PC-S3HC-04/2022
Personal Cover - Superior 3 Health Cover SECTION A - GENERAL INFORMATION AND DEFINED TERMS POLICY PURPOSE 1 Your Superior 3 Health Cover plan is a major medical policy designed to assist You with meeting the financial costs associated with the health services covered by this plan. POLICY 2 The terms of Your Superior 3 Health Cover plan with Us are set out in this Policy and the attached Policy Schedule , complete with any endorsements.
The Policy Schedule includes personal details of the people insured and may include special terms of Your contract. This Policy is a contract of insurance between You and Us . It includes the following parts: • Your application for insurance; and
• this Policy wording; and • the Policy Schedule ; and
• any addendum to the Policy Schedule ; and • any other written notice that We give You ; and • any written notice that You give Us .
PREMIUM RATES AND TERMS OF THIS POLICY
3 We may change the premium rates, terms and conditions of this Policy at any time by giving You thirty (30) days written notice to Your last known
postal address advising You of such changes.
4 We will charge You a policy fee, which forms part of Your Total Premium. The policy fee is used to pay the ongoing administration costs of this Policy. The policy fee is specified in Your Policy Schedule. We may change this policy fee from time to time. If this occurs any such change will be notified to You in writing. The annual Total Premium or instalment of the Total Premium is payable for the entire life of the Policy together with any increases in Premium applicable where an additional benefit or amendment to the Policy has been effected or selected. 5 We strongly recommend that You seek prior approval for any claim to ensure that the medical treatment or procedure is covered under the terms and conditions of Your Superior 3 Health Cover plan. We recommend You contact Us as soon as possible to start this process. We can be contacted on 0800 800 242. In order for a claim to be paid where We have provided You with pre-approval advice, Your policy must be in force on the date You have the medical treatment or procedure for which We have pre- approved. 6 We reserve the right to seek a second medical opinion in certain circumstances. All costs related to a second medical opinion will be paid for by Us . We require You to comply with any reasonable requests We or Our medical examiner may make including attending any examinations or tests. 7 To enable You to consider the Policy in detail You will have a free look period of fourteen (14) days after You receive Your Policy terms and conditions document. During this period, if You decide that the Policy does not suit Your needs, then You may return it to Us and receive a full refund of all Total Premiums paid and the Policy will be cancelled. You will be deemed to have received Your policy document three (3) business days after it was posted by Us . 8 The Superior 3 Health Cover plan complies with the Health Funds Association of New Zealand (Inc) Code of Practice for Health Insurance Underwriters.
POLICY FEE
PRIOR APPROVAL
SECOND OPINION
FREE LOOK
PERIOD
CODE OF PRACTICE
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DEFINED TERMS
9 In this Policy certain words have particular meanings. These words are in Bold and the meanings set out below. Interpretation Throughout this Policy ' We ', ' Our ' ' Us ' or ‘ AIA New Zealand ’ means AIA International Limited - New Zealand Branch, and/or any related and/or authorised companies and/or agents (including company officers acting in the scope of their authority). ' You ' or ' Your ' means the Lives Assured . ACC Means the Accident Compensation Corporation as defined by the Injury Prevention, Rehabilitation and Compensation Insurance Act 2001, or its successor under any subsequent legislation. Allowance Contribution toward the cost of treatment specified. Annual Excess The amount shown on the Policy Schedule which We do not pay. It is the amount You pay. ( Note: An excess of $100 per Life Assured per claim automatically applies for the first two years from the Policy Commencement Date to the Additional Specialists Visits and Diagnostics Procedures Benefit). Annual Renewal Date Means the annual anniversary of the Policy Commencement Date . Audiologists Means a practising member of the New Zealand Audiological Society. Cancer Immunotherapy Means immunotherapy for the proven treatment of cancer which stimulates or restores the ability of the immune (defence) system to fight this disease. Cancer Immunotherapy Medicines Means PHARMAC or Non PHARMAC medicines for the proven treatment of cancer which stimulate or restore the ability of the immune (defence) system to fight this disease. Cancer Targeted Therapies Means targeted therapies which interfere with specific molecular targets on cancer cells to inhibit their growth, progression and spread. Care Provider An employee whether indirectly or directly employed by the Private or Public Hospital . Chemotherapy Medicines Means PHARMAC and non PHARMAC medicines that have been registered by Medsafe, and are used according to Medsafe indications. Child or Children Any person under the age of twenty-one (21) who, in Our opinion, is financially dependent on, and may be under the legal guardianship of You or Your spouse or partner. Chiropractor Means a person registered as a Chiropractor with the Chiropractic Board of New Zealand and who holds a current Annual Practising Certificate.
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Congenital Means a condition present at birth acquired by hereditary or genetic origin, or acquired during foetal life. Day Stay Clinic or Facility Means a healthcare facility (usually involving an operating theatre) where a patient has been admitted for a planned clinical intervention and/or Diagnostic Procedure by a Specialist , or at Our discretion a General Practitioner , and the patient leaves the facility within twenty-four (24) hours. Dentist Means a person registered with the Dental Council of New Zealand and who holds a current Annual Practising Certificate. Diagnostic Procedures Investigative medical procedures undertaken by a Specialist to determine the causes of a condition. General Practitioner Means a person who holds a current practising certificate issued by the Medical Council of New Zealand and is practising Primary Care medicine but excluding a General Practitioner who is himself/herself the Life Assured , the spouse, civil union partner, de facto partner, lineal relative, or business partner/associate of You . Hospice Means a healthcare facility providing palliative care services for terminally ill patients that holds regular or associate service membership with Hospice New Zealand. Insured Person Means a person specified as an Insured Person in Your Policy Schedule . Lead Maternity Carer All pregnant women in New Zealand are required to choose a Lead Maternity Carer (LMC) to coordinate the care they will receive throughout their pregnancy, labour, and birth, up to 4-6 weeks after the baby is born. Your LMC can be a midwife, a General Practitioner , a hospital-based team, or an obstetrician. Life Assured Means the Life Assured or Lives Assured listed in Your Policy Schedule . Medical Practitioner Means a person who holds a current practising certificate and fellowship issued by the Medical Council of New Zealand and who has qualified in an approved surgical, anaesthetic or non-surgical discipline. Medsafe Means the New Zealand Medicines and Medical Devices Safety Authority. Medsafe is responsible for the regulation of medicines and medical devices
in New Zealand. Minor Surgery Specific surgery deemed as minor by Us . Non PHARMAC
Means medicines that have been registered by Medsafe, and are used according to Medsafe indications, but are not funded by PHARMAC for use in a private facility.
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Nurse A registered or enrolled Nurse except a spouse, lineal relative or business partner/associate of You who holds a current Annual Practising Certificate issued by the Nursing Council of New Zealand. Oral Surgeon Means a person registered with the Dental Council of New Zealand and who holds an Annual Practising Certificate and is qualified to perform surgery. Oral and Maxillofacial Surgeon Means a person registered with the Dental Council of New Zealand and who holds an Annual Practising Certificate qualified in this surgical specialty. Osteopath Means a person registered as an Osteopath with the Osteopathic Council of New Zealand and who holds a current Annual Practising Certificate. PHARMAC Means the Pharmaceutical Management Agency, the New Zealand government agency that decides which pharmaceuticals to publicly fund. Physiotherapist Means a person registered as a Physiotherapist with the Physiotherapy Board of New Zealand and who holds a current Annual Practising Certificate. Policy Means this contract of insurance between You and Us . It includes the following parts: • Your application for insurance; and • any addendum to the Policy Schedule ; and • any other written notice that We give You ; and • any written notice that You give Us . Policy Commencement Date Means the Commencement Date of the Policy as specified in Your Policy Schedule . Policy Schedule Means the most recent Policy Schedule issued to You by Us , including any endorsements. • this Policy wording; and • the Policy Schedule ; and Policy Year Means the twelve (12) month period which starts from the Policy Commencement Date and ends on the First Anniversary Date . Each subsequent Policy Year is from Policy Anniversary Date to Policy Anniversary Date . Premium Means the Premium specified in Your Policy Schedule or in any
subsequent notice issued to You by Us . Preventative and Routine Screening
A diagnostic investigation or procedure undertaken when the Life Assured has no symptoms and is undertaken as a preventative measure to screen for early detection of diseases.
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Primary Care Means day-to-day medical services provided by a General Practitioner . Private Hospital A privately owned hospital approved by Us which is licensed as a Private Hospital in accordance with the Health and Disability Services (Safety) Act 2001. Public Hospital A hospital service or institution licensed in accordance with the Health and Disability Services (Safety) Act 2001 directly or indirectly owned or funded by the New Zealand Government or any of its agencies. Related Surgery A subsequent surgery performed within 3 months of an initial surgery for the purpose of treating the same medical condition, where the Life Assured has had an accepted Private Hospital Surgical Benefit claim and paid any applicable Annual Excess . For example, if surgeries are staggered on the advice of an appropriate specialist for best medical practice. Specialist(s) A Medical Practitioner qualified in a specialist field of medical or surgical practice and who is currently vocationally registered as a specialist in that field with the New Zealand Medical Council. Top-Up Additional coverage to supplement New Zealand Government, ACC or other Insurers contributions to Overseas Treatment. Total Premium Means the sum of the Premium and policy fee together with any applicable GST as specified in Your Policy Schedule . Usual, Customary and Reasonable Charges and fees that are based on Our estimate of what are Usual, Customary and Reasonable charges and fees for services provided are under similar circumstances by persons or providers with equivalent experience or qualification.
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SECTION B - SUPERIOR 3 HEALTH COVER BENEFIT FEATURES
PRIVATE HOSPITAL - SURGICAL BENEFITS
• Private Hospital or approved Day Stay Clinic or Facility charges for Chemotherapy Medicines for the treatment of cancer, Radiotherapy, Cancer Immunotherapy Medicines or Cancer Targeted Therapies . Treatment can be administered by oral, intravenous infusion, instillation, or intraoperative means. Oral treatment for Chemotherapy, Cancer Immunotherapy and Cancer Targeted Therapies where referred by a Specialist that does not require admission to a Private Hospital or Day Stay Clinic or Facility , will also be covered. Treatment is covered for prescription drugs including: − Drugs listed on the PHARMAC Pharmaceutical Schedule and/or − Non PHARMAC subsidised Medsafe indicated Chemotherapy Medicines for the treatment of cancer. The drugs must be listed on the PHARMAC Pharmaceutical Schedule as being approved for the condition being treated and/or must be Medsafe indicated for the condition being treated, taking into account any restrictions where applicable. • Cardiologist’s fees and Angiography related charges. 2 We will reimburse You for the Usual, Customary and Reasonable expenses incurred for ailments not requiring surgery, where You have been admitted to a Private Hospital in New Zealand upon referral by a Specialist , subject to a maximum of $100,000 per Life Assured , per Policy Year for: 1 We will reimburse You for the Usual, Customary and Reasonable expenses incurred for surgery in a registered Private Hospital in New Zealand, where You have been admitted upon referral by a Specialist , subject to a maximum for all related costs of $200,000 per Life Assured , per Policy Year . Any applicable excess is payable by You to the treatment provider. Expenses We will reimburse in accordance with the terms above, include: • Surgeon and Anaesthetist's fees • Theatre fees • Post-operative and ancillary charges • Perfusionist fees • High Dependency Unit charges • Nursing fees • Prosthesis (subject to the schedule of maximums) • Accommodation fees in a Private Hospital • Prescription drugs including: − Drugs listed on the New Zealand Pharmaceutical Management Agency ( PHARMAC ) Pharmaceutical Schedule and/or − Non PHARMAC subsidised Medsafe indicated Chemotherapy Medicines for the treatment of cancer, administered to You while You are in a Private Hospital or prescribed upon Your immediate discharge from a Private Hospital for a maximum period of one (1) month. The drugs must be listed on the PHARMAC Pharmaceutical Schedule and/or be Medsafe indicated as being approved for the condition being treated, taking into account any restrictions where applicable. • Diagnostic Procedures and Specialist consultations during the twelve (12) months period prior to or after surgery provided they relate to the condition being treated and they have been recommended by a Specialist .
PRIVATE HOSPITAL - NON-SURGICAL
BENEFITS
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• Accommodation fees in a Private Hospital . • Prescription drugs including: − Drugs listed on the PHARMAC Pharmaceutical Schedule and/or − Non PHARMAC subsidised Medsafe indicated chemotherapy medicines for the treatment of cancer administered to You while You are in a Private Hospital . The drugs must be listed on the PHARMAC Pharmaceutical Schedule as being approved for the condition being treated and/or must be Medsafe indicated for the condition being treated, taking into account any restrictions where applicable. • Diagnostic Procedures and Specialist consultations provided they relate to the condition being treated and that they occur within the six (6) month period prior to or after admission to a Private Hospital and they have been recommended by a Specialist . Any applicable excess is payable by You to the treatment provider. 3 We will reimburse You for the cost of the following specific Diagnostic Procedures if they have been recommended by a Specialist or General Practitioner , even if they do not lead to treatment in a Private Hospital , up to $125,000 per Life Assured per Policy Year for: • CT scan • MRI scan • Angiogram • Colposcopy (if carried out under a general anaesthetic) • Cystoscopy (if carried out under a general anaesthetic) • Myelogram (if carried out under a general anaesthetic) • Gastroscopy • Colonoscopy • Hysteroscopy • Laparoscopy Changes in technology in the future may see other major Diagnostic Procedures being introduced which involve significant expense. We may from time to time and at Our discretion, consider reimbursing the cost of such procedures. Any applicable excess is payable by You to the treatment provider. 4 We will cover the costs of the surgical removal of wisdom teeth carried out on You by an Oral Surgeon or Oral and Maxillofacial Surgeon after You have been referred by a General Practitioner or Dentist , up to $200,000 per Policy Year . The wisdom teeth must be totally impacted and totally unerupted, or totally impacted and partially unerupted. Any applicable excess is payable by You to the treatment provider. We do not cover any other dental treatments including, but not limited to, periodontal surgery, orthodontal, endodontal or prosthodontal surgery, or implant prosthesis, check-ups, fillings, caps, repair of broken teeth, cost of gold, titanium or other exotic materials.
SPECIFIC DIAGNOSTICS
BENEFIT
ORAL SURGERY
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SECTION C - SUPERIOR 3 HEALTH COVER BENEFITS
HOME NURSING
1 We will cover the costs of home nursing care provided by a Nurse within a six (6) month period after Private Hospitalisation and on referral from Your treating Specialist or General Practitioner up to $150 per day, up to $6,000 per Life Assured , per Policy Year . No excess applies. A Specialist’s or General Practitioner's Certificate must be forwarded to Us stating the reason why home nursing care is required and the length of time it is required. The home nursing care must relate to the condition(s) treated in the Private Hospital . 2 We will cover the costs of post-operative physiotherapy, chiropractic or osteopathic treatment by a Physiotherapist , Chiropractor or Osteopath required within a six (6) month period of leaving a Private Hospital on referral from Your Specialist , or General Practitioner up to $1,000 per Life Assured , per Policy Year . No excess applies. Treatment undertaken must relate to the condition(s) treated in the Private Hospital . 3 For treatment not available in a Private Hospital in Your immediate area, which requires at least one (1) overnight stay, We will pay for return economy air travel, road transport or road ambulance within New Zealand to the nearest Private Hospital for You and one (1) support person, up to $3,000 per claim. No excess applies. Treatment must be recommended by a Specialist or General Practitioner . The Travel Benefit does not apply to the cost of air travel to or from the Chatham Islands or any other New Zealand Territorial Islands. which requires at least one (1) overnight stay, We will pay for accommodation for You and one (1) support person to accompany You to the maximum of $200 per night (total amount of accommodation for both You and Your support person), with a maximum of $3,000 per claim. Accommodation costs for You and the support person must directly relate to the hospitalisation of the Life Assured . No excess applies. 4 For treatment not available in a Private Hospital in Your immediate area, 5 Covers treatment at an overseas hospital where such treatment cannot be provided in New Zealand. This benefit provides Top-Up cover for reasonable return economy travel costs of the person requiring treatment plus the costs of the treatment, less the amount payable by the New Zealand Government up to a maximum of $25,000 per Life Assured per Policy Year. You must provide evidence of the New Zealand Government’s acceptance to partially fund the treatment and the amount they are willing to pay. Such treatment must be recommended by a Specialist or General Practitioner and be recognised by Us as being a conventional form of treatment. No excess applies. 6 If, during the course of any medical procedure or treatment in a Public or Private Hospital , You 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 thirty (30) days of such recorded and proven incident; and
POST-OPERATIVE PHYSIOTHERAPY, CHIROPRACTIC OR OSTEOPATHIC
TREATMENT
TRAVEL BENEFIT
ACCOMMODATION
BENEFIT
OVERSEAS TREATMENT
GRANT
MEDICAL
MISADVENTURE
BENEFIT
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• 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; and • the death is independent of any other cause other than the termination of life support system after brain death has been established. The maximum death benefit is $30,000 per Life Assured . No excess will apply. Policy are residing in Australia up to a maximum of twenty-four (24) months provided premiums continue to be paid. The maximum amount payable for any claim covered under the Policy while in Australia will be up to 50% of the stated maximums in this Policy , paid in New Zealand currency. For the purpose of this clause the definition of Resident/Residing in Australia is as follows: 7 Your cover will continue while You or any Insured Persons on the “Continuously living in a fixed abode in Australia for a period of greater than four weeks (28 days) as distinguished from a visitor or transient.” We may request that You provide evidence satisfactory to Us to establish that You are residing in Australia. Practitioner not performed under a general anaesthetic. The maximum amount payable per Life Assured , per Policy Year is $1,000. No excess applies. 8 We will cover the costs of Minor Surgery performed by a General 9 We will pay up to $2,000 per Policy to cover the costs of treatment recommended by the Lead Maternity Carer or Obstetrician resulting from diagnosis of a medical condition that is affecting or may affect the pregnancy, labour or birth. Diagnosis must be made within sixty (60) days of the expected delivery date. No coverage is available for any condition arising post birth. Caesarean Sections are specifically excluded. No excess applies. 10 A payment of $3,500 will be paid if You , Your spouse or partner (being insured under the Policy ) dies before turning age sixty-five (65). The payment will be paid to the Policy owner or survivors of them or the estate. This benefit will be void and We shall not be liable to pay if the Life Assured , whether sane or insane, dies by his or her own hand. 11 If You die before sixty-five (65) years of age We will continue to provide Superior 3 Health Cover and waive the Total Premium for the insured surviving partner and insured Children on this Policy for up to two (2) years or until the insured surviving partner reaches the age of sixty-five (65), whichever occurs first. 12 If You are admitted to a Public Hospital for three (3) or more consecutive nights, You will receive $200 for the fourth and each subsequent night, up to a maximum of ten (10) nights. The maximum amount payable per Life Assured , per Policy Year is $2,000. The Public Hospital cash benefit does not apply to any admission as a fee paying patient in a Public Hospital , maternity care or admission due to an accident. No excess applies. 13 If You are admitted to a Hospice for three (3) or more consecutive nights, You will receive $100 for the fourth and each subsequent night, up to a maximum of ten (10) nights. The maximum amount payable per Life Assured , per Policy Year is $2,000. No excess applies.
COVER WHILE IN AUSTRALIA
SPECIALIST MINOR
SURGERY
COMPLICATIONS OF PREGNANCY OR CHILDBIRTH
FUNERAL BENEFIT
WAIVER OF PREMIUM
PUBLIC HOSPITAL CASH BENEFIT
HOSPICE COVER
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HEALTH FUNDING AUTHORITIES - FEE PAYING PATIENTS
14 We will cover treatment carried out in a Public Hospital up to the limits specified under Your Policy , provided We have given Our approval and the Private Involvement Protocols (or any replacement protocols) set by the Ministry of Health for the treatment of private patients in Public
IN A PUBLIC HOSPITAL
Hospitals have been followed.
EXCESS WAIVER
15 If You suffer one (1) or more of the Trauma conditions listed below and as a result are admitted to a Private Hospital or admitted as a fee paying patient to a Public Hospital , We will waive the excess selected (if any). The Trauma conditions are: 1. Heart Attack 2. Stroke 3. Coronary Artery Bypass Surgery 4. Critical Cancer. Diagnosis must be made in writing by a Specialist , to Us and be based upon radiological, clinical, histological or laboratory evidence acceptable to Us . Trauma conditions defined as: 1 HEART ATTACK Heart Attack means the death of a portion of the heart muscle as a result of inadequate blood supply to the relevant area. The basis for Diagnosis of a heart attack will be: • Confirmatory new electrocardiogram (ECG) changes indicative of ischaemia; and • A diagnostic rise and fall (other than as a result of cardiac or coronary intervention) in either: In addition, if the above criteria are not met, We will pay a claim based on evidence satisfactory to Us that You have been Diagnosed as having suffered a myocardial infarction resulting in: • A permanent reduction in the left ventricular ejection fraction to less than 50%, which is the result of the death of a portion of the heart muscle. For the purpose of this policy, the assessment of the ejection fraction should be made at least ninety (90) days after the event that lead to the Diagnosis of a heart attack. 1. Troponin I in excess on 2.0ug/L; or 2. Troponin T in excess on 0.6ug/L. 2 STROKE Stroke (resulting in functional loss) means any cerebrovascular accident or incident producing permanent neurological deficit causing either: • You to suffer at least 25% permanent impairment of whole person function^; or • You to be constantly and permanently unable to perform at least two (2) of the numbered activities of daily living without the physical assistance of someone else (if You can perform the activity on Your own by using special equipment, We will not treat You as unable to perform that activity). This requires clear evidence on a CT, MRI or similar scan that a stroke has occurred and evidence of:
BENEFIT
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• infarction of brain tissue; and • intracranial or subarachnoid haemorrhage ; or • embolisation.
Cerebral symptoms due to transient ischaemic attacks, cerebral injury resulting from trauma or hypoxia, and vascular disease affecting the eye or optic nerve or vestibular functions are excluded. ^as defined in the American Medical Association publication ‘Guides to the Evaluation of Permanent Impairment’ 6th Edition. 3 CORONARY ARTERY BYPASS SURGERY Coronary Artery Bypass Surgery means the actual undergoing of surgery to correct the narrowing or blockage of one (1) or more coronary arteries with bypass grafts for the first time, due to disease of those arteries. The operation must be considered necessary by a Specialist Cardiologist. Non-surgical techniques such as Angioplasty , catheter based techniques, laser or other intra-arterial procedures are excluded. 4 CRITICAL CANCER Critical Cancer means the presence of one (1) or more malignant tumours, characterised by the uncontrolled growth and spread of malignant cells and the invasion of tissue, provided the Diagnosis is unequivocal as confirmed by histopathology. This includes leukaemia, lymphomas, Hodgkin’s disease, malignant bone marrow disorders but excludes the following: • Malignant Melanoma less than 1.5 mm maximum thickness as determined by histological examination based on Breslow thickness and Malignant Melanoma less than Clark Level 3. • A growth histologically described as Carcinoma-in-Situ. • All hyperkeratosis or basal cell carcinomas of the skin. • All squamous cell carcinomas of the skin unless there has been spread to other organs. • Kaposis Sarcoma and other cancers which are directly attributed to AIDS and HIV infections. • All tumours of the prostate unless histologically classified as having a Gleason score greater than 6 or having progressed to at least a clinical TNM classification T2N0M0 as defined by AJCC 6 th Edition 2002. • Tumours treated by endoscopic procedures alone. • We will allow cover for carcinoma-in-situ of the breast where it results in the entire removal of the breast specifically to arrest the spread of malignancy. This procedure must be the appropriate and necessary treatment. Diagnostics Procedures benefit. The $100 excess per Life Assured per claim form submitted will no longer apply after You have had continuous cover in place for two (2) years from the Policy Commencement Date. 16 This benefit is included with the optional Specialists Visits and
EXCESS WAIVER LOYALTY BENEFIT
STERILISATION LOYALTY BENEFIT
17 This benefit is included with the optional Specialists Visits and
Diagnostics Procedures benefit. The Sterilisation Loyalty Benefit applies after You have had continuous cover in place for two (2) years from the Policy Commencement Date . It specifically covers vasectomies and tubal ligation procedures, excluding reversals. Vasectomies carried out by a General Practitioner will be covered. Prior approval must be obtained in writing from Us prior to incurring any costs.
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BILATERAL BREAST REDUCTION / BARIATRIC SURGERY ALLOWANCE
18 We will provide a combined Allowance of up to $7,500 per Life Assured over the lifetime of the Policy after three (3) years of continuous cover towards the costs of: • Bilateral Breast Reduction Surgery 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. • Bariatric Surgery Medically necessary sleeve gastrectomy, gastric banding or bypass surgery including the costs of related consultations, tests and diagnostic imaging, where surgery is recommended by a Specialist because the Life Assured has all of the following: o 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: - coronary heart disease; - type 2 diabetes; - 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 o completed physical growth; and o previously failed attempts to lose weight. Excludes any other type of bariatric surgery, such as banded gastroplasty (stomach stapling). You must seek prior approval before this Allowance is payable. The maximum amount payable under this Allowance is $7,500 per Life Assured over the lifetime of the Policy across both bilateral breast reduction surgery and bariatric surgery combined. Once this amount has been exhausted no further Allowance is payable. An Annual Excess applies. 19 This Congenital Conditions Benefit covers the costs of surgery for any of the following Congenital conditions: • umbilical hernia • inguinal hernia • undescended testes • hydrocele • tongue tie • phimosis • squint The surgery must be performed in an Approved Facility by a Specialist, an Oral and Maxillofacial Surgeon , or a Medical Practitioner . You must seek prior approval before this Congenital Conditions Benefit is payable. We will cover up to $2,000 per Life Assured over the lifetime of the Policy . No Annual Excess applies.
CONGENITAL CONDITIONS BENEFIT
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SECTION D - OPTIONAL BENEFITS
ADDITIONAL
1 If Your Policy Schedule shows that You have selected this optional benefit, We will reimburse the costs of Specialist consultations and Diagnostic Procedures if they do not relate to a claim for treatment in a Private Hospital . To qualify for reimbursement the procedure or consultation must be recommended by a Specialist or General Practitioner . Diagnostic tests covered include, but are not limited to: • X-rays • Mammography • Ultrasound • Audiology (Performed by Audiologists ) • Urodynamic Assessments
SPECIALIST VISITS AND DIAGNOSTIC PROCEDURES
• Audiometric Tests • Laboratory Tests • Colposcopy (not performed under general anaesthetic) • Allergy Testing • Holter Monitoring
• ECG • EEG • EMG
But do not include Preventative and Routine Screening tests. We specifically exclude the payment of costs relating to Hearing Aid equipment. Specialist consultations with a Psychiatrist are covered for an initial assessment of mental health, for the first consultation only. This assessment should include one (1) or more of a review of previous records, a clinical assessment, or a production of a written summary and recommendations. All forms of psychiatric treatment are specifically excluded as set out in Section G “Exclusions”. We will reimburse You for the Usual, Customary and Reasonable costs of up to $3,000 per Policy Year on each person insured on the Policy Schedule . A $100 excess per Life Assured per claim form submitted will apply in all circumstances for the first two years from the Policy Commencement Date to the Additional Specialists Visits and Diagnostic Procedures benefit. If Your Policy Schedule shows that You have selected this Optional Waiver of Premium Benefit, Total Premiums will be waived in the event that an adult Life Assured meets the definition of disablement as set out below: The adult Life Assured continues, having provided supporting medical evidence acceptable to Us , to be totally disabled as a result of bodily injury or illness which commenced during the period of insurance which directly and independently of any other cause, wholly prevents the Life Assured from engaging in his/her normal or usual business, occupation or work from which he/she derives remuneration or income, or in any business, occupation or work for which he/she is suited by way of education, training or experience. The Waiver of Premium Benefit will cease at age sixty-five (65) or when the adult Life Assured returns to work, whichever is sooner.
OPTIONAL WAIVER 2
OF PREMIUM BENEFIT
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SECTION E - OTHER IMPORTANT INFORMATION GOVERNING THIS POLICY 1 • Where the ACC provides cover for an injury, illness or condition,
INJURY
PREVENTION, REHABILITATION AND COMPENSATION ACT 2001 (KNOWN AS ‘ACC’)
You must obtain approval of the ACC for the provision of treatment in a Private Hospital ; or • Where the ACC approves the claim but declines to pay the costs of surgical treatment. We may meet the cost of that treatment when You provide Us , prior to Your treatment, with a copy of the ACC 's decision; or • Where the ACC accepts Your claim, We will provide Top-Up payments for the difference between ACC reimbursements and Our Usual, Customary and Reasonable charges applicable for surgical and medical costs. • Where the ACC declines Your claim outright, We may require You to appeal the ACC decision through the documented ACC Review Process ( www.acc.co.nz/ claimscare/resolve-issues/ask-for-a-review) or any subsequent appeal process. All appeals must be made within the ACC timeframes of three (3) months post original decision. 2 You can suspend the cover and Total Premium payments under this Superior 3 Health Policy for a period of between three (3) and twenty-four (24) consecutive months if You reside outside of New Zealand for longer than three (3) consecutive months or You have been subject to involuntary redundancy provided the Policy has been in force for at least twelve (12) consecutive months. You must advise Us in writing before going overseas and when made redundant. We must have confirmed in writing that cover is suspended. The Superior 3 Health Policy may not be suspended for less than three (3) consecutive months. We will resume cover without requiring evidence of health for any insured person at the end of the requested period of suspension. Once cover is reinstated, Total Premiums must recommence. We will not pay any benefits under this Superior 3 Health Policy in respect of any event, symptom or condition that You became aware of, or sought treatment or advice for (whether diagnosed or not) that occurred while cover is suspended. The total period of time that Total Premiums may be suspended under this Superior 3 Health Policy is for a period of twenty-four (24) months. If cover for all adult Lives Assured has been suspended, cover for any Children covered by the Superior 3 Health Policy must also be suspended. You may extend cover under this Policy at any time to include: • Your spouse or partner - subject to health evidence and acceptance by Us . • any Child under the age of twenty-one (21) who, in Our opinion, is financially dependent on, and under the legal guardianship of You or Your spouse or partner subject to health evidence and acceptance by Us . If the category of cover specified in the Policy Schedule is either 'single parent' or 'family', additional Children (as defined above) can be insured under the Policy without any increase in Premiums . Otherwise, additional Premiums may be required. You may remove any person insured under the Policy at a Premium due date by written request to Us at least thirty (30) days before that date. Children receive automatic coverage for the first six (6) months after being born, subject to the exclusions specified in the Section G “Exclusions”.
SUSPENSION OF COVER
ADDITIONAL INSURED PERSONS
3
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If You require Your Child to be covered after this six (6) month period, You must advise Us of the Child's name, sex and date of birth before this free coverage period expires. However all Children are subject to an exclusion for Congenital (i.e. present at birth) disorders as specified in the Section G “Exclusions”. After the six (6) month period Children will be medically underwritten and the relevant Premium will then be charged. However, Children will not be covered under Your Policy after the age of twenty-one (21). • no longer financially dependent on, or under the legal guardianship of You or Your spouse or partner, may transfer to their own Policy if they make a written application to Us within three (3) months of their twenty-first (21 st ) birthday or the date (as determined by Us ) that they ceased to be dependent. No health evidence will be required for a person transferring from an existing Policy to his or her own Policy as long as the person has applied to Us and the new Policy has been issued within the three (3) month period outlined above. Medical underwriting will be required where the new Policy contains additional benefits to that of the original Policy . • Your spouse or partner may also transfer to their own Policy if they make a written application to Us within three (3) months of the date they were removed from the Policy . No health evidence will be required for a person transferring from an existing Policy to his/her own Policy as long as the person has applied to Us and the new Policy has been issued within the three (3) month period outlined above. Medical underwriting will be required where the new Policy contains additional benefits to that of the original Policy . A person who is: • over the age of twenty-one (21); or
TRANSFER TO OTHER POLICIES
4
ADDING OPTIONAL 5
Additional Specialist Visits and Diagnostic Procedures. This optional benefit can be added to Your Policy subject to the following: • A full health statement must be completed and forwarded to Us . • Any increase in Premium for the additional benefit will start from the Policy Commencement Date of the new benefit. • We do not have to agree to any optional benefit addition unless We are satisfied that the Life Assured is in good health. You may remove the optional benefit by giving Us thirty (30) days notice in writing. 6 If the Policy Schedule shows that Your Policy has an Annual Excess , We will deduct the amount of this excess from any claim that We admit under this Policy in respect of expense that You have undergone during the Policy Year , unless: • the claim is submitted under the optional Additional Specialists Visits and Diagnostics Procedures benefit or specific benefits listed under Section C “What Your Policy Covers - Superior 3 Health Cover Benefits” of this Policy . • We have already deducted the Annual Excess amount from another claim in respect of treatment undergone during the same Policy Year in respect of a person insured under this Policy . • It relates to a Related Surgery , in which case it will be waived. You are responsible for paying any Annual Excess to treatment providers.
BENEFITS
ANNUAL EXCESS
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WHEN CAN THIS POLICY END
7 This Policy will end when any of the following happens: • You ask Us in writing to cancel it. • You fail to pay the Total Premium or any Total Premium instalment within thirty (30) days after the due date for payment. • If We void Your policy from inception as outlined in Clause 8 “Responsibility for Truthfulness” below. 8 When You apply for insurance with AIA New Zealand , You have a legal duty of disclosure to AIA New Zealand . This means that: 1. All the statements that You make to AIA New Zealand (both written and oral) including the answers in: a. the application; b. any claim made by You ; c. any other communication by You with AIA New Zealand ; must be true and correct; and 2. You must disclose everything that You know, or could reasonably be expected to know, that is relevant to AIA New Zealand decision whether: a. to accept Your application for insurance; and b. if AIA New Zealand accepts Your application then on what terms AIA New Zealand will accept it and how much it will cost; or c. to accept Your claim on the insurance policy. 3. This duty of disclosure continues from the time You complete the application until either: a. the Policy Commencement Date or the date AIA New Zealand accepts Your application for insurance, whichever is later; b. AIA New Zealand declines or defers Your application for insurance. 4. You also have the same duty of disclosure to AIA New Zealand at the time that You extend, vary or reinstate Your insurance, and at any time when You make a claim on the Policy of insurance or otherwise communicate with AIA New Zealand . IMPORTANT If You do not comply with Your duty of disclosure, and AIA New Zealand would not have accepted Your application for insurance on the same terms or at the same premium if You had made full disclosure, then AIA New Zealand may: • decline any claim that You make; and/or • alter at any time the terms of any benefits under this Policy ; and/or • remove at any time any benefits under this Policy ; and/or • void Your insurance from inception; and/or • retain all Premiums , policy fees and recover any benefits paid. If You are not sure whether You are to disclose a particular fact, please ask Us or Your Insurance Adviser. 9 The benefit maximums stated in the Policy terms and conditions include Goods and Services Tax (GST) charged by the supplier of the goods or provider of the services.
RESPONSIBILITY
FOR
TRUTHFULNESS
GST
JURISDICTION AND 10
The laws of New Zealand apply to this Policy . The New Zealand courts have exclusive jurisdiction. All monetary amounts referred to in this policy are expressed and payable in New Zealand dollars and include GST.
CURRENCY
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NOTICES
11 Should You write to Us about this policy, You must send the letter to Our head office in New Zealand. The postal address of AIA New Zealand’s head office is:
AIA New Zealand Private Bag 300981 Albany AUCKLAND CITY 0752 The street address of AIA New Zealand’s head office is: AIA New Zealand AIA House 74 Taharoto Road 0622 Auckland
NO SURRENDER
12 This policy does not participate in the profits of AIA New Zealand . your Policy has no surrender value or cash value if it is cancelled. 13 You may at any time write to Us or to Your insurance adviser for further information about Your policy. We have a complaints procedure that is intended to resolve any problem quickly and fairly. If You have any questions or complaints about this Policy please phone Us on Our freephone 0800 800 242 or write to Us at the above address. If You have been through Our internal complaints procedure and the situation has reached a 'deadlock' then We will advise You of how to contact the Insurance and Savings Ombudsman for further assistance.
VALUE
COMPLAINTS
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SECTION F - PRIOR APPROVAL PROCEDURE AND MAKING A CLAIM
PRIOR APPROVAL
1
To have Your claim pre-approved: • Call Us on 0800 800 242 for a claim application form or log on to Our website www.aia.co.nz • On acceptance of Your claim, We will send You a pre-approval advice. You can then forward the Hospital's, Surgeon's or
Anaesthetist's account to Us and We will settle the claim with the service provider directly. Any shortfall in payment, such as any stated excess, is Your responsibility. In order for a claim to be paid where We have provided You with pre-approval advice, Your Policy must be in force on the date You have the medical treatment or procedure. • Pre-approval requires five (5) working days to be processed provided all requested information is submitted. Please be aware it may be necessary to request further information before completing assessment of Your claim. 2 To claim: • Call Us on 0800 800 242 for a claim form or log on to Our website www.aia.co.nz • Once You have completed the claim form, return it to Us along with the original receipts and invoices (photocopies or duplicates are not acceptable). • The claim form must be received by Us within twelve (12) months of the date of the insured event(s).
CLAIMING AFTER SURGERY OR HOSPITALISATION
OR AFTER A DIAGNOSTIC PROCEDURE
Any costs involved in completing the claim form and where appropriate providing an attached medical report (or any additional information We may request) will be at Your expense. Additional information may be requested by Us in order to assess and pay Your claim. Please refer to the checklist contained within the claim form to ensure You have supplied all of the requirements to Us . If You become aware, in respect of any health or medical procedure for which You have cover under this Policy that there has been a "medical misadventure" (as defined in the Injury Prevention, Rehabilitation and Compensation Act of 2001 or any replacement legislation) then: You must notify Us of that event together with all material details which are known to You . Those details must include: 1. the cause of the medical misadventure 2. the names and addresses of the health service providers(s) at fault 3. the level of increased fees caused by the medical misadventure 4. whether You have notified ACC and, if so, whether ACC has accepted cover. To this extent and where practical You must not: 1. pay the fees of any of the negligent health service provider(s) 2. pay the extra fees of the other health service provider(s) without Our written consent. If You are sued by the health service provider(s) We will conduct the defense at Our sole cost, but You must co-operate fully with Us throughout the proceedings. If We have paid any amounts to You in respect of health service provider fees for a health or medical procedure which
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has given rise to a medical misadventure, then We are to be subrogated to all the rights which You have to claim against the health service providers for recovery of those fees. We will pay all legal costs and related expenses in such recovery proceeding but You must provide all reasonable assistance and co-operation and agree to Our use of Your name in those proceedings.
Please note for claims while residing in Australia, call collect on +64 9 359 1605. Please refer to the Claims Form checklist to ensure all relevant information is supplied to Us.
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SECTION G - EXCLUSIONS (WHAT YOUR POLICY DOES NOT COVER)
• Within the first three (3) years from the Policy Commencement Date , if any event or circumstance (including illness or injury) occurs or expense or cost is incurred, (which otherwise may have given rise to a claim under this Policy ) directly or indirectly arising out of, medically related to or in any way traceable to or connected to, a Pre-Existing Condition , the resulting claim will not be payable. For the purpose of this exclusion a Pre-Existing Condition is any symptom, illness, injury or medical condition of which prior to the Policy Commencement Date : a. You and/or the Insured Person(s) were aware of; or b. You and/or the Insured Person(s) displayed symptoms of, or c. You and/or the Insured Person(s) had a direct indication that something was wrong; or d. You and/or the Insured Person(s) sought treatment or medical advice for. • Ailments wholly or partially attributable to the misuse of alcohol and/or prescription drugs. • Ailments wholly or partially attributable to the use of non-prescription drugs. • Acquired immune deficiencies (AIDS) or associated ailments including HIV and related ailments EXCEPT where the virus can be proved, to Our satisfaction, to have been acquired by accidental means in the course of the Life Assured’s normal occupation, or via blood transfusion. Seroconversion to the HIV infection must be demonstrated by testing within six (6) months of the accident. (Any incident giving rise to a potential claim must be reported to Us within thirty (30) days of the event causing the claim and supported by a negative HIV antibody test taken from the Insured Person after the incident. We can independently test the blood samples used and can require additional samples to be taken and tested. Ailments arising from HIV transmission via any form of sexual activity and/or non- prescribed intravenous drug use are excluded.) • Appliances and or devices including, but not limited to, surgical, medical or dental appliances. • Bariatric surgery for any condition including but not limited to obesity, diabetes and sleep apnoea, except where coverage is expressly stated in this Policy . • Congenital ailments including, but not limited to, complications thereof and or sequelae except where coverage is expressly stated in this Policy . • Any form of psychiatric treatment and or psychological treatment including, but not limited to: medical psychotherapy; any form of therapy or counselling; in-patient care in a Private Hospital or clinic; prescription or non-prescription drugs. • Any mental disorder as defined in the Mental Health (Compulsory Assessment and Treatment) Act 1992 (or any subsequent Acts). • Any geriatric or senile condition or geriatric hospitalisation, and disability support services. • Any injury or disability as a consequence of war, warlike hostilities, civil war or civil commotion. • Cosmetic treatment including complications thereof. • Elective treatment (such as treatment of or for an ailment not materially detrimental to health) including complications thereof. • Treatment and investigations deemed not medically necessary by Us .
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