a) Prior approval and direct payment process for claims:
Subject to the terms of this policy, Sovereign will pay all reasonable charges for medically necessary treatment up to the respective maximum cover . If the costs of the medical treatment or procedure are greater than the lesser of the maximum cover or the reasonable charges , the balance of the costs remaining after Sovereign has paid the lesser of the reasonable charges or the maximum cover will be your responsibility. If this policy is cancelled for any reason and there are outstanding claims relating to any medical treatment, procedure or other event covered under this policy that occurred before the date of cancellation, Sovereign must receive the relevant claim forms within 30 days of the cancellation date, otherwise the claim will not be payable. Sovereign is not under any obligation to consider a claim unless all of the required information is provided to us . All claims are paid in New Zealand dollars. You must submit all claims or all invoices/accounts relating to pre-approved claims to Sovereign within 12 months of the registered medical practitioner performing the medical treatment or procedure.
The policy owner must comply with the following requirements when seeking Sovereign ’ s prior approval and direct payment of any claims: > Prior approval requests should be made as soon as you are aware of a pending private hospital admission, MRI or CT scan or other specialised imaging procedure. We need a minimum of five working days to process a claim prior to the actual private hospital admission or procedure. Failure to notify Sovereign within the required timeframe
may result in a prior approval authorisation being declined or delayed until Sovereign has had the opportunity to fully assess the claim.
> The policy owner should provide Sovereign with:
details of the planned medical treatment or procedure, including an estimate of the cost; and
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– a copy of the registered medical practitioner ’ s referral letter and any other relevant clinical notes that may be requested by us in order to assess that the medical treatment or procedure being contemplated is medically necessary and falls within the terms and benefits of this policy.
4 . Claims on other insurers
Where another insurer, including but not limited to ACC , may have a responsibility in respect of a claim the following provisions apply: > It is the policy owner ’ s or life assured ’ s responsibility to advise Sovereign that another insurer is involved in a claim that has been submitted to Sovereign . > Before Sovereign accepts a claim under this policy, you must firstly make a claim to other insurers for any expense recoverable from a third party or under any contract of indemnity or insurance. Any expenses recoverable in this way will be deducted from the reimbursement provided by Sovereign under this policy. For the purposes of this policy ACC is defined as another insurer.
> Allow Sovereign in its sole discretion to:
contact the registered medical practitioner and obtain an estimate of the costs associated with the medical treatment or procedure under the claim;
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negotiate the proposed costs; and
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request that a second opinion is sought.
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If your claim is approved, Sovereign will allocate a prior approval reference number to the claim and will fax or post to you or the life assured a letter confirming that the claim has been approved. You must ensure that the prior approval number is quoted on all of the invoices/accounts relating to the pre-approved claim that are sent to Sovereign . b) When you pay for treatment yourself and then submit a claim for reimbursement: You should complete the claim form and send it to us together with the registered medical practitioner ’ s referral letter and/or medical certificate and all of the original receipts and itemised invoices. For any claim to be admissible regardless of payment method: > the medical treatment or procedure must be medically necessary , as evidenced by the registered medical practitioner ’ s referral letter and/or medical certificate and any other documentation requested by Sovereign to satisfy itself that the medical treatment or procedure is medically necessary ; and > premiums must be fully paid at the time the medical treatment or procedure takes place.
5 . For claims involving ACC:
a) It is the life assured ’ s or the policy owner ’ s responsibility to submit any accident related claim to ACC in the first instance. Where surgery is indicated, the life assured or policy owner must seek or obtain prior approval from ACC for private hospital costs . b) In respect of any accident related hospital treatment, Sovereign will not pay for MRI or CT scans or other specialised imaging procedures required within seven days of the injury occurring. c) If, due to the policy owner ’ s or life assured ’ s failure to comply with ACC’ s requirements, ACC refuses to cover the claim or ceases claim cover, the policy owner or life assured will be deemed by Sovereign to not have made a reasonable effort to secure cover and will therefore be ineligible to claim under this policy. d) If ACC declines cover for private hospital treatment of an accident related condition, Sovereign reserves the right to insist that the policy owner or life assured applies to ACC for a review of that decision before Sovereign accepts any
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710 ABH-UMB version 8 Effective 8 April 2022
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