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PRIVATE HEALTH
Welcome to Sovereign Private Health
Thank you for choosing Sovereign Private Health. Greater choice, when you need it.
This is your insurance policy document. Please take the time to read it carefully and then keep it and the schedule in a safe place. If you have any questions, please call us on 0800 500 108.
What is Private Health?
If you or a member of your family became ill, perhaps seriously, woul dn’ t you want access to expert care, when and where it suits you? Only private health insurance can give you that assurance. S overeign’ s Private Health Cover and Private Health Plus are designed to cover the significant costs associated with hospitalisation and surgery.
Free look period for 15 days
Please read this policy to ensure it provides the cover you are looking for. If you are unsure about anything, please contact your insurance adviser or us directly for assistance. Our contact details are set out on page 2. If you decide you no longer wish to purchase this policy, you may cancel it within 15 days of it starting, or within 5 working days of receiving your policy (whichever is the later date) and you will receive a full refund of any premium you have already paid to us. If you decide to do this, you can never claim a benefit under the policy.
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Contents
Welcome to Sovereign Private Health
1
How to contact Sovereign
2
A About this policy
3
B Guaranteed Enhancement Benefit
3
C Cancellation of the Policy
4
D How to make a claim
4
E Premiums
6
F Changes to your policy
6
G General terms and conditions
8
H Benefits – what you are covered for
10
I
Exclusions – what you are not covered for
22
J Defined terms
25
How to contact Sovereign
Online www.sovereign.co.nz
For information about S overeign’ s policies, an explanation of the benefits, frequently asked questions, terms and conditions and to apply for prior approval or make a claim please visit www.sovereign.co.nz
Call us 0800 500 108
For prior approval and claims enquiries, call us on 0800 500 108.
We are available 8am to 6pm Monday to Friday (excluding public holidays).
General correspondence
The mailing address for Sovereign ’ s head office is:
Freepost Sovereign Private Bag Sovereign Victoria Street West Auckland 1142
Phone, fax and email
Tel +64 9 487 9963 Fax +64 9 487 8003 Freephone: 0800 500 108 Freefax: 0800 329 768 Email: enquire@sovereign.co.nz
Physical address
Sovereign House 74 Taharoto Road Takapuna North Shore Auckland 0622
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A. About this policy
B. Guaranteed Enhancement Benefit
This document is the policy document. It explains what your policy covers. It should be read in conjunction with all the documents that form part of your policy. Your Private Health policy is a contract between the policy owner(s) named in the schedule (‘you’ or ‘your’) and Sovereign (‘we’, ‘our’ or ‘us’).
If at any time in the future, we make a change to a section and/or provision within a section of our Sovereign Private Health policy and the change is favourable to you, the enhanced section and/or provision will automatically be applied (passed back) to this policy, subject to the following: At claim time we will compare the enhanced section and/or provision in the latest version of Sovereign Private Health with this policy and will apply the section and/or provision that is most favourable to you. We will not apply changes to sections and/or provision set out in earlier versions of Sovereign Private Health which are not included in the latest version. The enhanced section and/or provision will only be applied to this policy if it relates to a benefit for which you have cover under this policy. The enhanced section and/or provision will be ‘applied’ to thi s policy with effect from the pass back date . The enhanced section and/or provision will only apply if the claim event first occurs on or after the pass back date . Eligibility criteria for individual benefits will still apply. If the claim event first occurred before the pass back date , then the claim will not be assessed or reassessed using the new wording. Any underwriting exclusions or special terms that apply to this policy will not be altered by any enhanced section and/or provision. Any associated increase in premium required will be applied when your premiums are next reviewed. Enhancements to sections and/or provisions that relate to Sovereign Private Health Plus will only be passed back where Sovereign Private Health Plus is listed in the schedule . Enhancements will not be passed back to built-in benefit sections and/or provisions that no longer exist. For the avoidance of doubt, where the definition of a provision or provisions is enhanced under this benefit, the enhancement will only be applied in respect of that provision or the provisions you are making a claim for. If the nature of the change to a section and/or provision means that it cannot be determined at the time of submitting a claim whether the change will be clearly favourable to you or not, you will need to elect whether or not the change will apply to the claim. After you have made the election, this election cannot be changed.
If more than one person is named in the schedule as policy owner , the policy is owned by all of them jointly.
Any notice to us to do with your policy must be given by all policy owners unless we are satisfied that, after reasonable efforts have been made, a policy owner cannot be located. In that case we may act on notice given by the other policy owner(s) and, if we do, we will not be liable to any person for any consequences.
The terms of your policy are set out and contained in the following documents:
> This policy document and any alterations made to it;
> The schedule which states who the policy owner(s) and lives assured are, as well as setting out other important information such as the excess , exclusions, endorsements and terms or conditions that apply to your policy; and > The optional benefit appendix for the Waiver of Premium Benefit, where you have chosen this benefit and it is shown in the schedule . Some words in this document are italicised indicating they are key terms that are defined in the section entitled ‘ Part J : Defined terms’ on pages 25 - 27. The headings in this policy document are for guidance only. They do not form part of the policy and they are not to be used when interpreting it.
Who does your policy cover?
The life or lives assured named in the schedule are covered under your policy. If there are multiple lives assured each life assured is covered separately.
When does your policy start?
Your policy starts on the risk commencement date stated in the schedule .
What does your policy cover?
Your policy covers the benefits set out at ‘Part H: Benefits – what you are covered for’ on pages 10 - 21, subject to meeting the terms and conditions of your policy and any exclusions that may apply.
What is not covered by this policy?
What you are not covered for is set out at ‘ Part I: Exclusions – what you ar e not covered for’ on pages 22 - 24.
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C. Cancellation of the policy
Information is material if it would have influenced the judgment of a prudent insurer in determining whether to cover a life assured or on what terms to have issued or continued with cover under this policy or in fixing the premium for this policy. A statement is substantially incorrect if the difference between what was stated and what is actually correct would have been considered material by a prudent insurer.
You wish to cancel your policy
You can cancel your policy at any time by giving Sovereign notice in writing. You are liable for all premiums due up to the date of the cancellation. Sovereign will refund any unused part of the premium already paid for any period more than one month beyond the date of cancellation. Otherwise there is no refund of any premiums . From the date Sovereign receives notice that you wish to cancel the policy, you will not be entitled to claim any benefits under this policy, other than for any health care service covered by this policy which was carried out prior to the date of cancellation, unless otherwise agreed to and confirmed in writing by Sovereign.
D. How to make a claim
Prior approval
We recommend you seek prior approval as soon as you are aware that you will need to make a claim. We need at least five working days to issue a prior approval. By seeking prior approval we are able to give you certainty of cover by addressing your eligibility prior to treatment taking place. There are some benefits for which prior approval is mandatory. These are listed in ‘ Part H: Benefits – what you are covered for ’ on pages 10 - 21.
When can Sovereign cancel your policy?
Sovereign can cancel this policy if the premium has not been paid within 31 days of the premium due date .
Sovereign can cancel this policy and decline liability for any claims made under this policy if you or any life assured , or anyone acting on your or any life assured ’ s behalf, makes a claim under this policy that is false or fraudulent in any respect. In the event that a false or fraudulent claim is established after payment of a claim, all amounts paid in relation to the false or fraudulent claim must be repaid by you to Sovereign.
Applying for prior approval
You can submit your prior approval request online or return the completed form to Sovereign as soon as you are aware that you will need to make a claim. You will also need to ask your registered medical practitioner to complete the relevant section of the claim form or to provide you with a referral letter as well as any relevant clinical notes that may be useful to assist us to assess whether the medical treatment or procedure is medically necessary and falls within the terms of this policy. The referral letter must include details of the initial consultation date, the history of the condition and details of any treatment received.
Non-disclosure or the provision of false or misleading information
Any information you or any life assured gives us, and any information given to us on your behalf, must be complete, true and correct. If you or any life assured fails to disclose material information to Sovereign prior to inception of this policy or any variation or reinstatement of this policy, or if you or any life assured has made a substantially incorrect statement in applying for this policy, Sovereign may, at its complete discretion either:
When you apply for prior approval we also need an estimate of the costs of treatment.
If your claim is pre-approved, Sovereign will allocate a claim number to your claim and will email, post or fax you or the life assured a letter confirming the claim has been pre-approved. The excess and any costs that are not covered, including costs which exceed the maximum cover will be clearly shown and you will need to pay these amounts directly to the health service provider. Sovereign will pay the health service provider directly upon receipt of the invoice or statement up to the maximum cover . Please ensure that the claim number is quoted on all claims correspondence and any invoices or accounts relating to the pre-approved claim that are sent to Sovereign. There may be certain costs, treatments or procedures that are not covered by this policy. Obtaining prior approval ensures you understand what will be covered and allows
> avoid this policy from its inception (this means the policy is deemed to have never existed); or
> alter the terms upon which cover is provided under your policy (such alteration of terms will be effective from the risk commencement date or such date of our choosing, at our discretion); or > remove from cover any life assured from inception but leave the policy in force for the remaining lives assured . If this policy is avoided or any terms altered or a life assured is removed from cover, we are entitled to retain all premiums paid in relation to the policy or that life assured .
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Sovereign an opportunity to negotiate costs with the health service provider or discuss alternatives with the registered medical practitioner or registered medical specialist .
All benefits, claims and premiums are paid in New Zealand dollars. All benefits and premiums are GST inclusive.
What are ‘reasonable charges’?
For benefits covered by your policy, Sovereign will pay the reasonable charges of health service providers, subject to the maximum amounts that apply for those benefits. We will not pay more than the reasonable charges in order to limit excessive or unreasonable charges by health service providers in private practice.
Reimbursement of treatment you have paid for
If you have not applied for prior approval and you have paid for your treatment you will need to complete the steps below for reimbursement. Ask your registered medical practitioner to complete the relevant section of the claim form or to provide you with a referral letter as well as any relevant clinical notes that may be useful to assist us to assess whether the medical treatment or procedure was medically necessary and falls within the terms of this policy. Submit your claim to Sovereign online, by email, post or fax, with the referral letter and original invoices and receipts as proof of payment. Please be aware that by paying for your treatment and seeking reimbursement afterwards there may be costs that are not covered by the policy including for example your excess or costs that exceed the maximum cover . If you seek prior approval we can let you know what these are before any treatment takes place.
Sovereign determines reasonable charges by regularly reviewing:
> Health service providers’ charges for particular services.
>
Sovereign’s own claims statistics.
> Sovereign’s experience of the New Zealand health market.
> International benchmarks of the relative value of health services.
If the proposed cost of your medical treatment is greater than the reasonable charges :
Sovereign’s Healthcare Partnership Programme
> Sovereign will negotiate with the health service provider on your behalf to facilitate a reduction in the proposed cost of the treatment or procedure where possible. By purchasing this policy you authorise Sovereign to do this. > Sovereign may request that you seek a second opinion for the treatment or procedure from an alternative health service provider. We can supply a list of providers near you that you can seek a second opinion from. If Sovereign is unable to negotiate a reduction in the cost and you choose to continue with the treatment or procedure with the particular health service provider: > You will be responsible for any difference between the reasonable charge and the cost of your medical treatment or procedure, regardless of the relevant benefit’s maximum cover . > You will be responsible to pay any costs that exceed the reasonable charge directly to your health service provider.
If the life assured’s treatment is being provided by one of Sovereign’s Healthcare Partnership Programme providers there is no need for you to seek prior approval or send us any claims information, the provider will do this on your behalf. Sovereign will then pay the provider directly, who will advise you of any costs you need to pay to them directly (e.g. costs not covered by the policy, your excess , or costs that exceed the maximum cover ).
For all claims
All claims must relate to a life assured under this policy. Unless expressly stated in the relevant benefit, the medical treatment or procedure must be medically necessary . Sovereign may request supporting evidence, including a second opinion, in order to satisfy itself that the treatment or procedure is medically necessary . Sovereign will only pay the costs incurred for medically necessary treatments or procedures covered under this policy up to the respective benefit's maximum cover .
You are responsible for payment of the excess as well as any costs that are not covered by this policy.
Excess
Please submit all claims to Sovereign within 12 months of the medical treatment or procedure.
The excess is the amount that you will be responsible to pay for any treatment or procedure before you are entitled to claim for, or be reimbursed for, any benefits that are payable under this policy. The excess applies to each life assured , per policy year .
If this policy is cancelled for any reason and there are any outstanding claims relating to any medical treatment, procedure or other event covered under this policy that occurred prior to the date the policy ended, please submit the relevant claim form and supporting information within 30 days of the date the policy ended.
You can choose the amount of the excess that will apply to the policy for each life assured .
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The available excess amounts under Private Health Cover are $0, $250, $500, $750, $1,000, $2,000 or $4,000. The excess will apply to each benefit available under Private Health Cover unless:
the benefits component of the premium increases with the life assured ’ s age each year until they reach 70 years of age. The corresponding premium increase will take effect from the first anniversary date after a life assured turns 21.
otherwise specified in the benefit; or
Changes to the premium
it relates to any surgery that occurs within 3 months of a related surgery, in which case it will be waived.
Subject to the above, the premium will increase at each anniversary date based on :
However, in any event an excess is only payable once per life assured per policy year .
the excess amount for each life assured ;
Sovereign ’s underlying premium rates at that time; and
The available excess amounts under Private Health Plus are $0 or $250. The excess will apply to each benefit available under Private Health Plus unless otherwise specified in the benefit. This excess is in addition to any applicable excess under Private Health Cover. However, in any event the additional excess is only payable once per life assured per policy year . If you would like to reduce the excess for a life assured they may be required to provide further health information before we agree to this. Please see section ‘Part F: Changes to your policy’ on pages 6– 8 for more details.
the age of the life/lives assured .
You will need to pay the new premium from the next premium due date . Sovereign will advise you in writing of any adjustments to your premium .
What happens if you do not pay your premium on time?
Sovereign is not liable to pay any claims while any premium is overdue and remains unpaid.
Overseas treatment
Sovereign is entitled to cancel your policy by giving you notice in writing if your premium remains unpaid for 31 days after the premium due date . If you want to have this policy reinstated, you will need to pay any outstanding premiums and apply to Sovereign to have the policy reinstated. Sovereign is not obliged to agree to reinstate the policy but may do so on any conditions it considers appropriate.
This policy offers a number of overseas treatment options as listed in ‘Part H: Benefits – what yo u are covered for’ on pages 10 - 21. There are costs associated with having treatment overseas that may not be covered by this policy. You should consider comprehensive travel insurance before travelling overseas.
E. Premiums
F. Changes to your policy Adding and removing family members
To ensure that your policy remains in force, you must pay the premium on the regular basis as agreed with Sovereign. You must pay all premiums to Sovereign directly. Premiums can be paid by direct debit, credit card, or debit card. Please contact us on 0800 500 108 if you want to discuss payment of your premium . Your premium is shown in your schedule . Your premium is payable to Sovereign on the first premium due date , which normally coincides with the risk commencement date . Thereafter your premium is due annually, monthly, fortnightly or weekly as agreed with Sovereign. The premium is made up of a policy fee and a benefits component based on the benefits available under this policy.
You may apply at any time in writing to Sovereign to extend cover under this policy to:
> The policy owner.
> The spouse or de facto partner of the policy owner .
> A child under the age of 21.
Sovereign is not obliged to agree to cover any additional life assured unless it is satisfied that the life assured is in good health. The assessment of a life assured ’ s good health is based on the health information provided about that life assured in the application for cover under this policy. If Sovereign deems it necessary to obtain further information beyond that provided in the application form, about a potential life assured ’ s good health, Sovereign may require a report from a registered medical practitioner to confirm or clarify the extent of any existing health conditions.
One of the factors affecting the benefits component of the premium is the age of each life assured , except that:
> All lives assured less than 21 years of age will pay the same premium .
> The premium does not increase with age from the first anniversary date after age 71.
If you add your child to this policy within the first three months after he or she is born, the child will be
At the first anniversary date after a life assured turns 21,
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automatically accepted for cover under this policy without the need to satisfy Sovereign of the child’s good health. If a child is added to the policy after the first three months after he or she is born, Sovereign will require health information about that child .
- if self-employed, experiences a 30% reduction in revenue (by comparing one month’s revenue against the same month for the previous year),
provided that:
> you notify Sovereign within three months of one of the above listed suspension events occurring and provide evidence to Sovereign of the suspension event; and
Your premium will increase for each life assured added to this policy.
You can remove a life assured from your policy at any time by giving Sovereign notice in writing.
> Sovereign acknowledges in writing receipt of that notification.
Adjusting your excess
Where cover is suspended in one of the circumstances described above, no premium for the particular life assured , or for all lives assured , is payable during the period of suspension and no cover will be provided for any claim event for that life assured or lives assured during the period of suspension. Cover for that life assured or the lives assured under this policy will be reinstated provided the premium is paid when the nominated period of suspension ends or within the maximum time periods described, whichever comes first.
You may request Sovereign to change the excess applicable to your policy.
Sovereign is under no obligation to agree to reduce the excess unless we are satisfied that the lives assured are in good health.
The lives assured may be required to provide further health information before we agree to reduce the excess .
A change in the excess will result in a change to your premium .
Transfer of ownership
Any change in your excess and your premium will start from the date notified to you in writing by Sovereign.
You may transfer the ownership of your policy at any time. To be valid the transfer must be on a transfer of ownership form and registered with us. If ownership of your policy has been transferred, references in this policy document to you, your and the policy owner(s) are references to the most recent transferee(s).
Upgrading from Private Health Cover to Private Health Plus
You may apply at any time to Sovereign to upgrade from Private Health Cover to Private Health Plus.
A trust cannot be the policy owner of this policy. No charge is payable for a transfer of ownership of the policy.
Sovereign is not obliged to agree to a change from Private Health Cover to Private Health Plus unless it is satisfied that each life assured is in good health. The assessment of a life assured ’ s good health is based on the health information provided about that life assured . If Sovereign deems it necessary to obtain further information beyond that provided in the application form, about a potential life assured’s good health, Sovereign may require a report from a registered medical practitioner to confirm or clarify the extent of any existing health conditions.
When can Sovereign change the terms of this policy?
It is Sovereign’s business practice to review this policy over its lifetime. This is to ensure it continues to provide cover for current medical treatments for common medical conditions at the time. It is also to ensure the insurance product remains commercially viable for Sovereign. Any changes to the terms of this policy will apply across all lives assured with the same policy. Sovereign will not make any changes to the terms of an individual policy owner’s policy (except for age related premium increases based on the existing schedule of premium rates) without the policy owner’s consent. The following are examples of circumstances when Sovereign may wish to change the terms of this policy across all policy owners :
Suspension of cover
You may request a suspension of cover for a life assured under this policy:
> for up to 24 months if they travel overseas for a period of up to twenty-four months; or
> for up to 12 months if the policy owner :
> To increase the level of benefits under the policy or to add new benefits.
- becomes unemployed or redundant;
- goes on leave without pay for any reason;
> To move all lives assured to a refreshed policy document with a new drafting style/layout and similar levels of benefits.
- experiences at least a 20% reduction in pay (comparing the most recent payslip against a previous payslip from the same year); or
> To take account of changes in the laws in New Zealand.
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> To allow for an unexpected increase in the type or level of claims that will not be sustainable long term based on the current schedule of premium rates or at any premium rates (uninsurable).
reimburse you for the remaining costs in accordance with this policy.
If you have two or more policies with Sovereign you cannot claim for, or be reimbursed for, an amount higher than the total cost of your treatment.
> To take account of a significantly escalated or new public health threat e.g. a pandemic.
Claims involving ACC
Sovereign will give you at least 30 days’ prior notice of any change to the terms of the policy (unless the changes are given effect as a result of the Guaranteed Enhancement Benefit). The notice will include an updated policy document and highlight any change to the premium and/or to your entitlements under it. You always retain the right to cancel this policy at any time.
This policy does not cover any costs arising from treatments or procedures for accidents or injuries including treatment injuries (medical misadventure) that ACC is legally responsible to pay. It is your responsibility to submit any accident related claim to ACC in the first instance. Where surgery is necessary, you must obtain prior approval from ACC before incurring private treatment costs. When ACC agrees to contribute to the life assured ’ s treatment costs, Sovereign may cover additional costs up to the reasonable charges or maximum cover of this policy. You must obtain Sovereign’s prior approval before incurring private treatment costs. If ACC declines the claim Sovereign reserves the right to require that the life assured applies to ACC for a review of that decision, before Sovereign has any obligation to consider a claim for treatment under this policy. If ACC upholds their decline decision Sovereign may cover your costs up to the reasonable charges or maximum cover of this policy. You must obtain Sovereign’s prior approval before incurring private treatment costs. Sovereign will not pay for any MRI or CT scans or other specialised imaging procedures recommended by a registered medical practitioner within seven days of an accidental injury claim being lodged with ACC . If ACC does not cover the claim due to the policy owner’s or the life assured ’ s failure to properly make a claim with ACC or comply with ACC’s claims requirements, we will deem this to mean that the policy owner or life assured has not made reasonable efforts to secure cover with ACC and so is not able to claim under this policy.
G. General terms and conditions Your obligations
You and every life assured agrees to:
> Provide complete and accurate information to Sovereign and comply with your duty of disclosure.
> Provide all information reasonably required by Sovereign in relation to the policy, any claims and the policy owner and/or life assured . > Attend, at Sovereign’s request, an examination or consultation with a registered medical practitioner or registered medical specialist of Sovereign’s choosing and at Sovereign’s cost. The registered medical practitioner or registered medical specialist will advise Sovereign of the results of the examination or consultation in order to assist Sovereign to determine the nature and extent of any medical condition and the cover available under the policy.
> Pay premiums as and when they fall due to ensure that the policy is not cancelled.
> Notify us as soon as possible of any change that might affect the policy. If in doubt, please call us to discuss.
> Notify us if you change your contact details. All notices from Sovereign to you will be deemed delivered if we have sent them to you using the contact details you last provided us with.
Subject to the laws of New Zealand
This policy is issued in New Zealand and is subject to the laws of New Zealand.
Claims on other insurers
No surrender value
It is your responsibility to advise Sovereign if there is another insurer, who is responsible under any contract of insurance or indemnity to pay for any costs for which you make a claim under this policy. You must make every reasonable effort to make a claim or seek recovery of costs from that insurer for any expenses recoverable. Any expenses covered by another insurer in this way will not be covered by Sovereign under this policy. However if there are other expenses that are not covered by your other insurer please send details of the level of payment to us along with your claim. We will deduct the payment made by your other insurer then
This policy does not participate in the profits of Sovereign. This policy has no surrender or cash value if it is cancelled.
Complaints
Your suggestions, compliments, queries and complaints are important to Sovereign, and help us to improve the service we provide to you. If you would like to make a complaint please send your complaint to Sovereign in writing or by email and we will investigate your complaint and respond to you.
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If you are not satisfied with the outcome of your complaint you have the right to refer your complaint to the Insurance and Financial Services Ombudsman. The Insurance and Financial Services Ombudsman provides a free dispute resolution service. The Insurance and Financial Services Ombudsman can only deal with a complaint after you have referred your complaint to Sovereign and received a response from Sovereign confirming that Sovereign’s internal complaints procedure has been exhausted. You can obtain more information about the Ombudsman from the website: www.ifso.nz
The Ombudsman’s address is:
Insurance and Financial Services Ombudsman PO Box 10-845 Wellington 6143 Phone: (04) 499 7612 or 0800 888 202
Privacy
We take your and all lives assureds ’ right to privacy seriously. We will comply with the Privacy Act 2020 and the Health Information Privacy Code 2020 at all times. For more information on what information we collect, how we will use it, security, access and correction of your and the lives assureds ’ personal inf ormation please see our Privacy Policy on our website or telephone us on 0800 500 108 to request a copy. If you believe we have breached your or any life assured ’ s right to privacy, please contact Sovereign and ask to speak with our Privacy Officer who will investigate this for you.
Code of practice
This policy complies with the Health Funds Association of New Zealand Industry Code.
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H. Benefits – what you are covered for
Your Private Health Cover policy provides cover for each life assured for the reasonable charges of the following:
Benefit
Benefit entitlement
Maximum cover
Private Health Cover and Private Health Plus
Covers the costs associated with surgery. Surgery must be performed in an approved facility by a registered medical specialist or an oral surgeon.
SURGERY
The excess applies to any claims under this benefit.
Cover is provided for the following costs:
>
Surgeon’s fees
>
Oral surgeon’s fees
>
Cardiologist’s fees
>
Anaesthetist’s fees
>
Perfusionist’s fees
>
Radiologist’s fees
Inpatient treatment costs
> Hospital fees including:
Unlimited
−
Accommodation
−
Operating theatre fees
−
Intensive/coronary care unit fees
−
Ancillary hospital charges
− Disposable laparoscopic equipment
−
Prostheses
Consultations with a registered medical specialist or oral surgeon (including second opinions) and diagnostic imaging and tests referred by a registered medical specialist or oral surgeon directly relating to the approved surgery, performed within twelve months before or after surgery. Physiotherapy , occupational therapy and prescription costs directly relating to the approved surgery provided within six months after surgery on the recommendation of a registered medical specialist or oral surgeon .
Outpatient treatment support costs
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Benefit
Benefit entitlement
Maximum cover
Private Health Cover and Private Health Plus
Costs for the surgical treatment of cancer are covered under the above Surgery benefit, as listed under Inpatient treatment costs and/or Outpatient treatment support costs. This benefit covers non-surgical cancer treatment costs up to the maximum cover for this benefit of the following treatments, procedures, consultations, tests, diagnostic imaging, support and care once a diagnosis of cancer has been made by a specialist . Except where stated below to the contrary, the excess applies to any claims under this benefit.
CANCER CARE
Consultations with a registered medical specialist for treatment or procedures relating to the treatment of cancer .
Specialist consultations
Diagnostic imaging and tests and procedures in connection with the detection or treatment of cancer including:
> CT, PET/CT and MRI scans
> Ultrasounds
> X-rays, scintigraphy
> Mammography
Diagnostic imaging and tests
> Colonoscopy
$500,000 per life assured per policy year , subject to maximums for specific treatments or procedures
> Laboratory tests
> Tumour genetic testing
> Gastrointestinal endoscopy
> Cystoscopy
> Hysteroscopy
> Diagnostic laparoscopy
Chemotherapy and immunotherapy treatment including targeted therapy, oral, intravenous infusion, instilled, and intraoperative chemotherapy provided by or under the direction of a registered medical specialist , whether administered in an approved facility or at home. This covers the cost of Pharmac and non-Pharmac subsidised MedSafe indicated cancer chemotherapy and immunotherapy drugs, subject to Sovereign criteria . This also includes the cost of materials, hospital accommodation and ancillary hospital charges .
Chemotherapy/immunotherapy
Prior approval must be obtained before the treatment takes place.
Radiotherapy treatment provided by a registered medical specialist in an approved facility including planning, shielding and accessories, field setup and simulation, subject to Sovereign criteria.
Radiotherapy
Prior approval must be obtained before the treatment takes place.
Implantation of radioactive seeds for the treatment of malignancies of the prostate.
Prostate brachytherapy
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Benefit
Benefit entitlement
Maximum cover
Private Health Cover and Private Health Plus
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 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 Private 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.
Breast Symmetry surgery following mastectomy
The procedures to achieve breast symmetry do not need to be medically necessary .
Prior approval must be obtained before the procedure takes place.
Covers support services following cancer treatment including:
> Psychologist consultations, therapy and counselling,
> Personal items such as wigs to cover hair loss, bras following a mastectomy,
$1,000 per life assured per policy year
> Lymphatic massage,
Post-cancer treatment care and support
> Home help services including meal preparation, cleaning, showering and child care, provided by a suitably qualified person (employed in the provision of home help services).
These support services and personal items do not need to be medically necessary.
No excess is payable for claims under this benefit.
If a life assured has treatment for cancer in a public hospital that would otherwise have been covered by the Cancer Care Benefit in this policy, the public hospital cancer treatment cash benefit will be paid to the policy owner . Treatment includes cancer surgery requiring an overnight stay in a public hospital or a course of chemotherapy and/or radiotherapy.
Public hospital cancer treatment cash benefit
$5,000 per life assured per lifetime
No excess is payable for claims under this benefit.
The costs of palliative, hospice and respite care at an approved facility .
Palliative, hospice and respite care
$1,500 per life assured per lifetime
No excess is payable for claims under this benefit.
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Benefit
Benefit entitlement
Maximum cover
Private Health Cover and Private Health Plus
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 Private Health policy:
DENTAL EVALUATION AND TREATMENT PRIOR TO QUALIFYING TREATMENTS
$1,500 per life assured per policy year
> 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.
No excess is payable for any claims under this benefit.
Covers the cost of a Psychiatrist or Psychologist consultation and/or counselling where the support treatment and/or consultations directly relate to a claim under the Surgery or Cancer Care benefits. After referral from a registered medical specialist the support treatment and/or consulations must be received within six months of your claim being accepted.
$2,500 per life assured per policy year
MENTAL HEALTH SUPPORT BENEFIT
No excess is payable for any claims under this benefit.
Covers the cost of minor surgery or treatment at an approved facility . The minor surgery or treatment must be carried out by a general practitioner or under the care of a general practitioner, such as a registered nurse . No excess is payable for any claims under this benefit. Covers the following costs up to the maximum cover for this benefit of hospitalisation in an approved facility for the treatment of a condition which does not require surgery, when referred by a registered medical specialist:
$3,000 per life assured per policy year
MINOR SURGERY BENEFIT
> Hospital accommodation fees
> Registered medical specialist’s fees
MEDICAL HOSPITALISATION
$500,000 per life assured per policy year
> Diagnostic fees
> Ancillary hospital charges Please note that hospitalisation and hospice care costs in relation to cancer are covered under the Cancer Care benefit and not this benefit.
The excess applies to any claims under this benefit.
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Benefit
Benefit entitlement
Maximum cover
Private Health Cover and Private Health Plus
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;
CONGENITAL CONDITIONS SURGERY BENEFIT
> phimosis;
$2,000 per life assured per lifetime
> squint.
The surgery must be performed in an approved facility by a registered medical 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.
Covers the cost up to the maximum cover for this benefit of the following diagnostic tests and imaging at an approved facility when referred by a registered medical specialist irrespective of whether surgery occurs:
> Angiogram
> Arthroscopy
> Capsule endoscopy
> Colonoscopy
> CT scans
$200,000 per life assured per policy year
> Cystoscopy
MAJOR DIAGNOSTIC IMAGING AND TESTS
> Gastroscopy
> Hysteroscopy
> Laparoscopy
> MRI scans
> Myelogram
> Myocardial perfusion imaging
> PET/CT
> Scintigraphy The excess applies to any claims under this benefit.
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Benefit
Benefit entitlement
Maximum cover
Private Health Cover and Private Health Plus
Covers the cost of home nursing care up to the maximum cover for this benefit where the care is provided by a registered nurse following a surgical or medical procedure covered by this policy, and such care is recommended by a registered medical specialist or registered medical practitioner.
$300 per day, up to $5,000 per life assured per policy year
HOME NURSING
No excess is payable for any claims under this benefit.
Upon the death of a policy owner (where the death is not caused by something excluded under this policy), Sovereign will provide cover under this policy for the surviving lives assured covered by the policy at the time of death, free of charge for a period of two years.
WAIVER OF PREMIUM ON DEATH
Two year’s free cover
No excess is payable for any claims under this benefit.
If a life assured dies between the ages of 21 and 70 (inclusive), the bereavement grant will be paid to the policy owner or to the policy owner’s estate.
$3,500 per life assured per lifetime
BEREAVEMENT GRANT
No excess is payable for any claims under this benefit.
If a child of a life assured dies before the age of 21, the Parents Grieving Benefit will be paid to the policy owner . Sovereign will pay a maximum of one claim per child under the Parents Grieving Benefit across all Sovereign policies for the life assured(s) irrespective of how many lives assured are covered under this policy.
PARENTS GRIEVING BENEFIT
$2,000 per child
No excess is payable for any claims under this benefit.
If a treatment covered by one of the other benefits of this policy is not available within 100km of your home or usual place of residence, Sovereign will pay up to the maximum cover for this benefit of transport and accommodation for the life assured and a support person to travel to obtain that treatment. In any policy year you can only claim once under the Treatment Away From Home In New Zealand Benefit or the Parent Accommodation Benefit.
$300 per day, up to $3,000 per life assured per policy year
TREATMENT AWAY FROM HOME IN NEW ZEALAND
No excess is payable for any claims under this benefit.
Covers the cost for accommodation expenses incurred by a parent accompanying a child who is listed on the schedule . The child must be undergoing medical treatment in an approved facility in New Zealand. In any policy year you can only claim once under the Treatment Away From Home In New Zealand Benefit or the Parent Accommodation Benefit. No excess is payable for any claims under this benefit. Covers the costs of ambulance transfer expenses incurred by the life assured for emergency transportation to or from hospital within New Zealand. This benefit is not payable in respect of any ambulance transfers provided for either personal or social reasons, or where the associated costs would be covered by ACC or any other benefit provision under this policy.
$200 per day, up to $3,000 per life assured per policy year
PARENT ACCOMMODATION BENEFIT
AMBULANCE TRANSFER BENEFIT
$200 per life assured per policy year
No excess is payable for any claims under this benefit.
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Benefit
Benefit entitlement
Maximum cover
Private Health Cover and Private Health Plus
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.
The excess applies to any claims under this 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 applicable benefit in New Zealand dollars, at a health service facility approved by Sovereign.
Maximum cover for the applicable benefit, subject to the additional limits, exclusions and requirements set out in this section
VOLUNTARY TREATMENT OVERSEAS
Treatment outside Australia
This benefit covers the costs for the approved treatment, procedure, consultation, test, diagnostic imaging, support recommended by a New Zealand registered medical specialist .
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. Where applicable, any translation services must be provided by an appropriate registered translator in New Zealand acceptable to Sovereign.
This benefit covers the cost of any translation services provided by an appropriate registered translator in New Zealand acceptable to Sovereign, where translation of any receipt or information into English is required by Sovereign to support a claim under the Voluntary Treatment Overseas Benefit.
$500 per life assured , per policy year
TRANSLATION COSTS
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