> _Markdown transcription of nib Ultimate Health Max policy wording, effective 2024-02-01. Source: https://assets.ctfassets.net/ja9v5o5o08yv/7Acf9tvW7QiaF1lSLqnV0p/8282b54901949d83eeda17b5398ea67c/Ultimate_Health_Max_Policy_Document__effective_for_new_policies_or_policies_renewing_from_1_February_2024_or_later_.pdf_ --- # Ultimate Health Max Policy Document ## Welcome to nib We're your partner in health and wellbeing. Our key purpose is to help Kiwis and their families live healthier and happier lives. We want to make your cover easy to use and empower you with the right tools to put your health into your hands. Wherever your health journey takes you, we'll be here to support you. --- # Contents ## 01. How this document works - 4 Cover Overview - 6 ## 02. Your Base Cover - 9 I've been referred for tests, or to see a health professional for consultation or treatment - 10 I need to stay in hospital for surgery or treatment - 14 I'm recovering from a stay in hospital - 23 I need financial support - 28 I want to be proactive about my health - 32 ## 03. Options - 34 Specialist Option - 35 GP Option - 37 Dental, Optical, and Therapeutic Option - 40 Non-PHARMAC Plus Option - 44 Proactive Health Option - 45 Serious Condition Financial Support Option - 47 ## 04. What we don't cover - 54 ## 05. Using your cover - 58 ## 06. Making changes to your policy - 61 ## 07. Conditions of your policy - 64 ## 08. About your premiums and benefits - 66 ## 09. Important Words - 69 --- # 01. How this document works ## Overview Your policy document provides information about your Base Cover and the Options you can add. ### BASE COVER A standard set of benefits that every **insured person** on your policy is covered for. ### OPTIONS An additional set of benefits you can add to your policy to provide extra cover for an **insured person**. Each Option provides you with additional cover. --- ## Cover Overview To make it easy to find what you're covered for, we've grouped the benefits under the different situations where you may need to use them. Under each of these categories, you'll find the related benefits that you can claim for. Some benefits can be used in multiple categories. Some benefits are only available to you if you've added the Option with those benefits to your policy. *This benefit may be used across multiple stages. ### I'm feeling unwell and need to see a doctor, dentist, or another health professional **GP Option** - GP Benefit* - Prescriptions Benefit - Physiotherapy Benefit - Nurse Practitioner Benefit **Dental, Optical, and Therapeutic Option** - Dental Benefit* - Eye Care Benefit - Ear Care Benefit - Acupuncture Benefit - Chiropractor Benefit - Osteopath Benefit - Foot Care Benefit - Speech, Occupation, and Eye Therapy Benefit - Loyalty – Orthodontic Benefit ### I've been referred for tests, or to see a health professional for consultation or treatment **Base Cover** - Diagnostic Investigations Benefit - Hospital Diagnostic Tests Benefit* - Hospital Specialist Consultations Benefit* - Second Opinion Benefit* - Skin Lesion Surgery Benefit - GP Surgery Benefit - Foot Surgery Benefit - Eye Injections Benefit - High-Risk Pregnancy Benefit - Loyalty – Sterilisation Benefit **Specialist Option** - Specialist Consultations Benefit - Specialist Second Opinion Benefit - Sports Physician Benefit - Diagnostic Tests Benefit - Cardiac Investigations Benefit ### I need to stay in hospital for surgery or treatment **Base Cover** - Surgical Benefit - Non-Surgical Benefit - Cancer Treatment Benefit - Non-PHARMAC Funded Medicines in Hospital Benefit - Travel and Accommodation Benefit - Parent Accommodation Benefit - Ambulance Transfer Benefit - Delayed Treatment Benefit - Cover in Australia Benefit - Overseas Treatment Benefit - Medical Tourism Benefit - ACC Treatment Injury Benefit - Loyalty – Weight Loss Surgery Benefit - Loyalty – Breast Reduction Surgery Benefit **Non-PHARMAC Plus Option** - Non-PHARMAC Plus Benefit* ### I'm recovering from a stay in hospital **Base Cover** - Non-PHARMAC Funded Medicines at Home Benefit - Cancer Treatment Accessories Support Benefit - Cancer Treatment Counselling and Support Services Benefit - Cardiac Counselling and Support Services Benefit - Physiotherapy Benefit - Therapeutic Care Benefit - Home Care Benefit - Follow-up Investigations for Cancer Benefit - Breast Symmetry Post Mastectomy Benefit - Hospital Diagnostic Tests Benefit* - Hospital Specialist Consultations Benefit* - Second Opinion Benefit* **Non-PHARMAC Plus Option** - Non-PHARMAC Plus Benefit* ### I need financial support **Base Cover** - Public Hospital Payment - Hospice Benefit - Funeral Support Benefit - Medical Misadventure Benefit - ACC Top-Up Benefit - Waiver of Premium Benefit - Terminal Illness Waiver of Premium Benefit - Loyalty – Suspending your Cover Benefit **Serious Condition Financial Support Option** - Serious Condition Benefit - Paralysis Benefit - Children's Benefit ### I want to be proactive about my health **Base Cover** - Loyalty – Check Up Benefit **GP Option** - GP Benefit* - Loyalty – Active Wellness Benefit **Dental, Optical, and Therapeutic Option** - Dental Benefit* **Proactive Health Option** - Screening Benefit - Allergy Testing and Vaccinations Benefit - Dietitian or Nutritionist Consultations Benefit - Stay Active Benefit - Loyalty – Health Check Benefit --- ## Understanding Your Policy Documents This policy document explains what you're covered for. You should read this along with your latest Acceptance or Renewal Certificate and the prosthesis schedule. Together, they are your policy. ### Your policy document tells you: - what you're covered for - what you're not covered for (general exclusions that apply) - any other important information you need to know about your cover ### Your Acceptance or Renewal Certificate tells you: - who's the **policyowner** - who's covered by your policy - whether you have selected any Options, which are an additional set of benefits you can add to provide extra cover - how much your policy costs - when your cover started - any special conditions, which can include: - **personal exclusions**. These are usually pre-existing conditions that an **insured person** has, which they won't be covered for. - **loadings**. These are additional costs that are added to your premium due to you, or someone else on your policy, having a specific health risk. ### The prosthesis schedule tells you: The maximum amount we'll pay for prosthesis. You need to refer to the most up-to-date list, available on our website and at mynib. ### Priority of documents: If there's any inconsistency between your policy document, your Acceptance or Renewal Certificate and the prosthesis schedule, your Acceptance or Renewal Certificate takes priority followed by your policy document and then the prosthesis schedule. Note that you're not covered for any personal or general exclusions that may apply, and you only have cover for the benefits in this policy document if you're an **insured person**. If you need to contact us, you can visit our Help Centre. ### Important words Some words in this policy document are in bold text. This means they have a specific meaning in relation to your policy. You can find the meaning of these words at the end of this document. In addition to this, where we use the words: - "Acceptance or Renewal Certificate", we're referring to the most recent version you have - "us", "our", "we" or "nib", we're referring to nib nz limited - "you", "your" or "yourself", we're referring to an **insured person** – an **insured person** may also be a **policyowner** --- # 02. Your Base Cover ## I've been referred for tests, or to see a health professional for consultation or treatment ### BASE COVER *Claims for this benefit are paid from the benefit limit(s) remaining this policy year on your Surgical or Non-Surgical Benefit (whichever applies). ### Diagnostic Investigations Benefit #### What am I covered for? We'll pay for you to have the following **diagnostic investigations** if your GP or **specialist** refers you for them: - Arthroscopy - Capsule endoscopy - Colonoscopy - Colposcopy - CT scan - CT angiogram - Cystoscopy - Gastroscopy - MRI scan - Myelogram - PET scan (including PET/CT scan) #### How much am I covered for? You can have an unlimited number of tests, up to your overall **benefit limit***. --- ### Hospital Diagnostic Tests Benefit #### What am I covered for? We'll pay for any **diagnostic investigations** you need up to six months before and after you're admitted to a **private hospital**. #### How much am I covered for? You can have an unlimited number of **diagnostic investigations** during this time, up to your overall **benefit limit***. #### What else do I need to know? To claim on this benefit, you'll need to have already had a related claim paid by us under your Surgical or Non-Surgical Benefit. --- ### Hospital Specialist Consultations Benefit #### What am I covered for? We'll pay for any **consultations** you need with a **specialist** or **vocational GP** up to six months before and after you're admitted to a **private hospital**. #### How much am I covered for? You can have unlimited **consultations** during this time, up to your overall **benefit limit***. #### What else do I need to know? To claim on this benefit, you'll need: - a referral from a GP or **specialist**; and - a related claim already paid by us under your Surgical or Non-Surgical Benefit --- ### Second Opinion Benefit #### What am I covered for? We'll pay for you to get a second opinion from a **specialist** or **vocational GP** up to six months before and after you're admitted to a **private hospital**. #### How much am I covered for? You can have unlimited **consultations** during this time, up to your overall **benefit limit***. #### What else do I need to know? To claim on this benefit, you'll need to have already had a related claim paid by us under your Specialist Consultations Benefit. --- ### Skin Lesion Surgery Benefit #### What am I covered for? We'll pay for skin lesion **surgery** by a **specialist**. Any **specialist** **consultations** relating to the skin lesion **surgery** will be covered under the Hospital Specialist Consultations Benefit, whether or not you are admitted to a **private hospital**. #### How much am I covered for? Up to the **benefit limit** remaining this policy year on your Surgical Benefit*. #### What else do I need to know? In addition to any personal or general exclusions that may apply, we also don't cover any of the following under this benefit: - laser therapy, cryotherapy, pulse light therapy or photodynamic therapy - **consultations** that don't relate to the skin lesion being removed --- ### GP Surgery Benefit #### What am I covered for? We'll pay for **surgery** by a GP. #### How much am I covered for? Up to $5,000 per **insured person** every policy year. #### What else do I need to know? In addition to any personal or general exclusions that may apply, we also don't cover any **consultations** or biopsies relating to your **surgery** under this benefit. --- ### Foot Surgery Benefit #### What am I covered for? We'll pay for **surgery** by a **podiatric surgeon** under local anaesthetic, as well as one **consultation** before and after your **surgery**, including any related x-rays. #### How much am I covered for? Up to $6,000 per **insured person** every policy year. #### What else do I need to know? In addition to any personal or general exclusions that may apply, we also don't cover the following under this benefit: - any **diagnostic investigations**, other than x-rays - removal of corns or calluses --- ### Eye Injections Benefit #### What am I covered for? We'll pay for intravitreal eye injections that are administered by a **specialist**. #### How much am I covered for? Up to $3,000 per **insured person** every policy year. #### What else do I need to know? To claim this benefit, you'll need a referral from your GP or **specialist**. --- ### High-Risk Pregnancy Benefit #### What am I covered for? We'll pay for treatment by an **obstetrician** to assess and monitor recognised risk factors with your pregnancy. This might include, for example, gestational diabetes, preeclampsia, and anaemia. #### How much am I covered for? Up to $4,000 for each pregnancy. #### What else do I need to know? - we don't consider IVF to be a risk factor - to claim on this benefit you'll need a referral from your GP or **specialist** In addition to any personal or general exclusions that may apply, we also don't cover the following under this benefit: - caesarean sections - treatment of ectopic pregnancies - any related **conditions** arising after the end of your pregnancy - pregnancies conceived before your **join date** - treatment in a public hospital --- ### Loyalty – Sterilisation Benefit #### What am I covered for? We'll pay for sterilisation (a procedure to prevent pregnancy) by a GP or **specialist** as a form of contraception. #### How much am I covered for? Up to the **benefit limit** remaining this policy year on your Surgical Benefit*. #### When will I be covered? After two years of continuous cover following your **join date**. #### What else do I need to know? - each **insured person** can only claim on this benefit once - you don't need to pay an excess on this benefit - if you suspend your cover, the suspension period doesn't count towards the two years - in addition to any personal or general exclusions that may apply, we also don't cover any procedures to reverse sterilisation under this benefit --- ### OPTIONS You may also have cover available under the following Option if you have added this to your policy: **Specialist Option** - Specialist Consultations Benefit - Specialist Second Opinion Benefit - Sports Physician Benefit - Diagnostic Tests Benefit - Cardiac Investigations Benefit --- ## I need to stay in hospital for surgery or treatment ### BASE COVER *Claims for this benefit are paid from the benefit limit(s) remaining this policy year on your Surgical or Non-Surgical Benefit (whichever applies). ### Surgical Benefit #### What am I covered for? If you're admitted to a **private hospital** for **surgery**, we'll pay for your: - surgeon's operating fees; - anaesthetist's fees; - intensivist's fees; - hospital accommodation (e.g. a bed or private room, but not including suites); - operating theatre fees; - surgically implanted prosthesis - laparoscopic disposables; - in-hospital x-ray examination and ECG; - intensive post-operative care and special in-hospital nursing; - in-hospital post-operative **physiotherapy**; - ancillary hospital charges (e.g. dressings, sutures, needles, bandages); and - in-hospital pharmaceutical prescriptions. We also cover the costs of alternative, less invasive, procedures which, in our opinion, replace **surgery** as the most appropriate treatment. This is covered under your Non-Surgical Benefit. This benefit also covers the following specific **surgeries** and treatments: - oral **surgery**, if it's performed by a registered **oral surgeon** or **maxillo-facial surgeon** - the removal of unerupted or impacted teeth by an **oral surgeon**, **dental practitioner**, or **maxillo-facial surgeon**. You'll be covered for this after one year of continuous cover following your **join date**. - **Specialist** micrographic **surgery** (also known as Mohs) - Varicose vein treatment if it's performed by a **vocational GP**, **specialist** or a Phlebologist who is a Fellow of the Australasian College of Phlebology, in private practice, and holds a current practising certificate. #### How much am I covered for? Up to $600,000 per **insured person** every policy year. #### What else do I need to know? Some other benefits on your policy are also paid out of this **benefit limit**, as they relate to your **surgery**. You'll find details of this under the "How much am I covered for?" section of each applicable benefit. In addition to any personal or general exclusions that may apply, we also don't cover the following under this benefit: - any **surgery** that isn't performed by a **specialist** - tooth extractions, except for unerupted or impacted teeth - any other dental treatments, including periodontic and endodontic treatment, orthodontic treatment and implants, and orthognathic **surgery** or exposure of teeth - cryotherapy, pulse light therapy, or photodynamic therapy as part of your Mohs **surgery** --- ### Non-Surgical Benefit #### What am I covered for? If you're admitted to a **private hospital** for treatment that doesn't involve **surgery**, we'll pay for your: - hospital accommodation (e.g. a bed or private room, but not including suites); - in-hospital x-ray examination and ECG; - intensive post-treatment care and special in-hospital nursing; - in-hospital post-treatment **physiotherapy**; - ancillary hospital charges (e.g. dressings, bandages); and - in-hospital pharmaceutical prescriptions #### How much am I covered for? Up to $300,000 per **insured person** every policy year. #### What else do I need to know? Some other benefits on your policy are also paid out of this **benefit limit**, as they relate to your hospitalisation. You'll find details of this under the "How much am I covered for?" section of each applicable benefit. In addition to any personal or general exclusions that may apply, we also don't cover the following under this benefit: - any treatment where admission isn't supported by medical evidence - any treatment that isn't managed by a **specialist** - any treatment where the main purpose, or only purpose, is to receive an injection (for example, a pain management injection) --- ### Cancer Treatment Benefit #### What am I covered for? If you're admitted to a **private hospital** for chemotherapy, immunotherapy, radiotherapy, or brachytherapy, we'll pay for your: - Chemotherapy; - Immunotherapy; - Radiotherapy; - Brachytherapy; - hospital accommodation (e.g. a bed or private room, but not including suites); - in-hospital x-ray examination and ECG; - intensive post-treatment care and special in-hospital nursing; - in-hospital post-treatment **physiotherapy**; - ancillary hospital charges (e.g. dressings, needles, bandages); and - in-hospital pharmaceutical prescriptions #### How much am I covered for? Up to the **benefit limit** remaining this policy year on your Non-Surgical Benefit*. #### What else do I need to know? - any costs relating to cancer **surgery** are covered under your Surgical Benefit - in addition to any personal or general exclusions that may apply, we also don't cover suites in a **private hospital** under this benefit --- ### Non-PHARMAC Funded Medicines in Hospital Benefit #### What am I covered for? We'll cover the cost of medicines you need in a **private hospital** that aren't funded by PHARMAC at the time of your treatment (see "What medications can I claim for?" for more information). #### How much am I covered for? Up to the **benefit limit** remaining this policy year on your Surgical or Non-Surgical Benefit.* #### What else do I need to know? The medicine must be approved by Medsafe and the reason for use within Medsafe approval. To claim on this benefit, you'll need to have already had a related claim paid by us under your Surgical or Non-Surgical Benefit. In addition to any personal or general exclusions that may apply, we also don't cover medicines that are administered or charged for in a public hospital or at home under this benefit. --- ### Travel and Accommodation Benefit #### What am I covered for? If you need **surgery** or treatment and it can't be provided by a **private hospital** within 100km of where you usually live, we'll cover your travel and accommodation costs to have your treatment at another **private hospital**. We'll also pay for a support person to travel with you and stay with you during your treatment. We'll cover the accommodation costs for you and your support person the night before your treatment, and also for your support person while you're in hospital. #### What type of travel costs am I covered for? We'll pay for the following travel costs for you and a support person: - air: return economy flights within New Zealand and return taxi fares between the hospital and airport; or - rail or bus: a return rail or bus trip within New Zealand and return taxi fares between the hospital and railway/bus station; or - car: mileage for road travel at the amount set by us #### How much am I covered for?* Accommodation: - up to $300 per night in total Travel: - for **surgery** or treatment: up to $3,000 per **insured person** every policy year - for cancer treatment: up to the **benefit limit** remaining this policy year on your Surgical or Non-Surgical Benefit #### What else do I need to know? To claim on this benefit, you'll need: - a recommendation from a **specialist**; and - a related claim already paid by us under your Surgical or Non-Surgical Benefit In addition to any personal or general exclusions that may apply, we also don't cover the following under this benefit: - vehicle hire - travel insurance - costs incurred when travelling outside New Zealand --- ### Parent Accommodation Benefit #### What am I covered for? If an **insured person** aged 20 or younger is being treated in a **private hospital**, we'll cover the cost of accommodation for the accompanying parent or legal guardian while they're in hospital. #### How much am I covered for?* - up to $300 per night - up to a **benefit limit** maximum of $3,000 per **insured person** every policy year #### What else do I need to know? To claim on this benefit, you'll need to have already had a related claim paid by us under your Surgical or Non-Surgical Benefit. --- ### Ambulance Transfer Benefit #### What am I covered for? We'll cover the cost of ambulance transfers by road, either: - from a public hospital to a **private hospital** - between **private hospitals** #### How much am I covered for? Up to the **benefit limit** remaining this policy year on your Surgical or Non-Surgical Benefit*. #### What else do I need to know? The transfer must be: - to the closest **private hospital**; and - recommended by a **specialist** who has cared for you for at least 24 hours while you were in hospital To claim on this benefit, you'll need to have already had a related claim paid by us under your Surgical or Non-Surgical Benefit. In addition to any personal or general exclusions that may apply, we also don't cover ambulance memberships under this benefit. --- ### Delayed Treatment Benefit #### What am I covered for? If the **surgery** or medical treatment you need is available privately in New Zealand but can't be provided for at least six months due to a lack of medical resources, we'll pay towards having your treatment overseas. We'll also cover return economy flights, accommodation, and transfers for you and one support person. #### How much am I covered for? The maximum amount we'll pay is the usual, customary and reasonable charges that would've been payable in New Zealand for the same **surgery** or treatment, up to your overall **benefit limit***. #### What else do I need to know? - any related **diagnostic investigations** and histology must be done before your departure - all details regarding your destination, travel, accommodation, and support person need to be approved by us before your departure - all medical facilities, providers, and health professionals that you use must have accreditation and/or registration that would be acceptable for New Zealand standards Payments: - any payments, **benefit limits** or excess on this benefit are in New Zealand Dollars - we'll use the exchange rate on the day we pay your claim to calculate the payment amount - payments will only be made to the selected New Zealand bank account of the **policyowner** or **insured person** and won't be paid directly to the **health service** provider In addition to any personal or general exclusions that may apply, we also don't cover the following under this benefit: - **surgery** or treatment that isn't available in New Zealand - **surgery** or treatment that isn't performed in an overseas **private hospital** - any **surgery** or treatment that can be claimed under the Overseas Treatment Benefit --- ### Cover in Australia Benefit #### What am I covered for? We'll pay for your **surgery** or treatment in Australia for all the benefits under your policy, except for: - Travel and Accommodation Benefit - Overseas Treatment Benefit - Delayed Treatment Benefit - ACC Top-up Benefit - ACC Treatment Injury Benefit - Ambulance Transfer Benefit - any cover provided under an Option #### How much am I covered for? The maximum amount we'll pay is the usual, customary and reasonable charges that would've been payable in New Zealand for the same **surgery** or treatment, up to your overall **benefit limit***. #### What else do I need to know? All medical facilities, providers, and health professionals that you use must have accreditation and/or registration that would be acceptable for New Zealand standards, and the **surgery** or treatment must comply with Australian law. We only pay for any medications that would be covered in New Zealand (see "What medications can I claim for?" for more information. Payments: - any payments, **benefit limits** or excess on this benefit are in New Zealand Dollars - we'll use the exchange rate on the day we pay your claim to calculate the payment amount - payments will only be made to the selected New Zealand bank account of the **policyowner** or **insured person** and won't be paid to the **health service** provider In addition to any personal or general exclusions that may apply, we also don't cover the following under this benefit: - **surgery** or treatment that relates to an injury which would be covered under ACC if it had happened in New Zealand - any ambulance costs - a claim for the same **surgery** or treatment under the Overseas Treatment Benefit – we'll pay under the benefit with the higher cover amount --- ### Overseas Treatment Benefit #### What am I covered for? If you require **surgery** or treatment that can't be performed in New Zealand, we'll pay for this **surgery** or treatment to be done overseas. We also pay for the reasonable travel costs, including accommodation, for you and a support person. #### How much am I covered for? Up to $30,000 per **insured person** for each overseas **surgery** or treatment. #### What else do I need to know? - to claim on this benefit, the Ministry of Health needs to have declined your application for funding under the 'High-Cost Treatment Pool' (or its replacement). You'll need to provide us with a copy of the letter declining your application - all medical facilities, providers, and health professionals that you use must have accreditation and/or registration that would be acceptable for New Zealand standards - we'll only pay for economy airfares Payments: - any payments, **benefit limits** or excess on this benefit are in New Zealand Dollars - we'll use the exchange rate on the day we pay your claim to calculate the payment amount - payments will only be made to the selected New Zealand bank account of the **policyowner** or **insured person** and won't be paid directly to the **health service** provider The treatment must meet all of the following criteria: - be a type that can't be performed in New Zealand - be recommended by the **specialist** who is treating you - be approved by us - comply with the local laws In addition to any personal or general exclusions that may apply, we also don't cover the following under this benefit: - desensitisation, vaccinations, immunology, or allergies - any costs you've already been paid under the Cover in Australia Benefit --- ### Medical Tourism Benefit #### What am I covered for? We'll cover the cost of overseas **surgery** or treatment under the following benefits, if the treatment can be provided in New Zealand within six months: - Surgical Benefit - Non-Surgical Benefit - Cancer Treatment in Hospital Benefit - Non-PHARMAC Funded Medicines in Hospital Benefit - Non-PHARMAC Funded Medicines at Home Benefit #### How much am I covered for?* The maximum amount we'll pay is 75% of the usual, customary and reasonable charges that would have been payable in New Zealand for the same **surgery** or treatment, up to your overall **benefit limit***. #### What else do I need to know? - you need to get pre-approval to use this benefit - all medical facilities, providers and health professionals that you use must have accreditation and/or registration that would be acceptable for New Zealand standards - the treatment must be a type that can be performed in New Zealand and must be recommended by the **specialist** who treated you in New Zealand - medications are only covered if they would've been covered in New Zealand - you can choose the country you want to be treated in, but receipts and medical reports must be provided in English at your own cost Payments: - any payments, **benefit limits** or excess on this benefit are in New Zealand Dollars - we'll use the exchange rate on the day we pay your claim to calculate the payment amount - payments will only be made to the selected New Zealand bank account of the **policyowner** or **insured person** and won't be paid to the **health service** provider In addition to any personal or general exclusions that may apply, we also don't cover the following under this benefit: - any complications or ongoing treatment related to the initial treatment - a claim for the same **surgery** or treatment under the Cover in Australia Benefit --- ### ACC Treatment Injury Benefit #### What am I covered for? If you become injured during a **health service** that we've paid for, we'll pay for the **surgery** or treatment needed to treat or repair your injury that is not covered by ACC. #### How much am I covered for? Up to the **benefit limit** remaining this policy year on your Surgical or Non-Surgical Benefit*. #### What else do I need to know? - to claim on this benefit, you'll need to provide evidence of an ACC treatment injury claim being submitted to ACC - if ACC declines to pay for the treatment, we may request an ACC review on your behalf - if we've paid for your treatment and ACC reimburses you, you must forward this money to us --- ### Loyalty – Weight Loss Surgery Benefit #### What am I covered for? We'll cover the cost of sleeve gastrectomy, gastric banding or bypass **surgery** if you meet all of the following criteria: - physical growth is complete; - previous attempts at weight loss haven't been successful long-term; - severe obesity, defined as one of the following: - body mass index (BMI) of 40 or greater; or - body mass index (BMI) of 35 or greater when at least one of the following **conditions** is also present: - coronary heart disease; - type 2 diabetes mellitus; - clinically significant obstructive sleep apnoea (which is proven by sleep studies); - moderate or severe osteoarthritis of weight bearing joints, for example hips and knees (radiological evidence required); or - blood pressure greater than 140/90 despite 6 months or more of antihypertensive medications, proven to be ineffective at maximum doses We'll also cover your related **consultations** and **diagnostic investigations**. #### How much am I covered for? $10,000 per **insured person** over the life of this policy deducted from your Surgical Benefit **benefit limit***. #### When will I be covered? After three years of continuous cover following your **join date**. #### What else do I need to know? - we only pay for the weight loss **surgeries** that are specified above, and don't cover any other treatment, for example banded gastroplasty (stomach stapling) - to claim on this benefit, you'll need to send us a report from your **specialist** before your **surgery** showing that you meet the criteria above - if you suspend your cover, the suspension period doesn't count towards the three years - in addition to any personal or general exclusions that may apply, we also don't cover any complications or follow-up treatment relating to your **surgery** under this benefit --- ### Loyalty – Breast Reduction Surgery Benefit #### What am I covered for? We'll cover the cost of bilateral breast reduction **surgery** if you meet all of the following criteria: - bra cup size is over DD - medical examination confirms macromastia - the amount of breast tissue to be removed is estimated to be at least 350 grams per breast - if the **insured person** is over 30 years, no suspicious lesions were found on a mammogram completed within 12 months of the date of **surgery** - at least two of the following symptoms have been present for a minimum of 12 months (non-injury related): - pain in the upper back, neck or shoulders - headaches (secondary to neck or back pain) - pain, discomfort or ulceration from bra straps cutting into shoulders (not just imprints of straps) - associated skin disorders that have not responded to conservative medical treatment We'll also cover your related **consultations** and **diagnostic investigations**. #### How much am I covered for? $10,000 per **insured person** over the life of this policy deducted from your Surgical Benefit **benefit limit***. #### When will I be covered? After three years of continuous cover following your **join date**. #### What else do I need to know? - to claim on this benefit, you'll need to send us a report from your **specialist** before your **surgery** showing that you meet the criteria above - if you suspend your cover, the suspension period doesn't count towards the three years - in addition to any personal or general exclusions that may apply, we also don't cover any tumescent liposuction or any follow-up treatment relating to your **surgery** under this benefit --- ### OPTIONS You may also have cover available under the following Option if you have added this to your policy: **Non-PHARMAC Plus Option** - Non-PHARMAC Plus Benefit --- ## I'm recovering from a stay in hospital ### BASE COVER *Claims for this benefit are paid from the benefit limit(s) remaining this policy year on your Surgical or Non-Surgical Benefit (whichever applies). ### Non-PHARMAC Funded Medicines at Home Benefit #### What am I covered for? We'll cover the cost of medicines used at home for up to six months after you're admitted to a **private hospital** for treatment. The medicine must be: - approved by Medsafe; and - reason for use is within Medsafe approval; and - not funded by PHARMAC at the time of your treatment. #### How much am I covered for? Up to the amount remaining this policy year on your Surgical or Non-Surgical Benefit*. #### What else do I need to know? To claim on this benefit, you'll need to have already had a related claim paid by us under your Surgical or Non-Surgical Benefit. --- ### Cancer Treatment Accessories Support Benefit #### What am I covered for? If you've had cancer **surgery** or treatment paid for by us under this policy, we'll contribute towards the costs of any of the following related to your **surgery** or treatment: - wigs - hats - scarves - mastectomy bras #### How much am I covered for? Scarf / hat: - up to $50 for each cancer **condition**, deducted from your overall **benefit limit*** Wig / mastectomy bra: - up to $500 for each cancer **condition**, deducted from your overall **benefit limit*** #### What else do I need to know? To claim on this benefit, you'll need: - to provide us with your receipts - a related claim already paid by us under your Surgical or Non-Surgical Benefit You must buy the accessory within six months of being admitted to a **private hospital** for your **surgery** or treatment. In addition to any personal or general exclusions that may apply, we also don't cover any accessories that aren't related to your cancer under this benefit. --- ### Cancer Treatment Counselling and Support Services Benefit #### What am I covered for? If you've had cancer **surgery** or treatment paid for by us under this policy, we'll pay towards the following **counselling** and support services related to your **surgery** or treatment: - Any of these **counselling** services: - grief **counselling** - illness crisis **counselling** - anxiety **counselling** - depression **counselling** - anger management - Any of these support services provided by an expert in their field: - stop smoking - drug addiction - alcohol addiction - gambling addiction - relationship guidance - budgeting advice - career advice - small business advice #### How much am I covered for? Counselling services: - up to $400 for each cancer **condition**, deducted from your overall **benefit limit*** Support services: - up to $300 for each cancer **condition**, deducted from your overall **benefit limit*** #### What else do I need to know? - the service(s) must occur within six months of being admitted to a **private hospital** for your **surgery** or treatment - the services must relate to your cancer treatment which was paid for by us - the services must be approved by us in advance and will be paid after you provide receipts - to claim on this benefit, you'll need: - a referral from the GP or **specialist** who treated your cancer **condition** - a related claim already paid by us under your Surgical or Non-Surgical Benefit - in addition to any personal or general exclusions that may apply, we also don't cover services provided by family members, friends, associates or anyone who doesn't meet our criteria under this benefit --- ### Cardiac Counselling and Support Services Benefit #### What am I covered for? If you've had heart **surgery** paid for by us under this policy, we'll pay towards the following **counselling** and support services related to your **surgery**: - Any of these **counselling** services: - grief **counselling** - illness crisis **counselling** - anxiety **counselling** - depression **counselling** - anger management - Any of these support services provided by an expert in their field: - stop smoking - drug addiction - alcohol addiction - gambling addiction - relationship guidance - budgeting advice - career advice - small business advice #### How much am I covered for? Counselling services: - up to $400 for each heart **surgery**, deducted from your overall **benefit limit*** Support services: - up to $300 for each heart **surgery**, deducted from your overall **benefit limit*** #### What else do I need to know? - the service(s) must occur within six months of being admitted to a **private hospital** for your **surgery** or treatment - the services must relate to your heart **surgery** which was paid for by us - the services must be approved by us in advance and will be paid after you provide receipts - to claim on this benefit, you need: - a referral from the GP or **specialist** who treated your cardiac **condition** - a related claim already paid by us under your Surgical or Non-Surgical Benefit - in addition to any personal or general exclusions that may apply, we also don't cover services provided by family members, friends, associates or anyone who doesn't meet our criteria under this benefit --- ### Physiotherapy Benefit #### What am I covered for? We'll pay for your **physiotherapy** treatment for up to six months after being discharged from a **private hospital**. #### How much am I covered for? You can have unlimited **physiotherapy** treatments during this time, up to your overall **benefit limit***. #### What else do I need to know? To claim on this benefit, you'll need: - a referral from the **specialist** who treated you while you were in hospital; and - a related claim already paid by us under your Surgical or Non-Surgical Benefit (whichever applies) The **physiotherapy** must relate directly to the **condition** you were in hospital for. --- ### Therapeutic Care Benefit #### What am I covered for? We'll pay for the following treatments for up to six months after you've been discharged from a **private hospital**: - Osteopathic treatment - Chiropractic treatment - Sports Physician treatment - Speech Therapy - Occupational Therapy - Dietitian **consultations** #### How much am I covered for? Up to $1,000 per **insured person** every policy year, deducted from your overall **benefit limit***. #### What else do I need to know? To claim on this benefit, you'll need: - a referral from the **specialist** who treated you while you were in hospital; and - a related claim already paid by us under your Surgical or Non-Surgical Benefit (whichever applies) The treatment must relate directly to the **condition** you were in hospital for. --- ### Home Care Benefit #### What am I covered for? We'll pay for you to have home care by a registered nurse, **nurse practitioner** or **healthcare assistant** for up to six months after you're discharged from a **private hospital**. #### How much am I covered for? Up to $300 per day, to a total maximum of $6,000 per **insured person** every policy year, deducted from your overall **benefit limit***. #### What else do I need to know? The care must meet all of the following criteria: - be recommended by a GP or **specialist** - be for activities of daily living - directly relate to the **condition** you were in hospital for To claim on this benefit, you'll need to have already had a related claim paid by us under your Surgical or Non-Surgical Benefit (whichever applies). In addition to any personal or general exclusions that may apply, we also don't cover any housekeeping or childcare costs under this benefit. --- ### Follow-up Investigations for Cancer Benefit #### What am I covered for? If you've had cancer **surgery** or cancer treatment paid for by us under this policy, we'll also pay for your related follow-up investigations for up to five consecutive years. You're covered for both: - an annual **specialist** **consultation** relating to your cancer - investigations relating to your cancer #### How much am I covered for? Up to $3,000 per **insured person** every policy year, deducted from your overall **benefit limit***. #### What else do I need to know? This benefit starts once your cancer treatment has ended. --- ### Breast Symmetry Post Mastectomy Benefit #### What am I covered for? If you've had a mastectomy covered under this policy, we'll pay for one or both of the following: - reconstruction of the breast you had removed to achieve breast symmetry - reduction of the other breast to achieve symmetry We'll also pay for any related **consultations**, **diagnostic investigations**, or further treatment that is related to this **surgery**. #### How much am I covered for? Up to the **benefit limit** remaining this policy year on your Surgical Benefit*. #### What else do I need to know? - you don't need to pay an excess on this benefit. - you'll need to provide us with a medical report from your **specialist** before any **surgery** --- ### ADDITIONAL COVER You may also have cover under the following Base Cover benefits, or Option if you have added this to your policy: **Base Cover** - Hospital Diagnostic Tests Benefit - Hospital Specialist Consultations Benefit - Second Opinion Benefit **Non-PHARMAC Plus Option** - Non-PHARMAC Plus Benefit --- ## I need financial support ### BASE COVER ### Public Hospital Payment #### What am I covered for? If you're admitted to a public hospital, we'll pay a benefit from the third night onwards. #### How much am I covered for? $300 per night, to a total maximum of $3,000 per **insured person** every policy year. #### What else do I need to know? - you don't need to pay an excess under this benefit - you can claim on this benefit once you've been in a public hospital for three or more nights in a row - to claim on this benefit, you'll need to provide us with the discharge summary from the public hospital – it needs to include the reason for your stay and the dates you arrived and left the public hospital - we'll only pay this benefit if you would have been able to claim under the Surgical Benefit, Non-Surgical Benefit, or Cancer Treatment Benefit in a **private hospital** - in addition to any personal or general exclusions that may apply, we also don't cover any stays in the private wing of a public hospital under this benefit --- ### Hospice Benefit #### What am I covered for? If you're admitted to a **hospice**, we'll make a payment to you from the third night of your stay onwards. #### How much am I covered for? $300 per night, up to a total maximum of $3,000 per **insured person** every policy year. #### What else do I need to know? - you'll need to have been in **hospice** for three or more nights in a row to be able to claim - to claim under this benefit, we'll need a summary from the **hospice** which includes the reason and length of your stay --- ### Funeral Support Benefit #### What am I covered for? If you die between the ages of 16 and 64 (inclusive), we'll pay this benefit. #### How much am I covered for? $10,000 for each deceased **insured person**. #### What else do I need to know? - you don't need to pay an excess on this benefit - the payment will be made to the **policyowner** or the estate of the deceased **insured person** after we receive a copy of the death certificate --- ### Medical Misadventure Benefit #### What am I covered for? If you die due to an error, negligence, oversight, or failure of a **health professional** to follow expected or usual standards during treatment or **surgery** that we're paying for, we'll pay a benefit. We refer to this as medical misadventure. #### How much am I covered for? $30,000 per **insured person**. #### What else do I need to know? - you don't need to pay an excess under this benefit - a copy of the **insured persons'** death certificate will need to be provided to us In addition to any personal or general exclusions that may apply, we also won't pay under this benefit if any of the following apply: - the death doesn't occur within 14 days of the medical misadventure - the cause of death has not been confirmed by a coroner's inquest - the medical misadventure is not the main cause of death - the medical misadventure happens during treatment or **surgery** that isn't covered by this policy - the death occurs as a result of treatment or **surgery** covered under the Medical Tourism Benefit --- ### ACC Top-Up Benefit #### What am I covered for? If your ACC claim payments don't fully cover the cost of the **surgery** or medical treatment you're having for a physical injury, we'll pay the difference. #### How much am I covered for? Up to the **benefit limit** remaining this policy year on your Surgical or Non-Surgical Benefit. #### What else do I need to know? You'll need to provide us with confirmation of how much ACC is paying. In addition to any personal or general exclusions that may apply, we also don't cover any injuries that occurred before your **join date** under this benefit. --- ### Waiver of Premium Benefit #### What am I covered for? We won't charge any premiums if a **policyowner** dies before the age of 70, or at the end of the Terminal Illness Waiver of Premium Benefit. #### How long will my premiums be waived for? We won't charge any premiums from the next billing date after the death of the **policyowner** or the end of the Terminal Illness Waiver of Premium Benefit, until the first of these happens: - two years have passed - any remaining **insured person** turns 70 years old After this, your premium payments will resume. #### What else do I need to know? - you don't need to pay an excess on this benefit - a copy of the death certificate will need to be provided to us - premiums won't be waived for any new **insured person**(s) or Option(s) added to your policy after we started waiving the premiums --- ### Terminal Illness Waiver of Premium Benefit #### What am I covered for? We won't charge any premiums if a **policyowner** is diagnosed with a terminal illness before the age of 70. #### How long will my premiums be waived for? We won't charge any premiums from the next billing date after your claim is submitted to us, until the first of these happens: - six months have passed - the **policyowner** dies After this your premium payments will resume, unless the Waiver of Premium Benefit is initiated. #### What else do I need to know? - you don't need to pay an excess on this benefit - you need to provide a letter from your **specialist** confirming your terminally ill diagnosis - this benefit must be used while the **policyowner** is terminally ill, it can't be used after they have died - premiums won't be waived for any new **insured person**(s) or Option(s) added to your policy after we started waiving the premiums - if the **policyowner** dies during this six-month period, the Waiver of Premium Benefit will start when this benefit ends --- ### Loyalty – Suspending your Cover Benefit #### What am I covered for? You can apply to put your policy or cover on hold for an **insured person** due to any of the following: - unemployment/redundancy - overseas travel/residence - parental leave You don't have to pay premiums for any cover that is on hold, and we won't pay any claims for suspended cover during this time. #### How long can I put my cover on hold? - unemployment/redundancy: for up to six months - overseas travel/residence: for at least 90 days, up to a maximum of 24 months - parental leave: for at least 90 days, up to a maximum of 12 months You can only suspend your cover for a total of 24 months in any 10-year period. #### When can I use this benefit? After one year of continuous cover following your **join date**. #### What else do I need to know? - you need to provide us with supporting documentation as part of your application to suspend your policy or cover - your premiums must be up-to-date before you can suspend your policy or cover - once your suspension period ends, your policy or cover will resume on the next available billing date - while your policy or cover for an **insured person** is suspended, the suspension period doesn't count towards any waiting periods on your policy – any waiting periods that have not ended will need to be completed when the cover restarts - if your policy has renewed while it's on hold, an increase in your premium may apply --- ### OPTIONS You may also have cover under the following Option if you have added this to your policy: **Serious Condition Financial Support Option** - Serious Condition Benefit - Paralysis Benefit - Children's Benefit --- ## I want to be proactive about my health ### BASE COVER ### Loyalty – Check Up Benefit #### What am I covered for? If you're 21 or older, we'll pay for you to have a wellness check by a GP. For example, this could include: - laboratory tests - ECG - blood pressure check - breast examinations - mole mapping - cervical smears - prostate examinations #### How much am I covered for? Up to $100 per **insured person**, after every three years of continuous cover. #### When will I be covered? After three years of continuous cover following your **join date**. #### What else do I need to know? - you don't need to pay an excess on this benefit - if you suspend your policy or cover, the suspension period doesn't count towards the three years - this benefit can't be accumulated – you have to use it in the year that you're entitled to it - when a **dependent child** turns 21, and if they continue to stay on this policy, they'll become eligible for this benefit. We'll pay this benefit to them after three years of continuous cover – the three years starts from the **policy anniversary date** that follows their 21st birthday --- ### OPTIONS You may also have cover under the following Options if you have added them to your policy: **GP Option** - GP Benefit - Loyalty – Active Wellness Benefit **Dental, Optical, and Therapeutic Option** - Dental Benefit **Proactive Health Option** - Screening Benefit - Allergy Testing and Vaccinations Benefit - Dietitian or Nutritionist Consultations Benefit - Stay Active Benefit - Loyalty – Health Check Benefit --- # 03. Options Your **Acceptance or Renewal Certificate** specifies any Option(s) that an **insured person**(s) has selected. These are the Options that are available to you: - Specialist Option - Non-PHARMAC Plus Option - GP Option - Proactive Health Option - Dental, Optical, and Therapeutic Option - Serious Condition Financial Support Option --- ## Specialist Option This section outlines the benefits that are covered under the Specialist Option. If you add your **dependent child** to this Option within four months of birth, we'll cover their **pre-existing conditions** under this Option, except for any **congenital** **conditions**. ### When will I be covered? You're covered for these benefits from your **join date** on this Option. ### What else do I need to know? - to claim on these benefits, you'll need a referral from a GP or **specialist** - we pay 100% of eligible costs under each benefit up to your available **benefit limit** - you don't need to pay an excess on this Option - we don't pay for any hospital services under this Option --- ### Specialist Consultations Benefit #### What am I covered for? We'll pay for **consultations** you need with a **specialist** or **vocational GP**. #### How much am I covered for? You can have an unlimited number of **consultations**. --- ### Specialist Second Opinion Benefit #### What am I covered for? We'll pay for you to get a second opinion from another **specialist** or **vocational GP**. #### How much am I covered for? You can have an unlimited number of second opinions. --- ### Sports Physician Benefit #### What am I covered for? We'll pay for any sports physician treatments that you need. #### How much am I covered for?* Up to $500 per **insured person** every policy year. --- ### Diagnostic Tests Benefit #### What am I covered for? We'll pay for any **diagnostic investigations** that you need. For example, this could include x-rays, ultrasounds, and mammograms. #### How much am I covered for? Up to $3,000 per **insured person** every policy year. --- ### Cardiac Investigations Benefit #### What am I covered for? We'll pay for any cardiac **diagnostic investigations** that you need, including: - Treadmills - Holter monitoring - Ambulatory blood pressure monitoring - Cardiovascular ultrasound - Echocardiography - Myocardial perfusion scans #### How much am I covered for? Up to $60,000 per **insured person** every policy year. --- ## GP Option This section outlines the benefits that are covered under the GP Option. If you add your **dependent child** to this Option within four months of birth, we'll cover their **pre-existing conditions** under this Option, except for any **congenital** **conditions**. ### When will I be covered? Unless otherwise specified under a benefit, you're covered by these benefits 90 days after your **join date** on this Option. ### What else do I need to know? - we pay 100% of eligible costs on each benefit up to your available **benefit limit** - you don't need to pay an excess under this Option - we don't pay for any hospital services under this Option --- ### GP Benefit #### What am I covered for? We'll pay for: - GP or **nurse practitioner** **consultations**; and - GP **surgery** performed in a GP room under local anaesthetic This includes home **consultations**, ECG, and cervical smears. #### How much am I covered for? You can have up to twelve GP and/or **nurse practitioner** **consultations** per **insured person** every policy year. For **consultations** we'll pay: - up to $55 per **consultation**, including after hours - up to $80 per home **consultation** - up to $25 per ACC top-up **consultation** For GP **surgery** we'll pay: - up to $200 for each procedure #### What else do I need to know? The amounts we'll pay for **consultations** and GP **surgery** can't be combined with each other. --- ### Prescriptions Benefit #### What am I covered for? We'll pay for your pharmaceutical prescriptions. #### How much am I covered for? Up to $15 per item, to a total maximum of $300 per **insured person** for all items every policy year. #### What else do I need to know? You'll need to provide us with your pharmacy receipts that show the patient's name, prescription number, name of the prescribed drug(s) and the cost of each item. In addition to any personal or general exclusions that may apply, we also don't cover the following under this benefit: - after-hours fees - administration costs - medicines that aren't prescribed by a GP, **specialist**, or **nurse practitioner** --- ### Physiotherapy Benefit #### What am I covered for? We'll pay for **physiotherapy** treatment that you need. #### How much am I covered for? - up to $40 per treatment/visit - up to $15 per ACC treatment - to a total maximum of $400 per **insured person** every policy year #### What else do I need to know? - to claim on this benefit, you'll need a referral from a GP or **specialist** - the amounts we'll pay for treatments can't be combined with each other --- ### Nurse Practitioner Benefit #### What am I covered for? We'll pay for the cost of visits with a **nurse practitioner**. #### How much am I covered for? Up to $30 per visit, to a total maximum of six visits per **insured person** every policy year. --- ### Loyalty – Active Wellness Benefit #### What am I covered for? We'll reimburse an **insured person** who was 21 or older at the last **policy anniversary date** for costs paid towards the following: - a gym membership - sports club membership - fitness equipment bought at a sporting retailer recognised by us #### How much am I covered for? $150 per **insured person** after every two years of continuous cover on this Option. #### When will I be covered? After two years of continuous cover following your **join date** on this Option. #### What else do I need to know? - you need to provide us with receipts - you can claim on this benefit if, in the two years prior to you becoming eligible for this benefit, you've claimed less than $150 in total on this Option - you must use this benefit in the year that you're entitled to it; it can't be accumulated - if you suspend your cover, the suspension period doesn't count towards the two years --- ## Dental, Optical, and Therapeutic Option This section outlines the benefits that are covered under the Dental, Optical, and Therapeutic Option. If you add your **dependent child** to this Option within four months of birth, we'll cover their **pre-existing conditions** under this Option, except for any **congenital** **conditions**. ### When will I be covered? Unless specified otherwise on a benefit, you're covered for these benefits six months after your **join date** on this Option. ### What else do I need to know? - we pay 80% of eligible costs on each benefit up to your available **benefit limit** - you don't need to pay an excess under this Option - we don't pay for any hospital services under this Option --- ### Dental Benefit #### What am I covered for? We'll pay for treatments by a **dental practitioner** including examination, cleaning, scaling, fillings, x-rays, removal of teeth, and crowns. #### How much am I covered for? Up to $500 per **insured person** every policy year. #### What else do I need to know? In addition to any personal or general exclusions that may apply, we also don't cover the following under this benefit: - treatments covered under the school dental service or government dental scheme - gold or other exotic materials - orthodontic treatment, until you are eligible for the Loyalty – Orthodontic Benefit on this Option --- ### Eye Care Benefit #### What am I covered for? We'll pay for: - **consultations** and examinations by: - Optometrists - Orthoptists - Opticians - **eyewear** when you've had a change in vision #### How much am I covered for? For **consultations** and examinations: - up to $55 per visit, to a total maximum of $275 per **insured person** for all visits every policy year For **eyewear**: - up to $330 per **insured person** every policy year #### What else do I need to know? In addition to any personal or general exclusions that may apply, we also don't cover **eyewear** for fashion reasons, or tinting and transition lenses under this benefit. --- ### Ear Care Benefit #### What am I covered for? We'll pay for audiometric tests and **audiology treatment** that you need. #### How much am I covered for? For audiometric tests: - up to $250 per **insured person** every policy year For **audiology treatments**: - up to $250 per **insured person** every policy year #### What else do I need to know? To claim on this benefit, you'll need a referral from a **specialist**. --- ### Acupuncture Benefit #### What am I covered for? We'll pay for acupuncture treatment you need. #### How much am I covered for? - up to $40 per visit - up to $15 per ACC visit - to a total maximum of $250 per **insured person** for all visits every policy year. #### What else do I need to know? - to claim on this benefit, you'll need a referral from a GP or **specialist** - the amounts we pay for treatments can't be combined with each other --- ### Chiropractor Benefit #### What am I covered for? We'll pay for chiropractic treatment and related x-rays. #### How much am I covered for? For chiropractic treatment: - up to $40 per visit - up to $15 per ACC visit - to a total maximum of $250 per **insured person** for all visits every policy year For x-rays: - up to $80 per **insured person** every policy year #### What else do I need to know? - to claim on this benefit, you'll need a referral from a GP or **specialist** - the amounts we pay for treatments can't be combined with each other --- ### Osteopath Benefit #### What am I covered for? We'll pay for osteopathic treatment and related x-rays. #### How much am I covered for? For osteopathic treatment: - up to $40 per visit - up to $15 per ACC visit - to a total maximum of $250 per **insured person** for all visits every policy year For x-rays: - up to $80 per **insured person** every policy year #### What else do I need to know? - to claim on this benefit, you'll need a referral from a GP or **specialist** - the amounts we pay for treatments can't be combined with each other --- ### Foot Care Benefit #### What am I covered for? We'll pay for podiatry treatment. #### How much am I covered for? Up to $40 per visit, to a total maximum of $250 per **insured person** for all visits every policy year. #### What else do I need to know? To claim on this benefit, you'll need a referral from a GP or **specialist**. --- ### Speech, Occupation, and Eye Therapy Benefit #### What am I covered for? We'll pay for any of the following: - speech therapy - occupational therapy - eye therapy #### How much am I covered for? Up to $40 per visit, to a total maximum of $300 per **insured person** for all visits every policy year. #### What else do I need to know? To claim on this benefit, you'll need a referral from a GP or **specialist**. --- ### Loyalty – Orthodontic Benefit #### What am I covered for? After you've had this Option for two continuous years, the Dental Benefit will be extended to cover Orthodontic treatment. #### How much am I covered for? Claims under this benefit are paid from the Dental Benefit. You're covered up to the **benefit limit** remaining on that benefit in the same policy year. #### When will I be covered? After two years of continuous cover following your **join date** on this Option. #### What else do I need to know? If you suspend your cover, the suspended period doesn't count towards the two years. --- ## Non-PHARMAC Plus Option This section outlines what is covered under the Non-PHARMAC Plus Option. If you have selected this Option, the **Acceptance or Renewal Certificate** will specify your **benefit limit**. ### When will I be covered? You're covered for this benefit from your **join date** on this Option. ### What else do I need to know? - we pay 100% of eligible costs under this benefit up to your available **benefit limit** - you don't need to pay an excess on this Option - we don't pay for any hospital services under this Option --- ### Non-PHARMAC Plus Benefit #### What am I covered for? After referral from a **specialist**, we'll cover the cost of medicines that meet all of the following criteria: - approved by Medsafe - reason for use is within Medsafe approval - not funded by PHARMAC at the time of your treatment The medicines must be