> _Markdown transcription of Southern Cross KiwiCare policy wording, effective 2026-04-01. Source: https://www.southerncross.co.nz/-/media/Southern-Cross-Health-Society/Health-insurance/Member-collateral/Plan-documents/Current-plan-documents/PD_KiwiCare_plan.pdf_ --- # KiwiCare and RegularCare Policy document Effective from 1 April 2026 ## Contents ### A Welcome to your health insurance plan > See page 6 ### B What the KiwiCare and the RegularCare plans cover > See page 11 ### C What the KiwiCare and the RegularCare plans don't cover > See page 28 ### D How to make a claim > See page 34 ### E Your responsibilities under this policy > See page 40 ### F Changing, cancelling or suspending your policy > See page 43 ### G Your regulatory protection > See page 47 ### H Glossary of terms > See page 49 --- ## You can have a KiwiCare plan or a RegularCare plan When your policy is taken out, the policyholder chooses either a KiwiCare plan or a RegularCare plan. The KiwiCare and RegularCare plans are shared cover plans – this means you're responsible for some of the cost for eligible healthcare services you receive. Both plans offer an excess option of $500. Read more about how excesses work from page 36. ### What KiwiCare covers The KiwiCare plan provides a contribution towards cancer treatment, surgical treatment, diagnostic imaging and tests as well as other healthcare services outlined under 'What the KiwiCare and the RegularCare plans cover' from page 11. ### What RegularCare covers The RegularCare plan provides the same cover as KiwiCare, with extra cover for some day-to-day treatments. **Underwritten by:** Southern Cross Medical Care Society, Level 1, Te Kupenga, 155 Fanshawe Street, Auckland 1010. As part of our commitment to you, this document meets the WriteMark Plus Plain Language Standard. The WriteMark Plus is a quality mark awarded to documents that achieve a high standard of plain language. --- ## Our financial strength rating is A+ (Strong) Southern Cross Medical Care Society, trading as Southern Cross Health Society, is the insurer of this policy. Standard & Poor's (Australia) Pty Limited has given Southern Cross Health Society an A+ (Strong) financial strength rating. The rating scale is: - AAA (Extremely Strong) - AA (Very Strong) - A (Strong) - BBB (Good) - BB (Marginal) - B (Weak) - CCC (Very Weak) - CC (Extremely Weak) - SD or D (Selective Default or Default) Ratings from 'AA' to 'CCC' may be modified with a plus (+) or minus (-) sign to show relative standing within the major rating categories. Full details of the rating scale are available at spglobal.com/ratings/en/about/intro-to-credit-ratings Standard & Poor's is an approved rating agency under the Insurance (Prudential Supervision) Act 2010. ## All dollar amounts are in New Zealand dollars and include GST All references to dollar amounts in this policy document mean New Zealand currency and include GST. --- ## How to contact us If you want to get in touch, you can reach us in a few ways. - Enquire online, at southerncross.co.nz/contact - Phone us from New Zealand on 0800 800 181, or from overseas on +64 9 979 9212 - Send us a letter, to Southern Cross Health Society, Private Bag 99934, Newmarket, Auckland 1149, Freepost Authority 1440. ## If you would like to make a complaint If you have a complaint about our treatment of your policy or the service we've provided (including financial advice, a claim, a benefit entitlement, or our decision to cancel your policy), please tell us so we can work with you to resolve your concerns. > To make a complaint, contact us directly using our details above. Or, visit our website for more information on our complaints and dispute resolution process at southerncross.co.nz/complaints To resolve a complaint about your membership of Southern Cross, please refer to the Rules of Southern Cross at southerncross.co.nz/rules or contact us. ## You can contact the Ombudsman if you're not satisfied We're part of the Insurance & Financial Services Ombudsman's approved dispute resolution scheme (IFSO). This scheme is a free and independent dispute resolution service that helps investigate or resolve complaints for consumers. If you're not satisfied with our response to your complaint or your complaint is not resolved, you can refer it on to IFSO. > For more information about IFSO or to contact them about a complaint, call 0800 888 202, or visit ifso.nz --- # Section A: Welcome to your health insurance plan Thank you for choosing us to take care of your health insurance needs. ## We want to make sure you understand your health insurance Take your time to read this policy document and the other documents that make up your health insurance policy listed on page 7 to make sure you understand your cover. ## This policy document explains the benefits, and terms and conditions of your policy This policy document explains what is and isn't covered, the policy limits, the terms and conditions of cover, how to make a claim, and your responsibilities under this policy. Some parts of this policy document will only apply to you if you have a specific plan or Cancer Cover Plus upgrade. We'll make it clear throughout this policy document if a certain part applies only to a specific plan or Cancer Cover Plus upgrade. Check your membership certificate to see which plan you're covered by and any Cancer Cover Plus upgrade that applies. We may make changes to this policy document from time to time, and this may change your cover under this policy. See the heading 'We may make changes that affect your policy' on page 9. > To access the latest policy document, contact us (see page 5 for contact details) or visit southerncross.co.nz/plans --- ## Some words in this policy document have specific meanings When we use the following words in this policy document, here's what we mean. - 'We', 'us', 'our' and 'Southern Cross' mean Southern Cross Medical Care Society trading as Southern Cross Health Society – our registered office is at Level 1, Te Kupenga, 155 Fanshawe Street, Auckland 1010 - 'You' and 'your' mean the policyholder and any dependant listed on the membership certificate - 'Cover' means the amount we'll pay for eligible claims as detailed under each benefit in the section 'What the KiwiCare and the RegularCare plans cover' from page 11. ## Words in italics are defined in the 'Glossary of terms' You'll also notice that some words and phrases in this policy document are in italics, like this. These words and phrases have specific meanings. They are defined in the 'Glossary of terms' from page 49. ## Headings in this document are for your convenience only We have used descriptive headings in this policy document to help you find information. You should not rely on these headings to interpret the terms and conditions of your policy. ## The documents that make up your health insurance policy Your health insurance policy is made up of: - this policy document - your application form - your health insurance medical declaration (where relevant) - your membership certificate - the eligibility criteria - the list of unapproved healthcare services - the list of prostheses and specialised equipment - the list of Affiliated Provider-only healthcare services - the list of policy variations - any changes made to the above documents from time to time. These documents are designed to be read together to outline the cover your policy provides. Your application form, health insurance medical declaration, and membership certificate are specific to your policy only. The policyholder can request a copy of these by contacting us or they can view the membership certificate on MySouthernCross. We may make changes from time to time that could affect your cover under this policy. See the heading 'We may make changes that affect your policy' on page 9. > To access the latest versions of the other documents listed above, contact us (see page 5 for contact details) or visit southerncross.co.nz/plans --- ## Your membership certificate contains information specific to your policy Your membership certificate contains: - the key dates relevant to your policy - the people covered under your policy - the name of your plan and any Cancer Cover Plus upgrade and excess that applies to your policy - the policyholder's Southern Cross membership number - any pre-existing conditions that you've made us aware of for the people covered under your policy - any other information specific to your policy. If information on your membership certificate contradicts what's stated in this policy document, the information on your membership certificate takes precedence over this policy document. ## The eligibility criteria set out any additional requirements that must be met for some healthcare services We'll only cover certain healthcare services if the additional terms and conditions set out in the eligibility criteria have been met. The terms of each benefit (starting on page 11) state if eligibility criteria apply. ## The list of unapproved healthcare services sets out specific healthcare services that we don't cover This list sets out the specific drugs, devices, techniques, tests, or other healthcare services that are not covered under any Southern Cross health insurance plans. ## The list of prostheses and specialised equipment sets out the specific items we cover as part of eligible surgical treatment This list sets out the prostheses, specialised equipment and consumables, and donor tissue preparation charges that we cover as part of eligible surgical treatment under your policy. We'll only cover prostheses, specialised equipment and consumables, and donor tissue preparation charges that are included on this list unless we tell you otherwise. ## The list of Affiliated Provider-only healthcare services sets out all the services that must be performed by an Affiliated Provider To be eligible for cover under your policy, certain healthcare services must be performed by a health services provider who is an Affiliated Provider contracted for that healthcare service. The terms of each benefit (starting on page 11) state if this requirement applies. Please note an Affiliated Provider may not be available in your hometown or city. Affiliated Providers may not offer all the healthcare services covered under this policy. For example, a health services provider may be an Affiliated provider for a consultation, but they may not be an Affiliated Provider for performing any surgery after that consultation. > To find an Affiliated Provider, and to see the healthcare services offered by an Affiliated Provider with Southern Cross, visit healthcarefinder.co.nz --- ## The list of policy variations sets out variations to your policy terms and conditions This is a list of variations to your policy terms and conditions that may apply from time to time. These variations include the way we treat some exclusions (those listed from page 28) and certain benefit terms, or new ways of delivering healthcare services we're testing. This may mean you can access additional cover while these variations are included on the list of policy variations published on our website. ## When cover starts under your policy The policyholder's cover under this policy starts on the policy start date and a dependant's cover starts on the date we add them to this policy. These dates are specified on your membership certificate. ## We may make changes that affect your policy We regularly review our health insurance plans to ensure they remain relevant. So, from time to time we may change the healthcare services that are eligible, the scope of cover, terms and conditions of your policy, and your premiums. If we change this policy document or your premiums, we'll tell the policyholder in writing what the changes are and the date that the changes will apply (this might be through MySouthernCross). The policyholder is responsible for telling dependants about any changes to the policy. ## We regularly update certain documents that form part of your policy The following documents that form part of your policy are regularly updated as we continuously review how we cover healthcare services and certain technology. So, you should always refer to our website at southerncross.co.nz/plans for the latest versions. - The eligibility criteria - The list of unapproved healthcare services - The list of prostheses and specialised equipment - The list of Affiliated Provider-only healthcare services - The list of policy variations ## The policyholder can cancel this policy if they don't like the changes If you're unhappy with any changes we're making, the policyholder can contact us within 1 month of the notification of changes to discuss options or cancel this policy (see page 5 for contact details). If the policyholder chooses to cancel this policy, we'll keep covering you for any period for which the premiums have been paid. --- ## Who can be covered under the KiwiCare plan and the RegularCare plan Both the KiwiCare plan and the RegularCare plan are only available to: - New Zealand citizens - New Zealand residents, and - those who are entitled to publicly funded healthcare for all services as determined by the New Zealand Ministry of Health from time to time. ## How these plans work with ACC and the public health system The New Zealand public healthcare system provides cover for all New Zealand residents for acute care and some elective treatment. ACC provides no-fault injury cover for everyone in New Zealand. The KiwiCare plan and the RegularCare plan are designed to complement the services provided by ACC and the New Zealand public healthcare system. This is why the plans do not provide cover for healthcare services related to acute care or to an accident, treatment injury or work-related gradual process injury that ACC is legally responsible for. In some cases, ACC will not pay the full amount charged for your treatment. In these cases, you may be able to make a claim under your policy – refer to the 'Accident and treatment injury top-up' benefit on page 26. ## How your Southern Cross membership works By applying for this policy, the policyholder has also applied for membership of Southern Cross for themselves and any dependants covered under this policy. By applying for membership, the policyholder agrees (both for themselves and on behalf of their dependants) to be bound by the Rules of Southern Cross Medical Care Society. > Read the Rules of Southern Cross Medical Care Society on our website at southerncross.co.nz/rules, or contact us if you have questions or want to request a copy (see page 5 for contact details) If the policyholder's membership of Southern Cross is terminated for any reason (including death), this policy will be terminated. If this policy is terminated (for whatever reason), the policyholder and any dependant's membership of Southern Cross will end. The policyholder can cancel this policy during the 14-day review period referred to under 'Making changes or cancelling within 14 days' on page 43. If this happens, then the policyholder and any dependant's membership of Southern Cross will end from the date that the 14-day review period started. --- # Section B: What the KiwiCare and the RegularCare plans cover This section details the healthcare services covered by the KiwiCare plan and the RegularCare plan. Check your membership certificate to see which plan you're covered by. We'll cover up to 80% of the actual charges incurred for eligible healthcare services. We'll cover these charges up to the policy limits and subject to any excess, as outlined in each benefit in this section. For a healthcare service to be eligible all the following must apply: - it's a healthcare service covered under or listed in the benefits in this section - it complies with any terms and conditions of your policy (such as eligibility criteria) that we may specify from time to time - it's an approved treatment - charges have been incurred, or will be incurred for the healthcare service - it's not excluded under your policy - it's performed in private practice by a health services provider with registration relevant to the healthcare service In addition, some healthcare services must be performed by an Affiliated Provider to be eligible for cover. The terms of each benefit state if this requirement applies. > Some healthcare services must be performed by an Affiliated Provider to be eligible for cover. To see the list of Affiliated Provider-only healthcare services, visit southerncross.co.nz/ap-only > To view eligibility criteria that apply to certain benefits, visit southerncross.co.nz/eligibility Contact us if you're unsure if a healthcare service is eligible under your policy. See page 5 for contact details. --- ## Policy limits and excess The terms of each benefit explain the policy limits and excess that may apply. There may also be policy limits in other parts of the policy. Policy limits may be a limit for each operation, procedure, item, day, or lifetime, or may be an annual limit. If the policy limit is 'unlimited', other terms and conditions (such as policy limits in other parts of the policy and excess) still apply. The policy limits and excess apply to each person covered under your policy individually. You'll be responsible for paying any amount exceeding the policy limits, and for paying any excess, directly to the health services provider. For more details about policy limits, see page 38. For more details about excess, see page 37. ## We're not liable for the quality of the healthcare services you receive We're not liable for the quality, standard, or effectiveness of any healthcare services you receive. This includes any actions of the health services provider or any of their employees or agents. --- ## Consultations Consultations are covered with certain specialists, psychiatrists, and dietitians. ### Specialist consultations **$4,000 each claims year** This benefit provides cover for consultations performed by a specialist who is an Affiliated Provider contracted for consultations. Consultations with a health services provider who is working under the supervision of a specialist are also covered if this type of consultation is: - included in the Affiliated Provider's contract with us, and - approved by us. This benefit also provides cover for getting a second opinion on your diagnosis or treatment plan by a specialist who is an Affiliated Provider contracted for consultations. Unless we or your Affiliated Provider tell you otherwise, we'll cover 80% of the actual charges incurred for consultations, to a maximum of $4,000 each claims year. No excess applies to this benefit. This benefit does not cover: - consultations with a psychiatrist, which are covered under the 'Psychiatrist consultations' benefit below, or - consultations related to skin lesions, which are covered under the 'Skin lesion services' benefit on page 18. ### Psychiatrist consultations **$600 each claims year** This benefit provides cover for psychiatrist consultations performed by a specialist who is vocationally registered in psychiatry. We'll cover 80% of the actual charges incurred for consultations, to a maximum of $600 each claims year. No excess applies to this benefit. ### Dietitian consultations **$80 each consultation up to $400 each claims year** This benefit provides cover for dietitian consultations only when you're referred by a specialist in private practice. The consultation must be performed by a dietitian registered with the New Zealand Dietitian Board. We'll cover 80% of the actual charges incurred for each consultation up to $80, to a maximum of $400 each claims year. No excess applies to this benefit. --- ## Imaging and tests The following diagnostic imaging and tests are covered. ### Diagnostic imaging **$8,000 each claims year** This benefit provides cover for diagnostic imaging performed by an Affiliated Provider contracted for diagnostic imaging. For certain imaging procedures, eligibility criteria need to be met before we'll cover them. This benefit covers the following imaging procedures. - 2D and 3D mammography - Computed tomography (CT scan) - CT angiogram (CTA) - Nuclear medicine scan (scintigraphy) - Ultrasound, except when related to obstetrics and varicose veins (legs) - X-ray, except when performed by a dentist or chiropractor This benefit also covers the following imaging procedures only when you're referred by a specialist in private practice. - Cone beam computed tomography (CBCT) - CT coronary angiogram (CTCA) - Magnetic resonance imaging (MRI scan) - MR angiogram (MRA) - Myocardial perfusion scan - Positron emission tomography/computed tomography (PET/CT) for specific diagnosed cancers and cardiac conditions Unless we or your Affiliated Provider tell you otherwise, we'll cover 80% of the actual charges incurred for imaging procedures, to a maximum of $8,000 each claims year. No excess applies to this benefit. ### Cardiac tests **$3,000 each claims year** This benefit provides cover for cardiac tests performed by an Affiliated Provider contracted for cardiac tests, but only when you're referred by a specialist in private practice. For certain tests, eligibility criteria need to be met before we'll cover them. This benefit covers the following cardiac tests. - Advanced electrocardiogram (A-ECG) - Dobutamine stress echocardiogram - Echocardiogram - Exercise ECG - Holter monitoring - Resting ECG - Stress echocardiogram - Transoesophageal echocardiogram (TOE) Unless we or your Affiliated Provider tell you otherwise, we'll cover 80% of the actual charges incurred for cardiac tests, to a maximum of $3,000 each claims year. No excess applies to this benefit. ### Diagnostic tests **$2,000 each claims year** This benefit provides cover for diagnostic tests performed in an approved facility only when you're referred by a specialist in private practice. Some diagnostic tests must also be performed by an Affiliated Provider contracted for diagnostic tests to be eligible for cover under this benefit. > To see which diagnostic tests must be performed by an Affiliated Provider to be eligible for cover, visit southerncross.co.nz/ap-only For certain tests, eligibility criteria need to be met before we'll cover them. This benefit covers the following diagnostic tests. - Ambulatory blood pressure monitoring (ABPM) - Ankle brachial index - Anorectal physiology studies - Bone marrow aspiration - Caloric reflex test - Colposcopy with or without biopsy under local anaesthetic or no anaesthetic - Compartment pressure study - Corneal pachymetry - Corneal topography - Electroencephalogram (EEG) - Electromyogram (EMG) - Electrooculogram (EOG) - Electroretinogram (ERG) - Endometrial biopsy under local anaesthetic or no anaesthetic - Fractional exhaled nitric oxide (FeNO) test - Full urodynamic assessment - Fluorescein angiography - Heidelberg retinal tomography (HRT) - Hydrogen breath test - Intraocular pressure (IOP) test - Laryngoscopy (in rooms) - Lumbar puncture - Lung diffusion study - Lung function test - Nasendoscopy (in rooms) - Oesophageal 24hr pH monitoring (gastric function study) - Oesophageal manometry test - Optical coherence tomography (OCT) - Overnight pulse oximetry - Proctoscopy - Retinal photography - Scanning laser polarimetry (SLP) - Segmental pressure test - Sigmoidoscopy (in rooms) - Simple urinary flow study - Sleep study - Specular microscopy - Spirometry - Ultrasound of the eye - Urea breath test (H. pylori breath test) - Vascular laboratory testing - Vestibular evoked myogenic potential (VEMP) - Video-assisted head impulse test (vHIT) - Videonystagmography (VNG) - Visual evoked potential (VEP) - Visual field test - Vulvoscopy with or without biopsy under local anaesthetic or no anaesthetic We'll cover 80% of the actual charges incurred for the diagnostic test, unless we, your Affiliated Provider or specialist tell you otherwise. The maximum we'll cover is $2,000 each claims year. No excess applies to this benefit. ### Laboratory tests **$56 each claims year** This benefit covers laboratory tests performed for diagnostic purposes but not funded by a government agency. The test must be performed by an accredited hospital, community-based or regional referral laboratory that's approved by International Accreditation New Zealand. We'll cover 80% of the actual charges incurred for laboratory tests, to a maximum of $56 each claims year. No excess applies to this benefit. --- ## Surgical treatment The following outlines your cover for surgical procedures, skin lesion services, and GP minor surgery. ### Surgical procedures **$100,000 each operation (Individual prostheses limits apply) Excess applies** This benefit provides cover for surgical procedures performed in an approved facility by a specialist or an Affiliated Provider contracted for that healthcare service. Some surgical procedures must be performed by an Affiliated Provider contracted for that surgical procedure to be eligible for cover under this benefit. > To see which procedures need to be performed by an Affiliated Provider to be eligible for cover, visit southerncross.co.nz/ap-only For certain surgical procedures, eligibility criteria need to be met before we'll cover them. If you're having two or more surgical procedures at the same time, or if your operation involves more than one surgeon (including an assistant surgeon), let us know at the time of prior approval so that we can determine the extent of your cover. This benefit provides cover for the charges incurred for each of the following components associated with the procedure. - Operating fees for one surgeon for each operation (unless we've accepted cover for more than one at the time of prior approval) - Anaesthetist's fees - Intensivist's fees - Perfusionist's fees - Hospital fees - Surgically implanted prostheses, specialised equipment and consumables, and donor tissue preparation. The list of prostheses and specialised equipment sets out which of these we'll cover and the maximum amount we'll pay towards each one. > To see the list of prostheses and specialised equipment, contact us (see page 5 for contact details) or visit southerncross.co.nz/lopse This benefit includes cover for some less invasive procedures and medical treatments which a specialist or Affiliated Provider may consider more appropriate for your condition. Contact us to check eligibility for cover before getting treatment. The charges associated with the following procedures are covered under this benefit to the extent stated below, subject to the stated policy limits and criteria. #### Major diagnostic procedures This benefit provides cover for major diagnostic procedures including, but not limited to, angiograms and endoscopies. Endoscopies include colonoscopy, gastroscopy, hysteroscopy, and cystoscopy. #### Intravitreal injections (eyes) This benefit provides cover for intravitreal injections. Only $100 is available towards the cost of the drug used for each injection, regardless of the type of drug used. #### Breast reconstruction This benefit provides cover for breast reconstruction procedures of the affected breast following an eligible mastectomy. Any reconstruction procedures after the initial reconstruction procedure are only covered when performed within 2 years from either: - placement of the first permanent implant - the first fat grafting procedure - therapeutic mammoplasty, or - flap surgery. No time limit restrictions apply for nipple reconstruction, including tattooing. #### Varicose vein procedures (legs) After 3 years of continuous cover on this plan, this benefit provides cover for up to two varicose vein procedures for each leg during your lifetime. If you have multiple procedures during a single operation, we count these as separate procedures under the lifetime limit for each leg. The procedures we cover for treatment of varicose veins (in legs) are: - endovenous laser treatment - ultrasound guided sclerotherapy - varicose vein surgery - cyanoacrylate embolisation - endovenous radiofrequency ablation (EVRFA). We'll also cover related duplex vein mapping, but the lifetime limit does not apply. #### Sclerotherapy or embolisation of simple vascular malformation This benefit provides cover for up to two sclerotherapy or embolisation procedures for each simple vascular malformation during your lifetime. #### Percutaneous medial branch thermal radiofrequency neurotomy This benefit provides cover for up to two percutaneous medial branch thermal radiofrequency neurotomy procedures during your lifetime. #### Skin lesion removal or Mohs closure under general anaesthetic or IV sedation This benefit provides cover for the following procedures when performed under general anaesthetic or IV sedation: - Excision and biopsy of skin lesions, or - closure of the wound following a Mohs surgery. The following applies to all healthcare services under this benefit. We'll cover 80% of the actual charges incurred for the components associated with the procedure, unless we, your Affiliated Provider or specialist tell you otherwise. The maximum we'll cover is $100,000 for each operation. Excess applies to this benefit. ### Skin lesion services **$5,000 each claims year (sub-limits apply)** This benefit provides cover for skin lesion consultations and eligible treatment of skin lesion services performed under local anaesthetic, no anaesthetic, or oral sedation by an Affiliated Provider contracted for these services or general practitioner. For certain skin lesion services, eligibility criteria need to be met before we'll cover them. This benefit covers: - excision, biopsy, curettage, and diathermy of skin lesions - cryotherapy of skin lesions - Mohs surgery (including excision and closure) We'll cover 80% of the actual charges incurred for skin lesion services unless we, your Affiliated Provider or general practitioner tell you otherwise. The maximum we'll cover is $5,000 each claims year. This limit includes the following sub-limits: - Up to $150 each claims year for cryotherapy of skin lesions performed by either an Affiliated Provider or a general practitioner. - Up to $800 each claims year for skin lesion services when performed by a general practitioner who is not an Affiliated Provider. No excess applies to this benefit. Skin lesion removal and Mohs closure procedures performed under general anaesthetic or IV sedation, are covered under the 'Surgical procedures' benefit on page 18. ### GP minor surgery **$800 each claims year** This benefit provides cover for minor surgeries performed by a general practitioner. This includes, for example, the removal or resection of ingrown toenails, steroid or cortisone injections, and abscess drainage. We'll cover 80% of the actual charges incurred for minor surgeries, to a maximum of $800 each claims year. No excess applies to this benefit. This benefit does not cover consultations or skin lesion services. --- ## Surgical allowances The following outlines your cover for gastric banding or bypass, breast reduction, breast symmetry, and prophylactic treatments. ### Gastric banding or bypass allowance **$5,000 during a lifetime** After 3 years of continuous cover on this plan, this benefit contributes towards one of the following bariatric procedures, including any follow-up treatment that may be required. - Gastric banding - Gastric bypass, for example, Roux-en-Y, mini gastric-bypass - Sleeve gastrectomy - Single anastomosis duodeno-ileostomy with sleeve (SADI-S) - Endoscopic sleeve gastroplasty For the above bariatric procedures, eligibility criteria need to be met before we'll cover them. We also need a medical report by a specialist to assess your eligibility for cover. An Affiliated Provider must perform all specialist consultations and diagnostic imaging related to this procedure. We'll cover 80% of the actual charges incurred for the procedure and any follow-up treatment, to a maximum of $5,000 during your lifetime. No excess applies to this benefit. ### Breast reduction allowance **$15,000 during a lifetime** After 3 years of continuous cover on this plan, this benefit contributes towards breast reduction procedures, including any follow-up treatment that may be required. For breast reduction procedures, eligibility criteria need to be met before we'll cover them. We also need a medical report by a specialist to assess your eligibility for cover. An Affiliated Provider must perform all specialist consultations and diagnostic imaging related to this procedure. We'll cover 80% of the actual charges incurred for the procedure and any follow-up treatment, to a maximum of $15,000 during your lifetime. No excess applies to this benefit. ### Breast symmetry allowance **$10,000 during a lifetime** This benefit contributes towards breast symmetry procedures by augmentation or reduction of the unaffected breast following an eligible mastectomy. This benefit also covers any follow-up treatment that may be required. For breast symmetry procedures, eligibility criteria need to be met before we'll cover them. An Affiliated Provider must perform all specialist consultations and diagnostic imaging related to this procedure. We'll cover 80% of the actual charges incurred for the procedure and any follow-up treatment, to a maximum of $10,000 during your lifetime. No excess applies to this benefit. ### Prophylactic treatment allowance **$30,000 during a lifetime** After 3 years of continuous cover on this plan, this benefit contributes towards prophylactic treatment to address a highly increased risk of developing a disease due to your medical history or genetic predisposition. This benefit also covers any follow-up healthcare services that are related to the prophylactic treatment. Unless your membership certificate specifically states otherwise, this benefit is not available to you if you've been confirmed as having a high risk of developing the disease that the prophylactic treatment is designed to prevent before your original date of joining. For prophylactic treatments, eligibility criteria need to be met before we'll cover them. You must get prior approval from us before the treatment is performed. > Find out how to apply for prior approval on page 34. An Affiliated Provider must perform all specialist consultations and diagnostic imaging related to the treatment provided. We'll cover 80% of the actual charges incurred for the treatment and any follow-up healthcare services, to a maximum of $30,000 during your lifetime. No excess applies to this benefit. --- ## Cancer treatment Healthcare services to support cancer diagnosis, surgery, treatment, and recovery are covered under a range of benefits under the KiwiCare plan and the RegularCare plan. The following outlines cover for chemotherapy for cancer and radiotherapy. ### Chemotherapy for cancer (base) **$48,000 each claims year (includes $8,000 for chemotherapy drugs that are not Pharmac approved but Medsafe-indicated) Excess applies** This benefit provides cover for chemotherapy treatment for cancer. The chemotherapy treatment must be performed by an Affiliated Provider contracted for chemotherapy treatment for cancer. This benefit provides cover for the following costs associated with chemotherapy treatment. - Pharmac approved chemotherapy drugs - Up to a maximum of $8,000 each claims year for chemotherapy drugs that are not Pharmac approved but are Medsafe-indicated for treatment of the cancer you've been diagnosed with - Administration of the chemotherapy drugs - Hospital accommodation in a single room - Ancillary hospital charges This benefit does not cover consultations. Unless we or your Affiliated Provider tell you otherwise, we'll cover 80% of the actual charges incurred for the costs associated with chemotherapy treatment, to a maximum of $48,000 each claims year. This amount includes the $8,000, mentioned above, for chemotherapy drugs that are not Pharmac approved but are Medsafe-indicated. Excess applies to this benefit. ### Cancer Cover Plus – Optional chemotherapy for cancer upgrades **Chemotherapy 100: $100,000 each claims year Chemotherapy 300: $300,000 each claims year Excess applies** You can upgrade from your 'Chemotherapy for cancer (base)' benefit set out above to one of the Cancer Cover Plus options: Chemotherapy 100 and Chemotherapy 300. Your current membership certificate will confirm whether you have one of these upgraded options. This upgrade replaces your cover under the 'Chemotherapy for cancer (base)' benefit except where the exclusion for family history of cancer applies. The chemotherapy treatment must be performed by an Affiliated Provider contracted for chemotherapy treatment for cancer. #### What the Chemotherapy 100 and Chemotherapy 300 optional upgrades cover Chemotherapy 100 and Chemotherapy 300 provide cover for the following costs associated with chemotherapy treatment. - Pharmac approved chemotherapy drugs - Chemotherapy drugs that are not Pharmac approved but are Medsafe-indicated for treatment of the cancer you've been diagnosed with - Administration of the chemotherapy drugs - Hospital accommodation in a single room - Ancillary hospital charges This benefit does not cover consultations. Unless we or your Affiliated Provider tell you otherwise, we'll cover 80% of the actual charges incurred for the costs associated with chemotherapy treatment, to a maximum of either: - $100,000 each claims year under Chemotherapy 100 - $300,000 each claims year under Chemotherapy 300. Excess applies to these upgrades. #### Cancer Cover Plus excludes cover for family history of cancer If the policyholder or any dependant has a family history of cancer as defined below, the specific cancer which they have a family history of will be excluded for them under Cancer Cover Plus. The exclusion for family history of cancer will not apply to the 'Chemotherapy for cancer (base)' benefit. Family history of cancer means both of the following statements apply to someone covered by this policy. - They have two or more biological siblings or parents (living or dead) who have been diagnosed with colorectal, breast, ovarian, or prostate cancer before the age of 55. - They were aware of, or should reasonably have been aware of, the diagnosis before the: - date the policyholder applied for Cancer Cover Plus, or - date they were added to the policy, if they were a dependant added after the policyholder applied for Cancer Cover Plus. ### Radiotherapy **Unlimited Excess applies** This benefit provides cover for radiotherapy planning and treatment performed by an Affiliated Provider contracted for radiotherapy treatment. Please note that only a limited range of radiotherapy treatments are covered and eligibility criteria will need to be met before we'll cover them. Unless we or your Affiliated Provider tell you otherwise, we'll cover 80% of the actual charges incurred for radiotherapy treatment. Excess applies to this benefit. This benefit does not cover specialist consultations, drugs, follow-up imaging, or any other healthcare services. --- ## IV infusions (non-cancer) **$600 each claims year** This benefit provides cover for IV infusions of drugs that are Medsafe-indicated for treatment of the condition you've been diagnosed with. The IV infusion must be provided in an approved facility by, or under the care of, a specialist. This benefit does not cover consultations related to infusions or the cost of drugs that are not Pharmac approved. We'll cover 80% of the actual charges incurred for infusions, to a maximum of $600 each claims year. No excess applies to this benefit. --- ## Allergy services **$600 each claims year** This benefit provides cover for allergy-related services, including allergy testing and desensitisation. The services must be provided by, or under the care of, either: - an Affiliated Provider contracted for allergy-related services, or - a general practitioner who has an Easy-Claim agreement with us. > You can find a general practitioner who has an Easy-Claim agreement with us or an Affiliated Provider at healthcarefinder.co.nz This benefit does not cover consultations or the cost of drugs that are not Pharmac approved. We'll cover 80% of the actual charges incurred, unless we, your Affiliated Provider, or your general practitioner tell you otherwise. The maximum we'll cover is $600 each claims year. No excess applies to this benefit. --- ## Psychiatric hospitalisation **$2,250 each claims year (sub-limits apply)** This benefit provides cover for admission and care by a specialist who is vocationally registered in psychiatry in an approved facility. We'll cover 80% of the actual charges incurred for psychiatric admission and care, to a maximum of $2,250 each claims year. This limit includes the following sub-limits: - up to $450 for each night or day-stay in hospital accommodation - up to $160 each claims year for ancillary hospital charges. No excess applies to this benefit. --- ## Overseas treatment allowance **$5,000 each claims year** This benefit provides a reimbursement towards medical expenses for treatment that you receive overseas if that treatment is not available in New Zealand. All the following must apply to the overseas treatment: - it's not available in public or private health facilities anywhere within New Zealand - it's recommended as necessary by a specialist for your health condition and is not experimental or unorthodox - it's widely accepted professionally in the country you receive the treatment as effective, appropriate, and essential based on recognised standards of the healthcare specialty involved. You must send us a medical report. We recommend you get prior approval from us before the treatment is performed. > Find out how to apply for prior approval on page 34. General exclusions apply to overseas treatment (see the section 'What the KiwiCare and the RegularCare plans don't cover' from page 28). This benefit does not cover accommodation or travel expenses. We'll cover 80% of the actual charges incurred for overseas treatment, to a maximum of $5,000 each claims year. No excess applies to this benefit. --- ## Recovery services We cover the following services to aid your recovery after treatment. ### Post-operative home nursing **$150 each day up to $900 each claims year** After 1 year of continuous cover on this plan, this benefit provides cover for home nursing care performed by a nurse. You must be referred by a specialist in private practice. The home nursing care must start within 14 days of related eligible surgical treatment, chemotherapy, or radiotherapy. We'll cover 80% of the actual charges incurred for each day of nursing care up to $150, to a maximum of $900 each claims year. No excess applies to this benefit. ### Post-operative speech and language therapy **$56 each visit up to $280 each claims year** This benefit provides cover for treatment by a speech and language therapist who is registered with the New Zealand Speech-language Therapists' Association. You must be referred by a specialist in private practice. The treatment must be performed within 6 months of related eligible surgical treatment, chemotherapy, or radiotherapy. We'll cover 80% of the actual charges incurred for each visit up to $56, to a maximum of $280 each claims year. No excess applies to this benefit. ### Post-operative physiotherapy **$30 each visit up to $180 each claims year** This benefit provides cover for physiotherapy treatment performed by either: - a physiotherapist registered with the Physiotherapy Board of New Zealand, or - a hand therapist registered with Hand Therapy New Zealand. The treatment must be performed within 6 months of related eligible surgical treatment, chemotherapy, or radiotherapy. We'll cover 80% of the actual charges incurred for each visit up to $30, to a maximum of $180 each claims year. No excess applies to this benefit. --- ## Support services We provide the following benefits to support you during treatment. ### Ambulance allowance **$144 each claims year** This benefit provides cover for ambulance transport to a public health facility. We'll cover 80% of the actual charges incurred for ambulance transport, to a maximum of $144 each claims year. No excess applies to this benefit. ### Travel and accommodation allowance **$400 each claims year** This benefit provides cover for travel and accommodation costs for any person covered under this policy if it's necessary for them to travel to receive an eligible healthcare service. This includes cover for travel and accommodation costs for one support person to travel with them. Travel costs cover public transport charges for buses, trains, taxis, shuttles, planes, ferries and ride sharing services. Accommodation costs cover charges for hotel or motel rooms, hospital flats, short-term rental accommodation through hosting platforms or hospital rooming fees for the support person. All the following must apply to be eligible for cover under this benefit. - The eligible healthcare service that the policyholder or dependant needs is not available in their hometown or city. - The policyholder or dependant must travel more than 100km away from their home to receive the eligible healthcare service. - All travel and accommodation is within New Zealand. This benefit does not cover car hire, mileage, or petrol costs. We'll cover 80% of the actual charges incurred for travel and accommodation costs, to a maximum of $400 each claims year. No excess applies to this benefit. ### Accident and treatment injury top-up If your ACC entitlement doesn't cover you for the full amount charged for healthcare services related to an accident, treatment injury or work-related gradual process injury, you can make a claim for the shortfall under the relevant benefit if that healthcare service is covered under your policy. The policy limits, terms and conditions of that benefit will apply. If you need a healthcare service related to an accident, treatment injury, or work-related gradual process injury, you must do everything you reasonably can to obtain ACC approval for payment of the cost of your healthcare service. This includes signing all documents and doing everything necessary to enable us to protect any entitlement from ACC. We'll cover up to 80% of the remaining cost of the eligible healthcare service after the ACC contribution has been deducted, up to the policy limits for the relevant benefit. --- ## Day-to-day treatment (only if you have RegularCare) If you have the RegularCare plan, this benefit provides cover for general practitioner and nurse visits, prescriptions, and more. No excess applies to this benefit. | What we'll cover | We'll cover 80% of the actual charges incurred up to the policy limits set out below: | |---|---| | **General practitioner services** Consultations and treatment performed by a general practitioner, or a nurse at a general practice clinic. | $45 for each visit. | | **Nurse services** Performed by a nurse. Services performed at a general practice clinic by a nurse are covered under general practitioner services as set out above. | $20 for each visit. | | **Prescriptions** Drugs prescribed by a health services provider. This excludes cover for drugs that are not Pharmac approved. | $400 each claims year. | | **Physiotherapy** Performed by a physiotherapist who is registered with the Physiotherapy Board of New Zealand. | $30 for each visit, to a maximum of $180 each claims year. | | **Orthoptist services** Consultations and treatment performed by a registered orthoptist. | $128 each claims year. | | **Audiology consultations** Performed by an audiologist who is a member of the New Zealand Audiological Society. | $40 for each visit, to a maximum of $128 each claims year. | | **Hearing tests** Performed by an audiologist or an audiometrist who is a member of the New Zealand Audiological Society. This includes pure-tone audiometry, impedance audiometry, tympanometry, and brainstem auditory evoked response tests. | $128 each claims year. | --- # Section C: What the KiwiCare and the RegularCare plans don't cover Your policy doesn't cover any costs related to, or incurred as a consequence of, certain conditions, healthcare services, or situations. These exclusions apply to all benefits available under your plan unless we've specified otherwise in this policy document, or the list of policy variations published on our website at southerncross.co.nz/variations --- ## Conditions that we don't cover We don't cover any costs related to, or incurred as a consequence of, the following conditions. ### Pre-existing conditions We don't cover any costs related to, or incurred as a consequence of, any pre-existing conditions unless we've clearly stated otherwise on your membership certificate. This exclusion doesn't apply to cover provided under the 'Day-to-day treatment' benefit on page 27 if you have the RegularCare plan. > For more information about pre-existing conditions, see page 40. ### Chronic conditions We don't cover any costs related to, or incurred as a consequence of, the following chronic conditions. - Cystic fibrosis - Dementia - Kyphosis - Loeys-Dietz syndrome - Marfan syndrome - Pectus carinatum - Pectus excavatum - Polycystic kidney disease - Scoliosis - Spina bifida ### Congenital conditions We don't cover any costs related to, or incurred as a consequence of, any congenital conditions except for umbilical hernia, inguinal hernia, undescended testes, hydrocele, tongue tie, phimosis, and squint. ### Gynaecomastia We don't cover any costs related to, or incurred as a consequence of, gynaecomastia. ### Illnesses or injuries related to substance abuse or self-harm We don't cover any costs related to, or incurred as a consequence of: - illnesses, injuries, conditions or disabilities that are caused or contributed to by the abuse of substances such as alcohol or drugs - self-inflicted illnesses or injuries. ### Injuries or disabilities related to war, active duty, or terrorism We don't cover any costs related to, or incurred as a consequence of, injuries or disabilities from: - war, or any act of war (whether declared or not) - active duty in the military of any country or international authority - terrorism. --- ## Healthcare services that we don't cover Below is a list of healthcare services that we don't cover unless we've specifically stated otherwise. ### Unapproved healthcare services We don't cover any costs related to, or incurred as a consequence of, specific drugs, devices, techniques, tests, and other healthcare services that haven't been approved by us before you receive the treatment. > To read the list of unapproved healthcare services, contact us (see page 5 for contact details) or visit southerncross.co.nz/unapprovedservices ### ACC covered healthcare services We don't cover any costs for healthcare services that are related to, or incurred as a consequence of, any accident, treatment injury, or work-related gradual process injury, except for what you're entitled to under the 'Accident and treatment injury top-up' benefit on page 26. ### Cosmetic treatments and procedures We don't cover any costs related to, or incurred as a consequence of, any surgery, procedure or treatment that changes, improves, or enhances appearance, regardless of whether it was done for medical, physical, functional, psychological, or emotional reasons. ### Pregnancy and childbirth We don't cover any costs related to, or incurred as a consequence of, pregnancy and childbirth, except for what we cover under the 'Day-to-day treatment' benefit for prescriptions and physiotherapy if you have the RegularCare plan (page 27). ### Termination of pregnancy We don't cover any costs related to, or incurred as a consequence of, termination of a pregnancy. ### Infertility or assisted reproduction We don't cover any costs related to infertility or assisted reproduction. ### Contraception and sterilisation We don't cover any costs related to, or incurred as a consequence of: - contraception, including the insertion or removal of intrauterine devices, except when used for medical reasons - sterilisation or its reversal, for example, vasectomy. ### Treatment of obesity We don't cover any costs related to, or incurred as a consequence of, treatment of obesity (including weight loss surgery), except for what we cover under the 'Gastric banding or bypass allowance' on page 19. ### Breast reduction We don't cover any costs related to, or incurred as a consequence of, breast reduction, except for what we cover under the 'Breast reduction allowance' on page 20. ### Subsequent breast reconstruction or symmetry surgery We don't cover any costs related to, or incurred as a consequence of, subsequent breast reconstruction surgery (including replacing prostheses) or breast symmetry surgery, except for what we cover under the following: - the 'Surgical procedures' benefit for breast reconstruction on page 17 - the 'Breast symmetry allowance' for breast symmetry procedures on page 20. ### Gender affirmation surgery We don't cover any costs for healthcare services directly related to, or incurred as a consequence of, gender affirmation (confirmation) surgery. ### Correction of refractive errors or astigmatism We don't cover any costs related to, or incurred as a consequence of, correction of refractive visual errors or astigmatism by surgery, or by surgically implanted intraocular lenses, or by laser treatment. ### Dental healthcare services We don't cover any costs related to healthcare services performed by a dentist, periodontist, endodontist, or orthodontist. ### Dental implants We don't cover any costs related to, or incurred as a consequence of, implantation of teeth, including titanium dental implants. ### Extraction of teeth We don't cover any costs related to, or incurred as a consequence of, extraction of teeth, which includes the complete extraction or partial removal of any part of a tooth, tooth root or tooth remnant. ### Surgery to assist or allow for orthodontic healthcare services We don't cover any costs related to, or incurred as a consequence of, surgery that's designed to assist or allow for orthodontic healthcare services. ### Health screening and maintenance services We don't cover any costs related to: - health screening, except for what we cover under the following: - the 'Diagnostic imaging' benefit for mammography and breast screening ultrasounds on page 13 - the 'Surgical procedures' benefit for colonoscopy on page 17 - maintenance examinations or medical check-ups - any examination required by a third party (including preparing reports) such as physical examinations for life insurance, travel insurance and driver licence. ### Vaccinations We don't cover any costs related to vaccinations. ### Prophylactic healthcare services We don't cover any costs related to, or incurred as a consequence of, prophylactic healthcare services, except for what we cover under the 'Prophylactic treatment allowance' on page 20. ### Treatment for any condition not detrimental to health We don't cover any costs related to, or incurred as a consequence of, treatment for any medical condition that's not causing significant problems to your physical health. ### Healthcare services that are not approved treatment We don't cover any costs related to, or incurred as a consequence of, healthcare services that are not approved treatment, as defined in the 'Glossary of terms' on page 50. ### Healthcare services provided at a public facility We don't cover any costs for healthcare services provided at a public facility that is directly or indirectly controlled by Health NZ Te Whatu Ora, except where we've approved it in writing before you receive the treatment. ### Healthcare services provided outside of New Zealand We don't cover any costs related to, or incurred as a consequence of, healthcare services provided outside of New Zealand, except for what we cover under the 'Overseas treatment allowance' on page 24. ### Healthcare services provided by a person who is not a health services provider We don't cover any costs related to healthcare services provided by a person who is not a health services provider, as defined in the 'Glossary of terms' on page 52. ### Healthcare services for skin using digital imaging technology We don't cover any costs related to healthcare services using technology (such as digital computer images) to help monitor and diagnose skin cancers and other skin lesions – for example, mole mapping. ### Pathology and laboratory tests We don't cover any costs for pathology and laboratory tests, except for what we cover under the 'Laboratory tests' benefit on page 16. ### Tissue, cell and organ transplants We don't cover any costs related to, or incurred as a consequence of, any of the following for either the donor or recipient: - organ transplants - transfusion or injection of autologous blood or blood products, except when used as part of eligible chemotherapy treatment, or where cell saver is used as part of eligible surgical treatment - autologous chondrocyte implants - stem cell transplants. ### Healthcare services related to abnormalities of the facial skeleton We don't cover any costs related to, or incurred as a consequence of, any healthcare services provided for the diagnosis, management, or treatment of developmental or congenital abnormalities of the facial skeleton and associated structures. ### Healthcare services related to mental health We don't cover any costs related to healthcare services for mental health, except for what we cover under the following: - the 'Psychiatrist consultation' benefit on page 13 - the 'Psychiatric hospitalisation' benefit on page 24. - the 'Day-to-day treatment' benefit, if you have the RegularCare plan, on page 27. ### Healthcare services provided to manage or treat snoring or upper airways resistance We don't cover any costs related to, or incurred as a consequence of, any healthcare services provided to manage or treat either snoring, or upper airways resistance, or both. ### Treatment of HIV We don't cover any costs related to, or incurred as a consequence of, treatment of HIV. --- ## Other costs that we don't cover Below are some other costs that we don't cover. ### Appliances, equipment, devices, or prostheses We don't cover any costs for: - appliances or equipment (surgical, medical, or dental), for example, CPAP machines, hearing aids, orthotics, crutches, surgically implanted lenses (except monofocal lenses) - prostheses - specialised equipment and consumables, or - donor tissue preparation. This exclusion doesn't apply to prostheses, specialised equipment and consumables, or charges for donor tissue preparation when used as part of an eligible surgical treatment and specifically included in the list of prostheses and specialised equipment. > To view the list of prostheses and specialised equipment, contact us (see page 5 for contact details) or visit southerncross.co.nz/lopse ### Acute care We don't cover any costs related to acute care. Acute care is covered by the public health system – read more about how these plans work with ACC and the public health system on page 10. ### Administrative charges We don't cover any administrative charges such as statement fees, cancellation fees, or nonattendance fees. ### Personal costs related to a stay in hospital We don't cover any hospital charges incurred for your personal convenience that are related to, or a result of, your stay in hospital, such as newspapers, meals for your family, alcohol, and TV rental. ### Long-term care We don't cover any costs related to, or incurred as a consequence of, long-term care where hospitalisation lasts, or is expected to last, more than 90 days. This includes, but is not limited to, geriatric in-patient care and disability support services. Disability support services are support services provided where a condition, disability, or illness has been, or is likely to be present for 6 months or more, excluding surgical or medical treatment. ### Respite and convalescent care We don't cover any costs related to, or incurred as a consequence of, respite and convalescent care. --- # Section D: How to make a claim This section explains the ways you can apply for prior approval or make a claim on your policy. It also explains the terms and conditions that apply to your policy. Before your healthcare service is provided, you should apply for prior approval to understand your eligibility under your policy. If the healthcare service is being provided by an Affiliated Provider who is contracted for that service or an Easy-Claim partner, your health services provider will let you know if they can arrange prior approval or claim on your behalf. If you're unsure, you can ask us. If we need any further information, we'll either contact you or your health services provider directly. We'll normally do this if information is missing or if we need extra information to process your prior approval or claim. --- ## Apply for prior approval or make a claim online, through our app or by contacting us You can apply for prior approval or make a claim: - online through MySouthernCross, at mysoutherncross.co.nz - through our MySouthernCross app, available through the Apple App Store or Google Play - by contacting us using our details on page 5. ## When to apply for prior approval Through prior approval we confirm whether a healthcare service is eligible for cover and the conditions that apply. We recommend that you apply for prior approval at least 5 working days before the healthcare service is being provided. You'll need to give us the estimated charges from your health services provider so we can determine the cover you're entitled to (including any excess you need to pay) and whether the estimated charges exceed any policy limits for that healthcare service. You do not need to apply for prior approval if you're using an Affiliated Provider for a contracted healthcare service because they will organise this on your behalf. ## Applying for prior approval can help you understand your eligibility If you don't apply for prior approval and you're not using an Affiliated Provider, you'll have to pay for the healthcare service yourself and then make a claim. We'll assess your claim under the terms of this policy and let you know if you're eligible for a reimbursement. Without a prior approval, you won't know if the healthcare service is eligible for cover under your policy. You also won't know how much you'll need to pay yourself. You may have to pay towards a healthcare service because it's not eligible for cover, an excess applies, or the actual charges exceed policy limits. ## Our Affiliated Providers provide added convenience Affiliated Providers are health services providers that we have contracts with to provide certain healthcare services. When you seek treatment from an Affiliated Provider, we'll cover 80% of the charges incurred for the eligible healthcare services they're contracted for. We'll cover these charges up to the relevant policy limits, unless we or your Affiliated Provider tell you otherwise. ## Affiliated Providers can organise prior approval and claim directly with us on your behalf Affiliated Providers can organise prior approval and claim directly from us for any contracted healthcare service. We'll treat this as a claim under your policy. So, you don't need to get prior approval or make a claim for an eligible healthcare service from an Affiliated Provider contracted for that healthcare service. ## Some healthcare services must be performed by an Affiliated Provider To be eligible for cover under your policy, certain healthcare services must be performed by a health services provider who is an Affiliated Provider contracted for that healthcare service. Please note that an Affiliated Provider may not be available in your hometown or city. Affiliated Providers may not offer all the healthcare services covered under this policy. For example, a health services provider may be an Affiliated Provider for a consultation, but they may not be an Affiliated Provider for performing any surgery after that consultation. > For more information on what healthcare services must be performed by an Affiliated Provider under your policy, contact us (see page 5 for contact details) or visit southerncross.co.nz/ap-only > To find an Affiliated Provider and to see the healthcare services offered by an Affiliated Provider with Southern Cross, visit healthcarefinder.co.nz --- ## You can use Easy-Claim to claim for everyday healthcare services Easy-Claim is a convenient way to authorise health services providers to claim electronically on your behalf for eligible healthcare services they've provided to you at the time of purchase or service. The providers that offer Easy-Claim are our Easy-Claim partners and they can check whether you're covered for a particular product or healthcare service immediately and make a claim on your behalf. > You can see which health services providers offer electronic claiming via Easy-Claim on our website at healthcarefinder.co.nz Your Southern Cross Member card is an accepted form of identification to enable you to authorise claims electronically. Any claim you make using Easy-Claim is treated by us as a claim under your policy and lets us know that you've authorised us to pay the health services provider directly. You'll need to pay the provider any remaining balance that you're responsible for. The first time you claim electronically through Easy-Claim for eligible drugs at a pharmacy, you're electing to electronically claim for that and any future eligible drugs that you get from that pharmacy. You must tell us or the pharmacy if you don't want any future eligible drugs to be automatically processed through Easy-Claim. --- ## What to send us when making a claim Include the following with your claim: - all itemised invoices for the healthcare service - all itemised receipts for any amount you've already paid for the healthcare service. Make sure you keep your original itemised invoices and receipts, and send us legible photographs or scanned copies along with your claim. We do not accept EFTPOS or credit card receipts. To help us process your claim, please send us your invoices and receipts within 12 months from the date you received the healthcare service. If we need any further information, we'll either contact you or your health services provider directly. We'll normally do this if information is missing or if we need additional information to process your claim. We'll assess the invoices and pay the health services provider directly. We'll reimburse the policyholder for any amounts you've already paid. --- ## Other things you should know about making a claim These additional terms and conditions apply to any claim you make under this policy. ### We may seek the advice of a health services provider chosen by us, to advise us about the medical facts or examine you in relation to your claim In exceptional circumstances, we may need to seek the opinion of a health services provider of our choosing, at our expense, to review and assess the medical facts or examine you in relation to a claim. We'll only do this when there's uncertainty on the level of cover under this policy or the nature or extent of your condition. You must co-operate with the health services provider we choose, or we will not pay your claim. ### Tell us if you have cover under another policy or are entitled to payment from someone else When you submit a claim for a healthcare service, you must tell us if you have cover under another insurance policy or if you're entitled to payment for the healthcare service from someone else. The amount you're covered for under your policy will be reduced by any payment from the other insurer or person. You must take all reasonable efforts to make a claim from the other insurer or get payment from the other person who is liable to pay for the healthcare service. It's your responsibility to let us know about any other cover or payment you get for any healthcare services you're claiming for under your policy. We have the right to recover from the policyholder any amounts we've covered for a healthcare service where the cost is recoverable from another insurer or other person. If you have more than one policy with us, you're not entitled to claim for, or receive payment for, any amount higher than the actual cost of the healthcare service provided. ### If you have an excess on your policy, this will affect the amount we cover This plan offers an excess option of $500. Check your current membership certificate to confirm if you have an excess on your policy. The excess is the amount you're required to pay each claims year before we'll pay towards the cost of eligible healthcare services covered under the following benefits. - 'Surgical procedures' benefit (page 16) - 'Chemotherapy for cancer (base)' benefit including the 'Cancer Cover Plus' options (page 21) - 'Radiotherapy' benefit (page 23) You're responsible for paying this amount directly to your health services provider. Once the excess amount for a claims year has been paid for a person covered under this policy, you won't need to pay it again towards any other eligible claims for that person until the next claims year. The excess applies to each person covered under the policy once each claims year. When a new claims year starts, each person's excess will return to its full value. **Point to note** Always send in your eligible claims, even if the cost of the healthcare service is less than your excess amount, as it will reduce the excess balance for your current claims year. --- ## How excesses work ### Example 1: How a $500 excess applies Say a $500 excess applies to your policy, an eligible surgical claim will be processed in the following way: **1st claim in the claims year where excess applies** - Cost of eligible surgical claim: $2,000 - We deduct your co-payment (20% of claim): $400 - We deduct your full excess: $500 - Amount we'll pay towards your claim: $1,100 **2nd claim in the claims year where excess applies** - Cost of second eligible surgical claim: $20,000 - We deduct your co-payment (20% of claim): $4,000 - No excess is remaining for this claims year: $0 - Amount we'll pay towards your claim