This policy provides 100% reimbursement of covered reasonable charges incurred as a result of a medically necessary procedure for the life assured up to the maximum cover amounts indicated below. This reimbursement is subject to the exclusions set out in this Benefit Sheet and may be subject to the application of excess.
ABSOLUTE HEALTH
BENEFIT SHEET
This policy provides 100% reimbursement of covered reasonable charges incurred as a result of a medically necessary procedure for the life assured up to the maximum cover amounts indicated below. This reimbursement is subject to the exclusions set out in this Benefit Sheet and may be subject to the application of excess .
1. Excess
If you have elected an excess option on your Absolute Health Benefit or Specialist and Diagnostic Testing Benefit, this will be shown in the schedule . The excess applies once per life assured per policy year . The Absolute Health Benefit excess applies to all benefits:
> except those benefits for which the excess is specifically excluded in this Benefit Sheet ; or
> unless it relates to any surgery that occurs within 3 months or a related surgery , in which case it will be waived.
However, in any event an excess is only payable once per life assured per policy year .
This policy allows for the optional inclusion of a Specialist and Diagnostic Testing Benefit, providing reimbursement for medically necessary consultations with specialists and diagnostic testing (as indicated).
This Benefit Sheet forms part of and is incorporated into your Absolute Health policy, the terms of which apply to this Benefit Sheet .
Prior approval service: Sovereign recommends that you seek Sovereign ’s approval prior to incurring costs related to any medical treatment to ensure that the medical treatment is covered under this policy.
BENEFIT
COVERED EXPENSES
MAXIMUM COVER
Covers reasonable charges incurred during a medical hospitalisation for treatment of a condition which does not require surgery when referred by a specialist including:
> Hospital accommodation fees
> Physician/ specialist fees
> Diagnostic fees
> Ancillary hospital fees: including, but not limited to, materials and medication prescribed while in hospital, physiotherapist fees. Non-surgical hospitalisations include but are not limited to admissions for treatment (other than surgery) of asthma, diabetes, stroke, cancer and oncology radiology/chemotherapy/immunotherapy treatment, lithotripsy or any other acute chronic illness. For cancer chemotherapy and immunotherapy treatment, this includes targeted therapy, oral, intravenous infusion, instilled, and intraoperative chemotherapy provided by or under the direction of a specialist, whether administered in a private hospital or at home. This covers the cost of Pharmac and non-Pharmac subsidised MedSafe indicated cancer chemotherapy drugs, subject to Sovereign criteria .
$300,000 per life assured , per policy year . Includes pre- admission and post discharge below.
Medical hospitalisation in a private hospital
Excess applies.
Prior approval must be obtained before the procedure takes place.
Page 1 of 12
711 ABH-BS version 8 Effective 08 April 2022
BENEFIT
COVERED EXPENSES
MAXIMUM COVER
Covers reasonable charges incurred during a surgical hospitalisation when referred by a specialist including:
> Surgeon fees
> Anaesthetist fees
> Diagnostic fees
> Hospital fees including:
–
Accommodation
–
Operating theatre fees
– Ancillary hospital charges including: anaesthetic supplies, dressings, pathology tests, ECG, post operative physiotherapy, medication (prescribed and taken while in hospital) – Disposable laparoscopic equipment (separate maximum cover may apply)
General surgery performed in a private hospital
Unlimited.
Includes pre- admission and post discharge below.
– Prostheses (separate maximum cover may apply)
Also covers reasonable charges incurred for the following procedures performed on a life assured admitted overnight to a private hospital , when recommended by a specialist :
Excess applies.
> Dilatation and curettage
> Arthroscopy
> Hysteroscopy
> Laparoscopy
Breast reconstruction of the affected breast only following a mastectomy for the treatment of diagnosed cancer.
Breast reconstruction following mastectomy
Prior approval must be obtained before the procedure takes place.
Cover is not provided for breast reconstruction following any mastectomy which is a prophylactic procedure.
Covers costs up to the maximum cover for procedures on the unaffected breast to achieve breast symmetry following a mastectomy. This will be available either during or following the mastectomy to treat the diagnosed cancer of the affected breast, which has been covered by your Sovereign health policy. Procedures covered under this benefit may include breast reduction surgery, but do not include breast reconstruction following a mastectomy carried out on the unaffected breast which is a prophylactic procedure. The procedures to achieve breast symmetry do not need to be medically necessary .
$50,000 per life assured per life of the policy.
Breast symmetry surgery following mastectomy
Prior approval must be obtained before the procedure takes place.
Covers support services following cancer treatment including:
$1,000 per life assured per policy year .
> Psychologist consultations, therapy and counselling, > Personal items such as wigs to cover hair loss, bras following a mastectomy, > Lymphatic massage, > Home help services including meal preparation, cleaning, showering and child care, provided by a suitably qualified person
Post-cancer treatment care and support
No excess applies.
Page 2 of 12
711 ABH-BS version 8 Effective 08 April 2022
BENEFIT
COVERED EXPENSES
MAXIMUM COVER
(employed in the provision of home help services).
These support services and personal items do not need to be medically necessary.
Covers reasonable charges of cardiac surgery or non-invasive cardiac procedures when referred by a specialist including:
> Cardiac surgeon and perfusionist fees
> Cardiologist and radiologist fees
> Anaesthetist fees
> Diagnostic fees
Unlimited.
> Hospital fees including:
Includes pre- admission and post discharge below.
Cardiac surgery/ procedures performed in a private hospital
–
Accommodation
–
Operating theatre fees
Excess applies.
–
Intensive/coronary care unit fees
– Ancillary hospital charges including: anaesthetic supplies, dressings, pathology tests, ECG, postoperative physiotherapy, medication (prescribed and taken while in hospital), stents including drug eluting stents, angioplasty catheters
– Cardiac prostheses (separate maximum cover may apply).
Covers reasonable charges of medically necessary oral surgery*, performed by an oral surgeon , when referred by a registered medical practitioner including:
> Oral surgeon fees
> Anaesthetist fees
> X-rays
> Hospital or day stay clinic charges (if applicable)
> Ancillary charges including: dressings, medication (prescribed immediately post surgery), anaesthetic supplies.
Unlimited
Includes pre- admission and post discharge below.
*Oral surgery procedures covered are:
Oral surgery performed in a private hospital or day stay clinic
> Removal of impacted wisdom teeth (procedure is only covered from 12 months after the commencement of this cover). > Removal of unerupted teeth (procedure is only covered from 12 months after the commencement of this cover).
Excess applies.
> Treatment of cysts, soft tissue swellings and enlargements.
> Temporomandibular joint surgery when surgical treatment is considered medically necessary. Cover is not provided for root canal treatment, dental repair or implants. Cover is also not provided for orthodontic treatment or orthognathic surgery of any kind. Covers dental evaluation and treatment performed by an oral surgeon or a dental practitioner , on the recommendation of the treating registered medical specialist as a precursor to the following treatments where those treatments are covered by your policy: > Chemotherapy and immunotherapy using antiresorptive drugs. > Radiotherapy treatment (head and neck).
$1,500 per life assured per policy year .
Dental evaluation and treatment prior to qualifying treatments
No excess applies.
Page 3 of 12
711 ABH-BS version 8 Effective 08 April 2022
BENEFIT
COVERED EXPENSES
MAXIMUM COVER
> Heart valve replacement surgery.
Prior approval must be obtained before any dental evaluation or treatment takes place.
Covers reasonable charges of specialist consultations and diagnostic procedures directly relating to a medical condition covered above and when referred by a specialist . Period covered is for six months before and twelve months after a covered medical hospitalisation or surgery. Physiotherapy and prescription costs directly relating to the approved surgery performed within six months after surgery. Covers reasonable charges incurred with an outpatient surgical procedure when recommended by a specialist (including related diagnostic testing performed in connection with the procedure). This benefit provides coverage for medically necessary angiograms, MRI and CT scans, regardless of whether surgery is performed or not. This benefit also covers reasonable charges incurred for the following procedures when recommended by a specialist :
Included as part of the above hospitalisation or surgery maximum cover .
Pre-admission and post discharge from a private hospital or day stay clinic
$100,000 per life assured , per policy year .
Outpatient care received at a private hospital , day stay clinic or specialist rooms approved by Sovereign
> Arthroscopy
> Cystoscopy
> Colonoscopy*
Excess applies.
> Dilatation and curettage
> Gastroscopy
> Hysteroscopy
> Laparoscopy
> Myelogram
*Cover is not provided for routine screening or periodic testing.
Covers reasonable charges incurred with any of the following outpatient surgical procedures performed by a registered medical practitioner under local anaesthesia in general practice surgery rooms.
This benefit only provides coverage for the medically necessary :
$500 per life assured per treatment to a maximum $1,000 per life assured per policy year .
> Excision of lesions, moles and cysts;
Non-specialist outpatient minor surgery
> Biopsies of lesions, moles and cysts;
> Wedge resection of toenails;
> Allergy desensitisation injections;
No excess applies.
> Skin prick testing;
> Varicose vein treatment;
> Vasectomy – only applies after two continuous years of cover. The vasectomy does not need to be medically necessary .
Page 4 of 12
711 ABH-BS version 8 Effective 08 April 2022
BENEFIT
COVERED EXPENSES
MAXIMUM COVER
Covers the cost up to the maximum cover for this benefit for surgery for any of the following congenital conditions :
> umbilical hernia;
> inguinal hernia;
> undescended testes;
> hydrocele;
> tongue tie;
> phimosis;
> squint.
$2,000 per life assured per lifetime.
Congenital conditions surgery benefit
The surgery must be performed in an approved facility by a specialist or oral surgeon , or by a general practitioner .
Prior approval must be obtained before the surgery takes place.
The pre-existing conditions exclusion does not apply to the Congenital conditions surgery benefit.
Subject to the maximum cover for this benefit, more than one claim may be made under this benefit.
No excess is payable for any claims under this benefit.
$300 per day up to a maximum of $5,000 per life assured , per policy year .
Covers reasonable charges of home care provided by a registered nurse when recommended by a specialist . This care must immediately follow discharge from a private hospital for a covered surgical or medical procedure.
Home nursing care
No excess applies.
All payments made under this benefit will be in New Zealand dollars and will be credited directly to the bank account nominated by the policy owner . We will not accept responsibility for costs associated with any complications during or following any treatment or procedure covered under this benefit that arise as a direct or indirect result of the treatment, procedure, consultation, test, diagnostic imaging, support, or care. No Medical Misadventure benefit is payable in relation to any treatment, procedure, consultation, test, diagnostic imaging, support, or care covered under this benefit. Prior approval must be obtained before the treatment, procedure, consultation, test, diagnostic imaging, support, or care takes place.
Benefit maximum for the applicable benefit applies, subject to the additional limits, exclusions and requirements set out in this section.
Voluntary treatment overseas
Treatment in Australia
Excess applies.
This benefit covers the costs for the approved treatment, procedure, consultation, test, diagnostic imaging, support or care, subject to the maximum cover under this policy for the applicable benefit in New Zealand dollars, at a health service facility approved by Sovereign .
Treatment outside Australia
This benefit covers the costs for the approved treatment, procedure, consultation, test, diagnostic imaging, support recommended by a New Zealand specialist .
Page 5 of 12
711 ABH-BS version 8 Effective 08 April 2022
BENEFIT
COVERED EXPENSES
MAXIMUM COVER
Cover is also provided for the cost of a single return economy class airfare for the life assured and one support person. The total amount payable under this benefit is 85% of the reasonable charges , subject to the maximum cover under this policy for the applicable benefit in New Zealand dollars, at a health service facility approved by Sovereign .
Treatment in and outside Australia
Following the treatment, procedure, consultation, test, diagnostic imaging, support or care, a receipt in English needs to be provided to Sovereign , together with any other information reasonably required by Sovereign from the health service provider. When a medically necessary treatment or procedure covered by one of the other benefits of this policy is available in New Zealand but is unable to be carried out within six months in an approved facility , and so is carried out in an overseas facility approved by Sovereign , this benefit will cover the reasonable charges of that treatment or procedure as if it was provided in New Zealand up to the maximum cover stated for the applicable benefit in New Zealand dollars. Cover is also provided for the cost of two return economy class airfares for the life assured and a support person. Prior approval must be obtained prior to the treatment or procedure taking place. Covers reasonable charges for medical treatment at an overseas hospital acceptable to Sovereign , where medical treatment covered under this policy cannot be provided in New Zealand. A specialist must recommend the medical treatment and approval of the claim must be received from Sovereign prior to the medical treatment. This benefit also includes two return economy class airfares for the life assured and a support person. This benefit specifically covers the transfer of a patient from one private hospital or day stay clinic to another private hospital or day stay clinic in a situation where complications have arisen and further treatment can only be provided by specialist services at the private hospital or day stay clinic to where the patient is being transferred. The benefit only applies to transfers within the North and South Islands of New Zealand. All reasonable charges for the following modes of transport will be met: air ambulance, road ambulance, road transport or economy airfares.
Treatment overseas where the waiting period for treatment in an approved facility in New Zealand is greater than six months
Benefit maximum for the applicable benefit applies.
Excess applies.
$30,000 per life assured , per policy year .
Overseas medical treatment
Excess applies.
No maximum cover .
Transfer benefit
No excess applies.
If a life assured dies when aged between 21 and 59 (inclusive), Sovereign will pay a death benefit of $2,500 to the policy owner or their estate (no excess applies).
Bereavement grant
No excess applies.
Covers reasonable charges of accommodation and/or transportation as required for a parent, guardian or support person who accompanies a life assured receiving a covered treatment outside their region of residence.
$300 per day up to a maximum of $3,000 per life assured , per policy year .
Caregiver accommodation
Page 6 of 12
711 ABH-BS version 8 Effective 08 April 2022
BENEFIT
COVERED EXPENSES
MAXIMUM COVER
$300 per day after the third day, up to a maximum of $3,000 per life assured , per policy year .
Lump sum payment paid if the life assured is admitted to a public hospital for a continuous period of more than three days (not including admissions on a private fee paying basis or for obstetric care).
Public hospital cash grant
For the purposes of this grant, a ‘day’ must include an overnight stay.
Upon the death of a life assured , prior to attaining the age of 70 years, and where the cause of death is not excluded under this policy, Sovereign will continue to provide cover under this policy for the surviving lives assured covered by the policy at the time of death, without requiring further premiums for 12 months from the date of death.
Waiver of Premium
No maximum cover .
Covers reasonable charges of sterilisation including vasectomies and female sterilisation procedures (i.e. tubal ligation and hysteroscopic sterilisation).
Applies only after two years of continuous cover.
Loyalty benefit: Sterilisation
Prior approval must be received from Sovereign .
Excess applies.
If, during the course of any medical procedure or treatment in a private hospital , a life assured should die directly as a consequence of any erroneous or negligent action, omission or failure to observe reasonable and customary standards by a care provider of the said hospital, a death benefit shall become payable, provided: > the death occurs within 30 days of such a recorded and proven incident; and > a public admission of such incident and liability is made by the said hospital and verified and confirmed by the relevant government authority , a court of law, coroner’s inquest or the Medical Council of New Zealand; and > the death is independent of any other cause other than the termination of the life support system after brain death has been established. Provides a contribution towards the cost, up to the maximum cover for this benefit, of medically necessary sleeve gastrectomy, gastric banding or bypass surgery including the costs of the related consultations, tests and diagnostic imaging for the life assured , where surgery is recommended by a specialist because the life assured has all of the following:
$30,000 per life assured .
Medical misadventure
$7,500 per life assured, per lifetime for the Bariatric surgery and Bilateral
a BMI of: a.
40 or more, or
b. 35 or higher and at least one of the following obesity- related diseases that is expected to be improved:
Loyalty benefit: Bariatric surgery
breast reduction loyalty benefits combined.
–
coronary heart disease;
–
type 2 diabetes;
Excess applies.
–
obstructive sleep apnoea;
– osteoarthritis in a weight bearing joint (radiological evidence required); or – blood pressure greater than 140/90 that cannot be effectively controlled via medication; and
completed physical growth; and
Page 7 of 12
711 ABH-BS version 8 Effective 08 April 2022
BENEFIT
COVERED EXPENSES
MAXIMUM COVER
previously failed attempts to lose weight.
Excludes any other type of bariatric surgery, such as banded gastroplasty (stomach stapling).
Prior approval must be obtained prior to the treatment or procedure taking place.
Cover under this benefit is only available to a life assured after three years of continuous cover under this policy.
Provides a contribution towards the cost, up to the maximum cover for this benefit, of bilateral breast reduction surgery including the costs of the related consultations, tests and diagnostic imaging for the life assured .
Excludes any surgery to correct any traumatic or post-surgical asymmetry, or to remove breast implants.
Loyalty benefit: Bilateral breast reduction
Prior approval must be obtained prior to the treatment or procedure taking place.
Cover under this benefit is only available to a life assured after three years of continuous cover under this policy.
Page 8 of 12
711 ABH-BS version 8 Effective 08 April 2022
2. Additional option – Specialist and Diagnostic Testing Benefit
This option, if selected, provides supplementary cover to the lives assured . It incurs additional premiums associated with the increase in benefits. If you have elected an excess option on your Specialist and Diagnostic Testing Benefit, this will be shown on the schedule . This excess applies once per life assured per policy year .
BENEFIT
COVERED EXPENSES
MAXIMUM COVER
Covers reasonable charges of a specialist when referred by a registered medical practitioner including:
> Cardiac surgeons
> Cardiologists
> Ear, nose and throat specialists
$5,000* per life assured , per policy year .
> Gastroenterologists
> General surgeons
Specialist consultations
> Gynaecologists
*Includes diagnostic tests below.
> Neurosurgeons
Excess applies.
> Oncologists
> Orthopaedic surgeons
> Urologists
Cover is not provided for obstetricians, psychiatrists or psychologists.
Covers the reasonable charges of diagnostic procedures directly relating to a medical condition when referred by a specialist including but not limited to:
> Allergy testing
> Audiology
> Audiometric tests
> CT scans
> Colonoscopy*
> Cystoscopy
> Electroencephalography (EEG)
> Electromyography (EMG)
Included as part of the maximum specialist consultation cover above.
> Exercise ECG
Diagnostic tests
> Gastroscopy
> Holter monitoring
Excess applies.
> Laboratory tests
> Mammography*
> MRI scans
> Myelogram
> Ultrasound
> Urodynamic assessments
> X-rays
*Cover is not provided for routine screening or periodic testing.
Page 9 of 12
711 ABH-BS version 8 Effective 08 April 2022
BENEFIT
COVERED EXPENSES
MAXIMUM COVER
Covers the cost up to the maximum cover for this benefit of the following procedures performed at an approved facility :
> bone screening (osteoporosis)
> bowel screening
> breast screening
> cervical screening
> heart screening
$500 per life assured for each three year period or $750 if the life assured is a member of AIA Vitality .
> prostate screening
> eye tests and/or visual field tests
> hearing tests
Health screening allowance
> skin checks
> aortic aneurysm screening
No excess applies.
Cover under this benefit is only available to a life assured after three years of continuous cover under Absolute Health. The health screening test does not need to be medically necessary but the procedure must be performed by or referred by a registered medical practitioner . If as a result of a health screening test, a diagnosis is made for a condition requiring treatment or care that is covered under another benefit in this policy, the costs incurred for the screening will be covered under that benefit and the maximum cover for this benefit will be reinstated.
Page 10 of 12
711 ABH-BS version 8 Effective 08 April 2022
Best Doctors is available for the life assured and their immediate family to use as many times as they need to. Best Doctors can provide additional advice on critical, chronic and degenerative conditions after the person who is suffering the condition has seen a specialist . The Best Doctors service can be accessed regardless of whether the condition is covered by this policy. Best Doctors is independent of Sovereign and Best Doctors terms and conditions and eligibility criteria apply. Neither Sovereign , its related companies, nor their directors, officers or employees accept any liability whatsoever for any loss or damage arising out of the use of the Best Doctors service, or the unavailability of Best Doctors. Sovereign is not responsible for any cost associated with becoming eligible to use, or use of, the Best Doctors service (including without limitation the cost of any medical consultations or treatment, travel, lodging, telephone calls, faxes or mail), unless covered by Sovereign policy.
Contact Best Doctors on 0800 425 005.
Best Doctors and the star-in-cross logo are trademarks of Best Doctors, Inc., in the United States and in other countries and are used under licence.
3. Exclusions
Sovereign will not pay any expenses incurred in relation to, or as a consequence of, any of the following:
> Any accommodation, flight and/or transport, except where expressly covered by a benefit in this policy; > A pre-existing condition , unless the symptom or condition was disclosed at the time of your application and accepted in writing by Sovereign ; > Any congenital conditions , except where expressly covered under the Congenital condition surgery benefit in this policy; > Reconstructive or reparative procedures or surgery, which result from, or which are traceable to, or are medically related to, any surgery performed prior to the risk commencement date ; > Any elective or cosmetic procedures and associated treatments (including, for example, surgery for breast enlargements, facelifts, varicose veins); > Breast reduction surgery (except where expressly covered under a benefit in this policy) and gynaecomastia; > Acne treatment, except where classified by a specialist as Grade 4 acne with serious medical implications; > The misuse of prescribed or non-prescribed drugs, including where they have not been taken in accordance with the manufacturer’s or a registered medical practitioner ’s directions; > Certifiable mental disease or psychiatric illness or any charges relating to services resulting from a referral to, or provided by, a psychiatrist. This includes all counselling services; > Suicide, self-inflicted injuries or illness. For the Waiver of Premium benefit and Bereavement grant benefit, this exclusion only applies for the first 13 months from the risk commencement date ; > Any accident, illness, condition or disability arising from, or caused or contributed to by, drug taking, intoxication or misuse of alcohol, or nuclear contamination; > Obstetric visits, pregnancy, childbirth, abortion, or any conditions or complications arising from any of the foregoing;
> Contraception of any type;
> Diagnosis, management and treatment of infertility;
> Circumcision, except where medically necessary ;
> Diagnosis, management and treatment of snoring, except where a specialist confirms diagnosis of sleep apnoea and the surgical treatment is medically necessary (pre-approval of any claim for treatment must be sought or obtained from Sovereign before any costs are incurred); > Any geriatric or dementia conditions, including disability support services; > New medical treatments, procedures or technologies that have not been approved by Sovereign ; > Treatment requiring periodontal, orthodontic, endodontal or cosmetic procedures , including, but not limited to, conditions arising out of neglect of dental services except where expressly covered under a benefit in this policy; > Sterilisation (except as provided under the Loyalty Benefit);
> Any surgery for the correction of refractive visual errors;
> Preventative treatment, or treatment or investigation of any condition that will not cause significant problems for the health of the individual if medical treatment is not received (including, for example, routine screening or mole mapping); > Treatment for obesity (including treatment of complications arising from any treatment for obesity), except where expressly covered by a benefit in this policy; > Bariatric surgery for any condition including but not limited to obesity, diabetes and sleep apnoea except where expressly covered by a benefit in this policy > Any disease or disorder of the skin or psychological treatment);
> Renal dialysis;
Page 11 of 12
711 ABH-BS version 8 Effective 08 April 2022
> Injuries of war or resulting from any terrorist act (whether war is declared or not);
> Organ donation and receipt;
> Charges for a treatment or procedure not provided by a registered medical practitioner practising within his or her scope of practice; > Treatment provided by a public hospital , except where expressly covered by this policy; > Physiotherapist, chiropractor, osteopath, naturopath, homeopath, acupuncturist, podiatrist, dietician, counsellor and speech therapy costs; > Nursing costs, except where expressly covered by this policy; > Prescription charges, except where expressly covered by this policy; > Any charge incurred for non-essential or personal items (for example, newspapers, spouse/family meals, alcohol, TV rental); > Any appliances, aids, implants or equipment including but not limited to implantable defibrillators, nerve appliances, hearing aids, cochlear implants, braces, crutches, mouth-guards, orthotics, insulin pumps, CPAP machines and any other appliances or equipment (surgical, medical or dental) except cardiac pacemakers, implantable loop recorders or where expressly covered under a benefit in this policy; > Any condition arising from participation in a criminal activity; > Any condition specifically excluded in the policy document; > Costs for treatment carried out outside of New Zealand (except where expressly covered under the Overseas Medical Treatment Benefit);
> Palliative care;
> Any part of a claim that you make under this policy to the extent that you are able to recover from sources outside of this policy, including any other contract of insurance, regardless of whether you claim from these other sources or not. > Any benefit under this policy for any additional surgery performed during any operation, which is not directly related to any medical condition or treatment covered under the terms of this policy.
Page 12 of 12
711 ABH-BS version 8 Effective 08 April 2022
Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12Powered by FlippingBook