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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712 PH-UMB version 9 Effective 8 April 2022
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