LPF TRUSTS MEDICAL SCHEMETERMS AND CONDITIONS

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CONTENTS

Opening hours and contact details 2

Introduction 3

Scheme rates 4

What is covered by the Scheme? 5

NHS claims 5

What is not covered by the Scheme? 6 - 7

How to make a private medical claim 8

Making a civil claim 9

Discretionary benefit schedule 10

Definitions 11

Terms 12

Please read this guidance carefully so you fully understand the terms and conditions.

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Opening hours and contact details:

Monday to Friday from 8.30am to 4.00pm

Tel: 0116 275 9930Fax: 0116 275 9949Email: Medical@lpf-trusts.co.uk

Kerry MeuldykMedical Scheme Account ManagerTel: 0116 275 9930Email: Kerry.Meuldyk@lpf-trusts.co.uk

Hannah WilliamsMedical Scheme NurseTel: 0116 275 9930Email: Hannah.Williams@lpf-trusts.co.uk

If you have any queries, please do not hesitate to contact the Scheme O�ce.

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INTRODUCTION

This document details the guidelines and current subscription costs for the LPF Trusts Medical Scheme.

with your claim. Under the terms of membership, you are obliged to recover the Scheme costs as special damages. Please note that there is an administration fee of £30 per medical claim.

Please note that all changes to your membership must be made in writing to the Medical Scheme.We will acknowledge any changes to membership in writing. Emails can be accepted as written authority providing that the address has been registered with the Scheme on our website. Withdrawals require a signature.

Please ensure that you keep up-to date with the current rules of the Scheme.

Further information can be found at the LPF Trusts’ website www.lpf-trusts.co.uk

Authorisation for any claim, test or procedure can be obtained by telephone, email or

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MEDICAL SCHEME RATES

STUDENT OFFICERS

CHILDREN

1st year FREE

First child £10.00

2nd year at the reduced rate of £21.20 per month

Additional children £5.00

70+

SINGLE MARRIED**

£21.20

£30.10

£31.60

£34.10

£34.50

£42.88

£44.41

£45.43

£46.45

£46.95

£42.20

£60.20

£62.70

£67.70

£68.50

£85.76

£88.82

£90.86

£92.90

£93.90

Married £42.20

1st child £10.00

2nd child £5.00

Total £57.20 These rates apply as of 1 February 2017.** Married refers to any co-habiting partnership

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WHAT IS COVERED BY THE SCHEME?

The Medical Scheme will consider authorising claims up to the limits shown on the Discretionary Benefit Schedule, for the following:

Consultations when referred by a General Practitioner (GP).

Imaging - such as MRI and CT scans.

Pathology, x-rays, ECGs and other diagnostic procedures.

In-patient stay at the authorised hospital if required.

Overnight parent/carer accommodation for up to 10 days when child hospitalised.

Operating theatre charges.

Drugs, dressings and medicines prescribed for in-patient treatment.

Orthotics and splints are limited to one fitting per member.

Physiotherapy.

Alternative medical therapy - chiropractic, osteopathy and acupuncture.

NHS cash benefit.

treatment or authorisation.

NHS claimsUnplanned admissionThe NHS benefit for unplanned admission is £25.00 per night with a maximum of £175.00 per claim.Pre-planned admission The NHS benefit for pre-planned admission is £100.00 per night with a maximum of £500.00 per claim.

Claims are subject to the following criteria: You must be referred for treatment by a GP.

You must see a consultant as an outpatient.

You are put on a NHS waiting list.

You must obtain authorisation from the Medical Scheme prior to treatment.

The condition requiring treatment must usually be covered by the Medical Scheme.

Treatment taking place in the NHS must not be due to exceeded limits for an ongoing claim with the Medical Scheme.

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WHAT IS NOT COVERED BY THE SCHEME?

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

Any treatment for chronic illness, injury or long-term pain management.

Any emergency treatment including blood transfusions and admissions for intravenous antibiotics or other fluids.

Joint replacements are limited to one replacement per joint (no re-fashioning of a previously replaced joint). In 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 lumbar-sacral spine.

Treatment undertaken in nature cure clinics, health hydros or similar establishments or private beds registered as a nursing home attached to such establishments.

Any treatment arising from pregnancy or childbirth.

Infertility, this includes investigations, contraceptive devices, sterilisation, reversal of sterilisation and termination of pregnancy.

Psychiatric or psychogeriatric treatment undertaken as an in-patient.

Alcoholism, drug abuse, self-harm and eating disorders or conditions arising therefrom or associated therewith.

Continuing treatment for any condition involving heart disease, cancer or any other malignant condition other than the original consultations and investigations up to diagnosis.

You would be advised to contact the Scheme as soon as possible in this instance so that further advice can be given.

Injury or disablement directly or indirectly caused or contributed to by war, invasion or while engaged or taking part on active service in military, naval or air services or

Supportive treatment of renal failure including dialysis.

Treatment directly or indirectly related to Acquired Immune Deficiency Syndrome (AIDS) or any syndrome or condition of a similar kind howsoever it may be named.

Treatment outside the UK, unless the member is a resident of that country and with

operations arising from any reserve military duty.

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Cosmetic treatment including for psychological purposes. The exception is where such treatment is required as a direct result of bodily injury on duty occurring during active membership to the Scheme.

Drugs, dressings and aids as an outpatient.

Private ambulance.

Private GP appointments.

Routine health checks, annual consultations and screening.

Transfer from the NHS to a private in-patient facility once treatment has commenced as an NHS in-patient.

Treatment for iatrogenic disease.

In-patient treatment for medical investigations or monitoring.

Any treatment that has been refused by the NHS or is a direct result of medical advice not being followed.

Any treatment for pre-existing symptoms or conditions regardless of whether they were treated that existed prior to the start of membership that you failed to inform us about.

A ‘second opinion’ from another consultant, specialist or healthcare provider.

Any specialist costs above BUPA rates for treatment undertaken outside of Leicestershire, Northamptonshire and Derbyshire.

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Injuries relating to, or derived from, semi-professional, or professional sportingactivity.

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1. Contact the Medical Scheme nurse for advice or guidance if needed.

2. Consult your GP who will carry out all relevant preliminary tests prior to referral.

3. This will generate a claim number and a claim form which will be sent to you for completion.

4. administration fee.

5. Contact the authorised hospital to arrange an appointment.

6. Attend the consultation and any necessary authorised appointments for tests or treatment.

appointments are made.

If you have any queries or concerns over the eligibility of your claim, please contact

HOW TO MAKE A PRIVATE MEDICAL CLAIM

7. The Scheme does not provide an enhanced treatment or recovery package.

Once a referral letter is in place, contact the Medical Scheme O�ce for authorisation.

Complete the claim form and return to the Medical Scheme O�ce along with the

All claims MUST be pre-authorised by the Medical Scheme O�ce before any

the Medical Scheme O�ce for advice.

Please forward any invoices received to the Medical Scheme O�ce.

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You are required under the terms of the Scheme to apply for reimbursement of medical costs under special damages as part of any civil claim. We recommend that you use the LPF Trusts’ solicitor, Straw and Pearce, as they are familiar with this requirement. Should you choose to, or are required to use another solicitor, you should inform the Scheme of their contact details and ensure the solicitor is aware of your medical claim and the requirement to apply for special damages. Failure to make a claim for special damages will mean that you may be required to reimburse the Scheme.

As we are a not-for-profit organisation, failure to collect special damages incurs extra costs to the Scheme which may increase future subscriptions.

MAKING A CIVIL CLAIM

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Leicestershire onlyAs of 1 February 2017

Specialist fees

(a) Consultations - 1 new and 4 follow-ups

(b) Pathology and radiology (outpatient) - £500

(c) Physiotherapy - 8 appointments

(d) Post-operative physiotherapy/hydrotherapy - 10 appointments

(e) Specialist Diagnostic Tests (Outpatient) e.g Nerve conduction tests, scopes, visual fields, ECG, speculum, vestibular testing, micro suction,

(g) BUPA Healthy Minds, psychiatric, psychogeriatric and psychological treatment - 1 new and 4 follow-ups

(h) Splints if part of treatment and approved - 3 appointments

Please note the Scheme does not cover outpatient dressings or take home drugs.

There is a maximum individual claim limit of £20,000, with a maximum limit of £30,000 over all claims in any Scheme year.

Please note: All tests or treatments must be pre-authorised by the Scheme O�ce.

DISCRETIONARY BENEFIT SCHEDULE

Physiotherapy can only be utilised to reach an acceptable level of fitness. We will not cover enhanced rehabilitation.

(f) Imaging - MRI 3 scans / CT 3 scans / Injections with imaging 2 injections.For multiple area imaging, each area is accounted as 1 scan.

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DISCRETIONARY BENEFIT SCHEDULE

Outside LeicestershireAs of 1 February 2017

Specialist fees

(a) Consultations - £800

(b) Pathology and radiology (outpatient) - £300

(c) Physiotherapy - 8 appointments

(d) Post-operative physiotherapy/hydrotherapy - 10 appointments

(e) Imaging MRI or CT - £1,500

(f) Outpatient diagnostics - £1,000

(g) Injections with imaging - 1 session every 2 years (maximum of 2 sessions on the same area)

(h) Psychiatric, psychogeriatric and psychological treatment - £600

(j) Splints if part of treatment and approved - £250 including VAT

Please note the Scheme does not cover outpatient dressings or take home drugs.

There is a maximum individual claim limit of £20,000, with a maximum limit of £30,000 over all claims in any Scheme year.

Please note: All tests or treatments must be pre-authorised by the Scheme O�ce.

Physiotherapy can only be utilised to reach an acceptable level of fitness. We will not cover enhanced rehabilitation.

(k) All members receiving treatment outside of Leicestershire will only be covered for treatment costs up to the Leicestershire pricing for any and all such treatments that the Scheme covers. Members outside Northamptonshire, Derbyshire and Leicestershire can elect to travel to these Counties for treatment and the Scheme will reimburse reasonable traveling costs negotiated with the Scheme Account Manager in advance.

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DEFINITIONS

1. ACUTE: Describing an illness that is of short duration, rapidly progressive, and in need of urgent care.

2. CHRONIC ILLNESS: A health condition or disease that is persistent or otherwise long-lasting in

term chronic is usually applied when the course of the condition lasts for more than three months.

3. DAY PATIENT: A patient who attends a hospital for treatment without staying overnight.

4. ELIGIBILITY:

of a pension under the Police Pension Regulations, may make application to join and may include their dependants. The LPF Trusts Medical Scheme trustees reserve the right to refuse any application and to terminate membership without giving any reason.

5. ELIGIBLE DEPENDANTS: A spouse and dependant children until the renewal date following their 18th birthday. Over 18 dependants may remain in the Scheme subject to standard charges. Members may make application to join other dependents e.g. grandchildren at the standard child rates.

6. GENERAL PRACTITIONER: A physician whose practice consists of providing ongoing care covering a variety of medical problems in patients of all ages, often including referral to appropriate specialists.

7. HOSPITAL (NHS): A National Health Service hospital in the United Kingdom.

8. HOSPITAL (PRIVATE): An independent hospital operated for profit.

9. IN-PATIENT: A patient who occupies a bed overnight in a hospital.

10. NHS CASH BENEFIT: Benefit payable for each pre-authorised night spent in an NHS hospital without charge for conditions covered by the Scheme.

11. OUTPATIENT: A term referring to a patient who receives care at a medical facility but is not admitted to the facility overnight, or for 24 hours or less. The term may also refer to the healthcare services that such a patient receives.

12. PHYSIOTHERAPIST: A healthcare professional that assesses, diagnoses, treats, and works to prevent disease and disability through physical means.

13. REGISTERED NURSE: A qualified nurse whose name is currently on any register or roll of nurses maintained by the recognised registration bodies in the United Kingdom.

14. SCHEME: LPF Trusts Medical Scheme.

15. SCHEME RENEWAL DATE: Triennially.

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16. SCHEME YEAR: Financial year.

17. SECOND OPINION: Obtaining an alternative view of a medical condition from a second specialist.

18. SPECIALIST: Healthcare professional who has completed advanced education and clinical training in a specific area of medicine.

19. TREATMENT: The management and care of a patient with the purpose of curing or substantially relieving a medical condition under the direction of a specialist.

approaches to prevent, reduce or stop pain sensation.Pain can be categorised into two domains:ACUTE: associated with injury, headaches, disease and other conditions.CHRONIC: endures beyond a normal healing time; identifiable as unremitting pain that lacks physical cause; pain that lasts longer than 12 weeks.Any treatment provided by a pain consultant is deemed as pain management.

This includes all of the below and any other injections administered by such specialists:

Epidural Root block Denervation Facet joint injections Steroid injections Trigger point injections Image guided injections.

When a pain management procedure has been authorised, LPF Trusts will cover an initial diagnosis and ‘injection’ and then one subsequent follow-up injection after three months as there is no guarantee of immediate relief from pain. The follow-up injection cannot be used after this point.Following treatment, if pain is not resolved, the LPF Trusts Scheme nurse will provide you with a letter for your GP advising that an onward referral to the pain clinic within the NHS should be considered if symptoms continue.

21. ALLERGY TESTINGLPF Trusts will only cover allergy testing if a presenting medical problem is being contra-indicated by the possibility of an allergy.

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TERMS

1. BENEFITS Benefit shall only be payable for treatment that has been

following direct referral from the member’s GP. All treatment must be given or supervised by a specialist.

In-patient care must not exceed 30 days per year.

There is a maximum individual claimlimit of £20,000, with a maximum limitof £30,000 over all claims in anyScheme year.

Children enrolled within three months of birth will be accepted without evidence of health.

Claims where a period of six months has elapsed since the last treatment undertaken will normally be deemed to be closed. Further treatment undertaken after this period will be regarded as a new claim.

All benefits payable are as per the approved benefit schedule. The benefit

schedule should be read in conjunction

with the rules of the Scheme.

Benefits are payable subject to all subscriptions, administration fees and other charges set by the LPF Trusts

Medical Scheme trustees being paid.

A dependent who has reached 18 will not be entitled to the full adult NHS benefit until the Scheme renewal date after their 18th birthday and are contributing at the standard adult rate.

No cash benefit cannot be claimed until a full 12 months’ continuous subscription has been paid.

2. CLAIMS All claims must be pre-authorised prior

to treatment. No claims will be settled retrospectively unless authorised by the Medical Scheme.

Clarity of any pre-exisiting conditions or symptoms will be confirmed by a report from a GP or specialist.

3. CONTRIBUTIONS Subscription fees to the LPF Trusts

Medical Scheme shall be paid by instalments on a monthly basis via the agreed payment method.

Failure to pay any subscriptions or administration fees to the LPF Trusts Medical Scheme shall void your membership.

Contributions will be held in trust by the LPF Trusts Medical Scheme for the benefit of the members.

You must give one month’s notice to withdraw from the Scheme to allow the Scheme time to inform payroll of the changes. The request must be in writing with a signature.

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4. GENERALTo enable the LPF Trusts Medical Scheme to keep its records up to date members shall notify the Schemeimmediately of any changes in circumstances. The LPF Trusts Medical Scheme will be allowed to use this information to advise members of any changes or benefit.

The member is not automatically entitled to private medical provision and all benefits provided by the Medical Schemetrust are at the absolute discretion of the trustees. No third party shall be entitled to enforce any provision of the Schemerules to obtain any medical provision detailed in the rules. No provision of these rules is enforceable by any third person other than the member or the trust and trustees.

The rules and provisions may be revoked, supplemented or varied from time to time or new rules introduced in their place by resolution of the trustees.

from any date specified by the trustees but not less than 28 days’ notice will be given to the member; save in the case of minor alterations or alterations that the trustees consider in their absolute discretion to be necessary or desirable so as to comply with law and they may

In the event that a member’s claim arises out of an accident or injury where a third party may be involved and may be legally liable to compensate the member then the member MUST notify

the Scheme immediately or as soon as is practical under the circumstances.

The member must also in the event of such claims provide all relevant information that is required of the Scheme to recover the costs of any medical provision provided to the member resultant from the accident or injury.

The Scheme does not cover approved expenses which at the time the treatment was incurred would, but for the existence of this Scheme, be insured by any existing policy or policies except in respect of any excess beyond the amount which would have been payable under such policy or policies had this

Any fraud, misstatement or concealment made on a member’s claim or application to join made by or on behalf of a Scheme member prior to joining or when

membership null and void and all claims thereunder shall be forfeited.

All medical information will be kept confidential and will be disclosed only to those involved in the treatment of the member or their approved agent and those managing the claim on the member’s behalf. All medical information will be kept in accordance with the Data Protection Act and law pertaining to medical records.

If there is any dispute as to the interpretation of the rules the decision of the trustees is final and binding.

TERMS CONTINUED

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Any appeal or complaint should in the first instance be brought to the attention of the Trust Manager, LPF Trusts, Unit B, Grange Business Park, Enderby Road, Whetstone, Leicestershire LE8 6EP.

Should the matter not be adequately resolved for either party then the trust manager will prepare such documents to be given to the trustees for them to form a decision in regard to any appeal or complaint. The person appealing or making a complaint will be invited to supply the trustees with any documentation that they feel would assist their appeal or complaint.

Please note that any member or dependant who has had continuing membership of the Scheme whose circumstances alter e.g. change of employment, may make application to pay premiums by Direct Debit and continue as a Scheme member. All such applications must be approved by the Scheme.

Any failed Direct Debit payments and returned cheques are liable for an extra administration charge.

TERMS CONTINUED

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LPF TrustsSuite B, Lancaster HouseGrange Business Park • Enderby RoadWhetstone • Leicestershire LE8 6EPT: 0116 275 9930E: medical@lpf-trusts.co.ukW: lpf-trusts.co.uk

Published February 2017.