nib health insurance — what's not covered

57 exclusions from wording effective 2024-09-20 · source PDF ↗

• anything cosmetic or reconstructive that is not medically necessary regardless of whether it's done for physical, functional, psychological, or emotional reasons (for example: treatment that improves, changes, or enhances your appearance)
• weight loss or bariatric investigations or treatment (for example: gastric banding, sleeve, and bypass), even if the purpose is to treat other health conditions (for example: diabetes or cardiovascular conditions)
• breast reductions
• Gynaecomastia
• Mastopexy
• assisted reproduction
• childbirth including caesarean sections
• hormone therapy
• infertility
• normal pregnancy, including termination of
• contraception
• erectile dysfunction
• sterilisation or reversal of sterilisation
• gender reassignment
• psychiatric, psychological, behavioural, or developmental conditions (for example: depression, ADHD, and eating disorders)
• injuries that are self-inflicted
• congenital or chromosomal disorders (for example: a birth defect)
• gene therapy
• genetic testing
• genetic conditions, in the absence of signs or symptoms that a condition exists at your join date
• concerns of familial risk or familial predisposition, in the absence of signs or symptoms that a condition exists
• any acute medical conditions or acute care
• ambulance society subscriptions
• injuries that are covered by ACC
• aids that assist with rehabilitation and mobility (for example: crutches, toilet frames, artificial limbs)
• continuous care (for example: geriatric, palliative, rehabilitation)
• mechanical tools or appliances (for example: insulin pumps, CPAP machines and equipment, pacemakers)
• organ or tissue transplants or donations (for example: organ transplants)
• specialised transfusions (for example: transfusion of blood, blood products and derivatives, and dialysis of any type)
• dentures
• dental implants
• Orthognathic surgery
• Periodontics, orthodontics, and endodontic procedures
• tooth exposure
• myopia, hypermetropia, presbyopia, radial keratotomy, and photo-refractive keratectomy
• any treatment for a condition relating to crime committed by you
• conditions or treatment relating to wars, riots, or terrorism
• HIV or AIDS
• treatment for allergies or allergic disorders (for example: desensitisation or patch testing)
• medicines that aren't funded by PHARMAC under the latest PHARMAC Pharmaceutical Schedule
• conditions not registered with the Ministry of Health as a disease
• pre-existing conditions (unless the condition was declared at application and was accepted by us)
• any form of risk management (for example: screening, preventative, or prophylactic health services)
• health surveillance testing
• sleep problems or disorders (for example: snoring, insomnia, or sleep apnoea)
• alternative or complementary medicine or therapy (for example: homoeopathy and natural therapy)
• experimental, unproven, or unconventional treatments or procedures
• services provided by someone who is not recognised by the Medical Council of New Zealand
• additional surgery or treatment that isn't covered under your policy
• expenses recoverable from a third party (for example: another insurer, company, or person)
• health services after the applicable benefit limit has been reached
• health services not covered under your policy
• anything that isn't medically necessary (for example: alcohol, toiletries, car parking, visitor meals, or administration costs)
• GP and out-of-hospital charges (including prescriptions)
• services or goods that were received or purchased outside of New Zealand (for example: goods bought online from another country)
• substance misuse (for example: misuse of alcohol or drugs)
• dementia

45 exclusions from wording effective 2025-11-24 · source PDF ↗

• anything cosmetic or reconstructive that is not medically necessary regardless of whether it's done for physical, functional, psychological, or emotional reasons (for example: treatment that improves, changes, or enhances your appearance)
• Abdominoplasty, Hyperhidrosis, Rectus divarication repair
• weight loss or bariatric investigations or treatment (for example: gastric banding, sleeve, and bypass), even if the purpose is to treat other health conditions (for example: diabetes or cardiovascular conditions)
• breast implants
• breast reductions
• Gynaecomastia
• revision of breast reconstruction
• assisted reproduction
• childbirth including caesarean sections
• hormone therapy
• infertility
• intrauterine devices
• pregnancy (for example: normal pregnancy, ectopic, or termination of)
• contraception
• erectile dysfunction
• sterilisation or reversal of sterilisation
• any treatment or procedures that are related to gender dysphoria
• gender reassignment
• psychiatric, psychological, behavioural, or developmental conditions (for example: depression, ADHD, and eating disorders)
• injuries that are self-inflicted
• congenital or chromosomal disorders (for example: a birth defect)
• congenital kyphosis, congenital scoliosis, cystic fibrosis, or pectus excavatum
• Marfan's syndrome
• gene therapy
• genetic testing
• hereditary or genetic conditions, in the absence of signs or symptoms that a condition exists from your join date
• any acute medical conditions or acute care
• ambulance society subscriptions
• injuries that are covered by ACC
• aids that assist with rehabilitation and mobility (for example: crutches, toilet frames, artificial limbs)
• continuous care (for example: geriatric, palliative, rehabilitation)
• mechanical tools or appliances (for example: insulin pumps, CPAP machines and equipment, pacemakers)
• organ or tissue transplants or donations (for example: organ transplants)
• specialised transfusions (for example: transfusion of blood, blood products and derivatives, and dialysis of any type)
• dentures
• dental implants
• Orthognathic surgery
• Periodontics, orthodontics, and endodontic procedures
• tooth exposure
• vision enhancement and correction (for example: myopia, hypermetropia, presbyopia, astigmatism, or laser treatment)
• Blepharoplasty
• any treatment for a condition relating to crime committed by you
• conditions or treatment relating to wars, riots, or terrorism
• HIV or AIDS
• treatment for allergies or allergic disorders

54 exclusions from wording effective 2024-02-01 · source PDF ↗

• laser therapy, cryotherapy, pulse light therapy or photodynamic therapy (Skin Lesion Surgery Benefit)
• consultations that don't relate to the skin lesion being removed
• any surgery that isn't performed by a specialist (Surgical Benefit)
• tooth extractions, except for unerupted or impacted teeth
• any other dental treatments, including periodontic and endodontic treatment, orthodontic treatment and implants, and orthognathic surgery or exposure of teeth
• cryotherapy, pulse light therapy, or photodynamic therapy as part of your Mohs surgery
• any treatment where admission isn't supported by medical evidence (Non-Surgical Benefit)
• any treatment that isn't managed by a specialist (Non-Surgical Benefit)
• any treatment where the main purpose, or only purpose, is to receive an injection (for example, a pain management injection)
• suites in a private hospital (Cancer Treatment Benefit)
• medicines that are administered or charged for in a public hospital or at home (Non-PHARMAC Funded Medicines in Hospital Benefit)
• vehicle hire (Travel and Accommodation Benefit)
• travel insurance (Travel and Accommodation Benefit)
• costs incurred when travelling outside New Zealand (Travel and Accommodation Benefit)
• surgery or treatment that isn't available in New Zealand (Delayed Treatment Benefit)
• surgery or treatment that isn't performed in an overseas private hospital (Delayed Treatment Benefit)
• any surgery or treatment that can be claimed under the Overseas Treatment Benefit (Delayed Treatment Benefit)
• surgery or treatment that relates to an injury which would be covered under ACC if it had happened in New Zealand (Cover in Australia Benefit)
• any ambulance costs (Cover in Australia Benefit)
• desensitisation, vaccinations, immunology, or allergies (Overseas Treatment Benefit)
• any costs already paid under the Cover in Australia Benefit (Overseas Treatment Benefit)
• any complications or ongoing treatment related to the initial treatment (Medical Tourism Benefit)
• injuries that occurred before your join date (ACC Top-Up Benefit)
• any stays in the private wing of a public hospital (Public Hospital Payment)
• housekeeping or childcare costs (Home Care Benefit)
• services provided by family members, friends, associates or anyone who doesn't meet our criteria (Cancer Treatment Counselling and Support Services Benefit)
• services provided by family members, friends, associates or anyone who doesn't meet our criteria (Cardiac Counselling and Support Services Benefit)
• ambulance memberships (Ambulance Transfer Benefit)
• caesarean sections (High-Risk Pregnancy Benefit)
• treatment of ectopic pregnancies (High-Risk Pregnancy Benefit)
• any related conditions arising after the end of your pregnancy (High-Risk Pregnancy Benefit)
• pregnancies conceived before your join date (High-Risk Pregnancy Benefit)
• treatment in a public hospital (High-Risk Pregnancy Benefit)
• IVF as a risk factor (High-Risk Pregnancy Benefit)
• any diagnostic investigations, other than x-rays (Foot Surgery Benefit)
• removal of corns or calluses (Foot Surgery Benefit)
• any surgery other than sleeve gastrectomy, gastric banding or bypass surgery (Loyalty – Weight Loss Surgery Benefit)
• any complications or follow-up treatment relating to weight loss surgery (Loyalty – Weight Loss Surgery Benefit)
• tumescent liposuction or any follow-up treatment relating to breast reduction surgery (Loyalty – Breast Reduction Surgery Benefit)
• procedures to reverse sterilisation (Loyalty – Sterilisation Benefit)
• the death doesn't occur within 14 days of the medical misadventure (Medical Misadventure Benefit)
• the cause of death has not been confirmed by a coroner's inquest (Medical Misadventure Benefit)
• the medical misadventure is not the main cause of death (Medical Misadventure Benefit)
• the medical misadventure happens during treatment or surgery that isn't covered by this policy (Medical Misadventure Benefit)
• the death occurs as a result of treatment or surgery covered under the Medical Tourism Benefit (Medical Misadventure Benefit)
• treatments covered under the school dental service or government dental scheme (Dental Benefit)
• gold or other exotic materials (Dental Benefit)
• orthodontic treatment, until you are eligible for the Loyalty – Orthodontic Benefit (Dental Benefit)
• eyewear for fashion reasons, or tinting and transition lenses (Eye Care Benefit)
• after-hours fees (Prescriptions Benefit)
• administration costs (Prescriptions Benefit)
• medicines that aren't prescribed by a GP, specialist, or nurse practitioner (Prescriptions Benefit)
• consultations or biopsies relating to surgery (GP Surgery Benefit)
• congenital conditions (Specialist Option, GP Option, Dental Optical and Therapeutic Option – dependent child pre-existing cover)