What does Accuro SmartCare cover?

Pharmac vs non-Pharmac drug cover

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.

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ACC interaction

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.

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Mental health cover

Annual 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.

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Pre-existing conditions

A pre-existing condition is any health or medical condition that you're aware of, or were experiencing signs or symptoms of, before the start of your policy, 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.

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IVF and assisted reproduction

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

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Oncology and high-cost cancer drugs

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.

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Gap payment rules

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.

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