HSF

Dental and Optical

Sundry items purchased at Dental Surgeries and Opticians premises, eg. solutions, cleaners, contact lens removers, floss, are not covered by benefit and charges for any kind of medication prescribed by a Dental Surgeon are not covered. Claims cannot be accepted for the purchase of spectacles supplied without prescription.

Consultations with Consultant Oral Surgeons, Consultant Facio-Maxillary Surgeons, Consultant Orthodontic Surgeons and Consultant Ophthalmic Surgeons are not covered under these benefits. These should be claimed under the Specialist and Investigations category. Treatment or operative procedures undertaken by these Consultants is not included in any category.

If eye laser treatment (to correct long or short sightedness) and assessments are carried out by a Consultant Ophthalmic Surgeon or undertaken in hospital as a day case patient or an inpatient claims cannot be accepted for Specialist and Investigations benefit or for Hospital or Day Case benefit in addition to the Optical category.

Rules concerning pre-existing conditions do not apply to this particular category.

General Practitioner, Prescription and Emergency Department

A grant is payable on the production of a receipted invoice supplied by one of the following:

General Practitioner (Family Doctor), indicating a visit to a surgery. Any procedures carried out during the visit are covered by the grant and may not be claimed for separately under this or any other category; Pharmacy (Dispensing Chemist), indicating that a prescription supplied by a General Practitioner has been dispensed. Only one grant is payable on each receipt regardless of the number of items; Hospital, indicating attendance at an Accident and Emergency Department. Limited to 12 individual grants in total between the above three types in any 12 consecutive calendar months. Rules concerning pre-existing conditions do not apply to this particular category.

Practitioner: Physiotherapy, Osteopathy, Chiropractic, Acupuncture, Homoeopathy, Chiropody/Podiatry

The maximum payable is between the above six headings. It is not, for example, €800 for each of the six. Claims will only be accepted with receipted invoices from qualified practitioners. Contributors in their own interests, should only consult properly qualified practitioners who are registered with professional organisations which maintain high standards. Benefit does not include the cost of any medication or any surgical appliances supplied or prescribed by the practitioners. Claims cannot be accepted for prophylactic treatments or Sports/Massage Therapy.

Specialist and Investigations

Benefit is payable for consultations on an outpatient basis only which are carried out by a doctor of consultant status. Treatment (including radiotherapy) and operative procedures (including delivery of a baby) are not covered, neither is any radiography during such treatment/procedures. Benefit is payable only on the initial consultation with a Consultant Psychiatrist, subsequent visits are classified as treatment. Benefit is not payable for examinations/investigations carried out for medico-legal reports, possible legal evidence or for insurance, employment, fitness/occupational assessments or immigration/emigration purposes.

The following are covered under investigations:

Any investigations undertaken, on an outpatient basis only, in a hospital X-ray, scanner, pathology or nuclear medicine/ medical physics department (or its equivalent elsewhere); electrocardiogram, electroencephalogram; electromyogram, audiogram and orthoptic investigations. Claims are accepted for visits to health screening clinics if a letter or certificate from the contributor's General Practitioner is provided and indicates that the screening was on his/her recommendation.

For allergy testing, the initial consultation and diagnosis of problems by a qualified practitioner with a personal consultation in a clinical environment (not a retail outlet) is covered but not any subsequent consultation, therapy or treatment.

The following are NOT covered:
All invasive investigations, such as endoscopies, and those carried out with some form of anaesthetic requiring occupancy of a bed on a day stay basis. The Day Case benefit may be claimed in these circumstances if applicable.

Hospital

The hospital or hospice must be in Ireland or the United Kingdom and its name and admission and discharge dates should be clearly stated on the claim form. Benefit is payable for up to 40 nights in any consecutive 12 calendar months. The benefit payable is the stated grant and no direct costs involved with the hospital admission are covered.

Benefit is restricted to 50 nights in total in a membership for admissions: to mental illness and geriatric (elderly medical/long stay/rehabilitation/respite care/General Practitioner care) wards. These 50 nights are counted as part of and not in addition to the ruling in the paragraph above eg. within a 12 month period the number of nights for which benefit is payable will not exceed 40 regardless of the reason for admission.

In accordance with the usual practice, the date of admission is counted as the first night but the date of discharge is not counted. Time spent within an Accident and Emergency Department (A&E) is not considered as part of an admission unless the hospital declares it to be so in accordance with their records. Claims must be submitted after each discharge from hospital. Weekend leave or longer periods of home leave do not count as a discharge, although benefit will not be paid for nights spent at home. Transfers from one hospital to another without a period at home in between are counted as a continuous period in hospital.

In cases of long stay admissions a claim may be submitted after 40 nights and benefit will be paid up to the number of nights due within the rules. Recuperation only, as appropriate, will be payable upon discharge. However, if an admission extends beyond 12 months a further claim may be claimed. There are special rules for these unusual circumstances. If, on the date of admission to hospital, the benefit limit is shown to have been reached in the preceding 12 months then no payment is made for that admission at all unless the current admission is of a duration which takes it past the anniversary of the discharge date 12 months earlier. In these cases the balance of nights due will be paid.

Recuperation

This grant is paid automatically, subject to qualifying for the appropriate number of nights benefit in the hospital categories and actually having been discharged. There is no requirement to make an additional claim. If readmissions occur after less than seven nights following discharge, and the second or subsequent admissions by virtue of their length would also qualify for a grant, only one such grant will be paid. The grant is not payable when an admission includes a confinement and qualifies for Birth Grant.

Day Case Surgery and Treatment

The claim form must be signed by an official at the hospital to verify the information given by the contributor. Anyone admitted overnight following a Day Case attendance will be entitled to Hospital and not the Day Case benefit. The following are not included: geriatric, psychiatric or rehabilitation day hospitals or units; an unplanned day or period spent in an accident and emergency or casualty department; minor surgery, treatment or procedures undertaken in outpatient or similar departments.

Birth Grant and Adoption Grant

The qualifying period relates to inpatient treatment and all other categories for consultation, investigation and treatment associated with the pregnancy. The Birth Grant is also paid for a still birth if an official certificate is submitted. Adoption is included in this category, however, a claim may not be submitted until HSF health plan membership has been of at least 10 months' duration. The adoption certificate should be dated after the end of this qualifying period and before the child's 10th birthday.

Personal Accident

1. Payment for any Permanent Disability not shown in the benefits will be based on a medical assessment of the disability in relation to the table and not in relation to the Insured Person's ability to work.
2. If the Insured Person was already disabled before an Accident or already had a condition which is gradually deteriorating, the benefit payment will be reduced. The reduced payment will be based on a medical assessment of the difference between:
   1. the Permanent Disability after the Accident; and
   2. the extent to which the Permanent Disability is affected by the disability or condition before the Accident.
3. If the Insured Person claims benefit for loss of limb, he/she cannot also claim for parts of that limb.
4. The most an Insured Person can receive for Permanent Disability resulting from any one Accident is the amount specified for Permanent Total Disablement.

Definitions

1. Accident means a sudden unforeseen and fortuitous identifiable event and the word accidental shall be construed accordingly.
2. Bodily Injury means injury to an Insured Person which (solely and independently of any other cause), results in the Insured Person’s Death, Permanent Disability, Temporary Disability or fracture of a specified bone or bones. Bodily Injury excludes any condition that results due to any gradually operating cause or degenerative process.
3. Permanent Disability means disablement which has lasted for at least 12 months and from which it is believed the Insured Person will never recover.
4. Permanent Total Disablement means disablement caused other than by loss of limb or Sight which, having lasted for at least 12 months, will in all probability entirely prevent the Insured Person from engaging in or giving attention to a profession or occupation of any and every kind for the remainder of his/her life.
5. Loss of Sight means total and irrecoverable loss of sight when an Insured Person’s name has been added to the Register of Blind Persons or when the degree of sight remaining after correction is 3/60 or less on the Snellen chart.
6. Temporary Disability means disablement which prevents the Insured Person from engaging in or giving attention to his/her normal, gainful occupation or which confines the Insured Person to his/her home on medical grounds.
7. Benefit Period means the total period (but not necessarily consecutive period) for which the Temporary Disablement Benefit is payable in respect of any one Accident to any Insured Person.
   Note: Odd days will be paid at 1/7 th of the specified weekly rate.
8. Deferment Period means a period of temporary disablement during which the Temporary Disablement Benefit shall not be payable.

Exclusions
No Benefits will be payable:

1. If the Bodily Injury is caused by: war or any act of war; the Insured Person serving full-time in the armed forces of any country or international organisation; suicide, attempted suicide or deliberate self-inflicted injury by the Insured Person (even if they are insane); the Insured Person taking part in air travel, unless as a passenger; a sickness or disease; Repetitive Stress (Strain) Injury or Syndrome or any other condition or injury which develops over a period of time.
2. For any disabilities caused by or arising from Post Traumatic Stress Disorder or related syndromes or any psychological or psychiatric condition.

The Personal Accident Benefits are underwritten on behalf of HSF health plan health plan by Chubb Insurance Company of Europe S.A. which is regulated by the Irish Financial Services Regulatory Authority for the conduct of business in Ireland. HSF health plan health plan is an intermediary acting on behalf of the contributor dealing exclusively with Chubb Insurance Company of Europe S.A..

The entire administration of the Personal Accident benefits, which may include medical and other enquiries, is carried out by Chubb as soon as receipt of your claim has been acknowledged. The address and contact telephone number will be indicated in the acknowledgement letter.