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MAJORCARE BENEFITS SHEET
The benefits listed in this MajorCare benefits sheet apply to policies with a Policy Inception Date of November 1 2003 or later.
1. The purpose of MajorCare MajorCare provides up to 100% reimbursement of all reasonable charges , for inpatient admissions to a private hospital or day stay clinic , up to the maximum amounts specified in this MajorCare benefits sheet (an excess may apply if selected), provided that the medical treatment or procedure falls within the terms and conditions of this policy. Except where otherwise stated in their MajorCare benefits sheet s in relation to a specific MajorCare benefit, all of the MajorCare benefits apply only where medical treatment has been recommended as medically necessary by a Registered Medical Practitioner and is provided by an eligible provider . Treatment under this MajorCare policy must be carried out in New Zealand, except where expressly covered under the overseas medical treatment benefit. If you re-enter a private hospital or day stay clinic within 28 days of being discharged for treatment related to the same condition, it will be treated as one admission. In the event of a re-admission occurring please notify Sovereign immediately in writing to update your prior approval. Sovereign recommends that you seek Sovereign ’s prior approval to a claim to ensure that the medical treatment or procedure is covered under this policy and Sovereign approves all medical treatment and procedures before you incur any cost. 2. The Benefits provided by MajorCare The specific MajorCare benefits covered and the maximum amounts that Sovereign will pay for any MajorCare benefit, less any excess , are listed below. The per annum maximum in respect of any MajorCare benefit is applied on the anniversary date of this policy. The excess that you have selected, applies once per life assured , per annum (with each year commencing on the anniversary date of this policy). Sovereign will deduct any excess from payments made to an eligible provider . The excess will apply across all MajorCare benefits unless a particular benefit is specifically excluded, as specified in this policy. Any MajorCare benefit claims will normally be categorised into the following services and billed accordingly. a) Private hospital – surgical benefits MajorCare pays for all reasonable charges relating to the medical services provided for private hospital and day stay clinic admissions, plus an additional $100,000 per annum for the special diagnostic benefit as specified in Section 2e
of this MajorCare benefits sheet . Private hospital admission must be made to a Sovereign approved facility and all medical treatment or procedures must be carried out by a Specialist . This MajorCare benefits sheet provides cover for: > General surgery performed in a private hospital , or day stay clinic including: - Surgeon Fees - Anaesthetist Fees - Diagnostic Fees (As specified in Section 2e) - Hospital Charges including: - Accommodation - Operating Theatre Fee - Intensive Care Fee / Special Nursing Fees - Ancillary Charges / Supplies: including but not limited to; dressings, post operative physiotherapy, pathology tests, anaesthetic supplies, ECG, medication (prescribed and taken in hospital) - Disposable Laparoscopic Equipment ( Sovereign benefit maximums may apply) - Prostheses ( Sovereign benefit maximums may apply). > Cardiac surgery and noninvasive cardiac procedures performed in a private hospital , or, day stay clinic including but not limited to angioplasty, coronary stent insertion. This includes: > Cardiac Surgeon and Perfusionist Fees > Cardiologist and Radiologists Fees > Anaesthetist Fees > Diagnostic Fees (As specified in Section 2e) > Hospital Charges including: > Accommodation > Operating Theatre Fees > Intensive / Coronary Care Unit > Ancillary Charges / Supplies: including but not limited to; anaesthetist supplies, ECG, angioplasty catheters, intravenous fluids, irrigating solutions, dressings, stents, including drug eluting stents, post operative physiotherapy, medication – prescribed and taken in hospital > Cardiac Prostheses ( Sovereign benefit maximums may apply).
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c) Pre Admission & Post Discharge From An Approved Private Hospital Or Day Stay Clinic Specialist Cover: Specialist consultations and diagnostic procedures are covered, on the recommendation of the Specialist , for up to three months before the private hospital or day stay clinic admission, and for up to three months after discharge, from a private hospital or day stay clinic , provided that they relate specifically to the medical condition, which resulted in the private hospital or day stay clinic admission occurring. Physiotherapy and prescription costs directly relating to the approved surgery performed within three months after surgery. NOTE: If you have selected the optional Specialist and Tests benefit, please refer to Section 3 of this MajorCare benefits sheet . d) Dental Evaluation and Treatment Prior To Qualifying Treatment Benefit MajorCare pays a maximum of all reasonable charges up to $1,500 per life assured per policy year. No excess is payable for any claims under this benefit. 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 using antiresorptive drugs. > Radiotherapy treatment (head and neck). > Heart valve replacement surgery. Prior approval must be obtained before any dental evaluation or treatment takes place. procedures performed on a life assured during a surgical or non-surgical admission to a private hospital or day stay clinic . This benefit includes but is not restricted to CT and MRI scans and angiograms. This benefit also applies to costs relating to pre admission and post discharge costs as described in Section 2c above. MajorCare pays a maximum of all reasonable charges up to $100,000 per life assured , per annum. e) Special Diagnostic Procedures Benefit MajorCare covers costs for specialised diagnostic f) Breast Reduction Benefit Sovereign will pay for breast reductions after a life assured has had or you have had cover in place for a minimum continuous period of 3 years from the risk commencement date of you r policy where: > a Specialist provides a medical report which states that surgery for breast reduction is medically necessary and that it is not being done for cosmetic reasons; and
> Oral surgery: MajorCare covers the removal of impacted wisdom teeth, the removal of unerupted teeth, and the treatment of cysts, soft tissue swellings and enlargements. In all cases oral surgery must be performed by an Oral Surgeon or Dentist suitably qualified to perform oral surgery, after referral by a Dentist or Registered Medical Practitioner . MajorCare does not cover root canal treatment, dental repair or implants. The MajorCare benefit includes; > Oral Surgeon ’s or Dentist ’s Fees > Anaesthetist Fees > X-rays > Private hospital or day stay clinic charges (if applicable) > Ancillary Charges / Supplies: including but not limited to; dressings, medication prescribed immediately post surgery, anaesthetic supplies. b) Private hospital – non-surgical benefit MajorCare covers all reasonable charges for admissions to a private hospital on referral by a Specialist or Physician for medical treatment of a condition, which does not require surgery. Non-surgical admissions are commonly referred to as medical admissions and include but are not limited to asthma, diabetes, stroke, cancer and oncology - radiology/chemotherapy treatment, lithotripsy or any other acute or chronic illness. For cancer chemotherapy treatment, this includes targeted therapy, immunotherapy medicines, oral, intravenous infusion, instilled, and intraoperative chemotherapy provided by or under the direction of a specialist in a Sovereign approved facility . This covers the cost of Pharmac and non-Pharmac subsidised MedSafe indicated cancer chemotherapy drugs, subject to Sovereign criteria . Prior approval of any claim should be sought or obtained from Sovereign before seeking medical treatment. MajorCare pays a maximum of all reasonable charges up to $300,000 per life assured , per annum, plus an additional diagnostic benefit of $100,000, as specified in Section 2d of this MajorCare benefits sheet . This benefit entitlement is limited to overnight admissions to a private hospital . This includes: > Physician / Specialist Fees > Diagnostic Fees (As specified in Section 2e) > Accommodation Fees > Ancillary Charges / Supplies: including but not limited to; materials and medication - prescribed while in hospital, physiotherapist fees.
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This benefit only provides coverage for the medically necessary: > Excision of lesions, moles and cysts; > Wedge resection of toenails; > Allergy desensitisation injections; This benefit also provides cover for Vasectomy after two continuous years of cover. The vasectomy does not need to be medically necessary. j) Caregiver Accommodation Benefit The caregiver accommodation benefit is available for a parent, guardian or support person who accompanies a life assured (under the age of 21) where the life assured is receiving treatment and overnight accommodation is required. This allowance is also available to any support person who accompanies a patient being transferred under Section 2n of this MajorCare benefits sheet . The amount payable under the caregiver accommodation benefit is $300 per day up to $3000 per annum (no excess applies). Sovereign will reimburse these costs up to the maximum on receiving proof of expenses incurred. k) Public Hospital Cash Grant This benefit is payable if a life assured is admitted to a public hospital for more than three days (not including admissions on a private fee paying basis). For the purposes of this benefit, a “day” must include an overnight stay. The amount payable under this benefit is $300 per day after the third day, up to a maximum of $3,000 per life assured , per policy year, per life assured per annum (no excess applies). l) Overseas Medical Treatment Benefit This benefit covers medical treatment at an overseas hospital acceptable to Sovereign , where medical treatment covered under this MajorCare policy cannot be provided in New Zealand. A Specialist must recommend medical treatment, and prior approval from Sovereign must be sought or obtained prior to seeking the medical treatment. The amount payable under this benefit is a maximum of $30,000 per policy year per life assured per annum. The maximum amount payable includes two return economy class airfares for the life assured and a support person (no excess applies).
> the medical condition and treatment comply with Sovereign’s criteria for the benefit entitlement. The maximum amount payable for this benefit is $6,000 per life assured . To be eligible for this benefit prior approval of any pending claim must be sought or obtained from Sovereign before any costs are incurred. Surgery to remove breast implants or surgery for reconstructive work relating to breast implants is specifically excluded under this policy.
g) Breast Symmetry Surgery Following Mastectomy Benefit
MajorCare pays a maximum of all reasonable charges up to $5,000 per life assured per life of the time. No excess is payable for any claims under this benefit. Following mastectomy, covers costs up to the maximum cover for procedures on the unaffected breast to achieve breast symmetry. This will be available either during or following a mastectomy, which has been covered by you r Sovereign health policy. Procedures covered under this benefit may include breast reduction surgery. The procedures to achieve breast symmetry do not need to be medically necessary. Prior approval of any claim should be sought or obtained from Sovereign before seeking medical treatment. h) Varicose Veins Benefit In special circumstances Sovereign will cover treatment for varicose veins. This benefit applies after a life assured has had or you have had cover in place for a minimum continuous period of 3 years from the risk commencement date of your policy. Sovereign will cover sclerotherapy and surgical treatment for varicose veins where: > a Specialist provides a medical report confirming that the treatment is medically necessary and that the treatment is not being carried out for cosmetic reasons; and > the medical condition and treatment comply with Sovereign ’s criteria for the benefit entitlement. Prior approval of any claim should be sought or obtained from Sovereign before seeking medical treatment. i) Non-Specialist Outpatient Minor Surgery Benefit MajorCare pays a maximum of all reasonable charges up to $500 per life assured per treatment to a maximum of $1,000 per life assured per policy year. No excess is payable for any claims under this benefit. 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.
m) Voluntary Treatment Overseas Benefit Treatment in Australia
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
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p) Home Nursing Benefit This benefit covers the cost of home care provided by a registered nurse , which has been recommended by a Specialist , immediately following the life assured being discharged from a private hospital after having had surgery or medical treatment covered under this MajorCare policy. The amount payable is $300 per day up to $5,000 per policy year per life assured , per annum (no excess applies). q) Waiver Of Premium Benefit If a life assured dies when aged between 21 and 60, Sovereign will continue to provide MajorCare cover for the remaining lives assured , without requiring further premiums for a period of 12 months from the date of death. This does not apply to adult children who have extended cover to their 25th birthday (no excess applies).
applicable benefit in New Zealand dollars, at a health service facility approved by Sovereign .
Treatment outside Australia This benefit covers up to 75% of the reasonable charges 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 and recommended by a New Zealand registered medical specialist . 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. 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 cover is available for flights or accommodation. 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 of any claim should be sought or obtained from Sovereign before seeking medical treatment, procedure, consultation, test, diagnostic imaging, support or care. n) Transfer Benefit This specifically covers the transfer of a patient from one Sovereign approved facility to another Sovereign approved facility , in a situation where complications have arisen and further treatment can only be provided by specialist services at the Sovereign approved facility where the patient is being transferred. The benefit only applies to transfers within the boundaries of the North and South Islands of New Zealand, excluding the Chatham Islands, Stewart Island and any other overseas dependencies. All reasonable charges for transfer costs relating to any combination of the following modes of transport will be met; air ambulance, road ambulance, road transport, or economy airfares (no excess applies). o) Bereavement Grant If a life assured dies when aged between 21 and 60, Sovereign will pay a death benefit of $2,500 to the policy owner or their estate (no excess applies).
3. Optional benefit:
Specialists and Tests benefit This benefit applies only if it is shown as an optional benefit in the schedule . After referral from a Registered Medical Practitioner , consultations with Specialists and diagnostic tests are covered. This is regardless of whether they occur within three months before admission and up to three months after discharge from a private hospital , whether for surgical or non-surgical treatment. The maximum amount payable under this benefit is $5,000 per life assured , per policy year per life assured , per annum for all reasonable charges . No excess applies to these benefits. a) The Specialists Benefit Includes: > Specialists fees covered include but are not limited to; Consulting Physician s, Oncologists, General Surgeons, Orthopaedic Surgeons, Neurosurgeons, Ear Nose & Throat Specialists, Cardiac Surgeons, Cardiologists, Gynaecologists, Urologist and Gastroenterologists (Obstetricians and Psychiatrists are specifically excluded): and > Ancillary charges for minor surgery performed in a Specialist ’s rooms where a local anaesthetic is administered.
b) Tests / Diagnostics Covered Include; > Allergy testing
> Angiogram > Audiology > Audiometric tests > Electroencephalography (EEG) > Electromyography (EMG)
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> Exercise ECG > Laboratory tests > Holter monitoring > Mammography > Ultrasound > Urodynamic assessments > X-rays
g) Suicide, self-inflicted injuries or illness, or, accident, illness, condition or disability arising from, or, caused or contributed to by; drug taking, intoxication or misuse of alcohol, or, nuclear contamination; h) HIV related disorders, including AIDS; i) Pregnancy, childbirth or abortion, or, any conditions or complications arising from any of the foregoing; j) Contraception of any type; k) Sterilisation, except when you have the optional Specialist and Tests Benefit. Refer to Section 3c above as special conditions apply; l) Diagnosis, management and treatment of infertility; m) Circumcision, except where a Specialist provides a medical report that states the surgery is medically necessary; n) Diagnosis, management and treatment of snoring, except where a medical Specialist confirms diagnosis of sleep apnoea and confirms surgical treatment is medically necessary. (Pre-approval of any claim for treatment must be sought or obtained from Sovereign before any costs are incurred); o) Any geriatric or dementia conditions, including disability support services; p) New medical treatments, procedures or technologies that have not been approved by Sovereign ; q) 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.; r) Any surgery for the correction of refractive visual errors; s) Elective or cosmetic surgery and associated treatments – including surgery or treatment, which a life assured chooses to undergo for cosmetic reasons (e.g. surgery for; breast enlargements or reductions, facelifts, varicose veins), where not having the surgery would not be detrimental to the life assured ’s health except where expressly covered under a benefit in this policy); t) Preventative treatment, or, treatment, or, investigation of any condition not detrimental to health; u) Treatment for obesity, including surgery, or, complications arising from any treatment for obesity; v) Mole mapping; w) Renal dialysis; x) Routine screening ; and y) Psychology, including any counselling services.
> CT Scan > MRI Scan
Routine screening is specifically excluded.
c) Sterilisation Benefit This benefit is included with the Optional Specialist and Tests Benefit. The benefit applies after you have had continuous cover in place for two or more years from your risk commencement date . It specifically covers vasectomies and tubal-ligation procedures. Vasectomies carried out by a General Practitioner will be covered. Prior approval should be sought or obtained from Sovereign before any costs are incurred. 4. Exclusions - Sovereign will not pay any benefit provided under MajorCare if the insured event is caused by or results from (either directly or indirectly) any of the following: a) Any medical condition, including chronic conditions, which existed at the time of your risk commencement date that you or the life assured was aware of, or, ought reasonably to have been aware. This includes the development or presence of underlying symptoms whether you have consulted a medical provider or not, unless the symptom or condition was disclosed at the time of your application and accepted in writing by Sovereign ; b) Any congenital conditions; c) Reconstructive, reparative procedures or surgery, which results from, or, which is traceable to, or, is medically related to, any surgery performed prior to your risk commencement date , or, which relates to cosmetic procedures carried out at any time; d) Injuries of war or resulting from any terrorist act (whether war is declared or not); e) The misuse of prescribed or non-prescribed drugs, where they have not been taken in accordance with the manufacturer’s, or, a Registered Medical Practitioner ’s, directions. f) Certifiable mental disease, psychiatric illness, or, any charges relating to services resulting from a referral to, or, provided by a psychiatrist;
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6. Maximum amounts payable relating to prostheses and Disposable Laporascopic Equipment Costs relating to these items will be reimbursed in accordance with the Sovereign benefit maximums listing. When pre-approving a claim, Sovereign will quote the Sovereign benefit maximums payable for the relevant item. 7. New Healthcare Technology and Treatments Cover will be extended to incorporate new technologies and treatments when Sovereign ’s medical advisory panel is satisfied that improved clinical outcomes will be achieved and that the medical treatment, procedure or product meets all of the appropriate regulatory requirements. 8. Public Hospitals Medical treatment carried out in a public hospital or under the direct control of a public hospital will be covered to the limits specified in the schedule if approved by Sovereign and if the “Protocols for the Treatment of Private Patients in a Public hospital ” specified by the Ministry of Health have been followed.
No amount will be paid under MajorCare for the following expenses: > Organ donation and receipt, except for reimbursement under the overseas medical benefit; > General Practitioner ’s costs except for sterilisation benefit, as specified in Section 3c; > Treatment or procedure not provided by an eligible provider ; > Treatment provided by a public hospital except where expressly covered under MajorCare; > Physiotherapists (except where expressly covered under MajorCare), chiropractors, osteopaths, naturopaths, homeopaths, acupuncturists, obstetrics and podiatrist’s costs; > Nursing costs (except where expressly covered under MajorCare); > Dentist s’ costs (except for oral surgery, which is expressly covered under MajorCare - special conditions apply); > Prescription charges (except where expressly covered under MajorCare); > Any charge for non-essential, or, personal items, while the life assured is an inpatient in any Sovereign approved facility (for example but not restricted to; newspapers, spouse/family meals, alcohol, TV rental, etc.); > Surgical, medical or dental appliances, other than surgical prostheses specified in the Sovereign benefit maximums listing, including but not limited to, cardiac pacemakers, nerve appliances, cochlear implants, bite splints and orthotics; > Any condition arising from participation in a criminal act; > Any condition specifically excluded by endorsement to the schedule ; > Costs incurred outside New Zealand (except where expressly covered under the Overseas Medical Treatment benefit in Section 2l); and > Palliative care. Sovereign will not pay any part of your claim that you can recover from sources outside your MajorCare policy, in particular under any other contract of insurance, whether you claim from these sources or not. 5. Multiple procedures Sovereign will not pay any MajorCare benefit for additional surgery that is performed during one operation, which is not directly related to the medical condition or treatment that is covered under the terms of this MajorCare policy. (For example but not limited to; abdominal scar revisions, pelvic floor repair when accompanying surgery for a hysterectomy.)
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