The Private Medical Insurance (Disentitlement to Tax Relief and Approved Benefits) Regulations 1989

PART III APPROVED BENEFITS

Approved treatments and associated services

6.—(1) Subject to paragraph (4), the treatments, medical services and other matters specified in this regulation, the costs of which may, in the circumstances set out in paragraph (2), be indemnified under a contract which is certified under section 56, are—

(a) treatment of the insured consisting of medical or surgical procedures (including diagnosis), the purpose of which is the relief of illness or injury,

(b) services provided to the insured of any of the kinds specified in the Schedule when they are associated with such treatment, and

(c) drugs and dressings used in the course of such surgical procedures.

(2) The circumstances referred to in paragraph (1) are circumstances in which—

(a) the treatment is given—

(i) in the United Kingdom by, or under the supervision of, a registered medical practitioner or registered dental practitioner, or

(ii) to the conditions specified in paragraph (3), outside the United Kingdom, to the insured as a resident or non-resident private patient in a private or health service hospital or, in the case of surgical procedures performed by a registered medical practitioner providing general medical services, as a private patient of that practitioner; and

(b) any services associated with the treatment are provided—

(i) in the United Kingdom, or

(ii) to the conditions specified in paragraph (3) and except for services provided for the purposes of convalescence, outside the United Kingdom, to the insured.

(3) The conditions specified in this paragraph are—

(a) that the amount of the indemnity provided under the contract for such treatment and services does not exceed that provided for the same treatment and services when they are given or provided in the United Kingdom; and

(b) that no more than two per cent. of the premium payable under the contract secures the indemnity in respect of the costs of such treatment and services, including the service consisting of transporting the insured from the place of treatment to the United Kingdom by air ambulance.

(4) The treatments specified in this regulation do not include any treatment which, during the period of five years preceding certification of the contract, has not been provided free by the Secretary of State under the National Health Service Act 1977 or the National Health Service (Scotland) Act 1978, or by the Department of Health and Social Services for Northern Ireland under the Health and Personal Social Services (Northern Ireland) Order 1972, more often than it has been provided in the United Kingdom otherwise than under any of those enactments.

(5) For the purposes of this Part of these Regulations—

(a) “the insured” means any person who is insured under the contract;

(b) a service is associated with a treatment if it is provided for the purposes of that treatment or is consequent on it.

Cash benefits

7.  The rules specified in this regulation, within which a cash benefit provided under a contract which is certified under section 56 is to fall, are that the benefit may not exceed £5 for each night that the insured is accommodated—

(a) in a private hospital, or

(b) in a health service hospital in circumstances where he is charged for the accommodation under section 65 of the National Health Service Act 1977(1), section 57 of the National Health Service (Scotland) Act 1978(2) or Article 31 of the Health and Personal Social Services (Northern Ireland) Order 1972(3) .

Other rights

8.  The other rights specified in this regulation which may be conferred by a contract which is certified under section 56 are—

(a) a right in the person making payments in respect of a premium under the contract to terminate it before the expiry of the indemnity period and to receive a refund of payments made in respect of the period following termination;

(b) waiver by the insurer of the right to payment of premium for any period in which the insured is receiving treatment the cost of which is indemnified under the contract and the right to receive a refund of payments made in respect of such a period;

(c) a right in the person making payments in respect of a premium under the contract to enter into a further contract at the end of the indemnity period.

(1)

Section 65 was amended by section 11(1) and (3) of and paragraph 62 of Schedule 1 to the Health Services Act 1980 (c. 53)

(2)

Section 57 was amended by section 11(2) and (3) of the Health Services Act 1980.

(3)

Article 31 was substituted by Article 3(9) of S.I. 1988/2249 (N.I. 24).