> _Markdown transcription of nib Ultimate Health policy wording, effective 2025-11-24. Source: https://assets.ctfassets.net/ja9v5o5o08yv/2I5CHtqWsDwQ2YtNOeSmFP/e2f58e9bf22d97e6cb7400f7181d6583/ultimate-health-policy-from-24-Nov-2025.pdf_ --- # Ultimate Health 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 - Cover Overview ## 02. Your Base Cover - I've been referred for tests, or to see a health professional for consultation or treatment - I need to stay in hospital for surgery or treatment - I'm recovering from a stay in hospital - I need financial support ## 03. Options - Specialist Option - GP Option - Dental, Optical, and Therapeutic Option - Proactive Health Option - Serious Condition Financial Support Option ## 04. What we don't cover ## 05. Using your cover ## 06. Making changes to your policy ## 07. Conditions of your policy ## 08. About your premiums and benefits ## 09. Important Words --- # 01. How this document works 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 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 Cancer Treatment Benefit - Travel and Accommodation Benefit - Parent Accommodation Benefit - Ambulance Transfer Benefit - Delayed Treatment Benefit - Overseas Treatment Benefit - ACC Treatment Injury Benefit ## I'm recovering from a stay in hospital ### Base Cover - 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* ### Serious Condition Financial Support Option - Serious Condition Benefit - Paralysis Benefit - Children's Benefit ## I need financial support ### Base Cover - Funeral Support Benefit - Medical Misadventure Benefit - ACC Top-Up Benefit - 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 ### GP Option - GP 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 --- ## How this policy document, your Acceptance or Renewal Certificate, and the Diagnostics Schedule work together This policy document explains what you're covered for. You should read this along with your latest Acceptance or Renewal Certificate, and the Diagnostics 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 - what your excess is - 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. If there's any inconsistency between your policy document and your Acceptance or Renewal Certificate, your Acceptance or Renewal Certificate takes priority. ### The Diagnostics Schedule tells you: - which diagnostic investigations don't have a co-payment. We'll pay 100% of the cost of these, up to the benefit limit remaining in the same policy year on the relevant benefit ### 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 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. --- # 02. Your Base Cover ## I've been referred for tests, or to see a health professional for consultation or treatment *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? We'll pay 80% of your eligible costs, unless your diagnostic investigation is listed on the Diagnostics Schedule. If the diagnostic investigation is listed on the Diagnostics Schedule, we'll pay 100% of your eligible costs. In each case, you can have an unlimited number of diagnostic investigations, up to your overall benefit limit*. #### What else do I need to know? In addition to any personal or general exclusions that may apply, we also don't cover any related consultations under this benefit. ### 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? We'll pay 80% of your eligible costs for diagnostic investigations during this time, unless your diagnostic investigation is listed on the Diagnostics Schedule. If the diagnostic investigation is listed on the Diagnostics Schedule, we'll pay 100% of your eligible costs. In each case, you can have an unlimited number of diagnostic investigations, 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? We'll pay 80% of your eligible costs for consultations during this time. 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? We'll pay 80% of your eligible costs for consultations during this time. 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 Surgical or Non-Surgical Benefit. ### Skin Lesion Surgery Benefit #### What am I covered for? We'll pay for skin lesion surgery by a specialist, as well as one related specialist consultation before or after your surgery. #### 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 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 minor surgery by a GP. #### How much am I covered for? Up to $1,500 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 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 $2,000 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 $1,000 per insured person over the life of this policy. #### 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 --- ## I need to stay in hospital for surgery or treatment *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 treatment including your hospital stay, your surgical and anaesthetist costs, and any required prosthesis. We'll also pay for related costs that are charged for your treatment while you're in hospital, such as physiotherapy, tests, and medications administered (see "What medications can I claim for?" for more information). This benefit also covers the following specific surgeries and treatments: - oral surgery, if it's performed by a registered oral or maxillo-facial surgeon - the removal of unerupted or impacted teeth by an oral surgeon, dental practitioner, or maxillofacial 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 an appropriate 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 treatment including your hospital stay and your specialist costs. We'll also pay for related costs that are charged for your treatment while you're in hospital, such as physiotherapy, tests and medications administered (see "What medications can I claim for?" for more information). #### 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 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 treatment including your accommodation, tests, physiotherapy, and medications administered while you're in hospital (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 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 Cancer Treatment Benefit #### What am I covered for? If you need treatment for cancer, we'll pay for the costs of chemotherapy or immunotherapy medicines that are administered in a private hospital and aren't funded by PHARMAC at the time of your treatment. #### How much am I covered for? Up to $20,000 per insured person every policy year, deducted from your overall benefit limit*. #### 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: - medicines that are administered or charged for in a public hospital - medicines that aren't approved by Medsafe ### 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 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 and parking costs - 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 Efficient Market Price that would've been payable in New Zealand for the same surgery or treatment, up to your overall benefit limit*. For more information on the Efficient Market Price, see "Choosing a recognised provider" section. #### 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 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 ### 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 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 ### 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 --- ## I'm recovering from a stay in hospital *Claims for this benefit are paid from the benefit limit(s) remaining this policy year on your Surgical or Non-Surgical Benefit (whichever applies). ### 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 - reduction of the other breast to achieve symmetry We'll also pay for any related consultations, diagnostic investigations, or further treatment that is and 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'll need to provide us with a medical report from your specialist before any surgery. --- ## I need financial support ### Funeral Support Benefit #### What am I covered for? If you die between the ages of 16 and 64 (inclusive), we'll pay a contribution towards your funeral costs. #### How much am I covered for? $5,000 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 provide compensation. 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 your 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 provided outside of New Zealand ### 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. #### 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, 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 ### 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 three months, up to a maximum of 24 months - parental leave: for at least three months, 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 --- # 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 - GP Option - Dental, Optical, and Therapeutic Option - Proactive Health 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 either 80% or 100% of eligible costs, depending on the 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? We'll pay 80% of your eligible costs. 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? We'll pay 80% of your eligible costs. You can have an unlimited number of consultations. ### 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? We'll pay up to $3,000 per insured person every policy year. We'll pay 80% of your eligible costs, unless the diagnostic investigation is listed on the Diagnostics Schedule. If the diagnostic investigation is listed on the Diagnostics Schedule, we'll pay 100% of your eligible costs. #### What else do I need to know? In addition to any personal or general exclusions that may apply, we also don't cover any screening under this benefit. ### 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? We'll pay 80% of your eligible costs up to a total of $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 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. --- ## 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'll pay 80% of eligible costs on 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 on 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? If you've paid for your treatment using a dental payment plan, we'll only pay up to the amount remaining on your benefit limit in the same policy year that your dental treatment happened. 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 the following under this benefit: - eyewear for fashion reasons, including consultations and examinations related to this purpose - tinting or transition lenses ### 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 - for treatment paid by a dental payment plan, we'll pay up to the benefit limit remaining in the same policy year that your orthodontic treatment occurred in --- ## Proactive Health Option This section outlines the benefits that are covered under the Proactive Health Option. ### When will I be covered? Unless specified otherwise under a benefit, you're covered by these benefits six months following your join date on this Option. ### What else do I need to know? - we'll pay 80% 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 ### Screening Benefit #### What am I covered for? We'll pay for the following screening tests: - bone screening - bowel screening - breast screening - cervical screening - heart screening - prostate screening - eye tests - visual field tests - hearing tests - mole mapping #### How much am I covered for? Up to $750 per insured person every policy year. ### Allergy Testing and Vaccinations Benefit #### What am I covered for? We'll pay for allergy testing and vaccinations administered by a health professional. #### How much am I covered for? Up to $100 per insured person every policy year. ### Dietitian or Nutritionist Consultations Benefit #### What am I covered for? We'll pay for dietitian or nutritionist consultations. #### How much am I covered for? Up to $300 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: - food, vitamins, or supplements - videos, books, or DVD ### Stay Active Benefit #### What am I covered for? We'll pay for the following: - gym memberships - weight-loss programmes - quit smoking programmes #### How much am I covered for? Up to $100 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: - food, vitamins, or supplements - videos, books, or DVDs - active wear, protective items, footwear, or equipment. ### Loyalty – Health Check Benefit #### What am I covered for? We'll pay for a medical check by a GP or nurse practitioner. #### 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? - this benefit can't be accumulated, you must use it in the year that you're entitled to it - if you suspend your cover, the suspended period doesn't count towards the two years --- ## Serious Condition Financial Support Option This section outlines the cover that is provided under the Serious Condition Financial Support Option. If you have selected this Option, the Acceptance or Renewal Certificate will specify your sum insured, which is the lump sum amount we'll pay if you meet the definition of a serious condition outlined in this section. ### Serious Condition Benefit We pay this benefit if you suffer one of the serious conditions listed and defined below. The diagnosis must be by a specialist based on testing we approve. We may require you to have a medical examination by an independent specialist. We only pay the sum insured once per insured person covered under this Option, except under the Paralysis Benefit and Children's Benefit. In addition to any personal or general exclusions that may apply, we also don't pay if you or your dependent child dies within 14 days of being diagnosed with a listed serious condition. ### When will I be covered? You will be covered for the following serious conditions three months after your join date on this Option. If any of these serious conditions occur, or you have any signs or symptoms of that serious condition in this three-month period, you won't have cover for that serious condition under this Option: - Aortic surgery - Benign tumour of the brain or spinal cord - Cancer – life-threatening - Cardiac arrest – out of hospital - Cardiomyopathy - Coronary artery angioplasty – three vessels or more - Coronary artery bypass grafting surgery - Heart valve surgery - Primary pulmonary hypertension - Myocardial infarction (heart attack) – major - Major organ transplant - Stroke You can claim for any other serious conditions outlined below from your join date on this Option. ### When does the Option end for you? This Option ends when the first of these things occurs: - the policy anniversary date after your 70th birthday - we pay you the sum insured for a condition under this benefit - you die ### How do I claim? You must tell us of your serious condition within 12 months of being diagnosed. You need to provide us with all of the following: - a copy of your birth certificate, driver's licence, or passport - a completed claim form - any medical certificates and information we need, at your own expense ### Serious Condition Definitions #### Advanced dementia (including Alzheimer's disease) Alzheimer's disease or other dementia resulting in permanent irreversible failure of brain function and significant cognitive impairment for which no other recognisable cause can be identified. Significant cognitive impairment means a deterioration or loss of intellectual capacity that results in a requirement for a permanent caregiver. #### Aortic surgery The undergoing of medically necessary surgery to: - repair or correct an aortic aneurysm; or - an obstruction of the aorta; or - a coarctation of the aorta; or - a traumatic rupture of the aorta. For the purpose of this definition aorta means the thoracic and abdominal aorta but not its branches. #### Aplastic anaemia Bone marrow failure resulting in anaemia, neutropenia, and thrombocytopenia requiring treatment over a period of at least two months with at least one of the following: - blood product transfusion; or - marrow stimulating agents; or - immunosuppressive agents; or - bone marrow transplantation. #### Benign tumour of the brain or spinal cord A non-cancerous tumour in the brain or spinal cord giving rise to characteristic symptoms of increased intracranial pressure such as papilledema, mental symptoms, seizures, and sensory impairment. The tumour must result in either: - medically necessary surgery to remove the tumour; or - neurological deficit causing: - documented functional loss that is deemed permanent; or - you being constantly and permanently unable to perform at least one of the activities of daily living without the physical assistance of another person. This does not include cysts, granulomas, cholesteatomas, malformations of the arteries or veins of the brain, haematomas, and tumours in the pituitary gland. #### Cancer – life threatening The presence of one or more malignant tumours including leukaemia, lymphomas and Hodgkin's disease. The malignant tumour is to be characterised by the uncontrollable growth and spread of malignant cells and the invasion and destruction of normal tissue. The following are not included: - Tumours showing the malignant changes of Carcinoma in Situ* (including cervical dysplasia CIN-1, CIN-2, and CIN-3) or which are histologically described as pre-malignant, unless it results directly in the removal of the entire organ*. - Stage 1 and stage 2 melanoma. - All non-melanoma skin cancers, unless there is evidence of metastases. - Prostatic cancers which are histologically described as TNM Classification T1 and T2 and Gleason score of 5 or less, unless they result directly in the removal of the entire organ*. - Chronic Lymphocytic Leukaemia less than Rai Stage 1. *The procedure used must be performed specifically to arrest the spread of malignancy and be considered to be the usual and necessary treatment. #### Cardiac arrest – out of hospital Cardiac arrest which has occurred outside of hospital and is not caused by or associated with any medical procedure. This must be documented by an electrocardiogram and be due to: - ventricular fibrillation; or - cardiac asystole. #### Cardiomyopathy Impaired ventricular function of variable aetiology, caused by primary disease of the heart muscle, causing permanent and irreversible physical impairment to the degree of at least Class 3 of the New York Heart Association Classification of cardiac impairment. #### Chronic liver failure End-stage liver failure with permanent jaundice, ascites or encephalopathy. #### Chronic lung failure End-stage respiratory failure requiring extensive, continuous, and permanent oxygen therapy and must result in either: - FEV1 <40% of predicted and/or arterial blood gases showing a PaO2 < 7.3kPa; or - you being constantly and permanently unable to perform at least one of the activities of daily living without the physical assistance of another person. #### Chronic renal failure End-stage renal failure presenting as chronic, irreversible failure of both kidneys to function as a result of which regular renal dialysis is instituted or renal transplantation performed. #### Coma A state of unconsciousness with no reaction to external stimuli or internal needs, resulting in either: - continuous mechanical ventilation by means of tracheal intubation for three or more consecutive days (24 hours per day); or - admission for at least five or more consecutive days (24 hours per day) in an authorised intensive care unit of an acute care hospital, on the recommendation of an appropriate specialist. #### Coronary artery angioplasty – three vessels or more The actual undergoing of coronary artery angioplasty that is considered medically necessary to correct or treat a narrowing or blockage of three or more coronary arteries during the same procedure. #### Coronary artery bypass grafting surgery The undergoing of medically necessary coronary artery bypass grafting surgery to correct or treat coronary artery disease. #### Deafness The complete and irrecoverable loss of hearing of both ears (whether aided or unaided) as a result of a condition and confirmed as still present after 90 days. #### Encephalitis resulting in functional loss The severe inflammatory disease of the brain resulting in neurological deficit, causing either: - documented functional loss that is deemed permanent; or - you being constantly and permanently unable to perform at least one of the activities of daily living without the physical assistance of another person. #### Heart valve surgery The undergoing of surgery to replace or repair cardiac valves as a consequence of heart valve defects or abnormalities. Repair via angioplasty, intra-arterial procedures, or other non-surgical techniques is specifically excluded. #### Intensive care Means that a condition has resulted in you requiring: - continuous mechanical ventilation by means of tracheal intubation for three or more consecutive days (24 hours per day); or - admission for at least five consecutive days (24 hours per day) in an intensive care unit of an acute care hospital, on the recommendation of an appropriate specialist. #### Loss of independent existence As a result of a condition where you are totally and permanently unable to perform (whether aided or unaided) at least two of the five activities of daily living, or suffers cognitive impairment that results in you requiring permanent and constant supervision. #### Loss of limbs and/or sight The total and irrecoverable: - loss of two or more limbs; or - loss of sight of both eyes; or - loss of one limb and the sight of one eye. The loss of sight of an eye means the complete and irrecoverable loss of sight (whether aided or unaided). For this serious condition only, the loss of a limb means complete loss of the use of an entire hand or entire foot. #### Loss of speech The complete and irrecoverable loss of speech (whether aided or unaided) as a result of a condition. #### Major head trauma resulting in functional loss Head trauma resulting in permanent neurological deficit causing either: - at least 25% impairment of whole person functions that is permanent; or - you being constantly and permanently unable to perform at least one of the activities of daily living without the physical assistance of another person. #### Myocardial infarction (heart attack) – major Means you have had a myocardial infarction (other than as a direct result of cardiac or coronary intervention) with the following documented evidence of myocardial infarction diagnosis: - laboratory confirmed rise and fall in troponin level - symptoms of myocardial ischaemia - ECG changes suggestive of ischaemia If the above criteria are not met then we will pay a claim based on satisfactory evidence that you have suffered a myocardial infarction which has resulted in a permanent reduction in the left ventricular ejection fraction to less than 50%. #### Major organ transplant Means either: - the undergoing of; or - being on a waiting list of a Transplantation Society of Australia or New Zealand recognised transplant unit for at least four weeks for the medically necessary human-to-human transplant from a donor to you of one or more of the following complete organs: kidney, liver, heart, lung, pancreas, small bowel, or the transplantation of bone marrow (excluding stem cells). #### Medically acquired HIV Infection with the Human Immunodeficiency Virus (HIV) where in nib's opinion the infection arose from you having one of the following medically necessary events: - transfusion with blood products; or - organ transplant to you; or - assisted reproductive techniques; or - a medical procedure or operation performed by a health professional. Notification and proof that the infection is medically acquired will be required via a statement from the recognised statutory health authority. This benefit will not apply in the event that any medical cure is found for AIDS or the effects of the HIV virus or a medical treatment is developed that results in the prevention of the occurrence of HIV. Infection in any other manner, including infection as a result of sexual activity or intravenous drug use, is excluded. We must have open access to all blood results and/or blood samples and be able to obtain independent testing of such blood samples. #### Motor neurone disease The unequivocal diagnosis of motor neurone disease. #### Multiple sclerosis resulting in functional loss Multiple sclerosis with significant persistent neurological deficit resulting in one of the following: - documented functional loss that is deemed permanent; or - you being constantly and permanently unable to perform at least one of the activities of daily living without the physical assistance of another person; or - a restriction of at least 7.5 as measured by the Expanded Disability Status Score (EDSS). #### Muscular dystrophy The unequivocal diagnosis of muscular dystrophy. #### Occupationally acquired HIV Infection with the Human Immunodeficiency Virus (HIV) where HIV was acquired as a result of an accident, or a malicious act of another person, during the course of carrying out normal occupational duties with seroconversion to HIV infection occurring within six months of the incident. Any incident giving rise to a potential claim must be reported to us within 90 days of the incident and be supported by a negative HIV antibody test taken by you, taken within seven days after the incident. This benefit will not apply in the event that any medical cure is found for AIDS or the effects of the HIV virus or a medical treatment is developed that results in the prevention of the occurrence of HIV. Infection in any other manner, including infection as a result of sexual activity or intravenous drug use, is excluded. We must have open access to all blood results and/or samples and be able to obtain independent testing of such blood samples. #### Paralysis The permanent and total loss of function of two or more limbs as a result of injury to, or disease of, the spinal cord or brain as defined below. - Hemiplegia: - the permanent and total loss of function of one side of the body as a result of injury to, or disease of, the spinal cord or brain. - Diplegia: - the permanent and total loss of function of both sides of the body as a result of injury to, or disease of, the spinal cord or brain. - Paraplegia: - the permanent and total loss of function of both legs as a result of injury to, or disease of, the spinal cord or brain. - Quadriplegia: - the permanent and total loss of function of both arms and both legs as a result of injury to, or disease of, the spinal cord or brain. - Tetraplegia: - the permanent and total loss of function of both arms and both legs and loss of head movement as a result of injury to, or disease of, the spinal cord or brain. For this serious condition only, a limb is defined as the complete arm or the complete leg. #### Parkinson's disease The unequivocal diagnosis of degenerative idiopathic Parkinson's disease as characterised by the clinical manifestation of two or more of the following: - tremor/shaking; or - bradykinesia; or - rigidity; or - postural instability. All other types of Parkinsonism are excluded (e.g. secondary to medication). #### Pneumonectomy The surgical excision of an entire lung. #### Primary pulmonary hypertension Primary pulmonary hypertension with substantial right ventricular enlargement, established by investigations including cardiac catheterisation. #### Severe burns Tissue injury caused by thermal, electrical, or chemical agents causing third-degree or full-thickness burns to at least: - 20% of the body surface area as measured by 'The Rule of Nines' or the Lund & Browder Body Surface Chart (or similar means of measurement as determined by us); or - 50% of both hands and requiring surgical debridement and/or grafting; or - 25% of the face and requiring surgical debridement and/or grafting. #### Stroke The suffering of a stroke as a result of a cerebrovascular event. This requires clear evidence or a similar appropriate scan that a stroke has occurred and shows: - infarction of brain tissue; or - intracranial or subarachnoid haemorrhage. This does not include transient ischaemic attacks, migraine, or cerebral injury resulting from trauma. #### Total and permanent blindness The complete and irrecoverable loss of the sight of both eyes to the extent that: - visual acuity is less than 6/60 vision, in both eyes after correction; or - field vision is constricted to 10 degrees or less; or - combined visual defects result in the same degree of visual impairment as that occurring in either of the above two points. ### Paralysis Benefit #### What am I covered for? If you meet the criteria of Paralysis under this Option, we'll pay you double your selected sum insured amount for this Option. #### How much am I covered for? The sum insured you've selected is specified on your Acceptance or Renewal Certificate. We'll pay double this selected amount. #### What else do I need to know? - you can only claim on this benefit once - this payment replaces any claim made for Paralysis under the Serious Condition Benefit ### Children's Benefit #### What am I covered for? If your dependent child aged between two and 20 is diagnosed with or suffers from one of the conditions defined in this Option, we'll make a payment of half your selected sum insured. #### How much am I covered for? The sum insured you've selected is specified on your Acceptance or Renewal Certificate. We'll pay half of this amount. This payment won't reduce your sum insured. #### When will I be covered? After three months of continuous cover following your join date on this Option. #### What else do I need to know? We'll only pay once per dependent child under your policy. --- # 04. What we don't cover WHAT WE DON'T COVER There are some things we aren't able to provide cover for. We've grouped these into categories to make it easier for you to read and understand. Unless specifically covered under a benefit or Option, we don't pay any claims that are related to and/or are consequences of any of the following: ## Cosmetic - anything cosmetic or reconstructive that is not medically necessary regardless of whether it's done for physical, functional, psychological, or emotional reasons (for example: treatment that improves, changes, or enhances your appearance) - Abdominoplasty, Hyperhidrosis, Rectus divarication repair ## Weight Loss - weight loss or bariatric investigations or treatment (for example: gastric banding, sleeve, and bypass), even if the purpose is to treat other health conditions (for example: diabetes or cardiovascular conditions) ## Breast - breast implants - breast reductions - Gynaecomastia - revision of breast reconstruction ## Reproductive Health - assisted reproduction - childbirth including caesarean sections - hormone therapy - infertility - intrauterine devices - pregnancy (for example: normal pregnancy, ectopic, or termination of) ## Sexual Health - contraception - erectile dysfunction - sterilisation or reversal of sterilisation ## Gender - any treatment or procedures that are related to gender dysphoria - gender reassignment ## Mental Health - psychiatric, psychological, behavioural, or developmental conditions (for example: depression, ADHD, and eating disorders) - injuries that are self-inflicted ## Congenital, Genetic, or Hereditary - congenital or chromosomal disorders (for example: a birth defect) - congenital kyphosis, congenital scoliosis, cystic fibrosis, or pectus excavatum - Marfan's syndrome - gene therapy - genetic testing - hereditary or genetic conditions, in the absence of signs or symptoms that a condition exists from your join date ## Emergency and Injury - any acute medical conditions or acute care - ambulance society subscriptions - injuries that are covered by ACC ## Rehabilitation and Mobility - aids that assist with rehabilitation and mobility (for example: crutches, toilet frames, artificial limbs) - continuous care (for example: geriatric, palliative, rehabilitation) - mechanical tools or appliances (for example: insulin pumps, CPAP machines and equipment, pacemakers) ## Transfusions or Transplants - organ or tissue transplants or donations (for example: organ transplants) - specialised transfusions (for example: transfusion of blood, blood products and derivatives, and dialysis of any type) ## Dental - dentures - dental implants - Orthognathic surgery - Periodontics, orthodontics, and endodontic procedures - tooth exposure ## Vision - vision enhancement and correction (for example: myopia, hypermetropia, presbyopia, astigmatism, or laser treatment) - Blepharoplasty ## Crime or Conflict - any treatment for a condition relating to crime committed by you - conditions or treatment relating to wars, riots, or terrorism ## Immune System Disease - HIV or AIDS ## Allergies - treatment for allergies or allergic disorders (for example: des