Explanations

Excess vs Out-patient allowance

Excess vs out-patient allowance

    • doctor with patient

      The two separate benefits

      When you joined us, you (or your corporate scheme) chose to pay an agreed amount towards the cost of eligible treatment – this is called your excess. If you or anyone on your plan needs to claim, you’ll pay the excess once for each person in each membership year if they have treatment.

      You or your corporate scheme also chose to have an out-patient allowance, which is an amount of money intended to pay for specified out-patient treatment. This will go towards eligible out-patient treatment such as x-rays, consultations and blood tests.

      Although these separate benefits help reduce your subscription payments, you can end up using both at the same time, which can be a little confusing.

      How they work together

      As they’re separate benefits, your excess and out-patient allowance can be used at the same time, depending on the type of treatment we’re billed for first.

      Every time we receive a bill for out-patient treatment it will be deducted from the allowance.

      If the first bill we receive in your membership year is an out-patient bill, then you will need to pay your excess and the cost of the treatment will be deducted from the out-patient allowance.

      Example

      Excess example 1

      Jenny has a mole on her hip that has recently been changing shape and growing. She’s been to her GP, who advises her to see a dermatologist to get it checked out.

      Jenny calls us, and we agree to her consultation with the dermatologist and advise that her plan has an excess and an out-patient allowance.

      Jenny has her consultation, and the dermatologist advises that he’d like to remove the mole in a couple of weeks at the local hospital.


      Excess example 2

      We receive the dermatologist’s bill of £250 for a consultation.

      The £250 comes out of Jenny’s out-patient allowance as it is out-patient treatment.

      As she has her £100 excess, she needs to pay this to the specialist and then we'll cover the remaining £150.


      Excess example 3

      A couple of weeks later, Jenny has her mole removed and we receive the bill for £500.

      As this is day-patient treatment, it doesn’t come out of her out-patient allowance and there’s no remaining excess to pay for the rest of the membership year.

       


      Excess example 4

      Soon after having the mole removed, Jenny has a follow-up consultation with the dermatologist, who thankfully confirms everything’s ok.

      A week later, we receive a bill for the follow-up consultation of £200. As it’s still the same membership year, we’ll cover the £200 with her out-patient allowance (as it’s out-patient treatment).

    • Definitions

      Pre-existing conditions

      A pre-existing condition is any disease, illness or injury that:

      • you have received medication, advice or treatment for in the five years before the start of your cover, or
      • you have experienced symptoms of in the five years before the start of your cover: whether or not the condition was diagnosed

      Trouble free

      Trouble-free means that you have not done any of the following for the medical condition you need treatment for:

      • had a medical opinion from a medical practitioner, including a GP or specialist
      • taken medication (including over-the-counter drugs)
      • followed a special diet
      • had medical treatment
      • visited a practitioner, physiotherapist, osteopath, chiropractor, homeopath, acupuncturist, optician or dentist