What is not covered
There are some costs and expenses that our insurance plans do not cover. We have grouped the exclusions under headings. These headings do not form part of the exclusion. Any exceptions to the exclusions are clearly shown. Please note there may be more than one exclusion to a particular condition or treatment.
We do not pay for any treatment for, or arising from, any:
- addictive condition or disorder, or
- misuse of medicines or alcohol, or
- substance or solvent abuse whether or not it is related to prescription medicines.
We do not pay for treatment to relieve symptoms commonly associated with any bodily change arising from any physiological or natural cause such as ageing, menopause or puberty and which is not due to any underlying disease, illness or injury. Please also read ‘HRT and Bone Densitometry’ in this section.
We do not pay for treatment to de-sensitise or neutralize any allergic condition or disorder.
We do not pay for any type of contraception, sterilisation, any treatment of sexual problems (including impotence, whatever the cause), sex changes, assisted reproduction (eg IVF treatment), termination of pregnancy, or treatment for, or arising from, any of these.
Exception: We pay for reasonable investigations into the cause of infertility. However, unless specifically agreed otherwise under the agreement we will only pay if:
- neither you nor your partner had been aware of any problems before joining, and
- you have both been members of this plan (or any Bupa Malta plan which included cover for this type of investigation) for a continuous period of two years before receiving the treatment.
Once the cause is confirmed, no further payment is made for additional investigations in the future.
We do not pay for treatment of a non-acute or chronic condition. By this we mean a disease, illness or injury (including a mental condition) which has at least one of the following characteristics:
- no known cure, or recurs
- leads to permanent disability
- is caused by changes to your body which cannot be reversed
- requires you to be specially trained or rehabilitated
- needs prolonged supervision, monitoring or treatment
Exception: We pay for treatment of a disease, illness or injury arising out of a chronic condition, or for treatment of any symptoms of a chronic condition that flares up. However, we will only pay if the treatment is likely to lead quickly to a complete recovery or to you being restored fully to your previous state of health, without you having to continue receiving the treatment. For example, we pay for treatment following a heart attack arising out of chronic heart disease.
We do not pay any increased treatment costs you incur because of complications directly caused by a disease, illness, injury or treatment for which cover has been excluded or restricted under your membership. For example, if cover for diabetes is excluded on your membership certificate, and if, because you have diabetes, you have to spend extra days in hospital after any operation, we would not pay for these extra days.
We do not pay for treatment of congenital conditions. By congenital conditions we mean any abnormality, deformity, disease, illness or injury present at birth whether diagnosed or not.
Exception: We will pay for treatment of a congenital condition if the treatment is received within the first 28 days of birth. We will not continue to pay for such treatment received on or after the 29th day of birth.
We do not pay for treatment for any disease, illness or injury resulting from nuclear or chemical contamination, war, riot, revolution acts of terrorism or any similar event.
Exception: We pay for treatment provided that:
- the company or employee have not recklessly put themselves in danger by entering a known area of conflict where active fighting/insurrections are taking place, or
- they were not an active participant, or
- they have not displayed a blatant disregard for personal safety, and
- there is a legitimate business reason for them to be there
We do not pay for hospital room and board for any of the following purposes:
- convalescence, rehabilitation, supervision or any purpose other than for receiving treatment covered by your membership of a type which normally requires you to stay in a hospital
- general nursing care or any other services which could have been provided in a nursing home or in any other establishment which is not a hospital
- receiving services from a therapist if:
- this is the primary purpose for you staying in the hospital, or
- if the services are not being provided during a period of treatment which needs to be provided by a specialist and for which you are covered under your membership of the plan.
We do not pay for treatment to change your appearance, such as a remodelled nose or facelift whether or not it is needed for medical or psychological reasons. We do not pay for treatment which involves the removal of healthy tissue (ie tissue which is not diseased), or the removal of surplus or fat tissue, whether or not it is needed for medical or psychological reasons.
This means that, for example, we do not pay for breast enlargement or reduction or any other treatment or procedure to change the shape or appearance of your breast(s) whether or not it is needed for medical or psychological reasons, for example for backache or gynaecomastia (which is the enlargement of breasts in men). And it also means that we do not pay for scar revision.
Exception: We pay for a surgical operation to restore your appearance after an accident, or as a direct result of surgery for cancer, if either of these takes place during your current continuous membership of the plan. Payment is made if this is part of the original treatment for the accident or cancer and you have obtained our written agreement before receiving the treatment.
We do not pay for treatment for, or arising from, deafness caused by a congenital abnormality, maturing or ageing.
Exception: We may pay for treatment of deafness arising as a result of an acute condition.
We do not pay for any dental or oral treatment. For example, we do not pay for the management of, or any treatment related to, jaw shrinkage or loss as a result of dental extractions; the provision of implants; gum disease; the repair of damaged teeth after an accident (such as crowns or caps). We also do not pay for surgical operations for the treatment of irreversible bone disease when related to gum disease or tooth disease or damage.
Exception: We pay for a surgical operation carried out by a specialist to:
- put a natural tooth back into a jaw bone after it is knocked out or dislodged in an accident;
- treat irreversible bone disease involving the jaw(s) which cannot be treated in any other way, but not if it is related to gum disease or tooth disease or damage;
- surgically remove a complicated, buried or impacted tooth root, for example in the case of an impacted wisdom tooth.
We do not pay for treatment for, or associated with, haemodialysis (removal of waste matter from blood by passing it through a kidney machine or dialyser) or peritoneal dialysis (removal of waste matter from blood by introducing fluid in the abdomen, which acts as a filter).
This is because it is not treating an acute condition. We can, however, pay for short-term dialysis when it is needed immediately prior to a transplant operation or if the dialysis is needed on a temporary basis for sudden kidney failure that results from a disease, illness or injury affecting another part of the patient's body. In cases where dialysis is covered (see exception below), if a member is receiving dialysis as an out-patient, usually at home, we will allow benefit for the cost of the solution (dialysate) and this will be paid from the out patient benefit section. We will not consider benefit towards any machines/equipment that may be required.
We do not pay for treatment which, in our reasonable opinion, is experimental or has not been proved to be effective based on established medical practice.
Exception: We may pay for this type of treatment if:
- it is shown that the treatment is approved as appropriate by a recognised medical body in the country in which you receive the treatment; and
- you have received our written agreement prior to the treatment
We need full clinical details from your specialist before we can make our decision.
We do not pay for treatment to correct your eyesight, for example for long or short sight or failing eyesight due to ageing, including spectacles or contact lenses.
Exception: We will pay for you to receive treatment for your eyesight if it is needed as a result of an injury or an acute condition, such as a detached retina.
We do not pay for treatment or services received in health hydros, nature cure clinics or any establishment which is not a hospital.
We do not pay for treatment for, or arising from, HIV or AIDS, including any condition which is related to, or results from, HIV or AIDS.
Exception: We pay for treatment if the person with AIDS or HIV:
- became infected five years or more after their current continuous period of membership began, or
- has been a member of this plan (or any Bupa plan) since at least July 1987 without a break in their cover
We do not pay for Hormone Replacement Therapy (HRT) or Bone Densitometry.
Exception: We may pay for Bone Densitometry scan recommended by your specialist to assess your condition as part of your treatment. We need full clinical details from your specialist before we can give our decision. If we agree to pay we will only pay for the initial scan plus one follow-up scan if this is carried out:
- within three years of you first starting the treatment, and
- during your current continuous period of membership of the plan
We do not pay for treatment for or related to learning difficulties, such as dyslexia, or behavioural problems, such as Attention Deficit Hyperactivity Disorder (ADHD) or development problems, such as shortness of stature.
We do not pay for any medicines or surgical dressings provided or prescribed for out-patient treatment, or for you to take with you on leaving hospital. We also do not pay for medicines that are provided, prescribed or used for the treatment of an excluded condition such as a sexually transmitted disease.
We do not pay for:
- treatment for transplants involving mechanical or animal organs
- expenses associated with the procurement of a donor organ
- treatment incurred as a result of the removal of a donor organ from a donor (even if the donor is another Bupa member)
Treatment for removal of an organ from you for purposes of transplantation into another person.
Following a transplant, the patient is likely to need lifelong medication. We can pay for this whilst the patient is in hospital.
We do not pay for supplying or fitting physical aids and devices (for example, hearing aids, spectacles, contact lenses, crutches and walking sticks).
Exception: We pay for covered prostheses or appliances.
A 'covered prosthesis' relates to the fitting of any integral part or device without which the surgical procedure could not necessarily be successfully performed.
Exception: If your cover, as detailed on a separate membership certificate, includes Optional Extra Benefits, we will pay for prosthetic and medical appliances you need as part of your treatment to the extent set out in the benefit plan.
We do not pay for treatment for a pre-existing condition, or a disease, illness or injury that results from or is related to a pre-existing condition.
Exception: We will pay for the cost of treatment of a preexisting condition or a disease, illness or injury which results from or is related to a pre-existing condition, if all the following requirements have been met:
- you gave us all the information we asked you for, before we sent you the first membership certificate for your current continuous period of membership which lists the person with the pre-existing condition
- neither you nor the person with the pre-existing condition knew about it before the effective from date on that membership certificate.
- we did not exclude cover for the costs of treatment when we sent you the membership certificate.
We are willing, at your renewal date, to review a special condition applied to your membership. We will do this if in our opinion no treatment is likely to be needed in the future directly or indirectly relating to the disease, illness or injury covered by the special condition or for a related disease, illness or injury.
If you would like us to consider such a review please contact us before your renewal date. Please note we need full, current clinical details from your general practitioner and/or specialist before we can give our decision.
We do not pay benefit for the following (subject to some limited cover being available as shown):
i) treatment for pregnancy or childbirth unless:
It is complicated by a medical condition needing treatment during and/or after pregnancy or childbirth and the pregnant mother has been insured by us under the plan for a continuous period of 12 months prior to the date of delivery. On the other hand, we will pay the costs of delivery of a baby by caesarean section if is medically necessary, if, the mother has been a member of the plan for at least 12 months prior to the date of delivery.
ii) treatment of any medical condition which arises during pregnancy or childbirth if the pregnancy was the result of any form of assisted conception or artificial insemination;
iii) foetal surgery which is surgery performed on an unborn child or medical treatment in connection with such surgery whether undergone by mother or the unborn child;
iv) intentional termination of pregnancy or any consequences of it;
v) investigations into and the treatment of infertility, contraception, assisted reproduction, sterilization (or its reversal) or any consequences of any of them or of any treatment for them including post-natal care of the mother, child or children however we will pay for initial investigations into the cause of infertility provided that you and your spouse have been insured by us under this policy for a continuous period of two years at the start of these investigations and were unaware of your infertility or inability to conceive before your insurance under this policy began.
We do not pay for health screening, such as routine health checks, vaccinations or any preventive treatment, for example treatment to remove tissue that is not diseased such as breast removal when there is no cancer present.
Exception: If your cover, as detailed on a separate membership certificate includes Optional Extra Benefits as set out in the benefit plan, we pay for health screening and dental check-up to the extent set in the benefit plan.
We do not pay for psychiatric treatment.
Exception: Out-patient psychiatric treatment: We will pay for psychiatric treatment carried out as out-patient treatment after you have been a member of the plan for the whole of the two years leading up to the treatment.
Day-case and hospitalisation psychiatric treatment: We may pay under the plan for psychiatric treatment carried out as day-case or hospitalisation treatment after you have been a member of the plan for the whole of the two years leading up to the treatment.
However, you must get our written agreement before the treatment takes place and we need full clinical details from your specialist before we can give our decision. If we agree we will only pay for up to a collective total of 30 days day-case and hospitalisation psychiatric treatment during your membership of this plan or any Bupa Malta plan whether your membership is continuous or not. This is the total number of days we will pay up to for day-case and hospitalsiation psychiatric treatment collectively and not individually.
We do not pay for treatment for or arising from intentionally inflicted injury (for example, a suicide attempt).
We do not pay for treatment for sexually transmitted diseases.
We do not pay for treatment for sleep disorders including insomnia, sleep apnoea (temporarily stopping breathing during sleep), snoring or any other sleep-related problems.
We do not pay for treatment for or relating to any speech disorder, for example, stammering.
Exception: We may, at our discretion pay for short-term speech therapy when such treatment is medically necessary as part of treatment for an acute condition, such as a stroke. The speech therapy must take place during and/or immediately following the treatment for the acute condition and be recommended by the specialist in charge of your treatment and be provided by a therapist. We need full clinical details from your specialist before we can make our decision. If we agree we will only pay for such treatment by a therapist to the extent set out in note1a to the benefit plan.
Exception: If your cover, as detailed on a separate membership certificate, includes Optional Extra Benefits as set in the benefit plan:
We pay for short-term speech therapy treatment to the extent set out in the benefit plan.
We do not pay any travel costs you incur when travelling to receive medical treatment.
Exception: We pay for emergency travel by local road ambulance to the extent set out in the benefit plan.
We do not pay for treatment provided by a specialist, general practitioner, therapist, or dental practitioner who is not recognised as having specialised knowledge of, or expertise in, treatment of the particular disease, illness or injury by the relevant authorities in the country in which the treatment takes place. We do not pay for treatment in any hospital, or by any specialist, general practitioner, therapist or dental practitioner or any other provider of services, to whom we have sent a written notice saying that we no longer recognise them for the purpose of our plans.