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AIA LIVING - PERSONAL OPTIONAL BENEFIT APPENDIX
Specialist and Testing Support Benefit
This appendix only applies if cover under the schedule for your policy includes the Specialist and Testing Support Benefit. This appendix forms part of and is incorporated into your AIA Living policy, the terms of which apply to this appendix .
Details of the benefit and the life / lives assured are shown in the schedule .
1. What am I covered for?
Reimbursement of medical services you have paid for
Your policy covers the benefits set out in section 9 ‘Benefits – what you are covered for’, subject to meeting the terms and conditions of your policy and any exclusions that may apply.
If you have not applied for prior approval and you have paid for your specialist consultation or test you will need to apply for reimbursement.
You will need to provide AIA with:
2. What am I not covered for?
details of the specialist consultation or test including all the original receipts and itemised invoices; and a copy of the registered medical practitioner’s referral letter and any other relevant clinical notes that may be requested by us in order to assess whether the consultation or test is medically necessary and falls within the terms of this policy.
What you are not covered for is set out at section 10 ‘ Exclusions – what you are not covered for’ .
3. 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. By seeking approval we are able to give you certainty of cover by addressing your eligibility prior to the specialist consultation or diagnostic test taking place. There may be certain costs or medical services that are not covered by this policy. Obtaining prior approval ensures you understand what will be covered and allows AIA an opportunity to negotiate costs with the health service provider or discuss alternatives with the registered medical practitioner or specialist on your behalf. Submit a claim or pre-approval request online by logging in to MyAIA, our customer portal. We need at least five working days to issue prior approval. AIA may request supporting evidence, including a second opinion, in order to satisfy itself that the specialist consultation or diagnostic test is medically necessary .
AIA’s Healthcare Partnership Programme
If the life assured’s medical service is being provided by one of AIA’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. AIA 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 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, AIA 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.
Applying for pre-approval
You will need to provide AIA with:
details of the planned specialist consultation or diagnostic test including an estimate of cost; and a copy of the registered medical practitioner’s referral letter and any other relevant clinical notes that may be requested by us in order to assess whether the consultation or test is medically necessary and falls within the terms of this policy. If your claim is pre-approved, AIA will provide written confirmation of the pre-approval, including details of any costs that are not covered that you will need to pay directly to the health service provider. AIA will pay the health service provider directly upon receipt of the invoice up to the maximum cover .
AIA determines reasonable charges by regularly reviewing:
Health service providers’ charges for particular services.
AIA’s own claims statistics.
AIA’s experience of the New Zealand health market.
International benchmarks of the relative value of health services. If the proposed cost of your medical service is greater than the reasonable charges : AIA will negotiate with the health service provider on your behalf to facilitate a reduction in the proposed cost
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of the consultation or diagnostic procedure where possible. By purchasing this policy, you authorise AIA to do this. AIA may request that you seek a second opinion for the consultation or diagnostic 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 AIA is unable to negotiate a reduction in the cost and you choose to continue with the consultation or diagnostic procedure with the particular health service provider: You will be responsible for any difference between the reasonable charge and the cost of your medical consultation or diagnostic 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.
costs.
AIA 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.
5. Claims on other insurers
It is your responsibility to advise AIA 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 AIA 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 reimburse you for the remaining costs in accordance with this policy. If you have two or more policies with AIA you cannot claim for, or be reimbursed for, an amount higher than the total cost of your medical services.
Excess
The excess is the amount that you will be responsible to pay towards the cost of any procedure or benefit you are entitled to claim, or be reimbursed for under this policy for a life assured . The excess applies separately for each life assured and is applicable per policy year . At the start of each policy year the excess will reset to its full value for each life assured . The available excess amounts are $0 or $250. The excess will apply to each benefit available under the Specialist and Testing Support Benefit unless:
otherwise specified in the benefit; or
6. AIA ’s Right to Amend Policy Terms
the full value of the applicable excess has already been paid by you for the life assured in the applicable policy year , in which case the excess will be waived for any further claims within the same policy year . You may request AIA to change the excess applicable to your policy. 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.
It is AIA ’s business practice to review this policy over its lifetime. This is to ensure it continues to provide cover for current consultations and diagnostic procedures for common medical conditions at the time. It is also to ensure the insurance product remains commercially viable for AIA . Any changes to the terms of this policy will apply across all lives assured with the same policy. AIA 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 AIA may wish to change the terms of this policy across all lives assured: To increase the level of benefits under the policy or to add new benefits. To move all lives assured to a refreshed policy document with a new drafting style/layout and similar levels of benefits.
4. Claims involving ACC
This policy does not cover any costs arising from 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. When ACC agrees to contribute to the life assured ’ s costs, AIA may cover additional costs up to the reasonable charges or maximum cover of this policy. You must obtain AIA’s prior approval before incurring costs. If ACC declines the claim AIA reserves the right to require that the life assured applies to ACC for a review of that decision, before AIA has any obligation to consider a claim under this policy. If ACC upholds their decline decision AIA may cover your costs up to the reasonable charges or maximum cover of this policy. You must obtain AIA’s prior approval before incurring
To take account of changes in the laws in New Zealand.
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).
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To take account of a significantly escalated or new public health threat e.g. a pandemic. AIA 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 Enhancement Pass Back 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.
7. 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 24 months; or
for up to 12 months if the policy owner :
- becomes unemployed or redundant;
- goes on leave without pay for any reason;
- experiences at least a 20% reduction in pay (comparing the most recent payslip against a previous payslip from the same year); or - 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 AIA within three months of one of the above
listed suspension events occurring and provide evidence to AIA of the suspension event; and
AIA acknowledges in writing receipt of that notification.
Cover will also be suspended for a life assured if their qualifying benefits with AIA are suspended. 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. 8. When will this appendix terminate for a life assured ? This appendix will terminate and eligibility for the Specialist and Testing Support Benefit will cease for a life assured when:
The life assured dies.
The benefit is cancelled.
All of the life assured’s qualifying benefits with AIA are cancelled or reduced below the minimum qualifying sum assured requirements.
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9. Benefits – what you are covered for
Your policy covers the cost up to the maximum cover for each life assured for the reasonable charges of the following services carried out in New Zealand:
Benefit
Benefit entitlement
Maximum cover
Covers medically necessary consultations with a specialist when referred by a registered medical practitioner .
$10,000 per life assured, per policy year
SPECIALIST CONSULTATIONS
The excess applies to any claims under this benefit.
Covers the following medically necessary diagnostic procedures performed at an approved facility when referred by a registered medical practitioner:
Allergy testing
Audiology tests
CT scans
Capsule endoscopy
Colonoscopy
Colposcopy
Cystoscopy
Electroencephalography (EEG)
Electromyography (EMG)
Exercise/Stress ECG
Gastroscopy
$100,000 per life assured, per policy year
DIAGNOSTIC IMAGING AND TESTS
Holter monitoring/24 Hour Ambulatory monitoring
Laboratory tests
Mammography
MRI scans
Myelogram
Myocardial perfusion imaging
PET/CT scans
Scintigraphy
Sleep studies
Ultrasound
Urodynamic assessments
X-rays
Cover is available for the cost of other diagnostic imaging and tests, subject to AIA’s prior approval.
The excess applies to any claims under this benefit.
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Benefit
Benefit entitlement
Maximum cover
Covers the cost up to the maximum cover for this benefit of obstetric care (including scans), infertility diagnosis and treatment carried out by a registered medical practitioner or a specialist at an approved facility. This benefit includes cover for reasonable accommodation costs incurred by a life assured for maternity, pregnancy or infertility related stays in an approved facility .
$1,500 per life assured, per policy year Claims for pregnancy or maternity care are additionally limited to
PREGNANCY, MATERNITY AND INFERTILITY ALLOWANCE
Pregnancy and maternity care is available to a pregnant life assured only.
Cover under this benefit is only available to a life assured who has had two years of continuous cover under the Specialist and Testing Support Benefit.
$1,500 per pregnancy
No excess is payable for any claims under this benefit.
Covers the following procedures performed at an approved facility :
bone screening (osteoporosis)
bowel screening
breast screening
cervical screening
heart screening
prostate screening
eye tests and/or visual field tests
$500 per life assured for each three year period or $750 if the
hearing tests
HEALTH SCREENING ALLOWANCE
skin checks
life assured is a member of AIA Vitality
aortic aneurysm screening
Cover under this benefit is only available to a life assured after three years of continuous cover , or after two years of continuous cover if the life assured is a member of AIA Vitality . The health screening test does not need to be medically necessary but the procedure must be performed by or referred by a registered medical practitioner. The pre-existing conditions exclusion and the congenital conditions exclusion do not apply to the Health Screening Allowance.
No excess is payable for any claims under this benefit.
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10. Exclusions – what you are not covered for
There is no cover under any of the benefits for costs that exceed the reasonable charges for the applicable consultation or procedure.
There is no cover under any of the benefits for costs arising from, or related in any way to, any of the exclusions listed below.
Exclusion name
Exclusion wording
Acne
Except where classified by a specialist as Grade 4 acne with serious medical implications.
Care provided for a sign, symptom, condition or disease that requires immediate or same day hospital admission for treatment or monitoring. Any treatment by a physiotherapist, chiropractor, osteopath, naturopath, homeopath, acupuncturist, podiatrist, dietitian, counsellor or speech therapist.
Acute care
Allied health
Congenital conditions
Any congenital conditions.
Contraception
Contraception of any type.
Criminal activities
Any injury or condition arising from participation in a criminal activity.
The misuse of prescribed or non-prescribed drugs, including where they have not been taken in accordance with the manufacturer’s or registered medical practitioner’s directions. Any elective or cosmetic procedure or any surgery, procedure or treatment that improves, alters or enhances appearance, whether or not undertaken for medical, physical, functional, psychological or emotional reasons. Any injury, illness, condition or disability arising from, caused or contributed by, drug taking, intoxication or misuse of alcohol. Diagnosis, management and treatment of infertility, except as specifically provided by the Pregnancy, Maternity and Infertility Benefit. Psychiatric, psychological and/or neurodevelopment disorders including treatment or counselling for but not limited to pre-senile dementia, senile illness or dementia, geriatric care including geriatric in- patient care and disability support services, intellectual disability (intellectual development disorder), autism spectrum disorder, attention deficit/hyperactivity disorder, specific learning disorders, motor disorders (including but not limited to Tourette’s disorder) or dyslexia.
Drugs
Elective or cosmetic
Illness arising from drugs/alcohol
Infertility
Mental illness
New medical services
New medical services that have not been approved by AIA in its sole discretion.
Obesity related medical services (including treatment of complications arising from any treatment for obesity; any disease or disorder of the skin or psychological treatment). Obstetric visits, pregnancy, childbirth or any associated conditions or complications except as specifically provided by the Pregnancy, Maternity and Infertility Benefit.
Obesity
Obstetrics
Out of scope services
Services not provided by a registered medical practitioner practising within their scope of practice.
Any pre-existing condition , unless the symptom or condition was disclosed to AIA at the time of your application and accepted as covered by AIA in writing. Preventative medical services, health surveillance screening or treatment or investigation (including as a result of family history) where the life assured has no medical symptoms or where the condition will not cause significant problems for the health of the life assured if medical treatment is not received, except where expressly covered by a benefit in this policy.
Pre-existing conditions
Preventative medical services and routine screening
Public hospital
Services carried out in a public hospital.
Correction of refractive visual errors or astigmatism by surgery, surgically implanted intraocular lens(es), or laser treatment. This includes any consultations relating to refractive visual errors.
Refractive visual errors
Services outside of New Zealand
Services carried out outside of New Zealand.
Snoring
Diagnosis, management and treatment of snoring.
Cystic fibrosis, polycystic kidney, Marfans syndrome, Loeys-Dietz syndrome, spina bifida, scoliosis, kyphosis, pectus excavatum and pectus carinatum.
Specified conditions
Termination of pregnancy Termination of pregnancy.
War/terrorism
Injuries of war or resulting from any terrorist act (whether war is declared or not).
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11. Key terms
be held in conjunction with the Specialist and Testing Support Benefit at all times. Charges, costs and fees that AIA has determined are reasonable for the consultation or procedure when carried out or taking place in New Zealand. For further details about how these charges are calculated and how they impact on your claims see the section 3 ‘How to make a claim’ . A person, acceptable to AIA , who holds a current practising certificate in compliance with the Health Practitioners Competence Assurance Act 2003 (or its successor) and who is registered and practising as a medical practitioner in New Zealand, other than:
A continuous period of cover from the risk commencement date during which the premium is paid for the life assured . The amount that you will be responsible to pay towards the cost of any procedure or benefit you are entitled to claim, or be reimbursed for under this policy for a life assured . The maximum amount AIA will pay for each benefit or combination of benefits, as specified for the benefit(s). A specialist consultation or diagnostic test provided by a registered medical practitioner or specialist that AIA deems on reasonable grounds is necessary for the diagnosis, care or treatment of the disease or illness involved. Under no circumstances will the following services be considered medically necessary:
continuous cover
reasonable charges
excess
maximum cover
registered medical practitioner
medically necessary
The policy owner(s) ;
The life assured ;
A family member of the life assured or policy owner(s) ; The business partner or associate of the life assured’s or policy owner(s) .
those that do not require the skills or services of a registered medical practitioner or specialist ; those provided mainly for the comfort or convenience of the life assured ; those services that do not relate to the medical treatment being provided.
Any preventative treatment, health surveillance testing (including as a result of family history), or investigative procedure performed by a registered medical practitioner where the life assured has no medical symptoms.
routine screening
Any disease, injury or medical condition for which, prior to the risk commencement date , the life assured knew they had or ought on reasonable grounds to have known they had, or for which they had experienced a symptom, consulted a registered medical practitioner , received treatment or services from a registered medical practitioner , or took prescribed drugs or medication. Eligible life, trauma, total permanent disablement or income protection benefits that meet AIA’s minimum requirements to add the Specialist and Testing Support Benefit. A qualifying benefit must
pre-existing condition
qualifying benefits
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