4 Best Doctors ®
Best Doctors is available for the life assured and their immediate family to use as many times as they need to. Best Doctors can provide additional advice on critical, chronic and degenerative conditions after the person who is suffering the condition has seen a specialist . The Best Doctors service can be accessed regardless of whether the condition is covered by this policy. Best Doctors is independent of Sovereign and Best Doctors’ terms and conditions and eligibility criteria apply. Sovereign may withdraw access to the service or change the terms on which access to the service is made available with 90 days’ notice. Neither Sovereign, its related companies, nor their directors, officers or employees accept any liability whatsoever for any loss or damage arising out of the use of the Best Doctors service, or the unavailability of Best Doctors. Sovereign is not responsible for any cost associated with becoming eligible to use, or use of, the Best Doctors service (including without limitation the cost of any medical consultations or treatment, travel, lodging, telephone calls, faxes or mail), unless covered by a Sovereign policy. CONTACT BEST DOCTORS ON 0800 425 005. Best Doctors and the star-in-cross logo are trademarks of Best Doctors, Inc., in the United States and in other countries and are used under licence.
5 How to make a claim
For any claim enquiries you should first call the Sovereign Claims Hotline on 0800 166 377. A claim form can be downloaded from Sovereign’s website (sovereign.co.nz). Sovereign recommends that you seek Sovereign’s approval prior to incurring costs related to any medical treatment to ensure that the medical treatment is covered under this policy. Alternatively you can pay for the medical costs incurred yourself and then submit your claim to Sovereign for reimbursement in accordance with section 5B below. A) PRIOR APPROVAL AND DIRECT PAYMENT PROCESS FOR CLAIMS: Prior approval and direct payment processes are streamlined. If you obtain prior approval from Sovereign, then we will pay the Registered Medical Practitioner or facility directly. You must comply with the following requirements when seeking Sovereign’s prior approval and direct payment of any claims: >> Prior approval requests should be made as soon as you are aware of the pending specialist consultation or diagnostic test. We need a minimum of five working days to process a claim prior to the actual procedure. Failure to notify Sovereign within the required timeframe may result in a prior approval authorisation being declined or delayed until Sovereign has had the opportunity to fully assess the claim. >> You should provide Sovereign 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 that the consultation or test being contemplated is medically necessary and falls within the terms and benefits of this policy. >> Allow Sovereign in its sole discretion to: - contact the Registered Medical Practitioners and obtain an estimate of the costs associated with the specialist consultation or diagnostic test under the claim; - negotiate the proposed costs; and - request that a second opinion is sought.
If your claim is approved, Sovereign will allocate a prior approval reference number to the claim and will fax or post to you or the life assured 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. B) WHEN YOU PAY FOR TREATMENT YOURSELF AND THEN SUBMIT A CLAIM FOR REIMBURSEMENT: You should complete the claim form and send it together with the Registered Medical Practitioner’s referral letter and/or medical certificate and all of the original receipts and itemised invoices to us. For any claim to be admissible regardless of payment method: >> the specialist consultations or diagnostic test must be medically necessary, as evidenced by the Registered Medical Practitioner’s referral letter and/or medical certificate and any other documentation requested by Sovereign to satisfy itself that the consultation or test is medically necessary; and > > premiums must be fully paid at the time the consultation or test takes place. If the costs of the consultation or test are greater than the lesser of the maximum cover or the reasonable charges, the balance of the costs remaining after Sovereign has paid the lesser of the reasonable charges or the maximum cover will be your responsibility. If this benefit is cancelled for any reason and there are outstanding claims relating to any specialist consultation or diagnostic test covered under this policy that occurred before the date of cancellation, Sovereign must receive the relevant claim forms within 30 days of the cancellation date, otherwise the claim will not be payable.
865 TCB-ST version 3 Effective 25 May 2015
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