month period
immediately following the start date, or in the case of a
renewed policy, the 12-month period immediately following
the renewal date - or other periods as agreed with the
employer.
Starting cover
7. We will cover each member (and dependants if applicable)
from the date stated in the dental healthcare agreement
or the date agreed with the employer (for company-paid
schemes administered by the employer).
We will provide cover on the terms set out in the current
membership rules until the renewal date, when we may offer
cover under a new set of membership rules which we will
issue to the employer.
By membership rules, we mean this dental insurance policy
document, certificate of cover (or a summary of the available
cover in the case of company-paid, employer-administered
schemes) and the healthcare agreement between the
employer and Unum Dental.
Ending cover
8. Cover will end for a member (and their dependants) when:
(i) The policy expires and is not continued
(ii) The member no longer works for the employer (or at the
end of that month if agreed with the employer)
(iii) They no longer meet the criteria for being a member (or
dependant) - unless otherwise agreed in writing by us
(iv) We give the member notice that we are cancelling cover
following an unpaid premium instalment
References to ‘we’ and ‘us’ below are to the underwriter, Unum Limited.
Page 2 of 4Continued on next page...NDP176 11/2016
(v) We give the member notice that we are cancelling cover
for them and/or their dependants according to clause 11
(vi) A false or fraudulent claim is made by a member or
dependant
(vii) We cancel cover according to our rights to do so as set
out in this policy
Cancellation
9. A member or dependant cannot cancel their membership
until the end of the insurance period, unless they leave their
employer or experience a qualifying event.
By qualifying event, we mean those life events defined
by the employer - or for company-paid schemes, birth or
adoption of a child, death of a member or dependant,
marriage or divorce of the member, a member entering a civil
partnership or a dissolution of a member's civil partnership.
Claims
10. To make a claim under this policy, a completed claim form
must be sent to us within 90 days of the treatment or, where
there has been a course of two or more treatments, within 90
days of the last treatment (unless not reasonably possible).
The claim form must be signed by, or on behalf of, the dentist
who carried out the treatment or course of treatments - and
the scheme administrator if the employer advises.
By dentist, we mean a dentist, dental surgeon or dental
practitioner registered with the General Dental Council or
equivalent outside the UK.
The receipt or receipts for the dental expenses incurred by
the member or dependant must also be sent to us. Where
the claim form and receipt(s) are received by us later than
90 days, we may choose not to accept the claim. In such
cases, we will act in a fair and reasonable way at all times.
We are required by law, in certain circumstances, to disclose
information to law enforcement agencies about suspicions of
fraudulent claims and other crime.
We will disclose information to third parties including other
insurers, the policyholder and/or any employer or trustee
connected with the scheme/policy, for the purposes of crime
prevention or investigation including reasonable suspicion
about fraud or otherwise improper claims.
Conditions
11. We are entitled, on giving reasonable notice of at least
14 days, to request that a member or dependant has a dental
examination - at our expense. If the member or dependant
refuses, we may cancel cover for that member and/or
dependants with immediate effect by giving the member
notice in writing.
12. We reserve the right to change the membership rules from
time to time, but no alteration will take effect until the
renewal date. We may amend the terms of this agreement
from time to time (subject to giving 60 days’ notice in writing
to the employer) to reflect any changes in Insurance Premium
Tax or any levy or imposition made under relevant legislation
or regulation.
13. For the purposes of the Data Protection Act 1998, Unum
Dental and the underwriters act as data controllers as defined
by the Data Protection Act, which means that the employer
will need to notify and obtain the necessary consents
from members before providing us with any personal data
or sensitive personal data which we need to set up and
administer the policy.
We have the right to request such data as is required to
quote for and administer the policy. We will record such
information accurately and keep it confidential and secure
and will use it solely for the purpose of quoting for, providing
and administering the policy and for marketing other Unum
products to the employer and its employees.
The employer must ensure that the data is correct at the time
it is provided to us and that alterations are notified to us in
reasonable time.
We will only process, transfer or permit access to any personal
data outside of the European Economic Area in compliance
with applicable data protection legislation.
Cancellation and avoidance of the policy
14. By giving notice in writing to the employer, we are entitled
to retrospectively cancel, nullify, or end the policy if we find
the employer has misrepresented, or failed to disclose, any
information in an attempt to mislead us.
15. By giving notice in writing to the employer, we may cancel
the policy with immediate effect if the employer is unable or
deemed unable to pay their debts within the meaning of the
Insolvency Act or otherwise ceases trading.
Any cancellation of this agreement will be without prejudice
to any accrued rights and obligations of both parties for the
period when the premium has been paid.
16. The policy’s premium must be paid when due, including
when paid in instalments. If any instalment is not paid
on the due date, we are entitled to cancel this policy with
immediate effect by giving notice in writing to the employer.
We are not liable to pay any claim for a member’s or
dependant’s treatment that takes place after the policy’s
cancellation. We may also offset any benefit payable for
a claim against any outstanding unpaid premium for that
member or dependant(s)
Continued on next page... Page 3 of 4NDP176 11/2016
Complaints
17. In the first instance, please direct any complaints to us at:
Unum Dental, Milton Court,
Dorking, Surrey RH4 3LZ
Tel: 020 7480 7201
We will do our best to resolve any complaint, but if the
employer is still dissatisfied, the employer has the right to
contact the Financial Ombudsman Service at the address
below without prejudice to the member’s or dependant’s
legal rights.
The Financial Ombudsman Service,
Exchange Tower,
London, E14 9SR
Helpline: 0800 023 4567 Mobiles: 0300 123 9 123
Email: [email protected]
Website: www.financial-ombudsman.org.uk
Financial Services Compensation Scheme
18. If Unum is unable to meet its liabilities, the employer may
be entitled to compensation from the Financial Services
Compensation Scheme (FSCS). Please note the FSCS does not
cover the Channel Islands or the Isle of Man.
19. This contract is subject to English law and by taking out the
policy, the employer accepts that any dispute will be subject
to the exclusive jurisdiction of the English courts.
20. Only the policyholder and we have legal rights under this
policy. No clause or term of this policy will be enforceable, by
virtue of the Contract (Rights of Third Parties) Act 1999, by
any other person, including any dependant.
This dental insurance is underwritten by Unum Limited under
the trading name, Unum Dental. Unum Limited is authorised
by the Prudential Regulation Authority and regulated by the
Financial Conduct Authority and the Prudential Regulation
Authority. Registered Office: Milton Court, Dorking, Surrey RH4 3LZ.
Registered in England 983768.
unum.co.uk/dental
NDP176 11/2016 Page 4 of 4