–
negotiate the proposed costs; and
You must submit all claims to Sovereign within 12 months of the health provider performing the medical treatment or procedure.
–
request that a second opinion is sought.
Subject to you requesting otherwise, Sovereign can nominate alternate providers of healthcare who Sovereign considers to be suitably qualified to perform the medical treatment or procedure under the claim. Following assessment and approval of the medical treatment or procedure Sovereign will allocate a prior approval reference number to the claim and will fax or post you or, the life assured and the Sovereign approved provider 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 . Sovereign may in its sole discretion reimburse any health care provider or eligible provider directly. If this MajorCare policy is cancelled for any reason and there are outstanding claims relating to any insured event occurring before the date of cancellation, Sovereign must receive the relevant claim forms within 30 days of the cancellation date, otherwise the claim(s) 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 also need to use your best efforts to notify Sovereign within 24 hours after an emergency private or public hospital admission, procedure or scan has taken place. b) When you pay for treatment yourself and then submit a claim for reimbursement: You should give Sovereign notice of a claim as soon as possible by calling our MajorCare Claims Hotline. On such notification Sovereign will send you a claim form. You should complete the claim form and send it together with the eligible provider ’s or health provider’s referral le tter and / or medical certificate and all of the original receipts and itemised invoices, to us .
5. 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.
For claims involving ACC :
a) It is the life assur ed’s or 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 required within seven days of the injury occurring. Under the ACC Act treatment within seven days of the injury occurring is deemed to be ‘acute’ requiring treatment to be undertaken in a public hospital . 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 apply to ACC for a review of that decision on the policy owner’s or life assured’s behalf. e) Where ACC agrees to contribute to the policy owner’s or life assured’s private hospital costs Sovereign may cover additional costs up to the reasonable charges or as specified in the MajorCare benefits sheet . f) Sovereign will not be liable for any additional costs where a lead care provider of ACC is used to provide private hospital medical treatment or procedures.
For any claim to be admissible:
> the medical treatment or procedure must be medically necessary, as evidenced by the health provider’s referral 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. Subject to the terms of this policy, Sovereign will pay all reasonable charges for medically necessary treatment up to the respective policy limits. If the costs of the medical treatment or procedure are greater than Sovereign ’s MajorCare benefit limits, or, the reasonable charges , the balance of the charges remaining after Sovereign has paid the reasonable charges will be your responsibility.
6. How can you amend this policy?
a) Adding family members
You may apply to Sovereign in writing to extend cover under this MajorCare policy at any time to include:
134 MAJUMB-SA version 7 Effective 5 December 2016
Page 4 of 9
Powered by FlippingBook