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.
9
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.
816 TCP-ST version 4 Effective 25 May 2015
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