> _Markdown transcription of Accuro SmartCare+ policy wording, effective 2026-05-16. Source: https://production-media-accuro.s3.ap-southeast-2.amazonaws.com/public/Collateral/Policy-Documents/2025/Health-Plan-Documents-1-September/SmartCare%2B-Sept-2025.pdf_ --- # Health Plan Document # SmartCare+ Here's all you need to know --- # Welcome to SmartCare+ Thank you for choosing SmartCare+. We want you to understand your policy and be confident in your health insurance cover, so please read this document carefully. You must provide true, correct, and complete information about yourself and any additional *Member* when setting up this policy and when making any changes. This Health Plan was previously issued under the Accuro brand. Accuro is becoming UniMed. You will still see reference to Accuro as we transition. Please note that the terms and conditions for this Health Plan are included within this document. The general UniMed terms and conditions do not apply to this Health Plan. ## Contents - SmartCare+ at a glance — 3 - The SmartCare+ cover and benefits — 5 - Hospital and Surgical+ base plan — 6 - Additional modules — 14 - What's not covered (exclusions) — 20 - How to submit a claim — 23 - How to apply for prior approval — 24 - How to make a claim after treatment — 25 - What we will pay — 27 - General conditions of your policy — 29 - What you need to do — 31 - Making changes to your policy — 33 - Other important information — 36 - How to contact us — 38 - Glossary — 39 ## Tell us about changes Please make sure that we have your most up-to-date contact details. Contact us if your circumstances change. --- # SmartCare+ at a glance This Health Plan document explains what's covered for all SmartCare+ policy holders (benefits) and what's not covered (general exclusions). Check your policy certificate for details that are specific to your policy, including personal exclusions, excesses and the modules you have cover under. This document and your policy certificate make up your policy. Please make sure you read these documents and keep them in a safe place. Your SmartCare+ policy starts from the date on your policy certificate, or the date specified for each additional Member. You'll be covered until your policy ends because it's been cancelled or terminated. ## Who SmartCare+ is for This SmartCare+ policy is only for New Zealand citizens, residents, or people who are entitled to funding under New Zealand's public healthcare system. We've designed this policy to complement the services that are provided by the public health system and the Accident Compensation Corporation (ACC). ## Extra care and support Some customers are more vulnerable to the risk of unfair outcomes or disadvantages due to their personal circumstances. This could be due to, for example, health or disability reasons, life events, financial or personal resilience, knowledge or confidence in managing financial matters. To help us recognise and act with the appropriate level of care please chat to one of our team about your needs so we can take extra care and provide support that fits your needs. The New Zealand healthcare system has three main components: **Accident Compensation Corporation (ACC)** provides comprehensive, no-fault personal injury cover for anyone in New Zealand. **The public health system** is subsidised by the government and provides cover for all New Zealand residents. It covers acute treatment (when surgery or treatment needs to happen immediately because of a medical emergency) and some elective treatments, which can take years to occur in the public health system. **The private health system** gives you control over when and where you're treated, including being able to choose the doctor, specialist or hospital that you prefer. Often people will decide to have elective treatment in the private health system as it's quicker. Treatment is 'elective' when it's scheduled in advance to happen at a later date because it isn't a medical emergency. ## Main benefits of SmartCare+ ### Hospital and Surgical+ base plan benefits: cover for each person in a policy year | Benefit | Amount | |---------|--------| | General surgery (including tests such as CT and MRI scans) | $500,000 | | Oral surgery | $300,000 | | Private hospital medical admission (including chemotherapy and radiation treatment) | $300,000 | | Multiple overseas treatment benefits | refer to benefit for limit | | Non-Pharmac subsidised drugs | refer to benefit for limit | ## Additional modules/Health Plan Start with the base plan and add additional modules When your policy starts, you begin with the base plan that everyone on the policy must have: the Hospital and Surgical+ base plan. You can choose to add any of our additional modules for yourself or any of the other additional Members on the policy. They don't need to be the same modules for all additional Members. Check your policy certificate to see the additional modules and additional Members on your policy. ### Hospital and Surgical+ base plan - Provides the base cover everyone must have ### Specialist+ module Cover for specialist consultations and diagnostic tests. ### GP+ module Cover for GP and nurse consultations, along with prescription drug costs. ### Natural Health+ module Cover for consultations with chiropractors, physiotherapists, osteopaths and other natural health providers. ### Dental and Optical+ module Cover for dental treatment and optical consultations and eyewear. ### Day to Day Health Plan Cover for everyday costs such as going to the doctor, natural therapist, dentist or optician. For more details on these modules please see the 'Additional modules' section on page 14. ## Terms used in this document We've explained some common health insurance terms. Words printed in italics are key terms as defined in the glossary on pages 39 to 41. Key terms only appear in italics the first time they are used. 'We' and 'us' means UniMed. 'You' means the Primary Member (the policy holder), and may include all other individuals attached to your policy as additional Members. For explanations of medical terms, please ask your GP or other healthcare provider, or consult the Health Navigator website at www.healthnavigator.org.nz --- # The SmartCare+ cover and benefits This Health Plan document lists what's covered for all SmartCare+ policy holders (benefits) and what's not covered (general exclusions). A general exclusion could be a medical condition or service that we've decided we won't cover for anyone who has this type of policy. Your policy certificate contains the details that are specific to your policy, such as what modules each person in your family is covered for, as well as any personal exclusions. A personal exclusion is where we've reviewed the medical information you've provided for us and have decided that a certain condition may pose too great a risk to insure against. Personal exclusions last for different lengths of time (from 1 year to life), depending on the medical condition. You'll automatically have the Hospital and Surgical+ base plan. Please check your policy certificate to see whether you have cover under any of the additional modules. Your policy certificate will list any excess applicable under your Health Plan. An excess applies to the base plan or additional modules once for each person for each year they have the policy. To find out what type of prescription drugs are covered under your policy, refer to the 'Conditions of cover for prescription drugs' section on page 30. --- # Hospital and Surgical+ base plan The following benefits apply to the Hospital and Surgical+ base plan. Please take the time to read over these and ensure you understand them. Contact us if you have any queries about any of our benefits. ## Standard benefits: ### General surgery **$500,000 for each person in a policy year** **An excess applies to this benefit** If you're wanting to *claim* under this benefit, we strongly recommend you seek prior approval before your treatment. This benefit covers the costs of *Reasonable charges* associated with the surgical treatment of a non-acute medical condition. The benefit covers the procedure(s) and all subsequent treatment or expenses listed below. - Private hospital or public hospital costs (provided protocols for a private hospital set by the Ministry of Health for the treatment of private patients in public hospitals have been followed) - Physiotherapy while in hospital - Surgeons' fees - Anaesthetists' fees - Costs of essential *prostheses* listed in the Accuro schedule - Pre-operative and post-operative diagnostics, consultations, or tests, if they occur within 1 year before or after the approved surgery All costs must be associated with the original diagnosis, including any complications of the initial surgery. This benefit also includes diagnostic surgeries such as a hysteroscopy, cystoscopy, laparoscopy and arthroscopy. We may consider that an alternative, less invasive procedure or *medical treatment* is the most suitable method of treatment instead of the proposed surgery. If so, we'll cover the costs associated with this rather than paying the surgical claim. Oncology consultations and treatment following surgery are covered under the private hospital medical admission benefit. #### This includes: **Spinal Surgery** This benefit covers the costs of spinal surgeries. You can claim this benefit as needed but it only provides cover up to $200,000 for each person over their lifetime. A list of all spinal surgeries which fall under this benefit can be found under the Resources page on the Accuro website. **Major diagnostic procedures** This benefit covers the costs of *Reasonable charges* for the following diagnostic procedures. - Angiograms - CT scans - Dilation and curettage - Endoscopies, such as a colonoscopy or gastroscopy - MP scans - MRI scans - Myelograms - PET scans Cover applies whether or not you're admitted to a hospital. **Breast reconstruction** This benefit covers the costs of a breast reconstruction of the affected breast only after a mastectomy for the treatment of breast cancer. The reconstruction of the affected breast must occur within 24 months after a mastectomy that we've approved under this policy. **Breast symmetry** This benefit covers the costs of unilateral breast reduction surgery on the unaffected breast in order to achieve breast symmetry after a mastectomy for the treatment of breast cancer. The reduction of the unaffected breast must occur within 24 months after a mastectomy that we've approved under this policy. ### Oral surgery **$300,000 for each person in a policy year** **An excess applies to this benefit** This benefit covers the costs of *Reasonable charges* associated with oral or maxillofacial surgery listed below. - Surgical removal of impacted or unerupted teeth - Surgical removal of cysts or soft tissue swellings - Surgical drainage of oral abscesses - Pre-operative and post-operative diagnostics, consultations or tests if they occur within 1 year before or after the approved surgery This benefit doesn't cover the insertion or removal of dental implants, or the exposure of a tooth. You must be treated by a New Zealand-registered oral or maxillofacial specialist, in an accredited private hospital or clinic. A New Zealand-registered medical practitioner, dental surgeon, or dentist must refer you or the additional Member on your policy. A registered oral surgeon or registered dentist must perform the surgical removal of unerupted and impacted teeth. They must write to us to confirm the status of the impacted or unerupted teeth. ### Private hospital medical admission **$300,000 for each person in a policy year** **An excess applies to this benefit** This benefit covers the costs of *Reasonable charges* for admission to a private hospital for reasons other than surgery, such as cancer treatment. Your condition must have directly resulted from the diagnosis of any non-acute (non-urgent) medical condition. The non-surgical hospital treatment must be recommended by an appropriate registered medical practitioner as being necessary to improve the health of the Member. This benefit covers the following costs that occur during the period of *hospitalisation*. - Private hospital accommodation fees - Other hospital costs, including intravenous fluids, dressings, and prescription drugs throughout hospital admission - Chemotherapy drugs administered orally at home that are prescribed by a registered medical specialist and to be used during an approved cycle of chemotherapy treatment under this policy - Registered medical specialist fees, including fees directly related to the hospital admission and that have occurred within 6 months of the date of admission - Diagnostic procedures, including diagnostic procedures directly relating to the hospital admission that occurred within 6 months of the date of admission - $2,000 for each person in a policy year towards personal accessories that are needed during or within 6 months after the cancer procedure or medical treatment, such as a wig, hat, scarf, or mastectomy bra. ### Prophylactic surgery **$80,000 for each person** **An excess applies to this benefit** This benefit covers the costs of prophylactic (preventative) surgery if you have an increased risk of developing cancer because of a high-risk status or gene mutation. You can claim this benefit as many times as you need to but it only provides cover up to $80,000 for each person over their lifetime. To claim under this benefit, you must meet the requirements listed in the eligibility criteria for Prophylactic surgery. ### Non-Pharmac subsidised drugs **An excess applies to this benefit** This benefit covers the costs of *Reasonable charges* associated with accessing the most effective treatment available. This is regardless of whether or not the drug qualifies for a government or other subsidy, such as Pharmac funding. With this benefit, we'll reimburse the costs of all drugs registered by Medsafe for use in New Zealand where: - the treatment is prescribed by a registered medical specialist as the appropriate medical treatment for the condition - the treatment or condition is not excluded elsewhere in this Health Plan document - the drug is being prescribed within the guidelines set by Medsafe. If the drug qualifies for a government or other subsidy, we'll reimburse the rest of the cost. All costs under the non-Pharmac drugs benefit are included in the maximum limit of the surgical or non-surgical benefit, whichever applies for the relevant treatment under the Hospital and Surgical+ base plan. ### Overseas treatments **An excess applies to this benefit** #### Treatment outside of New Zealand **$30,000 for each person in a policy year** This benefit covers reimbursement of *Reasonable charges* for a surgical procedure or medical treatment performed at an overseas hospital, where the procedure or treatment isn't available in New Zealand. To qualify for this benefit, the Member must: - be in New Zealand when they are diagnosed and must not have started an appropriate medical process in New Zealand - request a surgical procedure that is medically necessary and is not experimental or being trialled - get the procedure or treatment pre-approved by us - make sure the procedure meets all policy criteria including being subject to all excess, Reasonable charges, maximums, and exclusions described elsewhere in this policy. A New Zealand-registered medical specialist must provide us with written confirmation that the surgical procedure or medical treatment is necessary and no similar treatment is available in New Zealand. We don't cover travel and accommodation costs. #### Medical tourism This benefit covers reimbursement of a surgical procedure or treatment performed at an overseas hospital if you're able to have the procedure in New Zealand within 6 months. If treatment isn't available in New Zealand within 6 months, you can claim under the Overseas waiting list benefit. We'll reimburse up to 75% of the *Reasonable charge* as if it had been undertaken in New Zealand. We'll pay you in New Zealand dollars. We'll decide which country you can travel to for the required medical treatment. To qualify for this benefit: - a registered medical specialist must recommend that the Member has the medical procedure or medical treatment - the procedure or treatment must be available in New Zealand within the 6 months after the recommendation - the Member must get prior approval from us for the procedure or treatment - the procedure must meet all policy criteria and is subject to all excess, Reasonable charges, maximums, and exclusions described elsewhere in this policy. All costs are included in the maximum limit that applies to the surgical or non-surgical benefit, whichever applies for the relevant treatment under the Hospital and Surgical+ base plan. #### Overseas waiting list This benefit covers reimbursement of a surgical procedure or treatment performed at an overseas hospital if the procedure isn't available in New Zealand within 6 months. We'll reimburse the *Reasonable charge* as if it had been undertaken in New Zealand. We'll pay you in New Zealand dollars. We'll decide which country you can travel to for the required medical treatment. To qualify for this benefit: - a registered medical specialist must recommend that the Member has the medical procedure or medical treatment - the procedure or treatment can be provided privately within New Zealand but can't be provided within 6 months because of insufficient medical resources - the Member must get prior approval from us for the procedure or treatment - the procedure must meet all policy criteria and is subject to all excess, Reasonable charges, maximums, and exclusions described elsewhere in this policy. All costs are included in the maximum limit that applies to the surgical or non-surgical benefit, whichever applies for the relevant treatment under the Hospital and Surgical+ base plan. #### Cover while in Australia This benefit covers reimbursement of medical costs incurred for non-acute (non-urgent) medical conditions that are treated in Australia. We'll reimburse the *Reasonable charge* for the treatment if it had been undertaken in New Zealand. We'll pay you in New Zealand dollars. The Member must meet all policy criteria and is subject to all excess, Reasonable charges, maximums, and exclusions described elsewhere in this policy. All costs are included in the maximum limit that applies to the surgical or non-surgical benefit, whichever applies for the relevant treatment under the Hospital and Surgical+ base plan. Services that fall under 'Other benefits' below do not qualify for cover under this benefit. ### Minor surgery **$3,000 for each claim** **An excess applies to this benefit** This benefit covers the costs of *Reasonable charges* for minor surgery performed by a New Zealand-registered medical practitioner in private practice. This includes the removal of moles, cysts, and toenails. The procedure must be medically necessary — without it, the physical wellbeing of the Member would be affected. ## Other benefits Other benefits that we offer are summarised below. ### Mental health **$1,000 for each person in a policy year** **No excess applies to this benefit** This benefit covers the costs of *Reasonable charges* for consultations with a psychiatrist, psychologist, psychotherapist or counsellor. They must be registered either under the psychiatry scope with the Medical Council of New Zealand, as a psychologist with the New Zealand Psychologists Board, as a psychotherapist with the Psychotherapists Board of Aotearoa New Zealand, or as a counsellor with the New Zealand Association of Counsellors or other relevant association. ### Post-operative therapy **$1,500 per event** **No excess applies to this benefit** This benefit covers the costs of *Reasonable charges* associated with post-operative therapy provided within 12 months following a related surgery, cycle of chemotherapy or radiation treatment that we've approved under this policy. This includes: - Occupational therapy - Physiotherapy - Speech and language therapy - Osteopathy - Chiropractic treatment - Dietitian/Nutritionist consultations - Lymphedema physiotherapy You must be treated by a New Zealand-registered health or medical practitioner with a current practising certificate who is registered with their professional association. The treatment must occur and be completed within 12 months after the event date of your surgery or treatment. This doesn't include costs for personal items such as food/food substitutes, materials or garments. ### Home nursing **$6,000 for each person in a policy year** **No excess applies to this benefit** $150 a day. This benefit covers the costs of post-operative home nursing care by a New Zealand-registered nurse. You need a referral for home nursing by a New Zealand-registered medical specialist. Post-operative nursing care must begin within 6 months after related surgery, or after a cycle of chemotherapy or radiation treatment that has been approved under this policy. ### Parent accommodation **$3,000 for each person in a policy year** **No excess applies to this benefit** $300 a night for accommodation. This benefit covers reimbursement of accommodation expenses paid by a parent accompanying a child aged under 18 years, who is listed on the policy certificate. The child must be undergoing medical treatment with overnight admission in a New Zealand private hospital that we've approved under this policy. This benefit is for one adult only. You must send receipts for reimbursement with your claim. ### Hospice stay **$2,000 for each person in a policy year** **No excess applies to this benefit** $50 a night, up to a maximum of 10 nights for each admission. This benefit covers the cost of hospice care for the Member if they are admitted to a hospice and the admission lasts 4 or more nights in a row. The hospice must hold regular or associate service membership with Hospice New Zealand. ### Transport and accommodation **$3,000 for each person in a policy year** **No excess applies to this benefit** A registered medical specialist must confirm in writing that the condition of the Member cannot be treated at a local private facility. The specialist must tell you to travel to an alternative private hospital in New Zealand. We'll reimburse one of the costs below for the Member. **Air transport** Return economy airfares and return taxi fare from the airport to the private hospital **Rail transport** Return train fares and return taxi fare from the station to the private hospital **Road transport** - Return bus fares and return taxi fare from the station to the private hospital - Return private car journey, calculated on the mileage travelled at $0.30 a kilometre These costs must directly relate to an overnight admission in a private hospital under your policy. You must send receipts for reimbursement with your claim. Pre-operative and post-operative consultations or treatments do not qualify. #### This includes: **Support person benefits** This benefit includes cover for the costs of a support person. A registered medical specialist must confirm in writing that you need a support person to accompany the Member to the alternative private hospital in New Zealand. We'll reimburse one of the transport costs and accommodation below for the support person. **Air transport** Return economy airfares and return taxi fare from the airport to the private hospital **Rail transport** Return train fares and return taxi fare from the station to the private hospital **Road transport** - Return bus fares and return taxi fare from the station to the private hospital - Return private car journey (if not travelling with the patient), calculated on the mileage travelled at $0.30 per km **Accommodation expenses incurred up to $200 per night, for a maximum of 10 nights** These costs must directly relate to an overnight admission in a private hospital of the Member under this policy. You must send receipts for reimbursement with your claim. Pre-operative and post-operative consultations or treatments do not qualify. ### Public hospital **$3,000 for each person in a policy year** **No excess applies to this benefit** $300 a night. This benefit is paid only if you're admitted to a public hospital for four or more nights in a row. ### Health-related appliances **$200 for each person in a policy year** **No excess applies to this benefit** This benefit covers the cost of health-related appliances after an approved surgery. Appliances must be purchased or hired within 6 months of the approved surgery. This benefit doesn't cover any bond required to hire appliances. ### Ambulance transfer **$200 for each person in a policy year** **No excess applies to this benefit** This benefit covers the costs of ambulance transfers to or from a public or private hospital in New Zealand for necessary treatments and not for personal or social reasons. The transfers must be authorised by a registered medical specialist. This benefit is only available to private, fee-paying patients for any non-acute (non-urgent) medical condition. We must have pre-approved your initial admission to hospital. ### Medical misadventure **$30,000 for each person** **No excess applies to this benefit** We'll pay a medical misadventure benefit if the Member dies as a direct result of any medical error or mishap by a registered medical provider in a public or private hospital in New Zealand. This benefit applies only if: - the death of the Member occurs within 30 days of the medical error or mishap - the public or private hospital accepts a public admission of such an incident and liability - the instance of medical misadventure is verified and confirmed by the relevant government authority, a court of law, a coroner's inquest, or the Medical Council of New Zealand. We'll deduct any bereavement grant previously paid for a Member from the medical misadventure benefit. ### Bereavement grant **$10,000 for each person** **No excess applies to this benefit** $10,000 payable into the bank account of the deceased Member's estate. We'll pay a bereavement grant to the deceased Member's estate if a Member on this policy dies from illness between the ages of 25 to 65 years (inclusive). A copy of the death certificate and proof of the executor, administrator or solicitor acting for the estate must be provided. ### ACC top-up **An excess applies to this benefit** We cover any shortfall between what ACC pays and the actual costs of the surgical procedure or medical treatment in an approved private hospital or facility. We deduct the excess, which you must pay. You must send us a copy of ACC's decision before getting treatment. These other terms apply. - The Member must receive ACC's acceptance of their claim before treatment. They must also give us evidence of ACC's acceptance and the amount that ACC will pay for the treatment. - We may ask the Member to apply for a review of ACC's decision. We may ask for your permission to seek legal advice at our cost. You must reimburse us for any cost ACC subsequently covers from the review. - We only provide cover if a claim has been paid under a benefit of the Hospital and Surgical+ base plan or another additional module that the Member holds. The benefit's maximum limit will apply to all costs paid. ## Loyalty benefits Loyalty benefits allow you to use your insurance not just for treatment but to maintain good health after you've held your SmartCare+ policy for more than two years. No personal exclusions or excess applies to these benefits: however, some benefits have conditions about when they can be claimed, so please read conditions carefully. For further information and other Member offers, please visit Accuro's website accuro.co.nz/memberbenefits ### Sterilisation **$5,000 for each policy** This is a one-off contribution up to $5,000 toward the total cost of the procedure. After 2 years of continuous cover, this benefit covers the costs of *Reasonable charges* of sterilisation including vasectomies and female sterilisation procedures. It doesn't include reversals. ### GP health check **$150 for each person every 3 policy years** After 3 years of continuous cover, this benefit covers the costs of a health check performed by a New Zealand-registered medical practitioner (GP). Children aged 25 years or younger don't qualify for this benefit. ### Discounts for those with healthy weight After 3 years of continuous cover and with confirmation from your GP that your body mass index (BMI) is between 18.5 and 24.99, your *premium* on the Hospital and Surgical+ base plan will be discounted as follows. - 5% discount after 3 years of continuous cover - 10% after 6 years of continuous cover - 15% after 9 years of continuous cover, and every 3 years following Children aged 25 years or younger don't qualify for this benefit. Your BMI discount entitlements are assessed on your anniversary every 3 years. We'll stop this discount if we do not receive confirmation of your BMI status at your 3 yearly anniversary or if your BMI falls outside the 18.5 to 24.99 range. Please note this discount doesn't apply to any current or previous members of a Group insurance scheme. ### Screening endoscopies **$1,000 for each person every 3 policy years** After 3 years of continuous cover, this benefit covers 80% of the *Reasonable charges* of colonoscopies and gastroscopies. You must use this benefit within 12 months of entitlement. Children aged 25 years or younger don't qualify for this benefit. ### Bowel screening **one kit for each person every 3 policy years** After 3 years of continuous cover, this benefit provides you with a bowel-screening kit. Please contact us if you wish to redeem this benefit and we'll arrange for the kit to be sent to you. Children aged 25 years or younger don't qualify for this benefit. ### Weight-loss or breast reduction surgery **$8,000 for each person** This is a one-off contribution of 50% of the cost up to $8,000 toward the total cost of the procedure. After 5 years of continuous cover, this benefit covers the costs of *Reasonable charges* for surgery for weight-loss or breast reduction. For breast reduction surgery, an underlying medical condition must apply. It doesn't include the removal of implants or cosmetic reduction. --- # Additional modules You can choose to add any of our additional modules for yourself or any additional Member on your policy. These modules include: - Specialist+ module - GP+ module - Natural Health+ module - Dental and Optical+ module. Check your policy certificate to see if you're covered under any of these modules. You won't have these modules unless you've asked us to add them to your policy. We recommend that you read over the benefits carefully and make sure you understand them. Please contact us if you have any queries about the following modules, or would like to add an additional module to your policy. ## You can also add our Day to Day Health Plan Our Day to Day Health Plan provides a mixture of the benefits from our additional modules, up to a maximum of $600 for each person in a policy year. This Health Plan is designed to help you cover the everyday costs of staying healthy, such as going to the doctor, dentist or optician. It covers the costs of prescription drugs and the annual flu vaccine. You can also enjoy natural therapy treatments to help improve your health and wellbeing. Contact us if you'd like to add Day to Day Health Plan to your policy. ## Specialist+ module The Specialist+ module is our most popular additional module. It provides access to private tests and specialist consultations to speed up the time to reach your diagnosis. This is an additional module, so please check your policy certificate to see if you're covered and if there is an excess. ### Specialist consultations **$5,000 for each person in a policy year** **An excess applies to this benefit** This benefit covers the costs of *Reasonable charges* for consultations with a registered medical specialist when referred by a registered medical practitioner, even when you don't require hospitalisation. This includes: - Cardiac surgeons - Cardiologists - Ear, nose and throat specialists - Gastroenterologists - General surgeons - Gynaecologists - Neurosurgeons - Oncologists - Ophthalmologists - Orthopaedic surgeons - Paediatricians - Urologists #### This includes: **Mental health consultations** **$1,000 for each person in a policy year** This benefit covers the costs of *Reasonable charges* for consultations with a psychiatrist, psychologist, psychotherapist or counsellor. They must be registered either under the psychiatry scope with the Medical Council of New Zealand, as a psychologist with the New Zealand Psychologists Board, as a psychotherapist with the Psychotherapists Board of Aotearoa New Zealand, or as a counsellor with the New Zealand Association of Counsellors or other relevant association. **Second opinion** This benefit covers the costs of *Reasonable charges* for you to consult a registered medical specialist for a second opinion on a diagnosis or a treatment plan that is covered under this policy. You must have received your first diagnosis from a registered medical specialist. ### Diagnostic tests and treatment **$5,000 for each person in a policy year** **An excess applies to this benefit** This benefit covers the costs of *Reasonable charges* of diagnostic procedures that directly relate to a medical condition when referred by a registered medical specialist. This includes: - Allergy test - Ambulatory blood pressure monitoring - Audiology - Audiometric test - Bone density scan - Cardiovascular ultrasound - Cardioversion - Colposcopy - Dobutamine transoesophageal echocardiography - Electroencephalography (EEG) - Electromyography (EMG) - Exercise electrocardiogram (ECG) - Holter monitoring - Laboratory test - Mammography - Nerve conduction test - Nuclear scanning - Stress echocardiogram - Ultrasound - Urodynamic assessment - X-ray Please note that some diagnostic tests are covered under the Hospital & Surgical+ base plan. These are specifically listed under the General Surgery benefit. ### Loyalty benefits We give you extra benefits after you've held the Specialist+ module for more than 3 years. **Screening** **$250 for each person every 3 policy years** After 3 years of continuous cover, this benefit covers the costs of a mammogram or prostate check performed by a New Zealand-registered medical practitioner. Children aged 25 or younger don't qualify for this benefit. **Pregnancy and infertility treatment** **$2,000 for each person in a policy year** After 3 years of continuous cover, this benefit covers obstetric care during pregnancy, and infertility diagnosis and treatment by a registered medical specialist. This benefit doesn't cover antenatal ultrasounds. **Melanoma** **$200 for each person every 3 policy years** After 3 years of continuous cover, this benefit covers melanoma investigations. ## GP+ module The GP+ module provides cover for visits to your doctor, including cover for prescription drugs. This is an additional module, so please check your policy certificate to see if you have cover under this module. No excess applies to this module. This module has an initial *No-claiming period* of 90 days, which means that you can't make a claim for any benefit on the module, such as GP visits, in the first 90 days. ### General practitioner (GP) This benefit covers the costs of GP visits, including home and after-hours visits. Up to $55 for each GP visit. Up to $70 for each home visit or after-hour visit with a GP. ### Registered nurse This benefit covers the costs of practice nurse visits. Up to $35 for each visit. ### Prescription drugs and laboratory tests This benefit covers the costs of prescription drugs and laboratory tests ordered by a New Zealand-registered medical practitioner or registered medical specialist. Laboratory tests: $80 each policy year. Prescription drugs: up to $20 for each item, to a maximum of $400 in a policy year. ### Loyalty benefit We give you this extra benefit after you've held the GP+ module for more than 3 years. **Preventative checks** **$200 every 3 policy years** After 3 years of continuous cover, this benefit covers the costs of a preventative mammogram or prostate check performed by a New Zealand-registered medical practitioner. Children aged 25 or younger don't qualify for this benefit. ## Natural Health+ module The Natural Health+ module provides a diverse approach to keeping well. This is an additional module so please check your policy certificate to see if you have cover under this module. No excess applies to this module. This module has an initial *No-claiming period* of 90 days, which means that you can't make a claim for any benefit on the module, such as physiotherapy treatment, in the first 90 days. ### Healthcare practitioners **$800 for each person in a policy year** #### Osteopath and Chiropractor This benefit covers the costs of treatment by osteopath and chiropractor health practitioners. Up to $45 for each visit, to a maximum of $240 in a policy year for each health practitioner. Materials or supplements are not covered. #### Healthcare Practitioners This benefit covers the costs of treatment by the following health practitioners: - Acupuncturist - Dietitian - Homeopath - Medical herbalist - Naturopath - Nutritionist - Physiotherapist - Podiatrist - Reflexology treatment - Remedial body therapist - Traditional Chinese medicine practitioner Up to $45 for each visit, to a maximum of $200 in a policy year for each health practitioner. Materials or supplements are not covered. ### Loyalty benefits We give you these extra benefits after you've held the Natural Health+ module for more than 3 years. **Sick leave** **$100 each week, up to $500 for each person in a policy year** After 3 years of continuous cover, this benefit provides income during sick leave without pay. To qualify for this benefit, the Primary Member or partner (who is covered under this module) must present a certificate from their employer confirming unpaid sick leave. You must also send us a medical certificate from a registered medical practitioner. **Flu vaccination** **$40 for each person in a policy year** After 3 years of continuous cover, this benefit covers the flu vaccination. ## Dental and Optical+ module The Dental and Optical+ module provides cover for visits to the dentist and optician, as well as the purchase of prescription glasses or contact lenses. This is an additional module so please check your policy certificate to see if you have cover under this module. No excess applies to this module. This module has an initial *No-claiming period* of 90 days, which means that you can't make a claim for any benefit on the module, such as dental treatment, in the first 90 days. ### Dental cover **80% of the cost — $500 for each person in a policy year** This benefit covers the costs of dental treatment by a registered dental practitioner, including: - Cleaning - Dental check - Fillings - Scaling - Teeth removal - X-rays Your dental practitioner must be registered with the Dental Council of New Zealand and hold a current annual practising certificate. This benefit excludes orthodontic, periodontal, or orthognathic (jaw-correcting) treatments unless specified. ### Optical cover **Consultations** This benefit covers the costs of optometrist or orthoptist consultations. Practitioners providing assessments must belong to their professional body. 80% of the cost — up to $60 for each visit, to a maximum of $300 for each person in a policy year. **Glasses or contact lenses** This benefit covers the costs of prescription glasses or contact lenses. 80% of the cost — $300 for each person in a policy year. ### Loyalty benefit We give you this extra benefit after you've held the Dental and Optical+ module for more than 3 years. **Orthodontic** **80% of the cost — $750 for each person in a policy year** After 3 years of continuous cover, this benefit covers the cost of orthodontic treatment by a registered orthodontist. Practitioners providing assessments must belong to their professional body. --- # What's not covered (exclusions) We can't cover every kind of medical condition and treatment, so we have to exclude some things. We've listed these general exclusions below. Please contact us if you have any questions. Your personal exclusions will be listed on your policy certificate. We aim to fully explain what is not covered in your policy. Unless specifically provided for in the plans you select, SmartCare+ doesn't cover any claims as described below. ## Health conditions we don't cover It's important to know which conditions we don't cover. We've listed these below but please ask if you want to know about cover for a different condition that is not listed. ### Psychiatric, psychological and neurodevelopmental disorders We don't cover treatment or counselling for any psychiatric, psychological and neurodevelopmental disorders. This includes but isn't limited to: - attention-deficit or hyperactivity disorder - autism spectrum disorder - dyslexia - geriatric care including geriatric hospitalisation - intellectual disability (intellectual developmental disorder) - motor disorders (including but not limited to Tourette's disorder) - pre-senile dementia - senile illness or dementia - specific learning disorders ### Certain types of care We don't cover these types of care. - Any acute care - Any long-term care - Palliative care as defined by us (except where this policy specifies otherwise) ### Some conditions We don't cover these conditions. - Any pre-existing conditions, unless accepted by us - Any condition connected with the use of non-prescription drugs - AIDS or HIV infection or any condition arising from the presence of AIDS, HIV infection or sexually transmitted diseases - Congenital conditions diagnosed within 3 months of birth; this includes but is not limited to the investigation, treatment, or complications of any residual issues - Any health condition as a consequence of war, invasion, act of foreign enemy, terrorism, hostilities (whether war is declared or not), civil war, rebellion, revolution, or military or usurped power ### Obstetrics and gynaecology We don't cover any expenses arising from these obstetric or gynaecological conditions. - Pregnancy, childbirth, miscarriage, or any associated conditions or complications for the mother, or foetus or child - Treatment, investigation, and diagnosis of infertility and assisted reproduction - Sterilisation or contraception of any kind, or intrauterine devices (except a Mirena when used for medical reasons) - Termination of pregnancy *Acute care is covered by the public health system and ACC.* ## Tests, diagnostic procedures and treatments that we don't cover Below we list the various tests, procedures and treatments we don't cover. ### Treatment for preventative reasons We don't cover any expenses when no symptoms or evidence exist for a condition detrimental to your health; for example: - preventative healthcare services and treatments, maintenance or health surveillance testing, genetic-testing, employment-related examinations or screening - vaccination against any disease or condition - convalescence. ### Dental or eye treatment or surgery We don't cover these procedures including any treatment, investigations or consultations related to a procedure or any complications that may occur from one. - Dental care: orthodontic, endodontic, orthognathic (jaw correction), periodontal treatment, implants, or tooth exposure - Correction of visual errors or astigmatism — for example, consultations, surgery or laser treatment, surgically implanted intraocular lens(es), radial keratotomy, photo-reactive keratectomy, or any related complications ### Organ failure or donation We don't cover these procedures including any treatment, investigations or consultations related to a procedure or any complications that may occur from one. - Specialised transfusion of blood, blood products, or treatment for renal failure or renal dialysis - Organ donation and receipt - Specialised tertiary treatments such as transplants. This includes but is not limited to heart, lung, kidney, liver, bone marrow and stem cell transplants ### Other treatment or surgery We don't cover these procedures including any treatment, investigations or consultations related to a procedure or any complications that may occur from one. - Cosmetic procedures or other enhancement or appearance medicine as defined by us - Procedures or treatment relating to obesity or weight loss, performed for any reason - Breast reduction or treatment of gynaecomastia, regardless of whether medically necessary - Gender affirmation surgery/treatment or gender dysphoria - Sleep disturbances, snoring, or sleep apnoea - Robotically assisted surgery, not including robotically assisted prostate surgery - Chelation therapy or similar treatment as defined by us - Circumcision, except where medically necessary - Additional surgery performed during any operation that is not directly related to any medical condition or treatment covered under the terms of this policy - A treatment or procedure that is provided by a registered medical practitioner practising outside his or her scope of practice - New medical treatments, procedures, and technologies that have not been approved by us ## Other costs We don't cover these costs. - General practitioners' fees, prescription drugs, or medication (except where this policy specifies otherwise) - Any expense recoverable from a third party or insurance or any statutory scheme or any government-funded scheme or agent (for example, ACC) - Any medical costs declined by ACC if injury is caused by an accident outside New Zealand - Any medical costs incurred outside New Zealand - Medical mishap or misadventure - Any personal incidental expenses incurred whilst in hospital - for example, use of phone, family meals, soft drinks, or alcoholic beverages - Any costs not specifically provided for under a benefit section outlined in the plan ## Other expenses and costs we don't cover Below we list other expenses and costs that we don't cover. ### Appliances and devices We don't cover the following. - Personal health-related appliances; for example, hearing aids, personal alarms, orthotic shoes, crutches, wheelchairs, toilet seats, mouthguards, and artificial limbs - Medical devices; for example, cardiac pacemakers, nerve appliances, cochlear implants, or penile implants - Surgical or medical appliances; for example, glucometers, oxygen machines, respiratory machines, diabetic monitoring equipment, or blood pressure monitoring equipment - Any costs not specifically related to the consultation or treatment such as administration costs or statement fees ### Expenses arising from drugs, criminal activity, or self-harm We don't cover the following. - Disability or illness arising from misuse of alcohol, drugs, participation in a criminal act, or intentional self-injury - Attempted suicide or suicide within 13 months from the start date of the plan --- # How to submit a claim Choose one of two ways to submit a claim for your procedure or medical treatment. You can: 1. Get prior approval for your claim by submitting the details of your procedure or medical treatment before it takes place in order to confirm that it is covered under your policy. 2. Submit a claim after the procedure or medical treatment has already taken place. Use the flow chart below to help you decide whether you need to get prior approval or if you can make a claim afterwards. ``` Have you already had the treatment? No Yes | | v v Is your treatment likely to cost Submit a claim more than $1,000 or require hospitalisation? Or would you just like to make sure it's covered? Yes No | | v v Apply for prior Submit a claim approval ``` --- # How to apply for prior approval Prior approval is when we confirm cover under your policy before your procedure or medical treatment (such as a surgery) happens. We'll also tell you of any conditions or excess that may apply. We need 2 working days to process prior approvals. Prior approval is required: - for any procedure or medical treatment that is likely to cost $1,000 or more - if your procedure or medical treatment requires hospitalisation, day-stay, or in-patient care. If in doubt, get prior approval. If you don't get prior approval, we may not be able to approve your claim. ## Collect a prior approval form You'll need to complete a prior approval form. On Accuro's website you can find the prior approval form or submit a prior approval request through the Member portal, or we can post or email a copy to you. The Primary Member must sign this form, and so must the patient if they are over 16 years of age. ## Get an estimate of the cost Ask your healthcare providers and the hospital for an estimate of the cost for the procedure or medical treatment. Please try to get an estimate of the cost for all parts of your procedure and treatment. Include the number of nights in hospital, theatre fees, and any additional costs such as equipment and physiotherapy. This information allows us to make sure the full cost will be covered. We understand that the information you get will be an estimate and the actual costs may vary. If the cost is above what we judge to be a reasonable cost for the type of procedure or medical treatment (our *Reasonable charges*), we may ask for further information or we may recommend an alternative treatment or health service provider. If you choose to continue at the previous cost, you'll need to pay the difference between the amount we approve and the actual cost of the procedure or medical treatment, regardless of the benefit's maximum limit. You'll need to let us know if another insurer, including ACC, has a responsibility to pay for all or part of the procedure or medical treatment. ## Provide medical evidence You and all additional Members on your policy must give us all the information we reasonably need to assess your prior approval or claim. We're entitled to ask for information from the prior approval process, up to and following a claim being made. You'll need to provide some *medical evidence* for why the procedure or medical treatment is required, so that we can make sure it's covered under your policy. This medical evidence could be either a copy of the GP referral letter or a letter from the specialist that confirms why the treatment is needed. You may also need to ask the GP who holds the patient's medical history to complete Accuro's Medical report. We'll need this report if: - the patient having the procedure or medical treatment is within the first 5 years of their policy, and - this is the first time the patient is claiming for this medical condition. Please see the 'Why do you need to provide medical evidence' section on page 26 for further information. You'll need to pay for any costs associated with getting medical evidence. ## Submit your prior approval You can submit your prior approval by post or email, or through the online Member portal on Accuro's website. In some cases, we may need to contact you or the healthcare providers to request additional details to make sure we assess your prior approval correctly. We'll contact you if this is the case. Please call or email us if you're unsure about how to apply for prior approval, including whether or not you need to supply a Medical report. --- # How to make a claim after treatment When you're submitting a claim, you're asking for payment of a procedure or medical treatment that has already occurred. We'll pay up to the *Reasonable charges* for any necessary medical procedure or treatment that's covered by a benefit as outlined in your policy, up to the specified benefit limit. You can only claim for events that occur after the relevant health insurance cover has started. ## Collect a claim form If you haven't got prior approval, you'll need to complete a claim form. On Accuro's website you can find the claim form or submit a claim through the Member portal, or we can post or email a copy to you. The Primary Member must sign this form, and so must the patient if they are over 16 years of age. ## Collect invoices or receipts Include all invoices or receipts with your claim as well as any receipts if you've already paid for the procedure or medical treatment. ## Provide medical evidence You and all additional Members on your policy must give us all the information we reasonably need to assess your prior approval or claim. We're entitled to request information from the prior approval process, up to and following a claim being made. You'll need to provide some *medical evidence* for why you need the procedure or medical treatment so that we can make sure that it is covered under your policy. This medical evidence could be either a copy of the GP referral letter or a letter from the specialist that confirms why the treatment is required. You may also need to ask the GP who holds the patient's medical history to complete Accuro's Medical report. Please see the 'Why do you need to provide medical evidence' section on page 26 for further information. We recommend that you read your policy certificate, including any exclusions listed on it, as well as the 'What's not covered' section on pages 20 to 22 to make sure that the procedure or medical treatment is covered under your policy. If you're unsure, you can apply for prior approval beforehand, which confirms whether the procedure or medical treatment will be covered. ## Submit your claim You can submit your claim by post or email, or through the online Member portal on Accuro's website. Your Member portal on Accuro's website also allows you to start a claim and save it, so you can add invoices as you receive them and submit it all together when you have all the information. We may need to contact you or your healthcare providers to request additional details so that we assess your claim correctly. We'll contact you if this is the case. ## What if you already have prior approval? If you have already been approved to have the procedure or medical treatment, you'll just need to send us copies of the invoices and receipts if you've already paid the provider. Please include your membership number and claim number with the invoices. We'll then assess these and pay the providers directly. If you've already paid the invoices, we'll reimburse you. --- # Why do you need to provide medical evidence? We need medical evidence to confirm that the service you are claiming for is covered under your policy. We need medical evidence to assess a claim or prior approval. Medical evidence could either be a copy of the referral letter, or consultation notes from the GP, dentist or optometrist. We would also accept a copy of the specialist's letter or notes confirming the outcome of your consultation or treatment. The medical evidence must be from the medical professional who saw the patient for the condition. It must state why the consultation, procedure or treatment is, or was, required. ## When do we need a Medical report? You need to provide a Medical report form with your claim or prior approval if: - you did not provide your complete medical history at the time of submitting your application (that's all your medical notes from birth to the date you applied for health insurance with us), and - you're claiming within the first 5 years of your Hospital & Surgical+ base plan or Specialist+ module, and - you have not claimed for this condition before. The Medical report form needs to be completed by the GP (or dentist or optometrist) who holds your medical history. We need this form to give us the history of the condition, its symptoms, and when it first became apparent. Often the GP referral or specialist letter will not give us a comprehensive history of the condition, which is why we ask for the Medical report form to be completed. ## Things to remember We can only accept and provide cover for costs: - for a person who is covered under your policy - for events that occur after your policy begins - under a policy that has premiums paid up to date - for benefits listed in the base plan or modules you have cover for - charged at a reasonable and fair cost (within our *Reasonable charges*) - for services only in the private sector (unless listed otherwise in your Health Plan document). We recommend that you read the next section ('What we will pay'), as things listed here may affect your claim or the amount we're able to pay out for a particular procedure or medical treatment. Please call or email us if you're unsure about anything, including whether you need to send a Medical report with your claim. You must pay any costs involved in getting any of the information above. --- # What we will pay Excesses and limits on your policy will affect the amount we can pay. ## How an excess under your cover affects your claim Excesses apply to some benefits. An excess is the amount you have to pay when you have a claim, before we pay the rest up to the limit for that benefit. Different excesses may apply to your base plan and the Specialist+ module. The excess applies to each person covered by the base plan or additional modules for each policy year. All relevant excesses are listed on your policy certificate. If you make a claim for a benefit that has an excess, we take the excess off any payment we make for your claim — off either a reimbursement to you or a payment made to your health service provider. You're responsible for paying the excess amount directly to the health service provider. If your claim is less than your excess amount, we won't make a payment until further claims are received, meaning the full excess amount has been reached. This excess applies for each person and for each policy year. When we send you a prior approval, your excess will be clearly shown on the approval letter. You'll need to settle this amount directly with your health service provider. **For example, you have a $1,000 excess under the Hospital and Surgical+ base plan and claim for a $950 MRI scan. You need to pay the $1,000 excess before we can reimburse you for anything. The $950 you've already paid would go toward your excess, so we wouldn't reimburse you for this claim. However, if you needed another $950 MRI scan in the same policy year, you'd only have $50 of the $1,000 excess left to pay and we'd reimburse the remaining $900.** ## How policy benefit limits affect your claim Unless specifically stated in this Health Plan document, all benefit limits are for each person in each policy year. The benefit limits reset back to their maximum levels at the start of each policy year. You can't carry over your benefits from one policy year to the next, or transfer them to other Members covered by the policy. The minimum or maximum amount for each benefit that you can claim for an event is set out in the 'The SmartCare+ cover and benefits' section of this Health Plan document. We won't pay or reimburse any costs that amount to more than 100% of the actual costs incurred. As such you must claim any other refunds, subsidies, or entitlements available to you from another source first. This includes ACC, another health insurer, a government-funded agency, Work and Income, or your employer. We'll take any reimbursement from them off the total amount before we assess the amount against the benefit under your policy. Please note that we do not cover excess that is applicable for another insurance plan, whether it be another UniMed Health Plan or one from another insurer. Unless specifically stated in your policy or accepted in writing before the event, we do not cover any healthcare you receive in the public health system. This means a procedure or treatment in a public hospital or facility that is controlled directly or indirectly by Health New Zealand | Te Whatu Ora. **For example, if you had an x-ray that cost $110 and ACC agreed to cover $60 of it, we would only be able to assess reimbursement of the remaining $50 under your Specialist+ module.** --- # We will cover Reasonable charges '*Reasonable charges*' is the cost for a procedure or medical treatment that we judge to be reasonable and within a range of cost charged for the same procedure under similar circumstances. Our Reasonable charges make sure that healthcare providers are fair with the amount charged, and within a reasonable range, for similar medical treatment or procedures. For procedures that have a Reasonable charge applied to them, we look at the average cost as well as the range of charges for the same, or similar, procedure throughout New Zealand. The Reasonable charge that is set represents the cost that is within what we consider to be a reasonable range for that, or a similar, procedure. We understand that some healthcare providers charge more than others, which is why we set an upper limit, while maintaining costs within a reasonable range. If the cost for your procedure or medical treatment is above what we judge a Reasonable charge, we may ask for further information or you may want to consider an alternative treatment or healthcare provider. If you choose to proceed, then you will need to pay the difference between the amount we approve and the actual cost for the procedure or medical treatment, regardless of the benefit's maximum limit. You will need to pay this extra amount directly to your healthcare provider. If you apply for prior approval, our approval letter will advise you of this and the maximum amount we can cover. ## Maximum cost we will pay We'll pay the cost for a procedure or medical treatment that falls under your policy, up to the relevant benefit limit or the *Reasonable charges* for this procedure, whichever is less. If the cost for your procedure exceeds the maximum limit or the Reasonable charge, we can't pay the exceeded amount. The extra cost will be your responsibility. **For example, if a procedure has an average cost of $27,500 throughout New Zealand. We may determine that the Reasonable charge of $33,000 applies for this procedure. This means that if you were to have a procedure of this type, we'd provide cover up to $33,000 as it's unlikely that the procedure would cost above that. However, if it did cost over $33,000, you'd need to pay any costs over this. If it costs less than that, we only pay the actual amount charged.** **For example, if you had surgery done by your GP under the Minor Surgery benefit and it came to $4,500, we would only be able to provide reimbursement of $3,000. The remaining $1,500 would be your responsibility. This is because the benefit limit for Minor Surgery is $3,000 for each claim, so we are unable to provide cover for costs above this amount.** --- # General conditions of your policy In the next section we explain other circumstances that may affect your cover. ## We don't cover claims covered by ACC ACC is New Zealand's accident compensation scheme, which provides cover if you're injured. Your SmartCare+ Health Plan has been set up to complement this and won't cover claims related to accidents that ACC covers. If ACC doesn't cover the full amount for your treatment, we may be able to pay the difference if you have cover for this treatment under your policy. Special conditions apply to surgery or treatment covered by ACC. Under the ACC legislation, you can choose between: - **Full payment option** — ACC contracts a provider to carry out the procedure or medical treatment and pays the total cost. - **Partial payment option** — ACC contracts a provider to carry out the treatment, but only funds a portion of it. The full payment option should be your first choice, so you don't have to make any contribution towards the cost of surgery or treatment. In this case, you must submit all claims to ACC. ### If ACC agrees to partially pay Under the ACC partial payment option, you'll have to contribute to the cost of the healthcare services. We'll cover the difference in cost up to the *Reasonable charges* for this procedure or treatment, or up to the benefit limit in your policy, whichever is less. The treatment or procedure must be covered under your policy. **For example, you have an accident and need an x-ray. If ACC agreed to cover 80% of the cost, and you have the Specialist+ module, we'd pay the remaining 20%.** ### If ACC declines cover If ACC declines cover for treatment that is covered under your policy, we might ask them to review the decision, or submit an appeal. We'd need your support in this — you'd need to give us the ACC decline letter and any other relevant information within 3 months of its issue date. When you give us the decline letter and relevant information, you're giving our legal representative authority to review the case. In cases where ACC reverses its decision to decline the claim, we may seek reimbursement from ACC or you for any related claims that we've already paid. ### If ACC refuses cover or cover stops You need to make a reasonable effort to secure and maintain cover. If ACC refuses to cover a claim, or stops claim cover because you're not complying with ACC's requirements, you won't be able to claim under your policy. ## We don't cover events during a No-claiming period Some module have a 90-day *No-claiming period* that applies to all Members on the module. You're not covered for any events that happen during this No-claiming period. We state the No-claiming periods under the relevant modules in the 'The SmartCare+ cover and benefits' section. ## We waive the premium on death or terminal illness If the Primary Member or the partner on this policy dies or is diagnosed with a *terminal illness* up to the age of 70, we'll continue to provide cover for the Member-paid premium for the remaining additional Members who are covered under this policy for whichever of these is earlier: - 36 months or - until the oldest surviving person on the policy reaches the age of 70. Once notified, the waiver of premium will start from the date of death or diagnosis of a terminal illness. Any changes made to your policy during the waiver of premium like the addition of a new Member or increase in cover will not be eligible for the waiver of premium. Once the waiver of premium ends, the premium payments for all remaining additional Members will be the responsibility of the policy's Primary Member. ## Conditions of cover for prescription drugs Your policy offers different cover for prescription drugs, depending on what type of healthcare services they relate to. - Drugs prescribed and administered in hospital are covered as part of hospital charges related to surgical treatment, or to non-surgical hospitalisation under the Hospital and Surgical+ base plan. - Chemotherapy drugs taken as part of a course of chemotherapy treatment are covered as part of the private hospital medical admission benefit under the Hospital and Surgical+ base plan. - Any other drugs are only covered under the prescription drugs and laboratory tests benefit in the GP+ module, which is an additional module. Unless outlined differently in the policy, prescription drugs must be: - listed under section A to I of the *Pharmac Schedule*, note that section H is only applicable if the drug is used during a procedure in a private facility - Pharmac-approved - medically necessary - prescribed by a registered medical practitioner. You must also meet Pharmac's funding criteria and the drugs must be funded for the relevant claim. If the prescription drugs require special authority from Pharmac to be covered, we need confirmation from the registered medical practitioner that you do meet the special authority criteria before we can assess cover for the prescription drug cost. As part of the Hospital and Surgical+ base plan, the non-Pharmac drugs benefit covers *Medsafe*-registered prescription drugs. Under this benefit: - prescription drugs must be registered by *Medsafe* for use in New Zealand - the treatment is prescribed by a registered medical specialist as being the appropriate medical treatment for the condition - the treatment or condition is not excluded elsewhere in this Health Plan document - the drug being prescribed is within the guidelines set by *Medsafe*. All costs under the non-Pharmac drugs benefit are included in the maximum limit of the surgical or non-surgical benefit, whichever applies for the relevant treatment under the Hospital and Surgical+ base plan. The non-Pharmac drugs benefit is not able to be used with any benefit on an additional module. --- # What you need to do Your responsibilities are explained in the next section. ## You must disclose pre-existing conditions Our Health Plans are set up to cover treatment of signs, symptoms and conditions that arise after your policy has started. This means that when you apply for your policy, you must disclose all pre-existing conditions for all additional Members, including congenital conditions. A *pre-existing condition* is: - any health or medical condition that you're aware of, or were experiencing signs or symptoms of, before the start of your policy - a medical event that occurred before the start of your policy. Our underwriters need to know about all previous and current signs, symptoms and conditions so they can fully assess your application. We'll list any excluded conditions on your policy certificate. Personal exclusions may be placed on your policy because of pre-existing conditions or any other additional Member's pre-existing conditions. We don't place personal exclusions on policies for all pre-existing conditions. Make sure you check how long each exclusion applies for. After the time period listed with the exclusion has passed, you can then claim for that condition. We may decline your claim if you need a procedure or medical treatment for, or related to, a pre-existing condition that you didn't include on your application form, and that you or the additional Member knew about or should have known about. We reserve the right to exclude any declared or non-declared pre-existing condition or congenital condition from your policy at any time. The exclusion may be backdated to apply from the start of your policy. **For example, if you had a hernia at the start of your policy, we'd place a personal exclusion for this condition for a period of 5 years. You'd be unable to claim for anything relating to your hernia within the first 5 years of your policy. However, once you'd had the policy for 5 years, the exclusion would drop off and you could then claim for services relating to your hernia.** ## Your duty of disclosure Everyone seeking insurance under this policy has a legal duty to disclose everything they knew (or ought to have known) that would have influenced our decision to provide cover. All information given to us must be true, correct and complete. If the information given is untrue, incorrect or incomplete, we don't have to pay a claim. We may also treat all or any part of your policy as if it did not exist, cancel it, or amend the terms applying to you or an additional Member. We can take any of these actions immediately if: - any information given to us is untrue, incorrect or incomplete - you or any additional Member has not told us about something else that is relevant to our decision to accept a claim, and any reasonable person in the circumstance would have known that information. If we've already paid the claim, we will recover the amounts paid from you. If, at any time, we become aware of any pre-existing condition that you haven't disclosed, we'll add this to your policy certificate, and it will be recorded as an excluded condition. In some circumstances, where we identify fraudulent behaviour, we may take legal action against you or the additional Member involved. ## You must pay your policy's premium You must continue to pay your premium