> _Markdown transcription of AIA AIA Real Health policy wording, effective 2024-03-10. Source: https://www.aia.co.nz/content/dam/nz/en/docs/our-products/policy-wordings/policy-wordings-legacy/real-personal/aia-real-health-cover-policy-wordings.pdf_ --- # REAL Health – Personal Cover ## SECTION A – GENERAL INFORMATION AND DEFINED TERMS ### Welcome to AIA New Zealand's REAL Health This Policy document will explain exactly what Your REAL Health plan covers. Please take the time to read it through carefully, and should You have any questions, don't hesitate to contact either Your adviser or AIA New Zealand. ### POLICY PURPOSE Your REAL Health plan is a major medical policy designed to assist You with meeting the financial costs associated with the health services covered by this plan. ### POLICY The terms of Your REAL Health plan with Us are set out in this Policy and the attached Policy Schedule, complete with any endorsements. The Policy Schedule includes personal details of the people insured and may include special terms of Your contract. This Policy is a contract of insurance between You and Us. It includes the following parts: - Your application for insurance; and - this Policy wording; and - the Policy Schedule including any endorsements; and - any addendum to the Policy Schedule; and - any other written notice that We give You; and - any written notice that You give Us. ### FREE LOOK PERIOD To enable You to consider the Policy in detail You will have a free look period of fourteen (14) days after You receive Your Policy document. During this period, if You decide that the Policy does not suit Your needs, then You may return it to Us and receive a full refund of all Total Premiums paid and the Policy will be cancelled. You will be deemed to have received Your Policy document seven (7) days after it was posted by Us. ### RESPONSIBILITY FOR TRUTHFULNESS When You apply for insurance with AIA New Zealand and when You make a claim on the Policy, You have a legal duty of disclosure to AIA New Zealand. The duty of disclosure means that: 1. All the statements that You or any Life Assured make to AIA New Zealand (both written and oral), including the answers in: a. the application; b. any claim made by You; and c. any other communication by You or any Life Assured with AIA New Zealand; must be complete, true and correct. 2. You and any Life Assured must disclose everything that You or any Life Assured know, or could reasonably be expected to know, that is relevant to AIA New Zealand's decision whether: a. to accept Your application for insurance, on what terms AIA New Zealand will accept it and how much it will cost; or b. medical evidence to support Your application needs to be provided and translated; or c. to accept Your claim on the Policy. 3. This duty of disclosure in relation to Your application for insurance continues from the time You complete the application until either: a. the Policy Commencement Date or the date AIA New Zealand accepts Your application for insurance, whichever is later; or b. AIA New Zealand declines Your application for insurance. 4. You and any Life Assured also have the same duty of disclosure to AIA New Zealand throughout the term of the Policy whenever You or any Life Assured communicate with AIA New Zealand and whenever You extend, vary or reinstate Your insurance. #### IMPORTANT If You or any Life Assured do not comply with Your duty of disclosure, AIA New Zealand may at its discretion do any or all of the following: 1. Decline any claim that You make; 2. Alter the terms of any Benefits under the Policy; 3. Remove any Benefits under the Policy; 4. Avoid Your Policy from the Policy Commencement Date; 5. Retain all Premiums, policy fees and recover any Benefits paid; 6. Terminate this Policy. If You are not sure whether You should disclose a particular fact, please ask Us or Your Insurance Adviser. ### PRIOR APPROVAL We strongly recommend that You seek prior approval for any claim to ensure that the medical treatment or procedure is covered under the terms and conditions of Your REAL Health Plan. We recommend You contact Us as soon as possible to start this process. We can be contacted on 0800 800 242 or email nz.claims@aia.com. In order for a claim to be paid where We have provided You with pre-approval advice, Your Policy must be in force on the date You have the medical treatment or procedure for which We have pre-approved. ### SECOND OPINION We reserve the right to seek a second medical opinion in certain circumstances. All costs related to a second medical opinion will be paid for by Us. We require You to comply with any reasonable requests We or Our medical examiner may make including attending any examinations or tests. ### DEPENDANT CHILDREN A Child will become subject to adult Premium rates on the next Policy anniversary date after they reach age twenty-one (21). We will automatically continue to cover that person on this Policy as an adult Life Assured and deduct the additional Premium based on their age, gender and Annual Excess for the cover, from the same payment source and at the same frequency as this Policy, unless You advise Us otherwise. ### ADDING AND REMOVING FAMILY MEMBERS Requests for changes can be made at any time by writing to Us to extend cover under this Policy for: - The spouse or partner of the Policy Owner - A Child under the age of twenty one (21) AIA New Zealand is not obliged to agree to cover any additional Life Assured unless We are satisfied that the Life Assured is in good health. This will be determined based on the information provided on the application at the time. If additional Lives Assured are added to this Policy, the Policy Premium will be increased with the applicable Premium. You can remove any Life Assured from this Policy at any time by giving Us thirty (30) days written notice. ### NEW BORN BABIES Your new born Child will automatically be covered for the first four (4) months at no additional Premium. You must advise Us of the Child's name, gender, and date of birth before this coverage period expires and the applicable Premium will be payable. Thereafter an application form will need to be completed and the Child will be medically underwritten. The Policy Premium will increase with each Child added to this Policy. Congenital conditions are not covered. ### TRANSFERING TO ANOTHER POLICY A person who is: - over the age of twenty-one (21); or - no longer financially dependent on, or under the legal guardianship of You or Your spouse or partner, may transfer to their own Policy if they make a written application to Us after their twenty-first (21st) birthday or the date (as determined by Us) that they ceased to be dependent. No health evidence will be required for a person transferring from an existing Policy to his or her own Policy. Medical underwriting will be required where the new Policy contains additional Benefits to that of the original Policy. Your spouse or partner (following a separation) may also transfer to their own Policy if they make a written application to Us. No medical underwriting will be required for a person transferring from an existing Policy to his or her own Policy. Medical underwriting will be required where the new Policy contains additional Benefits to that of the original Policy. ### WHEN CAN THIS POLICY END This Policy will end when any of the following happens: - You ask Us in writing to cancel it by giving Us thirty (30) days' notice; or - You fail to pay the Total Premium within thirty (30) days after the Premium due date; or - If We avoid Your Policy from inception as outlined in Clause 4 "Responsibility for Truthfulness" above. ### ADDING OPTIONAL BENEFITS The Optional Specialist and Tests Benefit and Optional Waiver of Premium on Total Disablement Benefit can be added to Your Policy subject to the following: - A new application form - Any increase in Premium for the additional Benefit will start from the Policy Commencement Date of the new Benefit. - We do not have to agree to any additional optional Benefit unless We are satisfied that the Life Assured is in good health. You may remove any optional Benefit by giving Us thirty (30) days written notice. ### GST The Benefit maximums stated in the Policy include Goods and Services Tax (GST) charged by the supplier of the good or provider of the services. ### JURISDICTION AND CURRENCY The laws of New Zealand apply to this Policy. The New Zealand courts have exclusive jurisdiction. All monetary amounts referred to in this Policy are expressed and payable in New Zealand dollars and include GST. ### CODE OF PRACTICE The REAL Health Plan complies with the Health Funds Association of New Zealand (Inc) Code of Practice for Health Insurance Underwriters. ### PRIVACY We will comply with the Privacy Act 1993 and the Health Information Privacy Code 1994 at all times. If you believe We have breached Your or any Life Assured's right to privacy, please contact Us. ### PREMIUM RATES We may change the Premium rates of this Policy at any time by giving You thirty (30) days written notice to Your last known postal address. ### GUARANTEED TERMS AND CONDITIONS AND FUTURE UPGRADES The terms and conditions of this Policy are guaranteed, subject to the permitted changes set out below. We will only change the terms and conditions of this Policy to: - Add new Benefits or increase existing Benefits; or - Where legislation and/or government policy that impacts this Policy changes; or - Where You fail to meet Your responsibility for truthfulness as set out in Clause 4 above; or - For Premium rate changes as set out in Clause 17. ### POLICY FEE We will charge You a policy fee, which forms part of Your Total Premium. The policy fee is used to pay the ongoing administration costs of this Policy. The policy fee is specified in Your Policy Schedule. We may change this policy fee from time to time and You will be notified in writing of this change. ### ELIGIBILITY All Lives Assured must be eligible for publicly funded health and disability services as per the New Zealand Public Health and Disability Act 2000. We may request to see original or certified copies of the Lives Assureds' documents, including visas or work permits in passports, birth certificates or driver's licenses. We reserve the right to cancel the relevant Life Assured's cover if the relevant person no longer meets the criteria. ### NO SURRENDER VALUE This Policy has no surrender or cash value if it is cancelled. ### COMPLAINTS You may at any time write to Us or to Your Insurance Adviser for further information about Your Policy. We have a complaints procedure that is intended to resolve any problem quickly and fairly. If You have any questions or complaints about this Policy please phone Us on 0800 800 242 or write to Us. If You have been through Our internal complaints procedure and the situation has reached a 'deadlock', then We will advise You of how to contact the Insurance and Financial Services Ombudsman Scheme for further assistance. ### ACCIDENT COMPENSATION ACT 2001 (ACC) - Where the ACC provides cover for an injury, illness, or condition, You must obtain approval of the ACC for the provision of treatment in a Private Hospital; or - Where the ACC approves the claim but declines to pay the costs of surgical treatment, We may meet the cost of that treatment when You provide Us, prior to Your treatment, with a copy of the ACC's decision; or - Where the ACC accepts Your claim, We will provide Top-Up payments for the difference between ACC reimbursements and Our Usual, Customary and Reasonable charges applicable for eligible surgical and medical costs. - Where ACC declines Your claim outright, We may require You to appeal the ACC decision through the documented ACC Review Process. All appeals must be made within the ACC timeframes of three (3) months post original decision. ### DEFINED TERMS In this REAL Health Policy certain words have particular meanings. These words are in Bold and the meanings are explained below. #### Interpretation Throughout this Policy 'We', 'Our' 'Us' or 'AIA New Zealand' means AIA International Limited - New Zealand Branch, and/or any related and/or authorised companies and agents (including company officers acting in the scope of their authority). 'You' or 'Your' means the Life Assured. #### ACC Means the Accident Compensation Corporation as defined by the Accident Compensation Act 2001, or its successor under any subsequent legislation. #### Allowance Contribution toward the cost of the treatment specified. #### Annual Excess This is the amount shown in the Policy Schedule that the Life Assured will be responsible for paying before a claim can be paid or reimbursed. The Annual Excess resets after every Policy anniversary date, unless it relates to a Related Surgery, in which case it will be waived. #### Annual Renewal Date The 12 month anniversary of the Policy Commencement Date. #### Approved Facility Private Hospital, Day Clinic or Facility or other medical facility approved by AIA New Zealand. #### Audiologists A Recognised Health Professional who holds a current annual practising certificate, and is a member of the New Zealand Audiological Society. #### Benefit or Benefits Means an amount of money payable to or on behalf of a Life Assured, in respect of approved expenses incurred for treatment, in accordance with the Policy Schedule. #### Breast Reconstruction Includes nipple tattooing, internal prosthesis and expanders: - following a mastectomy for the treatment of diagnosed breast cancer, and/or - following a prophylactic mastectomy which has been covered as a Prophylactic Surgery under the Cancer Treatment Benefit – Surgical and Medical Treatments of this policy; or - where a claim for a prophylactic mastectomy would have been covered as a Prophylactic Surgery under the Cancer Treatment Benefit – Surgical and Medical Treatments of this policy, had the procedure not taken place in a Public Hospital. Breast Reconstruction also includes surgery on the unaffected breast to achieve breast symmetry following a mastectomy of the affected breast to treat diagnosed cancer. In no circumstances does Breast Reconstruction, as defined above, include prophylactic mastectomy surgery of the unaffected breast. #### Cancer Immunotherapy Medicines Pharmac Medicines or Non Pharmac Chemotherapy Medicines for the proven treatment of cancer which stimulate or restore the ability of the immune (defence) system to fight this disease. #### Clinical Psychiatrist or Psychiatrist Means a Registered Medical Specialist who is in Private Practice and holds a current annual practicing certificate. #### Congenital Health anomalies or conditions present at birth whether known or unknown. #### Child or Children Any person under the age of twenty-one (21) who, in Our opinion, is either the natural or legally adopted child of, or is under the legal guardianship of, You or Your spouse or partner. #### Chiropractor A Recognised Health Professional who holds a current annual practising certificate, and is a member of The Chiropractic Board of New Zealand. #### Counselling Means provision of professional assistance and guidance in resolving personal or psychological conditions provided by a Clinical Psychologist, Psychiatrist or Psychologist. #### Day Clinic or Facility A registered healthcare facility (usually involving an operating theatre) where a patient has been admitted for a planned clinical intervention and/or Diagnostic Procedure by a Registered Medical Specialist, or at Our discretion a Registered Medical Practitioner, and the patient leaves the facility within twenty-four (24) hours. #### Dentist A Recognised Health Professional who is registered with the Dental Council of New Zealand and who holds a current annual practising certificate. #### Diagnostic Procedures/Investigations Investigative medical procedures to determine the presence or cause of a sign, symptom or condition performed by a Registered Medical Practitioner or Registered Medical Specialist who holds a current annual practising certificate. #### Hospice A registered healthcare facility providing palliative care services for terminally ill patients that holds regular or associate service membership with Hospice New Zealand. #### Insured Person or Insured Persons Means the person or persons covered in the Policy Schedule. #### Life Assured Each person who is eligible for cover under this Policy and is listed on the Policy Schedule as a Life Assured. #### Medsafe Medsafe is the New Zealand Medicines and Medical Devices Safety Authority. Medsafe is responsible for the regulation of medicines and medical devices in New Zealand. #### Minor Surgery Specific surgery deemed as minor by Us. #### Non PHARMAC Medicines (excluding Chemotherapy) These are medicines that have been registered by Medsafe, and are used according to Medsafe indications, but are not funded by PHARMAC for use in a private facility. #### Non PHARMAC Chemotherapy Medicines These are chemotherapy medicines that have been registered by Medsafe, and are used according to Medsafe indications, but are not funded by PHARMAC for use in a private facility. #### Occupational Therapy Treatment that is provided by a Recognised Health Professional who holds a current annual practising certificate and is a member of the Occupational Therapy Board of New Zealand. #### Oral and Maxillofacial Surgeon An Oral Surgeon, Maxillofacial Surgeon or Oral Medicine Specialist registered with the Dental Council of New Zealand or a Registered Medical Specialist and registered in Oral Maxillofacial Surgery. #### PHARMAC The Pharmaceutical Management Agency is the New Zealand government agency that decides which pharmaceuticals to publicly fund. #### PHARMAC Medicines These medicines are funded by PHARMAC for use in a private facility, and meets PHARMAC's required special authority or conditions in order to be subsidised for community use. #### Physiotherapist A Recognised Health Professional who is registered with the Physiotherapy Board of New Zealand and who holds a current Annual Practising Certificate. #### Policy Commencement Date The commencement date of the Policy as specified in Your Policy Schedule. #### Policy Owner/s A person who administers the Policy and whose name is listed on the renewal certificate. This could be more than one person. #### Policy Schedule Means the most recent Policy Schedule issued to You by Us, including any endorsements or special conditions. #### Policy Year The twelve (12) month period which starts from the Policy Commencement Date and continues through to the end of the twelve (12) month period. #### Premium Means the Premium specified in Your Policy Schedule or in any subsequent notice issued to You by Us. #### Preventative and Routine Screening Diagnostic Investigations/Procedures undertaken when the Life Assured has no symptoms, as a preventative measure to screen for early detection of diseases. #### Private Hospital A privately owned hospital approved by Us which is licensed as a Private Hospital in accordance with the Health and Disability Services (Safety) Act 2001. #### Psychologist Means a Recognised Health Professional who is in private practice and holds a current annual practicing certificate; and is a member of The New Zealand College of Clinical Psychology (or its successor). #### Public Hospital A hospital service or institution licensed in accordance with the Health and Disability Services (Safety) Act 2001 directly or indirectly owned or funded by the New Zealand Government or any of its agencies. #### Recognised Health Professional A health professional registered with the Health Practitioners Competence Assurance Act 2003 who holds a current annual practising certificate in compliance and is a member of the appropriate body e.g., Medical Council of New Zealand, Dental Council of New Zealand or Chiropractic Board of New Zealand and approved by Us. #### Registered Medical Practitioner A medical practitioner who holds a current annual practising certificate and is registered with the Medical Council of New Zealand. This excludes Registered Medical Specialists. #### Registered Medical Specialist A medical specialist who is a member of an appropriately recognised specialist college and vocationally registered with the Medical Council of New Zealand in that speciality. This excludes General Practitioners (who are considered to be Registered Medical Practitioners). #### Registered Nurse A person who holds a current practicing certificate with the Health Practitioners Competence Assurance Act 2003, and is a member of the Nursing Council of New Zealand. #### Related Surgery A subsequent surgery performed within 3 months of an initial surgery for the purpose of treating the same medical condition, where the Life Assured has had an accepted surgery Benefit claim and paid any applicable Annual Excess. For example, if surgeries are staggered on the advice of an appropriate specialist for best medical practice. #### Top-up Additional coverage to supplement New Zealand Government, ACC, or other insurers contributions to overseas treatment. #### Total Premium Means the sum of the Premium and the policy fee together with any applicable GST as specified in the Policy Schedule. #### Usual, Customary and Reasonable Charges and fees that are based on Our estimate of the Usual, Customary and Reasonable charges and fees for services provided under similar circumstances by persons or providers with equivalent experience or qualifications. --- ## SECTION B – REAL HEALTH BENEFITS ### HOSPITAL SURGICAL BENEFIT (NON CANCER) We will reimburse You for the Usual, Customary and Reasonable expenses incurred for surgery in an Approved Facility in New Zealand, where You have been admitted upon referral by a Registered Medical Specialist or Oral Surgeon for non-cancer treatment. These costs are unlimited. An Annual Excess applies. Costs for the following is provided under this Benefit: - Surgeon's fees - Anaesthetist's fees - Perfusionist's fees - Hospital fees including: - Accommodation - Operating theatre fees - Intensive/coronary care unit fees - Prostheses - Ancillary hospital charges - Cardiologist's fees - Prescription medicines (including Non PHARMAC funded medicines (excluding chemotherapy)) for the Life Assured's stay at an Approved Facility and are administered during their admission for surgery, as well as thirty (30) days worth of take home approved medicine after their discharge from an Approved Facility. Conditions apply, refer to the Non-Pharmac Subsidised Drugs Benefit. - Diagnostic Procedures and Specialist consultations, performed twelve (12) months prior and post-surgery, are covered, provided they relate directly to the approved surgery, and have been recommended by a Registered Medical Specialist. - We will cover the costs of the surgical removal of wisdom teeth (totally impacted and totally un-erupted, or totally impacted and partially un-erupted), performed by a Dentist or Oral or Maxillofacial Surgeon (must be referred by a Dentist). Surgery must be performed in an Approved Facility. Please note that surgery costs in relation to cancer treatment are covered under the Cancer Treatment Benefit and not this Benefit. ### CANCER TREATMENT BENEFIT – SURGICAL AND MEDICAL TREATMENTS We will reimburse up to $500,000 per Life Assured per Policy Year, the amount for Usual, Customary and Reasonable expenses incurred in an Approved Facility where the Life Assured has been diagnosed with cancer by a Registered Medical Specialist. An Annual Excess applies. Cancer treatment includes but is not limited to: - Surgery - Oncologist consultations - Diagnostic imaging and tests - Chemotherapy/Immunotherapy - Radiotherapy - Prostate brachytherapy - Breast Reconstruction approved by us and performed by a Registered Medical Specialist in an Approved Facility - Prophylactic mastectomy and/or oophorectomy surgery ('Prophylactic Surgery') where the Life Assured has: - been diagnosed with breast or ovarian cancer; and - where the Prophylactic Surgery is directly related to an acceptable breast or ovarian cancer claim under the Cancer Treatment Benefit - Surgical and Medical Treatments of this policy, or where a claim for breast or ovarian cancer would have been acceptable had the treatment not taken place in a Public Hospital; and - tested positive for the BRCA1 or BRCA2 gene mutation after the Policy Commencement Date. The Prophylactic Surgery does not need to be medically necessary, but prior approval must be obtained before the surgery takes place. Under no circumstances is a claim payable under this Benefit for Prophylactic Surgery where the Life Assured has an exclusion on this policy for either breast cancer and/or ovarian cancer, or where the Life Assured has an exclusion on this policy for any disease or disorder of the breast and/or female genital tract where this relates to a personal history and/or a family history of breast or ovarian cancer. We may approve additional treatments at Our sole discretion. PHARMAC Medicines and Non PHARMAC Chemotherapy Medicines (including Cancer Immunotherapy Medicines) are covered in New Zealand, subject to Our prior approval, meeting Our criteria and Benefit maximums. #### Post Cancer Treatment We will cover post cancer treatments for a maximum of five (5) years for a claim that has been paid under this Benefit, per Life Assured per Policy Year, of up to $5000. This must be medically necessary treatment and referred by a Registered Medical Specialist. Usual, Customary and Reasonable costs of such treatments will be covered. This Benefit does not cover Routine Screening. ### MENTAL HEALTH SUPPORT BENEFIT The Mental Health Support Benefit covers the cost of a Psychiatrist or Psychologist consultation and Counselling where the support treatments and/or consultations directly relates to a claim under the Hospital Surgical Benefit or the Cancer Treatment Benefit. After referral by the appropriate Registered Medical Specialist and where We deem the support services appropriate We will cover up to $5,000 per Life Assured per Policy Year. ### HOME NURSING BENEFIT FOLLOWING CANCER TREATMENT OR SURGERY Upon authorisation by Us, We will cover the costs of home nursing care provided by a Registered Nurse up to six (6) months after an authorised medical or surgical procedure. The Life Assured must have stayed for a minimum of one (1) night in an Approved Facility. You will receive $150 per day with a maximum Benefit payable of $6,000 per Policy Year. A referral for this service must be made by the treating Registered Medical Specialist or Registered Medical Practitioner. No Annual Excess applies. ### HOME HELP ALLOWANCE FOLLOWING CANCER TREATMENT OR SURGERY BENEFIT If a claim for cancer treatment or surgery has been accepted by Us, which requires at least one (1) night's stay in an Approved Facility, We will cover the reasonable costs of home help services including meal preparation, cleaning, showering and child care provided by a suitably qualified person (employed in the provision of home help services) for up to seven (7) days following discharge from an Approved Facility up to $500 per Life Assured per Policy Year. Receipts specifying the services provided, dates and fees charged by a suitably qualified provider must be submitted with your claim. This Benefit does not apply to any accident related surgery or maternity. No Annual Excess applies. ### PUBLIC HOSPITAL CANCER TREATMENT CASH BENEFIT Should the Life Assured have treatment for cancer in a Public Hospital that would otherwise have been covered by the Cancer Treatment Benefit in this Policy, We will pay You a one off lump sum amount of $5,000 per Policy lifetime per Life Assured. Treatment includes cancer surgery (which requires a minimum of one night's hospital stay), chemotherapy or radiotherapy. No Annual Excess applies. ### HOSPICE BENEFIT If You are admitted to a Hospice facility, You will receive $100 per night up to a maximum of $2,000. This Benefit is payable once per Policy per Life Assured. No Annual Excess applies. ### CRITICAL CANCER EXCESS WAIVER BENEFIT If a Life Assured suffers a critical cancer condition as defined below and is admitted to a Private Hospital, or as a fee paying patient to a Public Hospital, We will waive the Annual Excess that You have selected, for a maximum of three (3) years per Life Assured. Diagnosis must be made in writing by a Registered Medical Specialist and be based upon medical evidence acceptable to Us. Critical Cancer means the presence of one (1) or more malignant tumours, characterised by the uncontrolled growth and spread of malignant cells and the invasion of tissue, provided the diagnosis is unequivocal as confirmed by histopathology. This includes leukaemia, lymphomas, Hodgkin's disease, malignant bone marrow disorders, but excludes the following: - Malignant Melanoma with less than 1.5 mm maximum thickness as determined by histological examination based on Breslow thickness, and Malignant Melanoma with a Clark Level less than 3. - A growth histologically described as Carcinoma-in-Situ. - All hyperkeratosis or basal cell carcinomas of the skin. - All squamous cell carcinomas of the skin unless there has been spread to other organs. - All tumours of the prostate unless histologically classified as having a Gleason score greater than six (6) or having progressed to at least a clinical TNM classification T2N0M0 as defined by AJCC 6th Edition 2002. - Tumours treated by endoscopic procedures alone. We will allow cover for Carcinoma-in-Situ of the breast where it results in the entire removal of the breast specifically to arrest the spread of malignancy. This procedure must be the appropriate and necessary treatment. ### HOSPITAL MEDICAL BENEFIT (NON-SURGICAL/NON-CANCER) We will reimburse You the Usual, Customary and Reasonable expenses incurred should you be admitted to an approved Private Hospital, upon referral by a Registered Medical Specialist for non-surgical and/or non-cancer treatment, subject to a maximum for all related costs of $500,000 per Life Assured, per Policy Year. Cover is provided (subject to prior approval by Us) for: - Hospital accommodation fees - Registered Medical Specialist's fees - Diagnostic fees - Ancillary charges An Annual Excess applies. ### NON-PHARMAC SUBSIDISED DRUGS BENEFIT Covers the Usual, Customary and Reasonable expenses incurred for accessing the most effective treatment available, irrespective of whether that treatment qualifies for PHARMAC funding. We will reimburse the costs of all medicines registered by Medsafe, provided they are used according to Medsafe indications for use in New Zealand (subject to Our prior approval) and meeting Our criteria where: - The treatment has been recommended by a Registered Medical Specialist as the appropriate medical treatment for the condition; and - The cost of the medicine is covered under the Hospital Surgical Benefit (Non Cancer); and - The medicine is being prescribed within the guidelines set by Medsafe. All costs under this Non-PHARMAC Subsidised Drugs Benefit are included within the benefit maximums that apply to the Hospital Surgical Benefit (Non Cancer). ### MAJOR DIAGNOSTIC TESTS BENEFIT Covers the Usual, Customary and Reasonable expenses incurred for up to $200,000 per Life Assured per Policy Year for specified Diagnostic Procedures in an Approved Facility following recommendation by a Registered Medical Specialist, irrespective of whether surgery or hospitalisation occurs (subject to prior approval by Us). An Annual Excess applies. Diagnostic Procedures covered include: - Angiogram - Arthroscopy - Capsule endoscopy - Colonoscopy - CT scan - Cystoscopy - Gastroscopy - Hysteroscopy - Laparoscopy - MRI scan - Myelogram - Myocardial perfusion imaging - PET - Scintigraphy Changes in technology in the future may see other major Diagnostic Procedures being introduced. We may at Our sole discretion, consider reimbursing the cost of such procedures. Routine Health Screening is excluded. ### POST-OPERATIVE PHYSIOTHERAPY AND OCCUPATIONAL THERAPY TREATMENT BENEFIT We will cover the costs of post-operative physiotherapy and Occupational Therapy treatment by a Physiotherapist or Registered Occupational Therapist for the Life Assured, where the treatment is required within a six (6) month period of discharge from a Private Hospital Approved Facility, and on referral from a Registered Medical Specialist or Registered Medical Practitioner. Treatment must relate to the authorised procedure or treatment. No Annual Excess applies. ### TRAVEL AND ACCOMMODATION IN NEW ZEALAND BENEFIT Should treatment for an approved Benefit not be available within Your immediate residential region (which is further than 100km away from Your home or usual place of residence), We will cover the costs of accommodation, transport for You and one (1) support person for up to $300 per day with a maximum of $3,000 per claim per Policy Year per Life Assured. Treatment must be recommended by a Registered Medical Specialist or Registered Medical Practitioner. The Travel and Accommodation in New Zealand Benefit does not apply to the cost of air travel to or from the Chatham Islands or any other New Zealand Territorial Islands. No Annual Excess applies. ### GLOBAL SURGICAL BENEFIT You can elect to have a medically necessary surgery, treatment, procedure, consultation, test, diagnostic imaging, support or care at Your choice of overseas Approved Facility, provided that: - The surgery, treatment, procedure, consultation, test, diagnostic imaging, support or care has been recommended by a New Zealand Registered Medical Specialist; and - The surgery, treatment, procedure, consultation, test, diagnostic imaging, support or care is available in New Zealand; and - You seek prior-approval for Your claim from Us (subject to AIA New Zealand's criteria); and - The surgery, treatment, procedure, consultation, test, diagnostic imaging, support or care would have otherwise been covered by Us in New Zealand under the applicable Benefit. We will reimburse up to a maximum of 85% of the Usual, Customary and Reasonable costs, which would have been incurred for the surgery, treatment, procedure, consultation, test, diagnostic imaging, support or care (as outlined in the applicable Benefit) if it had been undertaken in New Zealand per Life Assured per Policy Year. An Annual Excess applies. Should the costs of the surgery, treatment, procedure, consultation, test, diagnostic imaging, support or care be less than the 85% maximum detailed above, then AIA New Zealand will also reimburse the following costs up until the 85% maximum is reached: - accommodation costs for the Life Assured as deemed medically necessary and/or one (1) support person of up to NZ $500 per day for a maximum of ten (10) days; and - ordinary public transport costs to and from the destination for the Life Assured and one (1) support person (including economy airfare, taxi, bus, ferry and train). We will not accept responsibility for the costs associated with any complications that might arise as a direct or indirect result of the treatment undertaken at Your choice of overseas Approved Facility, unless the treatment costs for these complications (including medical emergency evacuation costs) and the other costs listed above remain below the 85% limit detailed above and occurs within six (6) months of the treatment. After six (6) months of the treatment referred above occurring, We will not accept responsibility for on-going treatment costs directly or indirectly associated with the surgical treatment undertaken at Your choice of overseas Approved Facility. No Medical Misadventure Benefit is payable should You claim under the Global Surgical Benefit. ### OVERSEAS TREATMENT BENEFIT Covers treatment at an overseas Approved Facility where the treatment cannot be provided in New Zealand. This Benefit provides Top-Up cover for the treatment and reasonable return economy travel costs of the person requiring treatment and one (1) support person, less any amount payable by the New Zealand Government up to a maximum of $30,000 per Life Assured per Policy Year. The treatment must be recommended by a Registered Medical Specialist and be recognised by Us as being a conventional form of treatment. No experimental or trialled procedures will be covered. No Annual Excess applies. ### TREATMENT IN AUSTRALIA This benefit covers the costs for any medically necessary approved surgery, treatment, procedure, consultation, test, diagnostic imaging, support or care. The maximum amount payable for any claim is 100% of New Zealand Usual, Customary and Reasonable charges for the medically necessary treatment that would have been covered by this Policy in New Zealand, at an Approved Facility up to the stated maximums in this Policy, paid in New Zealand currency. Prior approval must be obtained from Us prior to any treatment taking place. Premiums must be up to date. An Annual Excess applies. ### MINOR SURGERY BENEFIT We will cover the Usual, Customary and Reasonable expenses for approved minor surgery incurred as an outpatient of up to $3,000 per Life Assured per Policy Year, where performed by a Registered Medical Practitioner at an Approved Facility. No Annual Excess applies. ### PARENT ACCOMMODATION BENEFIT We will cover the cost of up to $200 per night with a maximum of $3,000 per Policy Year, for accommodation expenses incurred by a parent accompanying a Child who is listed on the Policy Schedule. The Child must be undergoing medical treatment in an Approved Facility in New Zealand. No Annual Excess applies. ### WAIVER OF PREMIUM BENEFIT If the Policy Owner dies, (where the death is not caused by something excluded under this Policy), We will waive Premiums and continue to provide cover for all surviving Lives Assured covered by this Policy for a period of up to two (2) years. No Annual Excess applies. ### PUBLIC HOSPITAL CASH BENEFIT If the Life Assured is admitted to a Public Hospital for three (3) or more consecutive nights, $300 will be paid from the fourth and each subsequent night, up to a maximum of ten (10) nights. The maximum amount payable per Life Assured, per Policy Year is $3,000. The Public Hospital Cash Benefit does not apply to any admission as a fee paying patient in a Public Hospital or for maternity care. This Benefit will not be paid in addition to the Public Hospital Cancer Treatment Cash Benefit. No Annual Excess applies. ### PUBLIC HOSPITAL CREDIT When You have a publicly funded treatment or procedure in a Public Hospital that would otherwise have been covered by a Benefit in this Policy and that treatment or procedure includes overnight admission of two (2) or more night's stay, We will waive the Life Assured's Premium for this Policy for twelve (12) months. A copy of the hospital discharge summary must accompany the claim form. Excludes hospital admissions for treatment of accidents or injuries or maternity admissions. No Annual Excess is payable for any claims under this Benefit. ### FUNERAL BENEFIT We will pay a Funeral Benefit of $3,500 if an adult Life Assured dies before turning age seventy (70), provided the death is not caused by something excluded under this Policy. The Benefit will be paid to the Policy Owner/s or to the Policy Owner/s estate. This Benefit is payable once per adult Life Assured. No Annual Excess applies. ### PARENTS GRIEVING BENEFIT If, during the term of this Policy, a Life Assured's Child dies, then We will pay a Parents Grieving Benefit immediately upon receiving written notification of the death of the Child subject to the following: - The amount of the Benefit is limited to $2,000. - We will only pay one (1) Parents Grieving Benefit per Child under this Policy irrespective of how many Lives Assured are under this Policy, or any other policy containing the Parents Grieving Benefit. - This Parents Grieving Benefit ceases when the Child reaches age twenty one (21). ### AMBULANCE TRANSFER BENEFIT We will cover the costs of ambulance transfer expenses incurred by the Life Assured for emergency transportation to or from hospital within New Zealand, of up to $200 per Life Assured per Policy Year. This Benefit is not payable in respect of any ambulance transfers provided for either personal or social reasons, or where the associated costs would be covered by ACC or any other benefit provision under this Policy. No Annual Excess applies. ### COMPLICATIONS OF PREGNANCY OR CHILD BIRTH BENEFIT We will cover the cost of obstetric care after a referral by a Registered Medical Practitioner or registered lead maternity carer (Midwife) for assessment and monitoring of a recognised risk factor(s) for up to $2,000 per Life Assured per Policy Year. Benefits are not paid if the Life Assured is admitted to a Public Hospital, or if related to a pregnancy that is conceived prior to the Policy Commencement Date. Conditions arising post birth are not covered. Caesarean Sections are specifically excluded. No Annual Excess applies. ### FEE PAYING PATIENTS IN A PUBLIC HOSPITAL BENEFIT We will cover the fees charged for treatment carried out in a Public Hospital up to the limits specified on this Policy once prior approval has been obtained by Us, and the Private Involvement Protocols (or any replacement protocols) set by the Ministry of Health for the treatment of private patients in Public Hospitals have been followed. This Benefit does not apply to any person who does not qualify for publicly funded health services in New Zealand. No Annual Excess applies. ### MEDICAL MISADVENTURE BENEFIT If, during the course of any medical procedure or treatment in an Approved Facility, a Life Assured should die as a direct consequence of any erroneous or negligent action, omission or failure to observe reasonable and customary standards by a care provider of the said Approved Facility, a death Benefit shall become payable, provided: - the death occurs within thirty (30) days of such recorded and proven incident; and - the incident is verified and confirmed by the relevant government authority, a court of law, coroner's inquest or the Medical Council of New Zealand; and - the death is independent of any other cause other than the termination of life support system after brain death has been established. No Medical Misadventure Benefit is payable if the death is as a direct or indirect result of the Life Assured claiming under the Global Surgical Benefit. The maximum Benefit is $30,000 per Life Assured. No Annual Excess applies. ### INTRAVITREAL EYE INJECTIONS BENEFIT We will cover the cost of intravitreal eye injections administered by a Registered Medical Specialist in an Approved Facility, on referral by a Registered Medical Practitioner or Registered Medical Specialist up to a maximum of $3,000 per Life Assured per Policy Year. No Annual Excess applies. ### SUSPENSION OF COVER BENEFIT After twelve (12) months of continuous cover, You can apply to suspend the cover and Total Premium payments under this Policy: - for up to twenty-four (24) consecutive months, if You reside outside of New Zealand for longer than two (2) months; or - for up to twelve (12) months if You: a. become redundant; or unemployed; b. go on Leave Without Pay for any reason; c. experience at least a 20% reduction in pay (comparing the most recent payslip against a previous payslip from the same year); or d. If self-employed, experience a 30% reduction in revenue (by comparing one month's revenue against the same month for the previous year) You must apply for the Suspension of Cover Benefit in writing and, if accepted, You will receive confirmation from Us in writing confirming the request has been approved. We will resume cover without requiring evidence of health for any Lives Assured at the end of the requested period of suspension. Once cover is reinstated, Total Premiums must recommence. We will not pay any Benefits under this Policy in respect of any claim event that first meets the criteria for an eligible claim while cover is suspended. If cover for all adult Lives Assured has been suspended, cover for any Children on this Policy will also be suspended. No Annual Excess applies. ### FERTILITY TREATMENT LOYALTY BENEFIT (AFTER EXHAUSTING PUBLIC OPTIONS) We will cover up to $25,000 per Policy after two (2) years of continuous cover for fertility treatment at an Approved Facility. To be eligible for the Fertility Treatment Loyalty Benefit the criteria for publicly funded fertility treatment in New Zealand must have been met and all publicly funded fertility treatment must have been exhausted before this Benefit is payable. You must seek prior approval before this Benefit is payable. As a part of the pre-approval process, We will require proof of the publicly funded treatment being exhausted. The Fertility Treatment Loyalty Benefit is available for fertility treatment and associated treatment costs. The maximum amount payable per Policy is $25,000 over the lifetime of the Policy. Once this amount has been exhausted no further Benefit is payable. No Annual Excess applies. Maximum age to be eligible to claim the Fertility Treatment Loyalty Benefit is forty three (43) years. ### CONGENITAL CONDITIONS BENEFIT This Benefit covers the costs of surgery for any of the following Congenital conditions: - umbilical hernia - inguinal hernia - undescended testes - hydrocele - tongue tie - phimosis - squint The surgery must be performed in an Approved Facility by a Registered Medical Specialist, a Oral and Maxillofacial Surgeon, or a Registered Medical Practitioner. You must seek prior approval before this Benefit is payable. We will cover up to $2,000 per Life Assured over the lifetime of the Policy. No Annual Excess applies. ### BILATERAL BREAST REDUCTION / BARIATRIC SURGERY ALLOWANCE We will provide a combined Allowance of up to $7,500 per Life Assured over the lifetime of the Policy after three (3) years of continuous cover towards the costs of: #### Bilateral Breast Reduction Surgery Bilateral breast reduction surgery including the costs of the related consultations, tests and diagnostic imaging for the Life Assured. Excludes any surgery to correct any traumatic or post-surgical asymmetry, or to remove breast implants. #### Bariatric Surgery Medically necessary sleeve gastrectomy, gastric banding or bypass surgery including the costs of related consultations, tests and diagnostic imaging, where surgery is recommended by a specialist because the Life Assured has all of the following: - a BMI of: a. 40 or more, or b. 35 or higher and at least one of the following obesity-related diseases that is expected to be improved: - coronary heart disease; - type 2 diabetes; - obstructive sleep apnoea; - osteoarthritis in a weight bearing joint (radiological evidence required); or - blood pressure greater than 140/90 that cannot be effectively controlled via medication; and - completed physical growth; and - previously failed attempts to lose weight. Excludes any other type of bariatric surgery, such as banded gastroplasty (stomach stapling). You must seek prior approval before this Allowance is payable. The maximum amount payable under this Allowance is $7,500 per Life Assured over the lifetime of the Policy across both bilateral breast reduction surgery and bariatric surgery combined. Once this amount has been exhausted no further Allowance is payable. An Annual Excess applies. --- ## SECTION C – OPTIONAL BENEFITS ### OPTIONAL SPECIALISTS AND TESTS BENEFIT If the Policy Schedule shows You have selected the Specialists and Tests Benefit, We will cover the Usual, Customary and Reasonable fees charged for Registered Medical Specialist consultations up to $10,000 per Policy Year per Life Assured and Diagnostic Procedures which have been referred by a Registered Medical Practitioner or Registered Medical Specialist up to $100,000 per Policy Year per Life Assured, if they do not relate to a claim for treatment in a Private Hospital or medical facility. Diagnostic Procedures covered include but are not limited to: - Allergy testing - Audiology tests - CT scans - Capsule endoscopy - Colonoscopy - Colposcopy - Cystoscopy - Electroencephalography (EEG) - Electromyography (EMG) - Exercise/Stress (ECG) - Gastroscopy - Holter monitoring/24 Hour Ambulatory monitoring - Laboratory tests - Mammogram - MRI scans - Myelogram - Myocardial perfusion imaging - PET/CT scans - Scintigraphy - Sleep studies - Ultrasound - Urodynamic assessments - X-rays Preventative and Routine Screening tests, and hearing aids are excluded. Psychiatrist consultations for an initial assessment of mental health are covered for the first consultation only. All forms of Psychiatric treatment are excluded as set out in Section E "Exclusions". An Annual Excess of nil or $250 will apply as stated on the Policy Schedule per Life Assured per Policy Year. ### OPTIONAL SPECIALIST AND TESTS LOYALTY BENEFITS #### Specialists and Tests Loyalty Health Screening Benefit If the Policy Schedule shows You have selected the Specialists and Tests Benefit, We will cover up to $500 per Life Assured, or up to $750 per Life Assured if that Life Assured is a member of AIA Vitality (a health and wellbeing programme offered by AIA New Zealand Limited) after every three (3) years of continuous cover, for tests or procedures for the following: - Prostate screening - Cervical screening - Mammogram - Blood glucose screening - Bowel screening - Bone screening (osteoporosis) - Heart screening - Eye tests and/or visual field tests - Hearing tests - Skin checks - Aortic aneurysm screening Health screening tests do not have to be medically necessary, but must be performed by a Registered Medical Practitioner or Registered Medical Specialist in an Approved Facility. No Annual Excess applies. #### Specialists and Tests Loyalty Family Allowance If the Policy Schedule shows You have selected the Specialists and Tests Benefit, We will cover up to $1,500 per Life Assured after two (2) years of continuous cover and every year thereafter for pregnancy scans, fertility treatment and birth care accommodation post-delivery at an Approved Facility. This Benefit does not apply to any person who does not qualify for publicly funded health services in New Zealand. No Annual Excess applies. #### Specialists and Tests Loyalty Sterilisation Benefit If the Policy Schedule shows You have selected the Specialists and Tests Benefit We will cover the Usual, Customary and Reasonable charges of a vasectomy or tubal ligation procedure performed by a Registered Medical Specialist after two (2) years of continuous cover. Reversals of previous sterilisation procedures are excluded. Vasectomies carried out by a Registered Medical Practitioner will be covered. No Annual Excess applies. #### Specialists and Tests Loyalty Excess Waiver Benefit If the Policy Schedule shows You have selected the Specialists and Tests Benefit, after two (2) years of continuous cover, any applicable Annual Excess on the Specialists and Tests Benefit will be waived per Life Assured. --- ## SECTION D – PRIOR APPROVAL AND MAKING A CLAIM Please note for claims while residing in Australia, call collect on +64 9 488 8800. Please refer to the Claims Form checklist to ensure all relevant information is supplied to Us. ### PRIOR APPROVAL To have Your claim pre-approved: - Call Us on 0800 800 242 for a claim application form or log on to Our website www.aia.co.nz or email Us nz.claims@aia.com - On acceptance of Your claim, We will send You a pre-approval advice. You can then forward the Hospital's, Surgeon's or Anaesthetist's account to Us and We will settle the claim with the service provider directly. Any shortfall in payment, such as any stated excess, is Your responsibility. In order for a claim to be paid where We have provided You with pre-approval advice, Your Policy must be in force on the date You have the medical treatment or procedure. - Pre-approval requires five (5) working days to be processed, provided all requested information is submitted. Please be aware it may be necessary to provide further information before completing assessment of Your claim. ### CLAIMING AFTER SURGERY OR HOSPITALISATION OR AFTER A DIAGNOSTIC PROCEDURE To claim: - Call Us on 0800 800 242 for a claim form or log on to Our website www.aia.co.nz or email Us nz.claims@aia.com - Once You have completed the claim form, return it to Us along with the original receipts and invoices (photocopies or duplicates are not acceptable). - The claim form must be received by Us within twelve (12) months of the date of the insured event(s). Any costs involved in completing the claim form and where appropriate providing an attached medical report (or any additional information We may request) will be at Your expense. Additional information may be requested by Us in order to assess and pay Your claim. Please refer to the checklist contained within the claim form to ensure You have supplied all of the requirements to Us. ### UNEXPECTED EVENTS ARISING FROM TREATMENT RECEIVED UNDER THIS POLICY ("MEDICAL MISADVENTURE") If You become aware, in respect of any health or medical procedure for which You have cover under this Policy that there has been a "medical misadventure" (as defined in the Accident Compensation Act 2001 or any replacement legislation) then: You must notify Us of that event together with all material details which are known to You. Those details must include: 1. the cause of the medical misadventure 2. the names and addresses of the health service provider(s) at fault 3. the level of increased fees caused by the medical misadventure 4. whether You have notified ACC and, if so, whether ACC has accepted cover. If a medical misadventure occurs as a result of a claim under this Policy then We are entitled to withhold claims, seek recovery of any claims paid, or pursue Your entitlement to future treatment expenses from ACC. --- ## SECTION E – EXCLUSIONS We will not pay any claims under this Policy for: - Any illness, injury or condition caused by or traceable to any medical condition of which You were aware or the Life Assured was aware, or displayed symptoms of, or for which treatment or medical advice had been sought prior to the Policy Commencement Date, which should have been disclosed to Us in the application form or by additional correspondence up to the date the Policy was issued (as per Your Duty of Disclosure outlined in Our application form and in this Policy document). Any ailment declared on Your application form which was not excluded by Us on Your Policy Schedule will be covered by this Policy, unless specifically excluded elsewhere in the document. - Any illness, injury, condition or disability arising from, caused or contributed by, drug taking, intoxication or misuse of alcohol. This includes the misuse of prescribed or non-prescription drugs, including where they have not been taken in accordance with the manufacturer's or Recognised Health Professional's directions. - Appliances and/or devices, including but not limited to, surgical, medical or dental appliances. - Bariatric surgery for any condition including but not limited to obesity, diabetes and sleep apnoea, except where coverage is expressly stated in this Policy. - Congenital conditions except where coverage is expressly stated in this Policy. - Any form of psychiatric treatment and/or psychological treatment including, but not limited to: medical psychotherapy; any form of therapy or counselling (except where cover is stated in this Policy); in-patient care in a Private Hospital or clinic; prescription or non-prescription drugs. - Any Non-PHARMAC funded medicines (except where these are specifically covered). - Any mental disease or disorder, behavioural and developmental conditions including but not limited to Attention Deficit Disorder. - Dementia and Alzheimer's disease. - Any continuous care (geriatric hospitalisation, palliative, respite, long-term care, convalescence and disability support services). - Any injury or disability as a consequence of war, warlike hostilities, civil war or civil commotion. - Cosmetic treatment including complications thereof. - Any treatment not medically necessary as defined by Us except where specifically included in the Policy. - All dental treatments, including but not limited to periodontal surgery, orthodontal, endodontal or prosthodontal surgery, implant prosthesis, check-ups, fillings, caps, repair of broken teeth, gold, titanium or other exotic materials except where cover is expressly provided by this Policy. - Infertility, or treatment for it, impotency or treatment for it, sterilisation and contraceptive procedures (except where coverage is expressly stated in this Policy). - Breast reduction except where coverage is expressly stated in this Policy. - Laser surgery that is not medically necessary (for cosmetic purposes). - Pregnancy, childbirth, abortion or caesarean sections (except where coverage is expressly stated in this Policy). - Reversals of sterilisation procedures. - Any medical condition, illness or injury that is either directly or indirectly caused by or results from intentional self-injury or attempted suicide or suicide. - Preventative or Routine Screening, (including as a result of family history), where there is no current medical condition (except where cover is stated in this Policy). - Expenses recovered or recoverable from a third party or under any other contract of indemnity or insurance including ACC. - Radial Keratotomy or Photo-refractive Keratectomy or any related complications. - Any investigation and/or treatment for sleep disturbances, snoring or obstructive sleep apnoea. - New or experimental medical technologies, treatments or procedures that have not been approved of in writing by Us. - Charges relating to naturopaths, homeopaths, acupuncturists, podiatrists, herbalists, nutritionists, dieticians or alternative treatment therapists. - Any treatment for obesity or weight reduction, except where coverage is expressly stated in this Policy. - Ancillary Public or Private Hospital charges of personal convenience nature. - Treatment for renal failure. - Treatment for sclerotherapy (for cosmetic purposes). - Any other exclusion or endorsement placed upon this Policy at time of underwriting or Policy issue including any complication related to that exclusion or endorsement. Where the Ministry of Health has declined the insured free access of the full Public Health Services, We will not cover the insured under this Policy, as Our Policy is designed to complement Ministry of Health and Disability services provided in the Public Sector. We reserve the right to claim expenses from any other source, including other insurers, wherever you may have additional coverage in respect to any claim made under this plan.