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Specialist and Diagnostic Testing Benefit This appendix only applies if cover under the policy schedule includes the Specialist and Diagnostic Testing Benefit. This appendix forms part of and is incorporated into the TotalCare Max policy, the terms of which apply to this appendix . Details of the benefit chosen and the names of the people insured for the benefit (called the life or lives assured) are shown in the schedule . It is Sovereign’s normal business practice to review this benefit on a regular basis. A review of this benefit may result in Sovereign changing this benefit and updating the policy document (which includes the TotalCare Max policy and this appendix ) accordingly. Except where otherwise stated, Sovereign will give you at least 30 days’ notice of any pending benefit and policy document changes. Such notice will include an updated schedule, policy document and appendix and will confirm the actual date from which the revised benefit and policy changes will take effect. OPTIONAL BENEFIT APPENDIX TOTALCARE MAX PERSONAL
>> General surgeons >> Gynaecologists >> Neurosurgeons >> Oncologists >> Orthopaedic surgeons >> Urologists Cover is not provided for obstetricians, psychiatrists or psychologists.
1 What am I covered for?
This appendix provides 100% reimbursement of covered reasonable charges incurred as a result of medically necessary consultations with specialists and diagnostic testing (set out in sections two and three), up to a maximum of $5,000 per life assured per policy year. This reimbursement is subject to exclusions set out in this appendix and may be subject to the application of an excess . The excess applies once per life assured per policy year . If at claim time, the life assured does not have a valid TotalCare Max Life, Family Protection, Accidental Death, Total Permanent Disablement, Living Assurance, Progressive Care, Disability Income Protection, Loss of Earnings, or Mortgage and Income Protection Benefit, no Specialist and Diagnostic Testing Benefit will be payable. Any premiums paid for the Specialist and Diagnostic Testing Benefit after the Life, Family Protection, Accidental Death, Total Permanent Disablement, Living Assurance, Progressive Care, Disability Income Protection, Loss of Earnings, or Mortgage and Income Protection Benefit has been cancelled will be refunded to the policy owner. Where the life assured is covered under a Sovereign Absolute Health or any other Specialist and Diagnostic Testing Benefit underwritten by Sovereign, no benefit will be payable under this Specialist and Diagnostic Testing Benefit.
3 Diagnostic Tests
Covers the life assured for the reasonable charges of diagnostic procedures directly relating to a medical condition when referred by a specialist including but not limited to: >> Allergy testing >> Audiology >> Audiometric tests >> CT scans >> Colonoscopy* >> Cystoscopy >> Electroencephalography (EEG) >> Electromyography (EMG)
>> Exercise ECG >> Gastroscopy
>> Holter monitoring >> Laboratory tests >> Mammography*
2 Specialist consultations
>> MRI scans >> Myelogram >> Ultrasound >> Urodynamic assessments >> X-rays
This benefit covers the life assured for reasonable charges of a specialist when referred by a Registered Medical Practitioner including: >> Cardiac surgeons >> Cardiologists >> Ear, nose and throat specialists >> Gastroenterologists
*Cover is not provided for routine screening or periodic testing.
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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.
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If a child is added to your benefit and the child is the first child to be covered under this benefit, a premium increase will be required. No premium increase will be necessary if one or more children are already covered under this benefit. If an additional adult is added then the appropriate premium will need to be calculated and paid. The additional adult will need to provide evidence of good health. B) R EMOVING A FAMILY MEMBER / DEALING WITH ADULT DEPENDANT CHILDREN >> Under normal circumstances children listed on the schedule are covered under this benefit until the first anniversary date after their 21st birthday. You will receive written notification from Sovereign advising you that a child’s cover under this policy is soon to expire prior to that anniversary date. >> On reaching the age of 21 each child covered under this benefit can elect to purchase their own Specialist and Diagnostic Testing Benefit from the range of policies being offered at that time by Sovereign to customers. The child must make written application to Sovereign within three months after the anniversary date following his/her 21st birthday to be able to purchase the benefit without providing evidence of good health. >> If a child insured under the policy has reached the age of 21 and is a dependant, then you can apply to have them remain on this benefit until the anniversary date following his/her 25th birthday. Sovereign may request you to provide proof to establish that a child insured under this policy is a Dependent. You will be charged the appropriate age related premium for each Dependent. On reaching the age of 25 each dependant can elect to purchase their own Specialist and Diagnostic Testing Benefit from the range of policies being offered at that time by Sovereign to retail customers. The Dependent must make written application to Sovereign within three months after the anniversary date following his/her 25th birthday to be able to purchase the benefit without providing evidence of good health. You may remove any life assured under this policy with effect from an anniversary date. You must advise us that you wish to remove a life assured from this policy at least 30 days before the applicable anniversary date. C) ADJUSTING YOUR EXCESS You may make a request to Sovereign in writing to change the excess . Sovereign is not under any obligation to agree to any change to the excess unless we are satisfied that the life assured is in good health. The life assured may be required to provide further health information before a change to the excess is made. Any change to the excess may result in a change to your premium . Any change to your premiums or excess will start from the date notified to you by Sovereign in the applicable policy endorsement.
6 Claims on other insurers
Where another insurer, including but not limited to ACC, may have responsibility in respect of a claim the following provisions apply: >> It is the policy owner’s or the 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 or the life assured must firstly make a claim to the 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.
7 For claims involving ACC
a) It is the life assured’s or the policy owner’s responsibility to submit any accident related claim to ACC in the first instance. b) In respect of any accident related hospital treatment, Sovereign will not pay for MRI or CT scans or other specialised imaging procedures required within seven days of the injury occurring. 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 benefit. d) If ACC declines cover for private hospital treatment of an accident related condition, Sovereign reserves the right to insist that the policy owner or life assured applies to ACC for a review of that decision before Sovereign accepts any claim. Where ACC reverses a decision for a previously declined claim, Sovereign reserves the right to seek reimbursement from ACC or the policy owner of any related claims paid by Sovereign. e) 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.
8 How can you amend this benefit?
A) ADDING FAMILY MEMBERS Y ou may apply to Sovereign in writing to extend cover under this benefit at any time to include: >> the spouse, civil or de facto partner of the policy owner; >> any child under the age of 21. Sovereign is not under any obligation to add any additional life assured unless we are satisfied that the life assured is in good health. Children are automatically covered under this benefit for the first three months after being born. For a child’s cover to continue after the first three months, you must advise us in writing of the child’s name, date of birth and gender. If you provide these details to us within this three month period, the child will automatically be accepted for cover under this benefit without the need to provide evidence of good health. Details received outside this period will result in the child having to be medically assessed.
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that you are able to recover from sources outside of this policy, including any other contract of insurance, regardless of whether you claim from these other sources or not.
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Exclusions Sovereign will not pay any expenses incurred in relation to, or as a consequence of, any of the following: >> A pre-existing condition, unless the symptom or condition was disclosed at the time of your application and accepted in writing by Sovereign; >> Any congenital conditions; >> Diagnosis, management and treatment for breast reconstruction or reduction, facelifts, varicose veins; >> Contraception; >> Circumcision, except where medically necessary; >> Acne treatment, except where classified by a specialist as Grade 4 acne with serious medical implications; >> The misuse of prescribed or non-prescribed drugs, including where they have not been taken in accordance with the manufacturer’s or a Registered Medical Practitioner’s directions; >> Certifiable mental disease or psychiatric illness or any charges relating to services resulting from a referral to, or provided by, a psychiatrist. This includes all counselling services; >> Suicide, self-inflicted injuries or illness, or any accident, illness, condition or disability arising from, or caused or contributed to by, drug taking, intoxication or misuse of alcohol, or nuclear contamination; >> HIV related disorders, including AIDS; >> Obstetric visits, pregnancy, childbirth, abortion, or any conditions or complications arising from any of the foregoing; >> Diagnosis, management and treatment of infertility; >> Diagnosis, management and treatment of snoring, except where a specialist confirms diagnosis of sleep apnoea and the surgical treatment is medically necessary (pre-approval of any claim for treatment must be sought or obtained from Sovereign before any costs are incurred); >> Any geriatric or dementia conditions, including disability support services; >> New medical treatments, procedures or technologies that have not been approved by Sovereign; >> Preventative treatment, or treatment or investigation of any condition that will not cause significant problems for the health of the individual if medical treatment is not received (including, for example, routine screening or mole mapping); >> Treatment for obesity (including treatment of complications arising from any treatment for obesity; any disease or disorder of the skin or psychological treatment); >> Charges for a treatment or procedure not provided by a Registered Medical Practitioner practising within his or her scope of practice; >> Treatment provided by a public hospital, except where expressly covered by this policy; >> Physiotherapist’s, chiropractor’s, osteopath’s, naturopath’s, homeopath’s, acupuncturist’s, podiatrist’s, dietician’s, counsellor’s, and speech therapy costs; >> Nursing costs, except where expressly covered by this policy; >> Cost for specialist consultation and tests carried out outside of New Zealand; >> Prescription charges, except where expressly covered by this policy; >> Any condition arising from participation in a criminal activity; >> Any condition specifically excluded in the policy document; >> Palliative care; >> Any part of a claim that you make under this policy to the extent
10 Key terms
In this policy the following words have defined meanings: CHILD/CHILDREN Any birth child/children or child/children under legal guardianship of: >> the policy owner; or >> the spouse, civil or de facto partner of the policy owner (if that person is a life assured). COSMETIC PROCEDURE Any procedure, surgery or treatment that is carried out to improve or enhance appearance or improve psychological wellbeing. DEPENDENT Any child aged between 21 and 25 years, who is financially Dependent on the policy owner and/or the life assured (for example, a financially Dependent 22 year old attending a full time tertiary course). EXCESS The amount, if applicable, which will be deducted from claims submitted prior to benefits being paid under this policy. This is the amount you are responsible to pay directly to the Registered Medical Practitioner. Any excess amount applicable to your coverage will be indicated on the schedule. IMMEDIATE FAMILY Means the eligible life assured’s partner (spouse, civil, or de facto) and any birth child or child under legal guardianship of the life assured and/or the life assured’s partner. MAXIMUM COVER The maximum amounts payable by Sovereign as set out in section one. MEDICALLY NECESSARY A service or supply furnished by a Registered Medical Practitioner is medically necessary if Sovereign determines that it is necessary for the diagnosis, care or treatment of the disease or illness involved. In no event will the following services or supplies be considered to be necessary: >> those that do not require the technical skills of a medical professional; >> those furnished mainly for the personal comfort and convenience of the person; >> those furnished solely because the person is an inpatient. PRE-EXISTING CONDITION Any disease, injury or medical condition for which, prior to becoming covered under this benefit, the life assured experienced a symptom, consulted a Registered Medical Practitioner, received treatment or services from a Registered Medical Practitioner, or took prescribed drugs and medicines. PRIVATE HOSPITAL A privately owned facility, approved by Sovereign, which is a ‘hospital care institution’ in terms of section 58 of the Health and Disability Services (Safety) Act 2001, as amended or replaced.
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PUBLIC HOSPITAL A “hospital care institution” in terms of section 58 of the Health and Disability Services (Safety) Act 2001, as amended or replaced, that is directly or indirectly owned or funded by the New Zealand Government or any of its agencies. REASONABLE CHARGES Charges for medical treatment that are determined by Sovereign in its sole discretion to be reasonable and within a range of fees charged under similar circumstances by persons of equivalent experience and professional status in the area in which the medical treatment is provided. ROUTINE SCREENING Any preventative treatment, health surveillance testing (including as a result of family history), or investigative procedures performed by a Registered Medical Practitioner where the life assured has no medical symptoms. SPECIALIST A Registered Medical Practitioner who is qualified in a specialist field of medical or surgical practice and who is registered as a specialist in that field with the New Zealand Medical Council.
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