Business healthcare PMI Cover Benefits and exclusions

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This document contains the benefits and exclusions for business healthcare PMI Cover from PruHealth.

Although we have included the benefit details relating to all of the available modules, for the purposes of the exclusion pages within this document, it has been assumed that the business healthcare plan will only include the Core Healthcare, Core Enhancement and Out-patient Treatment modules as standard. The ‘What’s not covered’ section on page 10 therefore contains the exclusions that would apply in this case. If other modules are selected, then the exclusions may vary.

Also, this document has been based upon the business healthcare plan being underwritten on a medical history disregarded (MHD) basis only and therefore no underwriting exclusions have been included.

We have tried to make sure this document is as clear and straightforward as possible by writing the terms in plain English. There are however certain words that have special meaning that we’d like to draw to your attention:

We/us/our – means PruHealth

You/your – means the insured member and insured dependants. Where the words ‘you’ or ‘your’ refer specifically to the insured member, we’ll say ‘you (the insured member)’

We have printed the remaining defined words in bold to help you identify them as you read through this document. You’ll find a full explanation of each word in the ‘Definitions’ section.

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Your benefits explained – PMI

In this section we have set out the rules on paying benefits and the specific exclusions that apply to each benefit. Other exclusions applying to your plan are contained within the ‘What’s not covered’ section. All benefits are per insured person, unless stated otherwise.

Important notes

All treatment must take place in a hospital on the most recent hospital list we have issued to you. In the rare circumstances where eligible treatment is unavailable in a hospital on the hospital list we’ve issued to you, we will make arrangements for it to take place at another convenient and appropriate hospital.

All treatment must be arranged by your GP or dental practitioner. Also, all treatment must be:

for a specific medical condition •

given by a

specialist, physiotherapist, qualified nurse or other practitioner recognised by us, and given just to cure an

acute condition or the acute flare-up of a chronic condition. We do not pay for treatment that takes place after your cover has ended, even if this is a continuation of treatment that started while you were still covered by this plan.

We will pay benefit after taking off any excess that may apply under this plan.

What we mean by the NHS wait option

This simply means that if treatment is available on the NHS within six weeks of the day your specialist tells you that you need in-patient or day-patient treatment, you agree to have your treatment as an NHS patient and cannot claim under your plan with us.

However, if in-patient or day-patient treatment is not available on the NHS within six weeks, then you can immediately choose to be treated in a private hospital on your chosen list and can claim under your plan with us, subject to our normal benefits, terms and conditions.

How we check if treatment is available on the NHS within six weeks

The NHS has details of waiting times for both specialists and hospitals. If you know which specialist is treating you, then we’ll check with the hospital to see if your specialist is able to treat you on the NHS within six weeks of telling you that you needed in-patient or day-patient treatment.

If you don’t know which specialist is going to treat you, then we’ll check the hospital waiting times to see if you can be admitted to a public ward of an NHS hospital in your Regional Health Authority within six weeks of being told you needed in-patient or day-patient treatment.

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Core Healthcare – Hospital charges

What’s covered

We will pay

We will not pay

Charges for in-patient treatment at a hospital on the most recent hospital list we’ve sent you

accommodation, nursing, drugs prescribed in a •

ward, intensive care

operating theatre charges, surgical dressings •

and drugs

surgical appliances needed as a vital part of •

an operation diagnostic tests

• , including pathology, radiology, CT, MRI and PET scans

physiotherapy

Charges for day-patient treatment at a hospital on the most recent hospital list we’ve sent you

accommodation, nursing, drugs prescribed in a •

ward, intensive care

operating theatre charges, surgical dressings •

and drugs

surgical appliances needed as a vital part of •

an operation diagnostic tests

• , including pathology, radiology, CT, MRI and PET scans

full cover

full cover

for medical aids or •

appliances (e.g. neck collars, splints and foot supports) for mobility aids •

(e.g. deposit on use of a wheelchair and crutches) for any prosthesis •

when the prosthesis is not an integral part of the treatment for personal expenses •

Core Healthcare – Consultants’ / specialists’ fees

What’s covered

We will pay

We will not pay

Specialist fees for in-patient and day-patient treatment that takes place at a hospital on the most recent hospital list we’ve sent you

surgeons’ and anaesthetists’ fees for operations •

and surgical procedures given as in-patient or day-patient treatment

physicians’ fees and other

specialist consultations

full cover

If Core Healthcare selected:

Core Healthcare – Treatment at a hospital not included on your list

What’s covered

We will pay

We will not pay

If you have in-patient treatment in a hospital that’s not on your hospital list then we’ll only pay a contribution towards all of the costs of your in-patient treatment, including your specialists’ fees.

If you have day-patient treatment in a hospital that’s not on your hospital list then we’ll only pay a contribution towards all of the costs of your day-patient treatment, including your specialists’ fees. Important notice: the amounts we pay in the above circumstances may be much lower than the total cost of your treatment, so we strongly recommend that you always go to a hospital that’s on your hospital list.

£300 per night

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Core Healthcare – Out-patient scans

What’s covered

We will pay

We will not pay

CT, MRI and PET scans undertaken as an out-patient at a hospital on the most recent hospital list we’ve sent you.

full cover

Core Healthcare – Cancer treatment

What’s covered

We will pay

We will not pay

The cover described within Core Healthcare also applies to the treatment of cancer. This section provides details of the other treatments covered that are specifically relevant to cancer.

Specific treatment Reconstructive surgery

Radiotherapy including internal and external radiotherapy

Chemotherapy (the use of drugs to destroy cancer cells)

cytotoxic drugs, antiemetics (anti-sickness drugs) •

and steroids as appropriate

hormone therapy or bisphosphonates therapy •

combined with chemotherapy

oral chemotherapy prescribed by an oncologist • full cover full cover full cover for reconstructive •

surgery that takes place after three years have elapsed from the last date of any in-patient or day-patient treatment for personal expenses •

for any

diagnostic

tests or treatment not considered clinically appropriate within the UK

Biological therapy (the use of substances that occur naturally in the body to destroy cancer cells or prevent them from developing or spreading), including

monoclonal antibodies (MABs) •

cancer

• growth blockers anti angiogenics •

full cover for a maximum of 12 months*

Stem cell therapy

Hormone therapy or bisphosphonates therapy (if prescribed on their own)

full cover

full cover for a maximum of 3 months*

*Important note:

This means we will not pay for this type of treatment for more than the limit specified, whether treatment is received in consecutive months or spread out over a longer period.

When the maximum limit has been reached, no further cover will be available for this type of treatment under this plan for the same or any related condition.

Treatment at home

Those treatments outlined under ‘Specific treatment’ that can be safely delivered in your home setting or another clinically appropriate setting that otherwise would require hospital admission as an in-patient or day-patient.

full cover subject to the relevant limits shown under ‘Specific treatment’

for any drugs that would •

normally be prescribed by your GP

for personal expenses •

Specialists’ fees for supervising the treatment Out-patient treatment

full cover

Treatment, including those outlined under ‘Specific treatment’, diagnostic tests and monitoring or follow-up consultations that are considered medically necessary.

full cover subject to the relevant limits shown under ‘Specific treatment’

for any monitoring or •

follow-up consultations that take place after five years have passed since your last cancer treatment

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Core Healthcare – Private ambulance

What’s covered

We will pay

We will not pay

The use of a private ambulance to and from hospital if a specialist recommended it as medically necessary.

full cover

Core Healthcare – NHS cash benefits

What’s covered

We will pay

We will not pay

NHS hospital cash benefits for

in-patient treatment received for a medical condition covered by the plan, as a non-paying NHS patient

£250 a night, up to a total

of £2,000 per plan year • if eligible under this plantreatment is not day-patient treatment received for a medical

condition covered by the plan, as a non-paying NHS patient

£125 per day, up to a total of £500 per plan year

Out-patient Treatment – Level 1

What’s covered

We will pay

We will not pay

Specialist fees for out-patient treatment at a hospital on the most recent hospital list we’ve sent you

specialist

• consultations and diagnostic tests, including pathology and radiology

physiotherapy

but if you have out-patient treatment in a hospital that’s not on your hospital list then we’ll only pay

up to £500 per plan year

up to £150 per plan year – please note this amount would then be deducted from your monetary limit

for routine medical or •

dental checks for routine sight and •

hearing tests for medical aids or •

appliances (e.g. neck collars, splints and foot supports) for mobility aids •

(e.g. deposit on use of a wheelchair and crutches) for spectacles, contact •

lenses, hearing aids, cochlear implants or dentures

for drugs or dressings •

that you take home

If Out-patient

Treatment

selected:

Other levels of cover are available under the Out-patient Treatment module and these are shown below:

Out-patient Treatment

We will pay

Level 2

up to £1,000 per plan year

but if you have out-patient treatment in a hospital that’s not on your hospital list then we’ll only pay up to £150 per plan year – please note this amount would then be deducted from your monetary limit

Level 3

full cover

but if you have out-patient treatment in a hospital that’s not on your hospital list then we’ll only pay up to £150 per plan year

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Psychiatric Treatment

What’s covered

We will pay

We will not pay

In-patient and day-patient treatment in any psychiatric hospital on the most recent hospital list we’ve sent you

accommodation, nursing, drugs prescribed on •

a ward, diagnostic tests, physicians’ fees and specialist consultations

Out-patient treatment in any psychiatric hospital on the most recent hospital list we’ve sent you

specialist

• consultations, ECT and diagnostic tests

full cover, for up to 28 days per plan year note: each session of day-patient treatment whether or not it is a half-day session will count as one full day towards the 28 day limit up to £1,500 per plan year

for any

treatment not under the control of a psychiatric specialist

If Psychiatric

Treatment

selected:

Additional Therapies

We will pay

Level 2

full cover

Additional Therapies – Level 1

What’s covered

We will pay

We will not pay

The following therapies or consultations after referral by your GP or specialist

chiropracticosteopathychiropody/podiatryacupuncturehomeopathy

consultations with a dietician (maximum of 2 •

per plan year)

up to £350 per plan year • for drugs or dressings that you take home for medical aids or •

appliances (e.g. neck collars, splints and foot supports) for mobility aids • (e.g. deposit on use of a wheelchair and crutches) for • treatment following self-referral where you’ve not visited your GP, unless this has been agreed by us in writing in advance of the treatment

If Additional

Therapies

selected:

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Private GP

What’s covered

We will pay

We will not pay

Private GP services including consultations, prescriptions, minor surgery and fees for the completion of claim forms at any private GP surgery.

up to £300 per plan year

If Private GP

selected:

Maternity Cover

What’s covered

We will pay

We will not pay

Private ante-natal and post-natal care, including specialist consultations, diagnostic tests and investigations, and delivery for a normal pregnancy in any hospital on the most recent hospital list we’ve sent you.

up to £3,000

per pregnancy • for any charges incurred before the mother-to-be has been covered under this plan for at least two continuous years for any • treatment as a result of pregnancy complications

If Maternity

Cover selected:

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Core Enhancement – Parent accommodation

What’s covered

We will pay

We will not pay

Accommodation for you or your insured husband, wife or partner to stay with your insured child under age 14 while they are receiving in-patient treatment in a hospital on the most recent hospital list we’ve sent you.

full cover • for personal expenses

If Core

Enhancement

selected:

Core Enhancement – Pregnancy complications

What’s covered

We will pay

We will not pay

Charges for in-patient and day-patient treatment at a hospital on the most recent hospital list we’ve sent you for the following conditions and directly associated complications ectopic pregnancy • miscarriage • missed abortion • still birth •

post partum haemorrhage •

retained placental membrane •

hydatidiform mole •

We will cover caesarean sections that are medically necessary but only in the following circumstances

where the baby is breech at the end of the •

pregnancy (at 36 weeks) and where it has not been possible to move the baby round to head first

if having twins and the first is in a breech position •

in an emergency (where there is an immediate •

threat to the life of the mother or baby) but we will not cover hospital charges and specialist fees where you choose to have your baby in a private facility except where these are directly related to the above complications

full cover • for charges if the mother has not been insured under the plan for at least 10 months for ante-natal care •

for any complication •

of pregnancy and childbirth not listed under the ‘What’s covered’ section for any complications •

following infertility treatment, IVF or other assisted reproduction for investigations and •

treatment of recurrent miscarriages

Core Enhancement – Investigations into infertility

What’s covered

We will pay

We will not pay

The costs of investigations into the cause of infertility. The investigations must take place in a hospital on the most recent hospital list we’ve sent you.

full cover • for any form of infertility treatment, IVF or other assisted reproduction for any investigations •

unless you or your insured dependant have been on the plan for two years

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Core Enhancement – Oral surgery

What’s covered

We will pay

We will not pay

Charges for in-patient and day-patient treatment at a hospital on the most recent hospital list we’ve sent you for the following oro-surgical procedures only

removal of buried, impacted or unerupted teeth •

removal of roots from antrum •

removal of complicated buried roots covered •

by bone

full cover • for any other dental treatment or

oro-surgical procedure

Core Enhancement – Home nursing

What’s covered

We will pay

We will not pay

The services of a qualified nurse for skilled nursing care at home. For you to qualify for this benefit, all home nursing must

immediately follow a period of

in-patient

treatment for a medical condition covered by the plan

be certified by your

specialist as necessary for

medical (not domestic) reasons

be skilled nursing care provided at your home, •

which would otherwise be provided in hospital as an in-patient

be given by a qualified

nurse and carried out

under the direction of your specialist

full cover for up to

13 weeks per plan year • for following home nursing in-patient treatment for psychiatric and mental conditions

for any charges •

for domestic or social reasons

Core Enhancement – Help at home

What’s covered

We will pay

We will not pay

The services of a qualified

nurse for secondary nursing care, or a

care assistant to provide personal care services (or both)

For you to qualify for this benefit, all secondary nursing care and personal care services must

immediately follow a period of

in-patient

treatment for a medical condition covered by the plan and be certified by your specialist or GP as being medically necessary because of your domestic and medical circumstances

be for those domestic duties which would •

normally be carried out by you or your insured dependant claiming this benefit, and not provided by your husband, wife or partner or a housekeeper regularly employed to do those duties

be authorised in advance by our claims •

department. If you don’t get our written approval before taking on costs for secondary nursing care and personal care services, we’ll only pay 50% of any of those costs that you are covered for

up to 3 hours per day for a maximum of 7 days per plan year

for services provided •

by anyone other than a qualified nurse or care assistant under the direction of your specialist or GP

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What’s not covered

The following exclusions are based on Core Healthcare, Core Enhancement and Out-patient Treatment being the only modules selected. Final exclusions may vary depending on the choice of modules for each business healthcare plan.

Below we’ve set out the exclusions that apply to this section of your plan. For ease of reference, we have divided the exclusions into the following categories:

Medical conditions • Treatments • General exclusions •

Medical conditions

We will not pay for the following: treatment

• of alcoholism, drug abuse or any addiction and treatment of any related medical conditions resulting from these

treatment

• of any self-inflicted illness or injury, or any treatment related to them, or treatment arising from attempted suicide

treatment

• of any illness or injury which is medically considered to be linked directly or indirectly with Human Immunodeficiency Virus (HIV) and/or Acquired Immune Deficiency Syndrome (AIDS) and/or any form or variation of HIV or AIDS, however caused

treatment

• of chronic conditions except treatment of an acute flare-up of a chronic condition treatment

• to maintain your state of health or to monitor your health on a regular basis treatment

• , including investigations and assessments, related to developmental problems and learning difficulties including but not limited to dyslexia, dyspraxia and behavioural problems such as ‘attention deficit hyperactivity disorder’ (ADHD)

treatment

• for myopia (short sightedness), hypermetropia (long sightedness), astigmatism or any other refractive error or treatment which results from, or is in any way related to, these conditions treatment

• of sleep apnoea, snoring, insomnia or other sleep disorders treatment

• for obesity, including surgery treatment

• of any psychiatric, mental or nervous conditions

Treatments

We will not pay for the following: the services of a

GP or dental practitioner or any person acting as one treatment

• , including surgery, to remove healthy or non-diseased tissue whether or not for psychological or medical reasons, including but not limited to breast reduction and blepharoplasty (eyelid lift)

cosmetic treatment, whether or not for psychological reasons, or any

treatment that results

from or relates to previous cosmetic treatment or reconstructive surgery. However, we will cover cosmetic treatment necessary as a direct result of an accidental injury that occurs after your cover start date

sex change/gender reassignment or

treatment which results from, or is in any way related to, sex

change/gender reassignment hormone replacement therapy •

dental treatment •

regular or long-term dialysis in chronic or final kidney failure •

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treatment

• or drug therapy which, based on established medical practice in the UK, is considered to be experimental or unproven

any

treatment using unlicensed drugs or the use of drugs outside the terms of their licence in the UK

rehabilitation

• following treatment out-patient

• drugs, medicines and dressings, surgical appliances (such as neck supports, shoe inserts and braces), dental appliances, hearing aids (such as cochlear implants), contact lenses, spectacles, and mobility aids such as wheelchairs and crutches

treatment

• that’s given solely to provide relief of symptoms including psychological support, terminal care or hospice care

any

treatment for, related to or arising from or as a consequence of male or female birth control including sterilisation and its reversal –

any type of contraception –

termination of pregnancy –

pregnancy, except the obstetric conditions listed in your benefit table –

childbirth, except the obstetric conditions listed in your benefit table –

treatment

– of infertility, but we will cover the cost of investigations into the cause of infertility providing you and, if applicable, your insured dependant have been covered under this plan for at least two continuous years before any investigations begin

investigations into or

treatment of impotence or other sexual dysfunction

any form of human-assisted reproduction –

any

treatment received within 91 days of birth by a dependant born as a consequence of any form of human-assisted reproduction

oral surgery, except those procedures shown in your benefit table •

any kind of alternative or complementary therapy •

anything to do with routine, precautionary or preventive examinations, dental check-ups, routine •

hearing and sight tests, vaccinations, screenings (including screenings of familial conditions) or preventive treatment

General exclusions

In addition to the specific exclusions detailed, the following general exclusions apply: treatment

• arising from nuclear or chemical contamination, war, invasion, act of foreign enemy, hostilities (whether war is declared or not), civil war, riot, civil disturbance, rebellion, revolution, military force or coup, act of terrorism

treatment

• received after the period covered by any premium or after the plan has been cancelled treatment

• in a hospital that’s not on the hospital list we’ve issued to you, unless specifically agreed by us

extra accommodation costs for going into

hospital early or leaving late because of your or your

insured dependant’s domestic circumstances or where there is no required treatment treatment

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Definitions

These definitions are shown in bold print throughout this benefits and exclusions document and have the same meaning wherever they appear.

Accidental injury

An injury directly caused by something accidental, outside the body, violent and visible. It does not include sickness, disease or any naturally occurring or deteriorating condition.

Acupuncture

A type of alternative medicine that must be carried out by a member of the British Acupuncture Council, or the Acupuncture Association of Chartered Physiotherapists, or by a medical practitioner who holds a Certificate of Basic Competence issued by the British Medical Acupuncture Society or a Diploma of Medical Acupuncture.

Acute condition

A disease, illness or injury that is likely to respond quickly to treatment which aims to return you to the state of health you were in immediately before suffering the disease, illness or injury, or which leads to your full recovery.

Acute flare-up of a chronic condition

A sudden and unexpected deterioration of a chronic condition that is likely to respond quickly to treatment.

Annual renewal date

The date, 12 months after the plan start date and each anniversary after that date.

Cancer

A malignant tumour, tissues or cells, characterised by the uncontrolled growth and spread of malignant cells and invasion of tissue.

Care assistant

A person attached to a registered nursing agency who is approved by that nursing agency as an approved carer or nursing auxiliary.

Check-up

A consultation with, or a visit to, any medical practitioner about any medical condition or any signs and symptoms of a medical condition.

Chiropody/podiatry

Disorders, diseases and deformities of the feet diagnosed and treated by a chiropodist/podiatrist. Treatment must be given by a practitioner who is registered with the Health Professions Council and recognised by us.

Chiropractic

A type of alternative medicine that must be carried out by a member of the General Chiropractic Council.

Chronic condition

A disease, illness or injury that has one or more of the following characteristics: it needs ongoing or long-term monitoring through consultations, examinations,

check-ups

and/or tests

it needs ongoing or long-term control or relief of symptoms •

it requires your

rehabilitation or for you to be specially trained to cope with it it continues indefinitely

it has no known cure •

it comes back or is likely to come back •

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Company

The employer who has agreed with us to operate a scheme for employees, paid for by the employer.

Cover start date

The date on which each insured person’s cover starts.

Day-patient

A patient who is admitted to a hospital or day-patient unit because they need a period of medically supervised recovery but does not occupy a bed overnight.

Dental practitioner

A registered licensed dental practitioner in general practice.

Diagnostic tests

Investigations, such as x-rays or blood tests, to find or to help find the cause of your symptoms.

Drug abuse

The taking of any drug, substance or solvent unless it was as prescribed by a GP or specialist.

Excess (per claim)

The amount you will have to pay each time you or your insured dependants make a new claim for treatment covered by this plan. If treatment for the same condition has gone on for more than a year, we will treat it as a new claim for any further treatment after that date.

Excess (per plan year)

The first amount which must be paid by you before we make any payment under this plan for treatment covered by this plan. Only one excess is payable in each plan year for each insured person.

General practitioner (GP)

A registered licensed medical practitioner in general practice.

Home nursing

Skilled nursing care provided by a qualified nurse. Home nursing must be supervised by an insured person’s specialist.

Homeopathy

A type of alternative medicine that must be carried out by a member of The Faculty of Homeopathy, Society of Homeopaths or Alliance of Registered Homeopaths.

Hospital

Any hospital that is on the most recent hospital list we have issued to you.

In-patient

A patient who is admitted to hospital and who occupies a bed overnight or longer, for medical reasons.

Insured dependant

Your insured husband, wife or partner, who live at the same address as you. •

Your insured children, who must be under the age of 25 at the

cover start date and at each

annual renewal date.

Insured member

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Nurse

A qualified nurse who is on the register of the Nursing and Midwifery Council (NMC) and holds a valid NMC personal identification number.

Osteopathy

A type of alternative medicine that must be carried out by a member of the General Osteopathic Council (GOsC).

Out-patient

A patient who attends a hospital, consulting room or out-patient clinic and is not admitted as a day-patient or an in-patient.

Physiotherapy

Treatment carried out by a person who is registered with the Health Professions Council (HPC) as a physiotherapist.

Plan start date

The date on which the plan began.

Plan year

A period of 12 months from the plan start date or from any annual renewal date.

Planholder

The company which has the contract with us.

Private ambulance

A road vehicle built just to use as an ambulance and run by a registered private ambulance service.

Rehabilitation

Medical services aimed at restoring a person’s independence following treatment of a disease, illness or injury.

Related condition

Any symptom, disease, illness or injury which reasonable medical opinion considers to be associated with another symptom, disease, illness or injury.

Specialist

A medical practitioner who is fully registered with the General Medical Council, and who is recognised by us in writing. They must either:

hold or have held a substantive consultant post with the NHS, or hold a Certificate of Completion •

of Training (CCT) and be registered on the Specialists Register, or

fulfil the qualification criteria requirements set by the Postgraduate Medical and Educational •

Training Board (PMETB) and be registered on the Specialists Register.

We reserve the right to withhold or remove recognition of any specialist, at our discretion, due to reasons such as fraud or unreasonable charges.

Treatment

Surgical or medical services (including diagnostic tests) that are needed to diagnose, relieve or cure a disease, illness or injury.

UK

Great Britain and Northern Ireland including the Channel Islands and the Isle of Man.

PruHealth is a trading name of Prudential Health Insurance Limited (registered number 02123483), and Prudential Health Services Limited (registered number 05933141). Prudential Health Insurance Limited provides and manufactures benefits under the plan and Prudential Health Services Limited distributes and services the plan and issues the documentation. Companies are registered in England and Wales. Registered offices at Laurence Pountney Hill, London EC4R 0HH. Both companies authorised and regulated by the Financial Services Authority. 0845 279 8877. Calls may be recorded/monitored to help improve customer service.

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