Accuro vs UniMed — Health Insurance

KidSmart

Prescription drugs covered under modules (other than the non-Pharmac drugs benefit) must be listed under section A to I of the Pharmac Schedule (section H only applicable if used during a procedure in a private facility), Pharmac-approved, medically necessary, and prescribed by a registered medical practitioner; the child must meet Pharmac's funding criteria. Separately, the non-Pharmac subsidised drugs benefit under the Hospital and Surgical base plan covers all Medsafe-registered drugs regardless of Pharmac funding status, where treatment is prescribed by a registered medical specialist as appropriate, the condition is not otherwise excluded, and the drug is prescribed within Medsafe guidelines. If the drug qualifies for a government or other subsidy, only the remaining cost is reimbursed. All costs under the non-Pharmac drugs benefit are included within the maximum limit of the applicable surgical or non-surgical benefit; this benefit cannot be used with any benefit on an additional module.

Source PDF · 2026-05-16

SmartCare

Unless outlined differently in the policy, prescription drugs must be listed under section A to I of the Pharmac Schedule (note that section H is only applicable if the drug is used during a procedure in a private facility), Pharmac-approved, medically necessary, and prescribed by a registered medical practitioner. Members must meet Pharmac's funding criteria and the drugs must be funded for the relevant claim. If prescription drugs require special authority from Pharmac to be covered, confirmation from the registered medical practitioner that the member meets the special authority criteria is required before cover can be assessed. Non-Pharmac-approved drugs are not covered under the prescription drug benefit.

Source PDF · 2026-05-16

SmartCare+

Standard prescription drugs (under the GP+ module) must be listed under sections A to I of the Pharmac Schedule, Pharmac-approved, medically necessary, and prescribed by a registered medical practitioner; the member must meet Pharmac's funding criteria. As part of the Hospital and Surgical+ base plan, the Non-Pharmac subsidised drugs benefit covers all drugs registered by Medsafe for use in New Zealand where: the treatment is prescribed by a registered medical specialist as the appropriate medical treatment for the condition; the treatment or condition is not excluded elsewhere in the Health Plan document; and the drug is prescribed within the guidelines set by Medsafe. If the drug qualifies for a government or other subsidy, only the remaining cost is reimbursed. All costs under the non-Pharmac drugs benefit are included in the maximum limit of the surgical or non-surgical benefit (whichever applies) under the Hospital and Surgical+ base plan, and the non-Pharmac drugs benefit cannot be used with any benefit on an additional module. No specific Keytruda example is mentioned.

Source PDF · 2026-05-16

SmartStay

Unless outlined differently in the policy, prescription drugs must be listed on the Pharmac Schedule (note that section H is only applicable if the drug is used during a procedure in a public or private hospital/facility), Pharmac-approved, medically necessary, and prescribed by a registered medical practitioner. Members must meet Pharmac's funding criteria and the drugs must be funded for the relevant claim. If special authority from Pharmac is required, confirmation from the registered medical practitioner that the member meets the special authority criteria is needed before cover can be assessed. Non-Pharmac drugs are not covered. Chemotherapy drugs administered orally at home that are prescribed by a registered medical specialist and used during an approved cycle of chemotherapy treatment are covered under the private and public hospital medical admission benefit.

Source PDF · 2026-05-16

StaffCare

Prescription drugs are only covered under the GP module (up to $20 per item, maximum $300 per person per policy year) for drugs ordered by a New Zealand-registered medical practitioner or registered medical specialist. Chemotherapy drugs administered orally at home that are prescribed by a registered medical specialist and used during an approved cycle of chemotherapy treatment are covered under the Non-surgical cancer treatment benefit. Other prescription drugs used during hospital admission are covered as part of the Private hospital medical admission and Non-surgical cancer treatment benefits. No explicit PHARMAC vs non-PHARMAC distinction or Keytruda-specific rules are stated in the policy wording.

Source PDF · 2026-05-16

StaffCare+

Prescription drugs (outside hospital) must be listed under section A to I of the Pharmac Schedule (section H only if used during a procedure in a private facility), Pharmac-approved, medically necessary, and prescribed by a registered medical practitioner; Pharmac funding criteria and special authority requirements must be met. As part of the Hospital and Surgical+ base plan, the non-Pharmac cancer drugs benefit covers Medsafe-registered cancer drugs up to $40,000 per person per policy year regardless of whether the drug qualifies for a government or other subsidy such as Pharmac funding; if the drug does qualify for a subsidy, only the remaining cost is reimbursed. All costs under the non-Pharmac cancer drugs benefit are included within the maximum limit of the General surgery benefit or the Non-surgical cancer treatment limit under the Private hospital medical admission benefit, whichever applies.

Source PDF · 2026-05-16

KidSmart

KidSmart is designed to complement ACC and will not cover claims related to accidents that ACC covers. If ACC does not cover the full amount, the policy may pay the difference (up to Reasonable charges and the benefit limit) if the treatment is covered under the policy. The guardian/child must first pursue the ACC full payment option. Under the ACC partial payment option, the policy covers the cost difference up to Reasonable charges or the benefit limit, whichever is less. If ACC declines cover, the insurer may ask for a review or appeal and requires the ACC decline letter within 3 months of issue. If ACC reverses its decision, the insurer may seek reimbursement for claims already paid. If ACC refuses or stops cover because of non-compliance with ACC requirements, no claim can be made under the policy. Any expense recoverable from ACC is excluded. ACC top-up benefit covers any shortfall between ACC's payment and actual private hospital costs; the applicable benefit's maximum limit applies.

Source PDF · 2026-05-16

SmartCare

The SmartCare Health Plan is designed to complement ACC and will not cover claims related to accidents that ACC covers. If ACC doesn't cover the full amount for treatment, the policy may pay the difference if there is cover for that treatment under the policy. Under the ACC full payment option, all claims must be submitted to ACC. Under the ACC partial payment option, the policy covers the difference in cost up to Reasonable charges or the benefit limit, whichever is less. If ACC declines cover, UniMed may ask for a review or appeal with the member's support; if ACC reverses its decision, UniMed may seek reimbursement. If ACC refuses or stops cover because the member is not complying with ACC's requirements, no claim can be made under the policy. Any expense recoverable from ACC is excluded. Any medical costs declined by ACC if injury is caused by an accident outside New Zealand are not covered.

Source PDF · 2026-05-16

SmartCare+

SmartCare+ is designed to complement ACC and will not cover claims related to accidents that ACC covers. If ACC does not cover the full amount for treatment, the policy may pay the difference if the treatment is covered under the policy. The full payment option (where ACC contracts a provider and pays the total cost) should be the member's first choice. Under the ACC partial payment option, SmartCare+ covers the difference in cost up to Reasonable charges or the benefit limit, whichever is less. If ACC declines cover, UniMed may ask for a review or appeal, requiring the member to provide the ACC decline letter within 3 months. If ACC refuses or stops cover due to non-compliance by the member, the member cannot claim under the policy. Any ACC reimbursement is deducted from the total before assessing the amount under the policy benefit. The ACC top-up benefit covers any shortfall between what ACC pays and the actual costs of the surgical procedure or medical treatment in an approved private hospital or facility, subject to the excess and benefit maximums.

Source PDF · 2026-05-16

SmartStay

SmartStay is designed to complement ACC and will not cover claims related to accidents that ACC covers. The full payment option (ACC contracts a provider and pays total cost) should be the first choice; in that case all claims must be submitted to ACC. Under the ACC partial payment option, SmartStay will cover the difference in cost up to the Reasonable charges or the benefit limit, whichever is less, provided the treatment is covered under the policy. If ACC declines cover, UniMed may ask for a review or appeal with member support, requiring the ACC decline letter and relevant information within 3 months of its issue date. If ACC refuses or stops cover due to member non-compliance with ACC requirements, no claim can be made under the policy. Any expense recoverable from ACC is excluded. Medical costs declined by ACC for injuries caused by accidents outside New Zealand are not covered. UniMed will not cover any excess applicable under another insurance plan.

Source PDF · 2026-05-16

StaffCare

The StaffCare Health Plan is designed to complement ACC and will not cover claims related to accidents that ACC covers. If ACC does not cover the full amount for treatment, the policy may pay the difference if there is cover for that treatment under the policy. Under the ACC full payment option, ACC pays the total cost and all claims must be submitted to ACC. Under the ACC partial payment option, the policy covers the shortfall up to Reasonable charges or the benefit limit, whichever is less. If ACC declines cover, the insurer may ask for a review or appeal, requiring the member to provide the ACC decline letter within 3 months. The insurer will not cover any medical costs declined by ACC if injury is caused by an accident outside New Zealand. Any expense recoverable from ACC is excluded. The ACC top-up benefit covers the shortfall between what ACC pays and actual costs of surgical procedure or medical treatment in an approved private hospital or facility, subject to the excess and benefit maximum.

Source PDF · 2026-05-16

StaffCare+

StaffCare+ is designed to complement ACC and will not cover claims related to accidents that ACC covers. The full payment option (ACC contracts a provider and pays the total cost) should be the first choice, in which case all claims must be submitted to ACC. Under the ACC partial payment option, StaffCare+ will cover the difference in cost up to the Reasonable charges or the benefit limit, whichever is less, provided the treatment is covered under the policy. If ACC declines cover for treatment covered under the policy, UniMed may ask for a review or appeal and needs the ACC decline letter and relevant information within 3 months of its issue date. If ACC refuses or stops cover because the Member is not complying with ACC's requirements, no claim can be made under the policy. An ACC top-up loyalty benefit is also available under the base plan: UniMed covers any shortfall between what ACC pays and the actual costs of the surgical procedure or medical treatment in an approved private hospital or facility, subject to the applicable excess and benefit maximum. We won't pay any costs that amount to more than 100% of actual costs incurred, and any ACC reimbursement is deducted before assessing the amount against the policy benefit.

Source PDF · 2026-05-16

KidSmart

MH sublimit: $1,000

The mental health benefit provides $1,000 per child per policy year for consultations with a psychiatrist, psychologist, psychotherapist or counsellor; no excess applies. Providers must be registered with the Medical Council of New Zealand (psychiatry scope), New Zealand Psychologists Board, Psychotherapists Board of Aotearoa New Zealand, or New Zealand Association of Counsellors or other relevant association. Treatment or counselling for psychiatric, psychological and neurodevelopmental disorders (including ADHD, autism spectrum disorder, dyslexia, intellectual disability, motor disorders, dementia, and specific learning disorders) is explicitly excluded under the general exclusions. There is no specific inpatient mental health admission benefit described.

Source PDF · 2026-05-16

SmartCare

MH sublimit: $1,000

The mental health benefit provides $1,000 per person per policy year for consultations with a psychiatrist, psychologist, psychotherapist or counsellor. No excess applies to this benefit. Providers must be registered under the psychiatry scope with the Medical Council of New Zealand, as a psychologist with the New Zealand Psychologists Board, as a psychotherapist with the Psychotherapists Board of Aotearoa New Zealand, or as a counsellor with the New Zealand Association of Counsellors or other relevant association. The policy does not cover treatment or counselling for psychiatric, psychological and neurodevelopmental disorders as listed under the general exclusions (including but not limited to ADHD, autism spectrum disorder, dyslexia, intellectual disability, motor disorders, dementia). There is no specific inpatient mental health admission benefit; the general exclusion for psychiatric and neurodevelopmental disorders applies.

Source PDF · 2026-05-16

SmartCare+

MH sublimit: $1,000

The mental health benefit under the Hospital and Surgical+ base plan covers $1,000 per person per policy year for consultations with a psychiatrist, psychologist, psychotherapist, or counsellor (no excess applies). Practitioners must be registered under the psychiatry scope with the Medical Council of New Zealand, as a psychologist with the New Zealand Psychologists Board, as a psychotherapist with the Psychotherapists Board of Aotearoa New Zealand, or as a counsellor with the New Zealand Association of Counsellors or other relevant association. Psychiatric, psychological, and neurodevelopmental disorders are generally excluded from cover (including ADHD, autism spectrum disorder, dementia, etc.). There is no specific inpatient mental health admission benefit described; the exclusion of psychiatric/psychological disorders applies broadly.

Source PDF · 2026-05-16

SmartStay

MH sublimit: $1,000

The private and public hospital medical admission benefit explicitly does not cover admission for mental health, psychiatric or psychological treatment or counselling. The Mental Health benefit provides $1,000 per person per policy year (no excess applies) for consultations with a psychiatrist, psychologist, psychotherapist or counsellor who are appropriately registered. The Specialist module also includes a separate mental health consultations benefit of $1,000 per person per policy year. General exclusions exclude treatment or counselling for any psychiatric, psychological and neurodevelopmental disorders.

Source PDF · 2026-05-16

StaffCare

MH sublimit: $1,000

The mental health benefit covers $1,000 per person per policy year (no excess applies) for consultations with a psychiatrist, psychologist, psychotherapist or counsellor who is registered with the relevant professional body. Inpatient or hospital admission for mental health, psychiatric or psychological treatment or counselling is explicitly excluded under the private hospital medical admission benefit. Treatment or counselling for any psychiatric, psychological and neurodevelopmental disorders is also listed as a general exclusion.

Source PDF · 2026-05-16

StaffCare+

MH sublimit: $1,000

The mental health benefit under the Hospital and Surgical+ base plan covers the costs of Reasonable charges for consultations with a psychiatrist, psychologist, psychotherapist or counsellor up to $1,000 for each person in a policy year; no excess applies. Providers must be registered with the Medical Council of New Zealand (psychiatry scope), New Zealand Psychologists Board, Psychotherapists Board of Aotearoa New Zealand, or the New Zealand Association of Counsellors or other relevant association. Separately, the Specialist+ module includes a mental health consultations sub-benefit of $1,000 per person per policy year within the specialist consultations benefit. Psychiatric, psychological and neurodevelopmental disorders are listed as a general exclusion and treatment or counselling for these conditions is not covered (including ADHD, autism spectrum disorder, dyslexia, geriatric care, intellectual disability, motor disorders, pre-senile dementia, senile illness or dementia, and specific learning disorders). There is no explicit inpatient mental health admission benefit described.

Source PDF · 2026-05-16

KidSmart

A pre-existing condition is any health or medical condition that you or any child was aware of, or were experiencing signs or symptoms of, before the start of the policy, or a medical event that occurred before the start of the policy. All pre-existing conditions must be disclosed at application. Personal exclusions may be placed on the policy certificate for pre-existing conditions; these last for varying periods (from 1 year to life). Children added under 6 months of age may be added with no personal exclusions placed due to their medical history. A Medical report is required within the first 5 years of the Hospital & Surgical base plan or Specialist module if the child was added after 6 months of age and their complete medical history was not supplied at application. We may decline a claim or add a backdated exclusion for any non-disclosed pre-existing condition.

Source PDF · 2026-05-16

SmartCare

A pre-existing condition is any health or medical condition that you're aware of, or were experiencing signs or symptoms of, before the start of your policy, or a medical event that occurred before the start of your policy. All pre-existing conditions for all Members must be disclosed at application. Underwriters assess the application and may place personal exclusions on the policy certificate; exclusions last for varying periods (from 1 year to life) depending on the medical condition. After the exclusion period has passed, the member can then claim for that condition. If a pre-existing condition is not disclosed and a claim arises relating to it, the claim may be declined. Undisclosed pre-existing conditions may be added as excluded conditions at any time, potentially backdated to the policy start date. A Medical report from the GP holding the patient's medical history is required when claiming within the first 5 years of the Hospital & Surgical base plan or Specialist module for a condition not previously claimed.

Source PDF · 2026-05-16

SmartCare+

A pre-existing condition is any health or medical condition that the member is aware of, or was experiencing signs or symptoms of, before the start of the policy, or a medical event that occurred before the start of the policy. All pre-existing conditions must be disclosed at application. The underwriters assess each condition and may place personal exclusions on the policy certificate, which last for varying periods (from 1 year to life) depending on the medical condition. Claims may be declined for undisclosed pre-existing conditions that the member knew about or should have known about, and any such exclusion may be backdated to the policy start date. For example, a hernia present at policy start would result in a 5-year personal exclusion. Medical reports are required for claims within the first 5 years of the Hospital & Surgical+ base plan or Specialist+ module where the member has not previously claimed for that condition.

Source PDF · 2026-05-16

SmartStay

All pre-existing conditions must be disclosed at application. A pre-existing condition is any health or medical condition the member was aware of, or experiencing signs or symptoms of, before the start of the policy, or a medical event that occurred before the start of the policy. Pre-existing conditions are excluded unless accepted by the underwriters. Personal exclusions are listed on the policy certificate and may last from 1 year to life depending on the medical condition. If a member does not provide their complete medical history at application, a Medical report from the GP holding the medical history is required for any new condition claimed within the first 5 years of the Hospital & Surgical base plan or Specialist module. UniMed reserves the right to exclude any declared or non-declared pre-existing condition or congenital condition at any time, with the exclusion potentially backdated to the policy start date. Example given: a pre-existing hernia attracts a 5-year personal exclusion.

Source PDF · 2026-05-16

StaffCare

Pre-existing conditions are excluded unless accepted by the insurer. With group insurance schemes, cover for pre-existing conditions may be offered in certain circumstances. If a full application is required, all pre-existing conditions must be disclosed. Personal exclusions may be placed on the policy certificate for pre-existing conditions, lasting from 1 year to life depending on the condition. After the exclusion period has passed, the member can then claim for that condition. If a pre-existing condition is not disclosed and a claim is made relating to it, the claim may be declined. The insurer reserves the right to exclude any declared or non-declared pre-existing condition or congenital condition at any time, backdated to the start of the policy if necessary.

Source PDF · 2026-05-16

StaffCare+

Our Health Plans are set up to cover treatment of signs, symptoms and conditions that arise after your policy has started. However, with group insurance schemes we offer cover for pre-existing conditions in certain circumstances. If not offered cover for pre-existing conditions on application, all pre-existing conditions must be disclosed for all Members. A pre-existing condition is any health or medical condition that you're aware of, or were experiencing signs or symptoms of, before the start of your policy, or a medical event that occurred before the start of your policy. Underwriters assess all previous and current signs, symptoms and conditions; any excluded conditions are listed on the policy certificate. Personal exclusions last for different lengths of time (from 1 year to life), depending on the medical condition. After the time period listed with the exclusion has passed, you can then claim for that condition. We may decline a claim if treatment is for a pre-existing condition not included on the application form that you knew about or should have known about. We reserve the right to exclude any declared or non-declared pre-existing condition or congenital condition at any time, which may be backdated to the start of the policy.

Source PDF · 2026-05-16

KidSmart

Treatment, investigation, and diagnosis of infertility and assisted reproduction is explicitly excluded.

Source PDF · 2026-05-16

SmartCare

Treatment, investigation, and diagnosis of infertility and assisted reproduction are specifically excluded.

Source PDF · 2026-05-16

SmartCare+

Treatment, investigation, and diagnosis of infertility and assisted reproduction are explicitly excluded. However, after 3 years of continuous cover under the Specialist+ module, a loyalty benefit of $2,000 per person per policy year covers obstetric care during pregnancy and infertility diagnosis and treatment by a registered medical specialist (this benefit does not cover antenatal ultrasounds).

Source PDF · 2026-05-16

SmartStay

Excluded. 'Treatment, investigation, and diagnosis of infertility and assisted reproduction' is a listed general exclusion under the Obstetrics and gynaecology exclusions.

Source PDF · 2026-05-16

StaffCare

Treatment, investigation, and diagnosis of infertility and assisted reproduction is explicitly excluded.

Source PDF · 2026-05-16

StaffCare+

Treatment, investigation, and diagnosis of infertility and assisted reproduction is explicitly excluded and not covered under this policy.

Source PDF · 2026-05-16

KidSmart

Chemotherapy drugs administered orally at home, prescribed by a registered medical specialist and used during an approved cycle of chemotherapy treatment, are covered under the private hospital medical admission benefit (up to $300,000 per child per policy year). Non-Pharmac subsidised drugs (including cancer drugs registered by Medsafe but not Pharmac-funded) are covered under the non-Pharmac subsidised drugs benefit, with costs included within the maximum limit of the applicable surgical or non-surgical benefit. Up to $2,000 per child per policy year is provided for personal accessories needed during or within 6 months after cancer treatment (e.g. wig, hat, scarf).

Source PDF · 2026-05-16

SmartCare

Non-surgical cancer treatment (including chemotherapy and radiation) is covered under the private hospital medical admission benefit, limited to $65,000 per person per policy year (included within the $200,000 benefit limit). Chemotherapy drugs administered orally at home, prescribed by a registered medical specialist and used during an approved cycle of chemotherapy treatment under the policy, are also covered. $2,000 per person per policy year is available for personal accessories needed during or within 6 months after cancer procedure or treatment (e.g. wig, hat, scarf, mastectomy bra). Oncology consultations and treatment following surgery are covered under the private hospital medical admission benefit. Prescription drugs must be Pharmac-approved and listed in sections A–I of the Pharmac Schedule; non-Pharmac drugs are not covered under the prescription drug benefit.

Source PDF · 2026-05-16

SmartCare+

Non-Pharmac subsidised drugs benefit under the Hospital and Surgical+ base plan covers the costs of Reasonable charges associated with accessing the most effective treatment available, including drugs not subsidised by Pharmac/government, provided they are registered by Medsafe for use in New Zealand, prescribed by a registered medical specialist as appropriate medical treatment, not excluded elsewhere in the Health Plan, and prescribed within Medsafe guidelines. If the drug qualifies for a government or other subsidy, only the remaining cost is reimbursed. All costs under the non-Pharmac drugs benefit are included in the maximum limit of the relevant surgical or non-surgical benefit (up to $500,000 for general surgery or $300,000 for private hospital medical admission). Chemotherapy drugs administered orally at home, prescribed by a registered medical specialist and used during an approved cycle of chemotherapy, are also covered under the private hospital medical admission benefit ($300,000 per person per policy year). A personal accessories benefit of $2,000 per person per policy year is available for items such as wigs, hats, scarves, or mastectomy bras needed during or within 6 months after a cancer procedure or medical treatment.

Source PDF · 2026-05-16

SmartStay

Not on file.

Source PDF · 2026-05-16

StaffCare

Non-surgical cancer treatment is covered up to $60,000 per person per policy year for admission to a private hospital or facility. This includes chemotherapy drugs administered orally at home prescribed by a registered medical specialist during an approved cycle of chemotherapy treatment under the policy, as well as other prescription drugs used during non-surgical cancer treatment in hospital. No specific high-cost cancer drug benefit (such as a named drug like Keytruda) or separate oncology drug sub-limit beyond the $60,000 non-surgical cancer treatment benefit is mentioned in the policy wording.

Source PDF · 2026-05-16

StaffCare+

The non-Pharmac cancer drugs benefit covers the costs of Reasonable charges for Medsafe-registered cancer drugs up to $40,000 for each person in a policy year, regardless of whether the drug qualifies for Pharmac funding or another government subsidy. The drug must be used in the treatment of cancer, prescribed by a registered medical specialist as the appropriate medical treatment, not excluded elsewhere in the Health Plan, and prescribed within Medsafe guidelines. If the drug qualifies for a government or other subsidy, only the remaining cost is reimbursed. All costs under this benefit are included within the maximum limit of the General surgery benefit or the Non-surgical cancer treatment limit ($65,000 per person per policy year, inclusive of non-Pharmac cancer drugs) under the Private hospital medical admission benefit. An excess applies to this benefit.

Source PDF · 2026-05-16

KidSmart

We will pay up to the Reasonable charges for any covered procedure or treatment, up to the specified benefit limit (whichever is less). If a provider charges above our Reasonable charges, the policyholder must pay the difference directly to the healthcare provider, regardless of the benefit's maximum limit. We will not pay or reimburse any costs exceeding 100% of actual costs incurred. Any refunds, subsidies or entitlements from other sources (ACC, another health insurer, government-funded agency, Work and Income, or employer) must be claimed first, and we deduct those amounts before assessing the remainder. We do not cover any excess applicable under another insurance plan.

Source PDF · 2026-05-16

SmartCare

UniMed covers Reasonable charges, defined as the cost for a procedure or medical treatment judged to be reasonable and within a range of cost charged for the same procedure under similar circumstances. If a provider charges above Reasonable charges, UniMed may ask for further information or recommend an alternative provider. If the member chooses to proceed at the higher cost, the member must pay the difference between the amount approved and the actual cost, regardless of the benefit's maximum limit, directly to the healthcare provider. UniMed will not pay more than 100% of actual costs incurred. Any refunds, subsidies, or entitlements from another source (including ACC, another health insurer, government-funded agency, Work and Income, or employer) must be claimed first and will be deducted from the total before UniMed assesses the remaining amount. UniMed does not cover excess applicable for another insurance plan.

Source PDF · 2026-05-16

SmartCare+

UniMed pays up to the Reasonable charges for a procedure or medical treatment, up to the specified benefit limit. If the cost for a procedure or medical treatment is above what UniMed judges to be a Reasonable charge, the member may be asked for further information or recommended an alternative. If the member chooses to proceed with a provider charging above the Reasonable charge, the member must pay the difference between the amount approved and the actual cost, regardless of the benefit's maximum limit. This extra amount must be paid directly to the healthcare provider. If a procedure cost exceeds the benefit maximum limit, the exceeded amount cannot be paid and is the member's responsibility. UniMed does not cover excess applicable under another insurance plan. Members must also claim any other refunds, subsidies, or entitlements (e.g. ACC, another insurer, government-funded agency) first, and UniMed deducts any such reimbursement from the total before assessing the claim.

Source PDF · 2026-05-16

SmartStay

UniMed pays up to the Reasonable charges for a procedure or medical treatment, or up to the relevant benefit limit, whichever is less. If the actual cost exceeds the Reasonable charge or benefit limit, the member must pay the difference directly to the healthcare provider. If a procedure has costs above what UniMed judges to be Reasonable charges, UniMed may ask for further information or recommend an alternative; if the member proceeds, they pay the excess cost. Prior approval letters will clearly state the maximum amount UniMed will cover and any excess applicable. UniMed will not reimburse or pay more than 100% of actual costs incurred; any amounts covered by ACC, another insurer, or government-funded agencies are deducted before UniMed assesses its portion. UniMed does not cover excess applicable under another insurance plan.

Source PDF · 2026-05-16

StaffCare

We cover Reasonable charges, defined as the cost for a procedure or medical treatment judged to be reasonable and within a range of cost charged for the same procedure under similar circumstances. If the cost exceeds Reasonable charges or the benefit limit, the member must pay the difference directly to the healthcare provider. The insurer will not reimburse any amount exceeding 100% of actual costs incurred. Members must first claim any other refunds, subsidies, or entitlements (including from ACC, another insurer, or government-funded agency), and the insurer will deduct those amounts before assessing the claim. The insurer does not cover an excess applicable under another insurance plan.

Source PDF · 2026-05-16

StaffCare+

UniMed pays up to the Reasonable charges for any covered procedure or medical treatment, up to the specified benefit limit. If the cost for a procedure exceeds what UniMed judges to be a Reasonable charge, the member must pay the difference between the amount approved and the actual cost directly to the healthcare provider, regardless of the benefit's maximum limit. If the cost exceeds the benefit maximum limit, the excess amount is also the member's responsibility. UniMed will not pay or reimburse any costs that amount to more than 100% of actual costs incurred; any reimbursements from ACC, another health insurer, a government-funded agency, Work and Income, or the employer are deducted before assessing the remaining amount. UniMed does not cover an excess applicable under another insurance plan. The applicable excess (per person, per policy year) is deducted from any payment made to the member or provider, and the member is responsible for paying the excess amount directly to the health service provider.

Source PDF · 2026-05-16