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While every effort has been made to ensure all information below is accurate & up to date, you should always refer to the the full policy document for each provider for the full information on each benefit
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Premier Health is a flexible health policy that can be tailored to help suit you and your family's needs and budget. And the good thing is, you can change your policy as you move through the different stages of life.
At the heart of your Premier Health policy is the Base Cover. We then offer a range of options that you can choose individually or any combination of, to customise a policy that best suits you.
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If you, or a member of your family, require surgery or medical treatment, Sovereign Absolute Health not only gives you the freedom to select the best specialists and the best hospitals, it generally ensures that you avoid a huge waiting list to receive essential treatment. This gives you greater certainty about the most important thing we need to protect – our health. |
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Major Medical Cover provides for the reimbursement of significant medical expenses,
in particular admission to private hospital for care or surgery in the event of a non-acute
medical condition such as cancer or heart disease so that you can get treatment when
you need it without having to endure public hospital waiting lists. |
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The VIP Plans are based on a series of modules. The foundation module ensures cover for the problems that are least predictable and have the highest potential cost, namely surgery and medical treatment in hospital.
Then, depending on your needs, you can add modules that cover specialist and diagnostic costs, GP and prescription charges and 75% reimbursement for dental and optical charges. |
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16-70
(individual consideration from age 70) |
16-70
(individual consideration from age 70) |
16-70
(individual consideration from age 70) |
16-70
(individual consideration from age 70) |
All |
All |
All |
All |
Lifetime |
Yearly renewable to age 100 |
Lifetime |
Lifetime |
Direct Debit, Credit Card |
Direct Debit, Credit Card |
Direct Debit, Credit Card |
Direct Debit, Credit Card |
Monthly, Yearly |
Monthly, Yearly |
Monthly, Yearly |
Monthly, Yearly |
Specialist, GP Cover, Dental & Optical, Lump Sum Trauma |
Specialist & Tests |
Specialist & Tests |
Specialist, GP Cover, Dental & Optical |
Yes, additional premium is based on number of children |
Yes, one additional premium for all children |
Yes, additional premium is based on number of children |
Yes, additional premium is based on number of children for up to 2 children. No additional premium for extra child(ren) |
Nil, $250, $500, $1000, $2000, $4000, $6000 |
Nil, $300, $600, $1200, $2000, $4000 |
Nil, $250, $500, $1000, $2000, $5000 |
Nil, $250, $500, $1000 |
Per Claim |
Per person per policy year |
per person per treatment |
Per person per policy year |
2.5% for having more than one person on a policy |
Policy fee waived for second life |
Policy fee waived for second life |
No discount |
Premiums based on age |
Premiums based on age |
Premiums based on age |
Premiums based on age and payment method (Direct Debit or Credit Card) |
Premiums are reviewed quarterly with changes applied on the yearly anniversary of your policy |
Premiums are reviewed quarterly with changes applied on the yearly anniversary of your policy |
Premiums are reviewed quarterly with changes applied on the yearly anniversary of your policy |
Premiums are reviewed quarterly with changes applied on the yearly anniversary of your policy |
New Zealand only |
New Zealand only |
New Zealand and Australia |
New Zealand only |
| Click an item to show/hide further details |
TOWER Health & Life cover the cost of surgery requiring an anaesthetic in an approved private hospital. Surgery includes (for example, without limitation): general and cancer surgery, cardiac surgery, orthopaedic surgery, laparoscopic surgery, oral surgery, angiography, angioplasty and lithotripsy.
TOWER Health & Life also cover the cost of intensive nursing care, x-rays, disposables and consumables, dressings, and drugs listed under Sections A to G of the PHARMAC Pricing Schedule, where they meet PHARMAC's funding criteria, etc.
Diagnostic investigations
TOWER Health & Life cover the cost of diagnostic investigations requiring an anaesthetic in an approved private hospital. Diagnostics covered include (for example, without limitation): endoscopy, gastroscopy, colonoscopy and cystoscopy. |
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| Covers reasonable charges incurred during a surgical hospitalisation when referred by a specialist including:
■ Surgeon fees
■ Anaesthetist fees
■ Diagnostic fees
■ Hospital fees including:
- Accommodation
- Operating theatre fees
- Ancillary hospital charges including: anaesthetic supplies, dressings, pathology tests, ECG, post operative physiotherapy, medication (prescribed and taken while in hospital)
- Disposable laparoscopic equipment (separate maximum cover may apply)
- Prostheses (separate maximum cover may apply).
Also covers reasonable charges incurred for the following procedures where the procedure is performed on a life assured admitted overnight to a private hospital, when recommended by a specialist:
■ Arthroscopy
■ Dilatation & Curettage
■ Hysteroscopy
■ Laproscopy |
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This surgical hospitalisation benefit will cover costs which have occurred as a direct result of
surgical treatment of a Non-acute Medical Condition, subject to the exclusions described
elsewhere in this Protection Benefit Sheet. The treatment must have been recommended by an
appropriate registered medical practitioner as being necessary to improve the health of the life
assured and must be carried out in a Private Hospital.
Surgeries included under the surgical hospitalisation benefit are:
■ General Surgery
■ Cardiac Surgery
■ Otolaryngological Surgery
■ Urological Surgery
■ Gynaecological Surgery
■ Ophthalmological Surgery (Not including laser eye surgery.)
■ Orthopaedic Surgery
■ Peripheral Vascular Surgery
■ Plastic Surgery (Non-Cosmetic)
■ Oral Surgery (Only if performed by a specialist oral surgeon. Dentists costs not covered.)
■ Maxillofacial Surgery
■ Weight Reduction Surgery (Not including liposuction)
■ Day Surgery performed by a Specialist (Non-Cosmetic)
■ Sterilisation Procedures (Only those occurring after 2 years from the Commencement Date)
The surgical hospitalisation benefit will cover the following costs associated with the surgery
during the period of hospital admission:
■ Surgeon's and anaesthetist's fees
■ Operating theatre fees
■ Private Hospital accommodation fees
■ Specialists consultations that occurred within 6 months of the admission date and which
were directly related to the surgery
■ Diagnostic procedures including diagnostic procedures which are directly related to the
surgery and which occurred within 6 months of the admission date
■ Prostheses
■ Outpatient fees for day surgery
■ Surgical sundries including intravenous fluids, irrigating solutions, dressings, and
prescriptions. This includes prescriptions which are directly related to the surgery for a
maximum period of six months following the surgery
■ Post-operative physiotherapy including physiotherapy treatment which is directly related
to the surgery for a maximum period of six months following the surgery |
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Surgery performed in a Private Hospital or other Southern Cross approved facility
Surgery performed by a Medical Practitioner Band II, III or IV, an Oral Surgeon or a Medical Practitioner vocationally registered in diagnostic and interventional radiology in private practice.
■ Surgeon Fees
■ Anaesthetist Fees
■ Intensivist Fees
Hospital Charges:
■ Accommodation
■ Operating Theatre Fee
■ Ancillary Hospital Charges - includes: anaesthetic supplies, dressings, pathology tests, medication (prescribed and taken in hospital), special in-hospital nursing, x-ray examination, ECG, in-hospital post-operative physiotherapy.
■ Disposable Laparoscopic Equipment
■ Prostheses (Prosthesis Schedule applies)
Reimbursement for oral surgery relates to all procedures undertaken during the one Operation. Removal of teeth is restricted to impacted and unerupted teeth only. No cover is provided for implants, and also excludes periodontal, orthodontic and endodontal procedures.
Cardiac Surgery performed in a Private Hospital or other Southern Cross approved facility
Cardiac surgery performed by a Medical Practitioner Band IV in private practice.
■ Surgeon Fees
■ Anaesthetist Fees
■ Intensivist Fees
■ Perfusionist Fees - including bypass machine supplies and octopus system.
Hospital Charges:
■ Accommodation
■ Operating Theatre Fee
■ Intensive Post-operative Care (including special nursing)
■ Ancillary Hospital Charges - including anaesthetic supplies, ECG and specialised x-ray, intravenous fluids, irrigating solutions, dressings, in-hospital post-operative physiotherapy and medication (prescribed and taken in hospital)
■ Prostheses (Prosthesis Schedule applies)
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TOWER Health & Life cover the cost of medical treatment (not involving surgery) in an approved private hospital. Medical treatments covered include (for example, without limitation): heart disease, treatment of respiratory disease (asthma, pneumonia, etc) and treatment for endocrine disease (diabetes, etc).
TOWER Health & Life also cover the cost of intensive nursing care, x-rays, disposables and consumables, dressings and drugs listed under Sections A to G of the PHARMAC Pricing Schedule where they meet PHARMAC's funding criteria, etc.
Cancer Treatment Benefit
TOWER Health & Life cover the cost of the chemotherapy agent(s) and radiotherapy (where this is available privately in New Zealand) used in a cycle of treatment for cancer administered outside the public health system, including the cost of a registered specialist or health service provider to administer these treatments. |
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Covers reasonable charges incurred during a medical hospitalisation for treatment of a condition which does not require surgery when referred by a specialist including:
■ Hospital Accommodation fees
■ Physician/Specialist fees
■ Diagnostic fees
■ Ancillary hospital fees: including, but not limited to, materials and medication prescribed while in hospital; Physiotherapist fees.
Non-surgical hospitalisations include, but are not limited to, admissions for treatment (other than surgery) of asthma, diabetes, stroke, cancer and oncology radiology/ chemotherapy treatment, lithotripsy or any other acute chronic illness.
Pharmaceutical treatment costs covered under this benefit are limited to subsidised prescription drugs specified in the New Zealand Pharmaceutical Schedule (as published by Pharmac) or any replacement schedule. |
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The non-surgical hospitalisation benefit will cover costs which have occurred as a direct result
of the diagnosis of any Non-acute Medical Condition, subject to the exclusions described
elsewhere in this Protection Benefit Sheet, for which non-surgical hospital treatment is
recommended by an appropriate registered medical practitioner as being necessary to improve
the health of the life assured.
The non-surgical hospitalisation benefit will cover the following costs, which are incurred
during the period of hospital admission:
■ Private Hospital accommodation fees
■ Specialists fees including specialist fees directly related to the hospital admission and
which have occurred within 6 months of the date of admission
■ Treatment costs, whether Pharmac subsidised or not, e.g. chemotherapy or radiotherapy.
Oral treatment for chemotherapy recommended by an appropriate registered medical
practitioner that does not require admission to a Private Hospital will also be covered.
■ Treatment costs for hyperbaric oxygen treatment when recommended by an appropriate
registered medical practitioner that does not require admission to a Private Hospital will
also be covered.
■ Diagnostic procedures including diagnostic procedures directly relating to the hospital
admission which occurred within 6 months of the date of admission
■ Sundries including intravenous fluids, dressings and prescriptions. This includes
prescriptions which are directly related to the hospital admission for a maximum period of
six months following the date of discharge |
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Angioplasty ($75,000 per operation, $2,000 per stent)
Coronary angioplasty performed by a Medical Practitioner Band III in private practice, and in a Private Hospital or other Southern Cross approved facility.
■ Cardiologist / Radiologist
Hospital Charges:
■ Accommodation
■ Operating Theatre Fee
■ Ancillary Hospital Charges - including anaesthetic supplies, angioplasty catheters, ECG and specialised x-ray, intravenous fluids, irrigating solutions, dressings, medication (prescribed and taken in hospital).
■ Stent
- conventional.
- drug eluting, no cover unless angioplasty procedure performed by an Affiliated Provider or other provider nominated by Southern Cross to provide coronary angioplasty services.
Varicose Veins (legs) (2 Varicose Veins procedures per leg per lifetime)
No cover for varicose veins unless the treatment is provided by an Affiliated Provider. Please be aware that not all procedures are available from all Affiliated Providers or in all areas, and that a limited range of procedures for leg varicose veins are funded. In order to receive cover the treatment must be Medically Necessary as determined by the agreed clinical guidelines, and not for Cosmetic Treatment. This benefit is inclusive of any consultations, treatment and/or follow up assessment or treatment that may be required.
Prostate Brachytherapy (Policy Limits will apply. Prior to receiving treatment your Affiliated Provider will advise the balance payable by you.)
No cover for Prostate Brachytherapy unless the treatment is provided by an Affiliated Provider.
Medical Hospitalisation ($25,000 per admission, $60,000 per Claims Year)
Referred by and under the control of a Medical Practitioner Band III or IV in private practice for treatment, convalescence or observation in a Private Hospital. Includes reimbursement for hospital accommodation (on a single room basis, excluding suites) and ancillary hospital charges.
Note: Excludes hospice, geriatric and psychiatric hospital care.
Psychiatric Hospitalisation ($330 per night, $200 for drugs/ancillary, $1,650 per admission - including, accommodation drugs/ancillary)
Referred by and under the control of a Medical Practitioner vocationally registered in psychiatry for treatment, convalescence or observation in a Private Hospital. Includes reimbursement for hospital accommodation and ancillary hospital charges.
Oncology ($25,000 per Course of Treatment, $60,000 per Claims Year)
Chemotherapy
Performed by a Medical Practitioner vocationally registered in radiation oncology or internal medicine, either as an out-patient or in a Private Hospital or other Southern Cross approved facility within New Zealand, including the cost of materials and prescription Chemotherapy Drugs, hospital accommodation (on a single room basis, excluding suites) and ancillary hospital charges.
Lithotripsy ($25,000 per admission, $75,000 per Claims Year)
Performed by a Medical Practitioner Band IV in a Private Hospital or other Southern Cross approved facility.
Hospice Cover
For overnight admissions for other than Accident or Treatment Injury conditions.
Child ($25 per night, up to $250 per admission, up to $1,200 per Claims Year)
Adult ($50 per night, up to $500 per admission, up to $2,400 per Claims Year)
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■ Covers Oral Surgery by a registered oral and maxillo-facial surgeon.
■ Only covers removal of unerupted and impacted teeth if a registered oral surgeon or registered dentist performs the procedure.
■ Does not cover any other dental treatments including periodontal, orthodontic and endodontal procedures and implants.
■ A 12-month stand-down period from the join date of each insured person applies to the extraction of wisdom teeth |
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Covers reasonable charges of medically necessary oral surgery*, performed by an oral surgeon, when referred by a registered medical practitioner including:
■ Oral Surgeon Fees
■ Anaesthetist Fees
■ X-rays
■ Hospital or day stay clinic charges (if applicable)
■ Ancillary charges including: dressings, medication
(prescribed immediately post surgery), anaesthetic
supplies.
* Oral surgery procedures covered are:
■ Removal of impacted wisdom teeth
■ Removal of unerupted teeth
■ Treatment of cysts, soft tissue swellings and
enlargements.
Cover is not provided for root canal treatment, dental repair or implants. Cover is also not provided for orthodontic treatment or orthognathic surgery of any kind. |
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■ Oral Surgery (Only if performed by a specialist oral surgeon. Dentists costs not covered.)
■ Oral treatment for chemotherapy recommended by an appropriate registered medical practitioner that does not require admission to a Private Hospital will also be covered.
Please see more details in "Surgical Hospitalisation Cover" and "Non-Surgical Hospital Cover" sections above |
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See "Surgical Hospital Cover" above
■ Removal of teeth is restricted to impacted and unerupted teeth only.
■ Excludes implants, periodontal, orthodontic and endodontal procedures. |
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■ Associated Oncology and Diagnostic Radiology and Imaging Benefit
Covers the cost of: Registered specialist consultations, Diagnostic radiology, Diagnostic imaging such as x-rays, ultrasound, mammography, scintigraphy, MRI and CT scans resulting from a referral by a GP or registered specialist where the registered specialist consultation, diagnostic radiology or diagnostic imaging directly relates to, or results in, the insured person having private chemotherapy or radiotherapy treatment for cancer which has been paid for under this policy.
■ Hospital Related Specialist Consultations Benefit
Covers the cost of registered specialist consultations up to six months prior to admission to an approved private hospital and up to six months after being discharged from that approved private hospital where those visits directly relate to that hospitalisation, after a referral from a GP or a registered specialist.
■ Hospital Related Diagnostic Radiology and Imaging Benefit
Covers the cost of diagnostic radiology and diagnostic imaging such as x-rays, ultrasound, mammography, scintigraphy, MRI and CT scans up to six months prior to admission to an approved private hospital and up to six months after being discharged from that approved private hospital, where those diagnostic procedures directly relate to that hospitalisation, after a referral from a GP or a registered specialist.
■ Hospital Related Cardiac Investigations Benefit
Covers the cost of cardiac investigations such as treadmills, holter monitoring, ambulatory blood pressure monitoring, cardiovascular ultrasound, echocardiography, myocardial perfusion scans and cardioversion up to six months prior to admission to an approved private hospital and up to six months after being discharged from that approved private hospital, when those investigations directly relate to that hospitalisation, after a referral from a GP or a registered specialist. |
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Covers reasonable charges of specialist consultations and diagnostic procedures directly relating to a medical condition covered above and when referred by a specialist.
Period covered is for three months before, and three months after, a covered medical hospitalisation or surgery.. |
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See "Surgical Hospital Cover" and "Non-Surgical Hospital Cover" sections above |
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Out-of-hospital Specialists
Following a referral from a Medical Practitioner Band I or II, pre and post operative consultations 4 months before
and after hospitalisation with a Medical Practitioner Band III or IV in private practice.
Benefit Maximum:
Pre operative consultation - Up to $175
Post operative consultation - Up to $125
Cover is excluded where the consultation does not relate to hospitalisation.
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Covers the cost of MRI and CT scans if a registered specialist recommends the scan, even when the insured person has not been, or will not be, hospitalised.
Benefit Maximum:
MRI Scan - up to $2,500 per policy year, less any excess
CT Scan - up to $2,000 per policy year, less any excess
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| This benefit provides coverage for medically necessary angiograms, MRI and CT scans, regardless of whether surgery is performed or not. |
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Major Diagnostics Benefit
The major diagnostics benefit will cover the costs of the following diagnostic procedures,
subject to the exclusions, which have been
recommended by an appropriate registered medical practitioner, whether they have occurred in
relation to a period of private hospitalisation or not:
■ MRI Scans
■ CT Scans
■ Arthroscopy
■ Laparoscopy
■ Dilation & Curettage
■ Cytoscopy
■ Myelogram
■ Hysteroscopy
■ Angiogram
■ Colonoscopy
■ Gastroscopy
Benefit Maximum:
Up to $200,000 per annum
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Angiography
Including MRI angiograms, CT angiograms, fluorescein angiograms, cardiac catheterization and all coronary and peripheral angiograms. No cover for CT coronary angiogram (CTA) unless procedure performed by an Affiliated Provider. Must be performed by a Medical Practitioner Band III or IV in private practice. Includes reimbursement for hospital accommodation.
Benefit Maximum:
Up to $60,000 per procedure |
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TOWER Health & Life cover the cost of treatment for minor surgery, performed by a registered specialist, on referral from a GP.
Benefit maximum
TOWER Health & Life pay up to $6,000 per policy year, less any excess.
TOWER Health & Life cover the cost of treatment for minor surgery on skin lesions performed by a registered specialist, on referral from a GP.
Note
TOWER Health & Life recommend pre-approval as some minor surgery is deemed cosmetic surgery and is not covered This Benefit does not include the pre and post minor surgery specialist consultations, or any other diagnostic costs associated with treatment.
Skin Lesions
TOWER Health & life cover the cost of treatment for minor surgery on skin lesions performed by a registered specialist, on referral from a GP.
Benefit maximum
All costs paid under this Benefit are included within the Benefit maximum for the Specialist Minor Surgery Benefit. |
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Covers reasonable charges incurred with an outpatient surgical procedure when recommended by a specialist (including related diagnostic testing performed in connection with the procedure).
This benefit provides coverage for medically necessary angiograms, MRI and CT scans, regardless of whether surgery is performed or not. This benefit also covers reasonable charges incurred for the following procedures when recommended by a specialist:
■ Arthroscopy
■ Cystoscopy
■ Colonoscopy*
■ Dilatation & Curettage
■ Gastroscopy
■ Hysteroscopy
■ Laproscopy
■ Myleogram
*Cover is not provided for routine screening or periodic testing.
Benefit Maximums:
$100,000 per life assured, per policy year - Excess applies |
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See "Surgical Hospital Cover" section above |
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Minor Surgery by Specialist
See "Surgical Hospital Cover" section above
Minor Surgery by a GP
Performed by a Medical Practitioner Band I in private practice including removal of cysts, moles and toenails.
Benefit Maximums:
$350 per operation |
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TOWER Health & Life cover the cost of post-treatment home nursing care by a registered nurse, up to six months after being discharged from an approved private hospital, on referral by a GP or registered specialist or up to six months after a cycle of chemotherapy or radiotherapy treatment.
Benefit maximum
Up to $150 per day.
Up to $6,000 per policy year. |
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Covers reasonable charges of home care provided by a registered nurse when recommended by a specialist.
This care must immediately follow discharge from a private hospital for a covered surgical or medical procedure.
Benefit Maximum:
Up to $125 per day
Up to $2,500 per year per life assured per policy year |
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The maximum post admission home nursing care benefit payable per life assured is $300.00 per
day for up to a maximum of 10 days. The post admission home nursing care benefit will
reimburse all costs incurred for home nursing care by a registered nurse following any private
hospital admission covered under this major medical cover benefit, subject to the exclusions
described elsewhere in this Protection Benefit Sheet. Such care must have been recommended
as necessary by the Private Hospital where the admission occurred.
No excess applies to this Post Admission Home Nursing Care
Benefit Maximums:
$300.00 per day for up to a maximum of 10 days |
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For the cost of care by a registered nurse recommended by a Medical Practitioner Band IV or Oral Surgeon immediately following general, oral or cardiac surgery.
Benefit Maximum:
$100 per day
$2,000 per Claims Year
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TOWER Health & Life cover the cost of post-treatment physiotherapy up to six months after being discharged from an approved private hospital on referral by the treating registered specialist or up to six months after a cycle of chemotherapy or radiotherapy treatment.
Benefit maximum
No limit per visit.
TOWER Health & Life pay up to $500 per hospitalisation or per cycle of chemotherapy or radiotherapy treatment. |
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TOWER Health & cover the cost of treatment associated with an abnormal pregnancy and/or childbirth, but excluding caesarean sections and ectopic pregnancies.
Benefit maximum
We pay up to $2,000 per policy year, less any excess. |
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| No cover for pregnancy or complications arising from pregnancy unless complications last more than 90 days after the end of pregnancy |
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| TOWER Health & Life cover any shortfall between what ACC pays for a physical injury and the actual costs covered of the surgical and/or medical treatment in an approved private hospital, less any excess. This is limited to the appropriate Benefit maximum, less any excess. A copy of ACC's decision must be supplied to us prior to treatment being undertaken. |
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OnePath does not pay for medical costs which are covered by ACC, however costs not covered by ACC can be claimed for. |
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| If the Accident Compensation Corporation (ACC) refuses to cover the cost of treatment in a Private Hospital or in the event that your ACC refunds are less than those that apply for non-Accident or non-Treatment Injury conditions under this Policy, we may make up the difference, if any, between the ACC contribution to the cost of treatment and the maximum payable under this Policy. The total refunded by Southern Cross, together with the payment made by ACC will not exceed the maximum payable under this Policy. |
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TOWER Health & Life cover the cost of surgical or medical treatment that cannot be performed at all in New Zealand, and reasonable travel cost, where the Ministry of Health provides partial funding, but that funding does not cover the full cost.
Benefit maximum
Up to $20,000 per overseas visit for treatment, less any excess. |
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Covers reasonable charges for medical treatment at an overseas hospital acceptable to Sovereign, where medical treatment covered under this policy cannot be provided in New Zealand.
A specialist must recommend the medical treatment and approval of the claim must be received from Sovereign prior to the medical treatment.
This benefit also includes two return economy class airfares for the life assured and a support person.
Benefit Maximums:
$20,000 per life assured, per lifetime - Excess applies |
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The overseas treatment benefit will reimburse overseas medical, travel and support person costs,
subject to the excess, maximums and exclusions detailed elsewhere in this Protection Benefit
Sheet. This benefit will only apply where the recommended treatment cannot be provided in
New Zealand. OnePath will determine at its sole discretion, the country to which the life
assured can travel for medical treatment. Any financial assistance which the life assured is
eligible for from any other persons or organisations, as a result of the unavailability of New
Zealand treatment options, will be deducted from any benefit payable under this overseas
treatment benefit.
Benefit Maximums:
$30,000 per life assured, per annum
Overseas Waiting List Benefit
The overseas waiting list benefit will reimburse overseas medical, travel and support person
costs, subject to the excess, maximums, limits and exclusions detailed elsewhere in this
Protection Benefit Sheet. This benefit will only apply where the recommended treatment is able
to be provided in New Zealand but cannot be provided in New Zealand within six months of the
recommended time as a direct result of insufficient medical resources. OnePath will determine
at its sole discretion, the country to which the life assured can travel for medical treatment. Any
financial assistance which the life assured is eligible for from any other persons or
organisations, as a result of the delay in accessing New Zealand treatment options, will be
deducted from any benefit payable under this overseas waiting list benefit.
The amount of reimbursement for overseas medical costs will be limited to the usual, customary
and reasonable costs which would be payable in New Zealand for the same treatment or
procedure. All maximums, excesses and benefit amounts referred to in this Protection Benefit
Sheet are in New Zealand dollars.
Benefit Maximums:
$200,000 per life assured, per annum |
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Reimbursement is available for receipted medical expenses (not accommodation or transport) for the cost of Medically Necessary treatment not available in the public or private sector within New Zealand, following approval from Southern Cross' Chief Medical Officer, based on a medical report you provide before treatment takes place. The treatment must be recommended by a Medical Practitioner Band III or IV in private practice. Ordinary Policy Exclusions apply.
Benefit Maximums:
$10,000 per Claims year
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This Benefit applies where a GP or registered specialist has recommended treatment and where that treatment cannot be performed in the insured person's local approved private hospital.
Rail or road travel
TOWER Health & Life cover the cost of rail or road travel within New Zealand where the nearest approved private hospital is more than 100km one way from the insured person's usual residence. We will reimburse the cost of mileage for road travel, at the amount determined by us from time to time, to and from the nearest approved private hospital, or the cost of return transport by rail or bus to and from the nearest approved private hospital.
Air travel
TOWER Health & Life cover the cost of a return economy airfare within New Zealand for the insured person requiring treatment and for a support person to travel to and from an approved private hospital. This Benefit applies where a GP or registered specialist has recommended treatment and where that treatment cannot be performed in the insured person's local approved private hospital.
Accommodation
TOWER Health & Life cover the cost of accommodation incurred by a support person during an insured person's hospitalisation or cycle of chemotherapy or radiotherapy treatment.
Benefit maximum
Rail or road travel
TOWER Health & Life pay up to $1,800 per hospitalisation or per cycle of chemotherapy or radiotherapy treatment for the cost of mileage, at the amount determined by us from time to time, or for the cost of a return rail or bus trip.
Air travel
TOWER Health & Life pay the cost of a return economy airfare within New Zealand for the insured person requiring treatment and one support person. We also pay the taxi fares from the airport of arrival to the approved private hospital (on admission) and from the approved private hospital (on discharge) to the airport of departure. This applies per hospitalisation or per cycle of chemotherapy or radiotherapy treatment.
Accommodation
Up to $150 per night for the accommodation costs incurred by the support person Up to $1,800 per hospitalisation or per cycle of chemotherapy or radiotherapy treatment. |
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This benefit specifically covers the transfer of a patient from one private hospital or day stay clinic to another private hospital or day stay clinic in a situation where complications have arisen and further treatment can only be provided by specialist services at the private hospital or day stay clinic where the patient is being transferred. The benefit only applies to transfers within the North and South Islands of New Zealand.
All reasonable charges for the following modes of transport will be met: air ambulance, road ambulance, road transport, or economy airfares.
Benefit Maximums:
$125 per day up to a maximum of $2,500 per life assured, per policy year - No excess applies |
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| If the required treatment is not available within the life assured's local community then OnePath
Life will reimburse the air or road ambulance costs associated with transferring the life assured
to or from a Private Hospital within New Zealand, subject to the exclusions described
elsewhere in this Protection Benefit Sheet. |
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When private treatment is not available in your hometown or city and you have to travel more than 100km from home for treatment. Payable to cover the person covered by this Policy requiring the Healthcare Service and a support person. Payable for public transport costs and hotel/motel rooms only.
Benefit Maximums:
$500 per Claims Year
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| Covers the cost of a road ambulance to and from an approved private hospital, within New Zealand for the insured person for hospitalisation, if a GP or registered specialist has recommended the transfer by ambulance. |
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TOWER Health & Life cover the cost per night of the accommodation incurred by a parent or legal guardian accompanying an insured child aged under five years listed in the acceptance certifificate or renewal certifificate, where that child is being treated in an approved private hospital, and a Benefit under Hospital-Surgical, Hospital-Medical or Cancer Treament has been paid
Benefit maximum
Up to $150 per night. Up to $1,800 per hospitalisation or per cycle of chemotherapy or radiotherapy treatment. |
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Covers reasonable charges of accommodation and/or transportation as required for a parent, guardian or support person who accompanies a life assured receiving a covered treatment outside their region of residence.
Benefit Maximums:
$125 per day up to a maximum of $2,500 per life assured, per policy year - No excess applies |
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The support person accommodation grant is payable, subject to the exclusions described
elsewhere in this Protection Benefit Sheet, where on the recommendation of an appropriate
registered medical practitioner, a support person is required to accompany a life assured outside
of their residential region for treatment, which is deemed necessary but cannot be provided
locally.
Benefit Maximums:
$300 per day for up to a maximum of 10 days
No excess applies to this Support Person Accommodation Grant.
Support Person Transfer Benefit
The support person transfer benefit is payable, subject to the exclusions described elsewhere in
this Protection Benefit Sheet, where on the recommendation of an appropriate registered
medical practitioner, a support person is required to accompany a life assured outside of their
residential region for treatment, which is deemed necessary but cannot be provided locally.
OnePath will reimburse the actual transport costs of the support person provided that those
costs are the usual, reasonable and customary costs for public transport directly to and from the
treatment destination. |
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For hospital expenses incurred when accompanying children 5 years or under where accommodation is provided in a Private Hospital.
Benefit Maximums:
$50 per night, $500 per Claims Year
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If a life assured dies when aged between 21 and 59 (inclusive), Sovereign will pay a death benefit of $2,500 to the policy owner or their estate (no excess applies).. |
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OnePath recognises that there will be immediate expenses associated with the death of a life
assured. In order to assist with these expenses OnePath will pay a funeral support benefit of
$3,000 immediately upon written notification of the death of a life assured who is older than
10 years. Where the life assured is 10 years or younger than OnePath will pay a funeral
support benefit of $2,000 immediately upon written notification of their death
No excess applies to this Funeral Support Benefit. |
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TOWER Health & Life cover the premiums due on this policy for all surviving insured persons if a policyowner dies before the age of 65 from any cause.
Benefit maximum
We pay the premiums:
For two years, or Until any surviving insured person is aged 65, whichever occurs first. |
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Upon the death of a life assured, prior to attaining the age of 70 years, and where the cause of death is not excluded under this policy, Sovereign will continue to provide cover under this policy for the surviving lives assured covered by the policy at the time of death, without requiring further premiums for 12 months from the date of death.
Benefit Maximum: 1 years premium |
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Upon the death of the Policyholder from a cause not excluded under the Policy before age 60 years, the surviving husband/wife or partner and Dependants named on the Policy will continue to qualify for the cover provided by the existing Policy free of charge for 24 months, from the date of the Policyholder's death.
Benefit Maximum: 2 years premium |
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After 12 months' continuous cover under this policy, the cover (including the premium payments) can be suspended as follows:
Overseas travel/residence
If the insured person lives or travels outside New Zealand for longer than three consecutive months the cover for the insured person can be suspended for between three and 24 months. To suspend cover you must tell us in writing before the insured person travels overseas, and provide any evidence of travel we require.
Unemployment
If you are registered as unemployed, cover can be suspended for between three and six months. To suspend cover you must tell us in writing within 30 days of you registering as unemployed and provide evidence of registration. |
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For 3 - 24 months while an insured person lives or travels overseas for longer than 3 consecutive months.
For 3 -6 months if you are registering as unemployed (After policy is inforce for at least 12 months) . |
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The Policyholder or their Dependant may suspend cover under the policy for a period of 2 to 12 calendar months if going overseas. The following conditions apply:
■ the suspension request must be in writing before leaving New Zealand;
■ the Policyholder or Dependant must have 12 continuous months cover up to the date of suspension;
■ the period of suspension must be between 2 and 12 calendar months;
■ the Policyholder or Dependant can suspend cover up to 3 times per Lifetime;
■ the Policyholder or Dependant must provide proof of departure, and re-entry to New Zealand;
■ the Policyholder or Dependant must have 12 continuous months cover between the end of the last suspension and beginning of the next.
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TOWER Health & Life make a cash payment when an insured person is admitted to a public hospital in New Zealand and is in the public hospital for three or more consecutive nights.
Benefit maximums
TOWER Health & Life pay $100 per night.
Up to $500 per policy year. |
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Lump sum payment paid if the life assured is admitted to a public hospital for more than three days (not including admissions on a private fee paying basis or for obstetric care).
Benefit Maximums:
$200 per day up to a maximum of $2,000 per life assured, per policy year - No excess applies |
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The Public Hospital cash grant will apply where the life assured is admitted to a Public
Hospital as a non-private fee paying patient, and where the admission lasts for more than 3
nights. The benefit will be payable for each extra night after the third night, subject to the
exclusions described elsewhere in this Protection Benefit Sheet.
Benefit Maximums:
$300 per night up to a maximum of 10 nights
No excess applies to this Public Hospital Cash Grant.
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If specifically accepted in writing by the Chief Medical Officer prior to treatment, treatment in a District Health Board (DHB) facility or under the direct or indirect control of a DHB will be covered up to the stated maximums in this Policy.
Public Hospital - Cash Grant
For overnight admissions for other than Accident, Treatment Injury or maternity conditions.
Benefit Maximums:
Child - $25 per night, up to $250 per admission, up to $1,200 per Claims Year
Adult - $50 per night, up to $500 per admission, up to $2,400 per Claims Year
Note: The above cash grants do not apply if the treatment in a DHB facility is reimbursed under another section in this Policy. |
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Sterilisation Benefit - After five years' continuous cover under this policy, an insured person is covered for the cost of male or female sterilisation as a means of contraception.
Benefit maximum
We pay up to $1,000 per procedure, less any excess.
Wellness - After an insured person aged 21 or over has been continuously covered under the Base Cover for 36 months, we cover the cost of a medical examination of that insured person by a GP including, for example, the cost of laboratory tests, ECG, blood pressure checks, breast examinations, cervical smears and prostate examinations.
Benefit maximum
We pay up to $100 per insured person aged 21 or over, after each 36 months of continuous cover. |
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Sterilisation Benefit - Covers reasonable charges of sterilisation including vasectomies and female sterilisation procedures (i.e. tubal ligation and hysteroscopic sterilisation). Prior approval must be received from Sovereign.
No maximum cover.
Applies only after two years of continuous cover.
Excess applies |
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Sterilisation (Surgery reimbursement levels apply) - After two years of continuous cover, reimbursement for treatment from a Medical Practitioner for sterilisation.
Bilateral Breast Reduction Allowance (50% of actual costs, up to $3,000 one-off payment) - After three years of continuous cover. Payable at the discretion of the Chief Medical Officer on receipt of a medical report prior to surgery by a Medical Practitioner Band IV, (this benefit also includes any subsequent treatment that may be required).
Gastric Banding/Bypass Allowance ($7,500 one-off payment) - After three years of continuous cover. Payable at the discretion of the Chief Medical Officer on receipt of a medical report prior to surgery by a Medical Practitioner Band IV, (this benefit also includes any subsequent treatment that may be required).
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No excess applies |
No excess applies |
Your chosen base cover excess applies, however there is a minimum excess on this add-on of $250 (so even if you have no excess on your base plan, there would still be a $250 excess on this add-on) |
Base cover excess applies |
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Covers reasonable charges of a specialist when referred
by a registered medical practitioner including:
Cardiac Surgeons
Cardiologists
Ear, Nose & Throat Specialists
Gastroenterologists
General Surgeons
Gynaecologists
Neurosurgeons
Oncologists
Orthopaedic Surgeons
Urologists
Cover is not provided for obstetricians, psychiatrists or psychologists. |
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The specialist benefit will cover the costs of any specialist consultations, subject to the
exclusions described elsewhere in this Protection Benefit Sheet, which have been recommended
by an appropriate registered medical practitioner and which do not form part of the costs
associated with surgery or Private Hospital admission.
For the purposes of this specialists benefit a specialist can include the following:
■ Registered Osteopath
■ Registered Naturopath
■ Registered Homeopath
■ Registered Chiropractor
■ Registered Acupuncturist |
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Medical Practitioner Band II
Initial consultation ($150)
Follow-up consultation ($115)
- No yearly limits on the number of consultations
Medical Practitioner Band III
Consultation following referral from a Medical Practitioner Band I or II.
Initial consultation ($300)
Follow-up consultation ($125)
- No yearly limits on the number of consultations
Oncologist
Consultation following referral from a Medical Practitioner Band I or II.
Initial consultation ($300)
Follow-up consultation ($125)
- Maximum per year: $1,500 per Claims year
Psychiatrist
Consultation following referral from a Medical Practitioner Band I or II.
- Maximum per year: $200 per Claims Year
Surgeons
Consultation following referral from Medical Practitioner Band I or II to a Medical Practitioner Band IV or an Oral Surgeon. Including consultations by a Medical Practitioner Band IV vocationally registered in Anaesthesia for chronic pain or pre-operative clinic consultations only.
Initial consultation ($175)
Follow-up consultation ($125)
Consultation with minor surgery (incl. preceding consultation) (Surgery reimbursement levels apply)
- No yearly limits on the number of consultations.
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Covers the cost of diagnostic radiology and diagnostic imaging tests, under the Benefit maximums below, after referral by a GP or registered specialist, even when the insured person has not been, or will not be, hospitalised for treatment.
Benefit maximum
TOWER Health & Life pay up to the following:
X-rays $1,200
Arteriogram $1,200
Ultrasound $500
Scintigraphy $400
Mammography $300
Benefit maximums are per policy year.
Cardiac Investigations Benefit
Covers the cost of cardiac investigations after referral from a GP or a registered specialist, even when the insured person has not been, or will not be, hospitalised. Investigations such as treadmills, holter monitoring, ambulatory blood pressure monitoring, cardiovascular ultrasound, echocardiography, myocardial perfusion scans and cardioversion are included.
Benefit maximum
We pay up to $60,000 per policy year. |
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Covers the reasonable charges of diagnostic procedures directly relating to a medical condition when referred by a specialist including:
Allergy Testing
Audiology
Audiometric tests
CT Scans
Colonoscopy*
Cystoscopy
Electroencephalography (EEG)
Electromyography (EMG)
Exercise ECG
Gastroscopy
Holter Monitoring
Laboratory Tests
Mammography*
MRI Scans
Myleogram
Ultrasound
Urodynamic assessments
X-Rays
*Cover is not provided for routine screening or periodic testing.
Benefit Maximums: Included as part of the maximum specialist consultation cover above |
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The diagnostic tests benefit will cover the costs of any specific diagnostic procedures, subject to
the exclusions described elsewhere in this Protection Benefit Sheet, which have been
recommended by an appropriate registered medical practitioner and which do not form part of
the costs associated with surgery, Private Hospital admission or the major diagnostic
procedures detailed in Clause 7. of this Protection Benefit Sheet.
Benefit Maximums: $3,000 per life insured per annum |
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(Maximum payable per Claims year stated in brackets)
Imaging
Carried out in a Private Hospital or other Southern Cross approved facility.
X-ray ($500 per Claims Year)
Mammography ($500 per Claims Year)
Ultrasound ($500 per Claims Year)
Nuclear Scanning* ($700 per Claims Year)
Computerised Axial Tomography (CT/CAT Scan)* ($60,000 per Claims Year)
Magnetic Resonance Imaging (MRI Scan)* ($60,000 per Claims Year)
Myocardial perfusion scan* ($1,500 per test)
* Must be referred by a Medical Practitioner Band II, III or IV in private practice.
Tests
Cardiac Tests* ($5,000 per Claims Year)
Diagnostic Tests* ($3,000 per Claims Year)
Audiologist ($200 per Claims Year)
Performed by a member of the NZ Audiological Society.
Audiometric Tests Including: Brain Stem Evoked Response* ($210 per Claims Year)
Allergy Testing ($175 per Claims Year)
Laboratory Tests (incurred charges) ($70 per Claims Year)
* Tests must be carried out following referral by a Medical Practitioner Band III or IV in private practice.
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Obstetrics (Up to $1,250 per Policy per Claims Year)
After three years of continuous cover, reimbursement for obstetric care carried out by a Medical Practitioner vocationally registered in obstetrics and gynaecology or anaesthesia and/or for accommodation in a Southern Cross approved facility.
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Covers the cost of GP visits, including home visits, ECG, cervical smears and minor surgery under local anaesthetic.
Benefit maximums
Up to $55 per GP clinic visit, including after hours.
Up to $80 per home visit.
Up to $25 per visit for ACC Top-up. You cannot use the $55/$80 per clinic/home visit Benefit to add to this.
Up to 12 GP visits per policy year. Minor surgical procedures are not counted in the 12 visits.
Up to $200 per minor surgical procedure. You cannot use the $55/$80 per clinic/home visit Benefit to add to this. |
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Cover not available |
Cover not available |
Medical Practitioner Band I
Surgery consultation (Up to $50 per consultation)
Home consultation (Up to $75 per consultation)
After hours (Up to $75 per consultation)
Practice nurse (where no Medical Practitioner Band I fee applies) (Up to $22 per consultation)
The above reimbursements have no yearly limits on the number of consultations.
Charges for prescription items on the Pharmac Schedule, Pharmac Approved and prescribed by a Medical Practitioner (all Bands).
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Covers the cost of medicines and drugs listed under Sections A to G of the Ministry of Health PHARMAC Pricing Schedule prescribed by a GP or registered specialist that meet the eligibility criteria for funding.
Benefit maximums
Up to $15 per item.
up to $300 per policy year. |
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Up to $400 per Claims Year |
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Covers the cost of physiotherapy treatment after referral by a GP or registered specialist.
Benefit maximums
Up to $40 per visit.
Up to $15 per visit for ACC Top-up. You cannot use the $40 per visit Benefit to add to this.
Up to $400 per policy year. |
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See "Other Paramedical Services" below |
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Covers the cost of visits to/by an independent nurse or nurse practitioner.
Benefit Maximums:
Up to $30 per visit.
Up to six visits per policy year. |
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See "General Practitioners Benefit" above |
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Registered Optometrist (Up to $50 per consultation)
Acupuncture (Carried out by a Medical Practitioner Band I or II) (Up to $40 per consultation)
Chelation Therapy (Carried out by a Medical Practitioner Band I) (Up to $40 per consultation)
Registered Physiotherapist* (Up to $50 per consultation, $250 per Claims Year)
Registered Orthoptist* (Up to $200 per Claims Year)
Registered Psychologist* (must hold a clinical diploma and be in private practice. Reimbursements are made for clinical treatments, excluding educational, industrial or sports psychology.) (Up to $300 per Claims Year)
Registered Podiatrist* (Up to $35 per consultation, $175 per Claims Year)
Ambulance (Emergency transportation only) (Up to $180 per Claims Year)
Registered Chiropractor* (Including x-rays and cost of medication) (Up to $50 per consultation, $250 per Claims Year)
Registered Osteopath* (Including x-rays and cost of medication) (Up to $50 per consultation, $250 per Claims Year)
NZ Registered Dietitian* (Up to $300 per Claims Year)
* On referral by a Medical Practitioner Band I or II.
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After 24 months' continuous cover under the GP Option, and at the end of every 24 months thereafter, providing claims for events that occurred within the preceding 24 month period under the GP Option are less than $150, each insured person aged 21 or over will receive a reimbursement of the cost of either:
Membership to a recognised gym or sports club, or
Sports/fitness equipment purchased from a recognised sporting retailer.
If you submit a claim for events which occurred within the preceding 24 month period after this Benefit has been paid, we will deduct the amount paid to you for this Active Wellness Benefit from the claim.
Benefit maximum
We pay up to $150 per insured person, aged 21 or over, after each 24 months of continuous cover under the GP Option. |
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Base cover excess does not apply . TOWER Health & Life will refund you 80% of the cost incurred up to the benefit maximums.
Note - A six-month stand down before benefits can be claimed under this option.
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Cover not available |
Cover not available |
Base cover excess does not apply. This section provides 75% reimbursement of medical charges up to the Policy Limits specified for each category of cover.
This cover includes annual general medical checkup by a Medical Practitioner (Policyholder only) for up to $90 per Claims Year
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Covers the cost of dental treatment by a registered dental practitioner or oral surgeon, including examination, cleaning and scaling, fi llings, associated x-rays and removal of teeth.
Benefit maximum
We pay up to $500 per policy year. |
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Dental - 75% of expenses incurred
Benefit maximum
$500 per Claims Year |
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Covers the cost of optometrist, orthoptist and optician examination fees and the cost of glasses and contact lenses when these are required as a result of a vision change.
Benefit maximums
Up to $55 per consultation/examination.
Up to $275 per policy year for consultations/examinations.
Up to $330 per policy year for each insured person for glasses and contact lenses. |
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Prescription lenses/spectacles (including frames) - 75% of expenses incurred
Benefit maximums
$400 per Claims Year |
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Covers the cost of audiometric tests and audiology after referral from a registered specialist.
Benefit maximums
Up to $250 per policy year for audiology.
Up to $250 per policy year for audiometric tests. |
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See "Diagnostic Tests" section under "Summary of Specialist & Tests Add on" table above
re: Audiologists & Audiometric Tests |
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Covers the cost of acupuncture by a GP or by a registered physiotherapist, after referral from a GP or registered specialist.
Benefit maximums
Up to $40 per visit.
Up to $15 per visit for ACC Top-up. You cannot use the $40 per visit Benefit to add to this.
Up to $250 per policy year. |
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See "Other Paramedical Services" section under "Summary of GP cover Add on" table above
re: Acupuncture benefit |
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Covers the cost of chiropractic treatment after referral from a GP or registered specialist.
Benefit maximums
Up to $40 per visit.
Up to $15 per visit for ACC Top-up. You cannot use the $40 per visit Benefit to add to this.
Up to $250 per policy year for visits.
Up to $80 per policy year for x-rays. |
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See "Other Paramedical Services" section under "Summary of GP cover Add on" table above
re: Chiropractor benefit |
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Covers the cost of osteopathy treatment after referral from a GP or registered specialist.
Benefit maximums
Up to $40 per visit. Up to $15 per visit for ACC Top-up. You cannot use the $40 per visit Benefit to add to this. Up to $250 per policy year for visits. Up to $80 per policy year for x-rays. |
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See "Other Paramedical Services" section under "Summary of GP cover Add on" table
re: Osteopath benefit |
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Covers the cost of podiatry treatment after referral from a GP or registered specialist.
Benefit maximums
Up to $40 per visit.
Up to $250 per policy year. |
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See "Other Paramedical Services" section under "Summary of GP cover Add on" table above
re: Podiatry benefit |
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Covers the cost of speech, occupational and eye therapy after referral from a GP or registered specialist.
Benefit maximums
Up to $40 per visit.
Up to $300 per policy year for the combined total of all of these therapies. |
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After an insured person has been continuously covered under the Dental and Optical Option for 24 months, the Dental Care Benefit will be extended to include orthodontic treatment up to the same Benefit maximums.
Benefit maximum
All costs paid under this Benefit are included within the Benefit maximum for the Dental Benefit of up to $500 per policy year. |
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TOWER Health & Life will not pay a benefit for –
The following health conditions:
a) A health condition in connection with the misuse of alcohol and/or prescription drugs.
b) A health condition in connection with the use of non-prescription drugs.
c) A psychiatric health condition or any mental disorder and subsequent treatment.
d) A dental health condition (except where the contrary is expressly specified in this policy).
e) Senile illness or dementia.
f) Acquired immune deficiencies (AIDS) or associated health conditions including HIV and related health conditions.
g) Infection by any sexually transmitted disease and any resulting complication.
h) A known congenital health condition. (i.e. a health condition which is recognised at birth, or diagnosed within three months of birth, whether it is inherited or due to external factors such as drugs or alcohol).
i) Any health condition as a consequence of war, invasion, act of foreign enemy, hostilities or warlike operations (whether war is declared or not), civil war, civil commotion, mutiny, rebellion, revolution, insurrection, act of terrorism, act of bio terrorism, peace keeping duties, or military or usurped power.
j) Any health condition not registered with the Ministry of Health as a disease entity.
k) Any pre-existing condition. This exclusion does not apply, however, in respect of a health condition declared on your application form and accepted by TOWER Health & Life.
l) Any acute health condition.
m) A health condition arising from a criminal offence by an insured person that resulted in a conviction.
n) Infertility, normal pregnancy and childbirth, termination of pregnancy, erectile dysfunction, sterilisation, contraception
or contraceptive procedures (except where the contrary is expressly specified in this policy).
The following tests, diagnostic procedures, treatments, or health services:
a) Geriatric care including geriatric hospitalisation or long term care.
b) Breast reduction.
c) The treatment of obesity.
d) Rehabilitation, convalescence, respite, disability support services costs (except where the contrary is expressly stated
within this policy).
e) Cosmetic treatment or elective treatment which does not improve an insured person’s health.
f) Preventative treatment and surveillance testing except where provided for under a Wellness Benefit.
g) Any investigation and/or treatment for sleep disturbances, snoring or obstructive sleep apnoea.
h) Treatment for self-inflicted injuries or attempted suicide.
i) Any services or treatment not normally conducted by a GP or registered specialist, and/or not recognised by the Medical Council of New Zealand or Ministry of Health (except where the contrary is expressly stated within this policy).
j) Specialised tertiary treatments such as heart, lung, kidney, liver and bone marrow transplants as provided by government funded agencies.
k) Specialised transfusions of blood, blood products, renal dialysis or CAPD as provided by government funded agencies.
l) Any treatment for the correction of myopia (short sightedness) or hypermetropia (long sightedness), or presbyopia (blurred vision) or any related complications except where provided for under the Dental Benefit.
m) Radial keratotomy or photo-retractive keratectomy or any related complications.
n) Any costs incurred as a result of cancellation of treatment under one of the eligible benefits except where that cancellation is on medical advice.
o) Costs incurred outside New Zealand (except where expressly specified otherwise in this policy).
The cost of:
a) Mechanical tools as determined by TOWER Health & Life. For example (without limitation): glucometers, oxygen machines, and respiratory machines.
b) Aids as determined by us. For example (without limitation): hearing aids, personal alarms, and orthotic shoes.
c) Appliances to assist with mobility as determined by TOWER Health & Life. For example (without limitation): crutches, wheelchairs, and artificial limbs. This does not include surgically implanted prostheses.
Cost and expenses recovered or recoverable from a third party or under any other contract of indemnity or insurance.
The cost of treating a physical injury or medical misadventure except as provided under the ACC top-up benefit. Where no ACC top-up maximum is specified, the amount TOWER Health & Life pay is the lesser of the actual costs of the treatment or the health plan benefit maximum, less the amount payable by ACC. Where the benefit maximum is subject to a maximum percentage of actual costs, eg 80%, this amount is subject to that maximum percentage.
Medicines or drugs that are not listed on the PHARMAC Schedule.
Any costs for a health condition that arose during a stand-down period. Stand-down periods do not apply to newborn dependent children added to the policy within 4 months of birth. |
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Sovereign will not pay any expenses incurred in relation to, or as a consequence of, any of the following:
■ An existing condition unless the symptom or condition was disclosed at the time of your
application and accepted in writing by Sovereign;
■ Any congenital conditions;
■ Reconstructive or reparative procedures or surgery, which results from, or which is traceable to, or
is medically related to, any surgery performed prior to the risk commencement date;
■ Any elective or cosmetic procedures and associated treatments (including, for example, surgery
for breast enlargements, facelifts, varicose veins);
■ Breast reduction surgery and gynaecomastia;
■ Acne treatment, except where classified by a specialist as Grade 4 acne with serious medical
implications;
■ The misuse of prescribed or non-prescribed drugs, including where they have not been taken in
accordance with the manufacturer’s or a registered medical practitioner’s directions;
■ Certifiable mental disease or psychiatric illness or any charges relating to services resulting from a
referral to, or provided by, a psychiatrist. This includes all counselling services;
■ Suicide, self-inflicted injuries or illness, or any accident, illness, condition or disability arising from,
or caused or contributed to by, drug taking, intoxication or misuse of alcohol, or nuclear
contamination;
■ HIV related disorders, including AIDS;
■ Obstetric visits, pregnancy, childbirth, abortion, or any conditions or complications arising from
any of the foregoing;
■ Contraception of any type;
■ Diagnosis, management and treatment of infertility;
■ Circumcision, except where medically necessary;
■ Diagnosis, management and treatment of snoring, except where a specialist confirms diagnosis of
sleep apnoea and the surgical treatment is medically necessary. (Pre-approval of any claim for
treatment must be sought or obtained from Sovereign before any costs are incurred);
■ Any geriatric or dementia conditions, including disability support services;
■ New medical treatments, procedures or technologies that have not been approved by Sovereign;
■ Treatment requiring periodontal, orthodontic, endodontal or cosmetic procedures, including, but
not limited to, conditions arising out of neglect of dental services;
■ Sterilisation (except as provided under the Loyalty Benefit);
■ Any surgery for the correction of refractive visual errors;
■ Preventative treatment, or treatment or investigation of any condition that will not cause significant
problems for the health of the individual if medical treatment is not received (including, for
example, routine screening or mole mapping);
■ Treatment for obesity (including treatment of complications arising from any treatment for obesity);
■ Renal dialysis;
■ Injuries of war or resulting from any terrorist act (whether war is declared or not);
■ Organ donation and receipt;
■ Charges for a treatment or procedure not provided by a registered medical practitioner practicing
within his or her scope of practice;
■ Treatment provided by a public hospital, except where expressly covered by this policy;
■ Physiotherapist’s, chiropractor’s, osteopath’s, naturopath’s, homeopath’s, acupuncturist’s, and
podiatrist’s costs;
■ Nursing costs, except where expressly covered by this policy;
■ Prescription charges, except where expressly covered by this policy;
■ Any charge incurred for non-essential or personal items (for example, newspapers, spouse/family
meals, alcohol, TV rental);
■ Surgical, medical or dental appliances, other than surgical prostheses specified in this benefits
sheet, including, but not limited to, cardiac pacemakers, nerve appliances, cochlear implants, bite
splints and orthotics;
■ Any condition arising from participation in a criminal act;
■ Any condition specifically excluded in the policy document;
■ Costs for treatment carried out outside of New Zealand (except where expressly covered under
the Overseas Medical Treatment benefit);
■ Palliative Care.
■ Sovereign will not pay any part of a claim that you make under this policy to the extent that you
are able to recover from sources outside of this policy, including any other contract of insurance,
regardless of whether you claim from these other sources or not.
■ Sovereign will not pay any benefit under this policy for any additional surgery performed during
any operation, which is not directly related to any medical condition or treatment covered under
the terms of this policy.
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OnePath will not pay any claim if a medical condition is either directly or indirectly caused by
or results from any of the following:
■ Self-inflicted harm including attempted suicide, alcohol or drug abuse; or
■ Pregnancy or complications arising from the pregnancy unless complications last more
than 90 days after the end of the pregnancy; or
■ Participating in a criminal act; or
■ HIV and related conditions including AIDS; or
■ Mental disease or disorder or psychiatric conditions; or
■ Geriatric conditions or senility; or
■ Congenital disorders.; or
■ War, whether declared or not, civil war, participation in any armed force or peacekeeping
activities resulting from an act of war or terrorism.
OnePath will also not pay any claim for any of the following costs:
■ Acute admission to a Public Hospital or Private Hospital; or
■ Cosmetic surgery or procedures; or
■ General practitioner's costs; or
■ Dentists costs; or
■ Prescription costs except those covered under the surgical and non-surgical
hospitalisation benefits outlined in clauses 5 & 6 of this Protection benefit sheet; or
■ Costs incurred outside of New Zealand and Australia except those specifically covered
under the overseas treatment and overseas waiting list benefits detailed in clauses 12 and
13 of this protection benefit sheet; or
■ Contraception of any kind; or
■ Treatment provided by a Public Hospital except under the public hospital cash grant
detailed in clause 16 of this protection benefit sheet; or
■ Preventative treatment; or
■ Infertility treatment of any kind; or
■ Sterilisation costs incurred within 2 years of the commencement date of this major
medical cover benefit; or
■ Medical costs which are covered by ACC; or
■ Laser eye surgery; or
■ Any treatment which has not been approved by the Minister of Health or someone
delegated by the Minister of Health to make such decisions for marketing in New
Zealand; or
■ Any treatment which is not recognised as the appropriate treatment for Non-acute
Medical Conditions, in the sole opinion of OnePath.
OnePath will also not pay any funeral support benefit claim if a life assured dies as a direct or
indirect result of self-inflicted harm including suicide or attempted suicide that occurs within
the first 13 months following the date this major medical cover benefit commenced. If the
policy is cancelled and subsequently re-started by you then this 13-month suicide exclusion
will also re-apply from the effective date of the policy reinstatement. |
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Unless specifically included in the Schedule of Benefits, no reimbursement shall be made for any expenses incurred in relation to, or as a consequence of, any of the following:
a) Pre-Existing Conditions; (including but not limited to those conditions specifically set out in the Membership Certificate);
b) treatment for pregnancy and childbirth;
c) diagnosis and treatment of infertility;
d) geriatric care, dementia, and Disability Support Services;
e) injury or disability suffered as a result of war or any act of war, declared or undeclared, or of active duty in the military, naval or air forces of any country or international authority, or as a direct or indirect result of terrorism;
f) cardiac pacemakers, nerve appliances, cochlear implants, bite splints and orthotics and any other appliances (surgical, medical or dental) other than surgically implanted Prostheses unless specifically included in the Schedule of Benefits or Prosthesis Schedule;
g) suicide or self-inflicted illness or injury; or accident, illness, condition or disability arising from, or caused or contributed to by, substance abuse, drug taking or intoxication, whether prescribed or recreational;
h) any "Accident" or "Treatment Injury" (subject to clause 4.4);
i) Cosmetic Treatment;
j) maintenance examinations or medical check ups;
k) sterilisation (or its reversal);
l) contraception of any type;
m) breast reduction; unless approved as an Allowance by the Chief Medical Officer;
n) obesity or any treatment of obesity;
o) HIV, HIV disorders including AIDS, and any medical condition that arises in any way from HIV infection;
p) conditions arising out of the neglect of dental services;
q) dental treatment of persons eligible for benefits or assistance under any Government dental benefits scheme for the time being in force;
r) dental titanium implants and/or related surgery;
s) services performed by a periodontist, endodontist or orthodontist, except as specifically provided under the dental benefit in the VIP Plans 3 and 4;
t) commitment for assessment and treatment under the Mental Health Act (Compulsory Assessment and Treatment) Act 1992;
u) psychiatric treatment, unless provided by a Medical Practitioner Band I or covered under the psychiatrist benefit, as specified in the Schedule of Benefits;
v) conditions specifically excluded in the Membership Certificate of the Policy;
w) organ transplant or any related expenses for both donors and recipients;
x) renal dialysis;
y) correction of refractive visual errors or astigmatism by surgery, surgically implanted intra occular lens(es), or laser treatment;
z) Chronic Conditions;
aa) Healthcare Services provided by a person who is not a Medical Practitioner;
bb) Healthcare Services provided outside New Zealand;
cc) Acute Care;
dd) diagnosis, management and treatment of snoring;
ee) diagnosis, management and treatment of developmental or congenital deformities or abnormalities of the facial skeleton and associated structures;
ff) hospital charges of a personal convenience nature;
gg) surgery designed to assist or allow the implementation of orthodontic Healthcare Services;
hh) physical examinations for life insurance, travel insurance, driver licence or any other examination or check up as required for a third party or preparation of reports;
ii) Unapproved Healthcare Services;
jj) vaccinations;
kk) Prophylactic Healthcare Services unless approved by the Chief Medical Officer;
ll) Health Screening;
mm) treatment of any condition not Detrimental to Health or any Healthcare Service not Medically Necessary;
nn) Congenital Conditions;
oo) Mole Mapping or dermatological surveillance;
pp) Surgically implanted lens(es) other than monofocal lens(es);
qq) Gynaecomastia;
rr) Healthcare services at a public facility directly or indirectly controlled by a DHB unless specifically accepted in writing by the Chief Medical Officer prior to treatment.
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