> _Markdown transcription of nib Ultimate Health Max policy wording, effective 2018-12-23. Source: https://www.nib.co.nz/Documents/Document/UltimateHealthMaxPolicyDocument20170701.pdf_ --- # Ultimate Health Max™ Policy Document ## Introduction Thank you for trusting nib to insure your good health. This Policy document explains what your Policy covers. It should be read in conjunction with all the documents that form part of your Contract of Insurance. It is important you read the information carefully to ensure you know what you are covered for, what you need to tell us, how to make a Claim and any other terms and conditions of your Policy. However you should always make enquiries with nib before undergoing any Health Service (see Claims on page 17). Unless specified, this Policy document only describes nib Ultimate Health Max Cover as at the date of issue of this Policy document. Each nib Cover can be amended from time to time in accordance with its terms. ### Contract of insurance Your Contract of Insurance consists of: - the Acceptance Certificate or Renewal Certificate (whichever is the later); - this Policy document (or any subsequent document that replaces this document); - the Prosthesis Schedule; and - any application(s) completed by the Policyowner and all the Insured Persons covered under the Policy (if any). In descending order of priority if there is any inconsistency. ### Words in capitals Some words in this document start with a capital letter, indicating a specific meaning which applies to Ultimate Health Max Cover only (see Glossary of important terms on page 72). ### This is an important document Please keep this Policy document and the other documents that form part of your Contract of Insurance in a secure place for future reference. ### How to contact nib Call us on **0800 123 nib (0800 123 642)** Fax us on **0800 345 134** Email us for general enquiries at **contactus@nib.co.nz** Email us for claims at **claims@nib.co.nz** nib nz limited PO Box 91630 Victoria Street West Auckland 1142 Go to **nib.co.nz** Our opening hours are Monday to Friday 8.00am to 5.30pm. We are closed on public holidays. My nib portal provides 24 hour access to your Policy and Claims details. This information can be found by visiting **nib.co.nz/portal** --- ## General terms of Ultimate Health Max cover ### Applying for an nib cover All applications for nib Cover must be accompanied by proof of identity and any other relevant information we require. We may at our discretion, refuse to accept an application until all necessary information has been provided or until the Premiums for the minimum period as determined by nib, have been paid. Subject to the terms of this Policy document we may, at our discretion, refuse an application to join nib as an Insured Person, as described below: - We have the right to refuse an application to join a Cover that has been closed for sale. - We have the right to refuse an application to combine a Cover currently for sale with a Cover that has been closed for sale. - We have the right to refuse an application to move a Cover that has been closed for sale to a Cover currently for sale. - We have the right to refuse an application to move to another nib Cover. - If we refuse an application, we will provide a reason for the refusal to the applicant. ### Duty of disclosure The Policyowner and all Insured Persons had a legal duty to disclose everything they knew (or ought to have known) which would have influenced the decision of a prudent insurer whether to accept the Policyowner's application, and if so, on what terms. For example, an Insured Person must have disclosed any medical condition or any sign, symptom, treatment or surgery of any medical condition they had at the time of applying, or have had in the past. All information given by, or on behalf of, the Policyowner or any Insured Person must be true, correct and complete. The Insured Person must have told us about any changes to the information given to us before any Commencement Date, Effective Date or Join Date (as applicable) of this Policy. If the Insured Person failed to do so, or if any of the above information was not disclosed to us or was not true, correct and complete, we can cancel this Policy or alter the terms and conditions of Cover provided under this Policy from the Commencement Date, Effective Date or Join Date (as applicable) and not pay any Claims after those dates. We may retain all the Premiums paid, and any Claims paid by us after those dates may be recovered from the Policyowner or the Insured Person. ### Financial Statements The Policyowner or any Insured Person can obtain a copy of nib nz limited's financial statements for the last reported financial year by writing to nib nz limited, PO Box 91630, Victoria Street West, Auckland 1142. ### Period of cover Your Cover starts from the Commencement Date, Effective Date or Join Date (as applicable) shown on your Acceptance Certificate or Renewal Certificate (whichever is the later). This is subject to any applicable Waiting Period. ### 14-day free-look period A 14-day free-look period applies to all nib Covers. The Policyowner can receive a full refund of Premiums if they decide to cancel the Policy within the first 14 days – providing no Claims have been made during that time, and that the cancellation is requested in writing. This period starts three days after we send you your Contract of Insurance. During this time, should you decide the Policy doesn't meet your needs, please send written confirmation to us and we will cancel the Policy and refund the full Premiums paid, providing no Claims have been made. ### Health cover reviews It is the Policyowner and all Insured Persons' responsibility to understand what is covered and what is not covered by their health insurance Policy. We recommend you review your health insurance at least once each year. We are happy to discuss your Cover – you are welcome to call us on **0800 123 nib (0800 123 642)**. ### nib recognised providers Claims are only eligible for Health Services carried out by an nib Recognised Provider. We will pay for Benefits under the Ultimate Health Max Cover, if the Insured Person attends an nib Recognised Provider, who must: - meet all the minimum criteria outlined by us relating to their education, qualifications and active membership of any governing body specified by us; - be in Private Practice; and - be recognised by nib. In the rare instance that we do not recognise a provider, for example in the case of suspected fraud, you are required to co-operate fully with our review process, which may include providing authority to our legal representative and providing us with any relevant information. This process and our success or failure in it, will not result in you having Out-of-Pocket Expenses for otherwise eligible expenses. ### Prosthesis Schedule For Surgery requiring Prosthesis, we will pay up to the maximum amount as defined in the Prosthesis Schedule available on our website at **nib.co.nz** This schedule is reviewed annually and the Policyowner and all Insured Persons must refer to the most up-to-date list, to understand what they are covered for and the limits that apply. ### Key information found on nib's website and my nib portal #### Our website Our website provides key information such as our Prosthesis Schedule and Claim forms. All the relevant information and forms can be found by visiting **nib.co.nz** #### My nib portal Our portal provides 24 hour access to: - submit and track your Pre-approvals and Claims - view your Claims history; - view your Policy details; and - send a quick request to update your details or make enquiries about your Policy. Our portal can be found by visiting **nib.co.nz/portal** ### Who is covered This Policy provides Cover for an Insured Person who is eligible to receive Health Services funded under the New Zealand Public Health and Disability Act 2000 (or its successor under any subsequent legislation) at all times. We may request to see originals or certified copies of each relevant Insured Person's documents (including visas or work permits in the Insured Person's passports, birth certificates or driver's licences). We reserve the right to cancel the relevant Insured Person's Cover if the relevant person no longer meets the criteria (see Cancelling the policy or cover on page 14). ### Dependent children A Dependent Child will become subject to adult Premium rates on the next Policy Anniversary Date after they reach age 21. We will automatically continue to cover that person on this Policy as an adult Insured Person and deduct the additional Premium based on their age, gender, smoking status and Excess for the Cover, from the same payment source and at the same frequency as this Policy, unless you advise us otherwise. If the smoking status is not known, smoker Premiums will apply. Unless otherwise approved by us, a person under 18 years of age is not eligible to be a Policyowner. A Dependent Child under age 18 must be accompanied on the Policy by at least one adult aged 18 or older as the Policyowner, or have his or her parent or legal guardian as the Policyowner. ### Who can view and change the policy The Policyowner is the primary account holder and has full and total authority to make changes to the Policy and make Claims enquiries about anyone on the Policy. If the Policy has more than one Policyowner then all the Policyowners must consent to any changes. The Policyowner must give us at least 30 days' prior notice in writing or by email before any changes can be made. The Policyowner may add or remove an Insured Person from the Policy, and may add or remove any nib optional Cover, at a Policy Anniversary Date (see Adding or removing an option on page 11). If we agree to any other change, we will make the requested change to this Policy on the same (or nearest equivalent) date in the month that corresponds to the date in the month of the Policy Anniversary Date, immediately after you request this change. For example, if the Policy Anniversary Date is 30 September and you request a change on 15 June, the Effective Date of the change will be 30 June. If we make the change on any other date, we will let you know. #### Adding an insured person The Policyowner can add a Partner, Dependent Child, parent or grandchild onto their Policy, providing the Insured Person meets the eligibility criteria (see Who is covered on page 10) and the Insured Person (or their parent or legal guardian if under 16 years old) consents to be added, including providing privacy consent. The person being added to a Policy will be required to serve any applicable Waiting Period from the Commencement Date, Effective Date or Join Date (as applicable). The Policyowner and any new Insured Person added must follow the relevant application process. Please call us on **0800 123 nib (0800 123 642)** for more details. We will charge an additional Premium for each Insured Person added. A new Insured Person added to this Policy from the Join Date (as applicable) is shown on the Acceptance Certificate or Renewal Certificate (whichever is applicable). #### Removing an insured person We will remove an Insured Person from this Policy: - at the written request of that Insured Person. He or she has the option, within 30 days of removal, to arrange a separate Policy on terms determined by us without providing any evidence of his or her current state of health; or - at the written request of the Policyowner. #### Changes in contact details The Policyowner must notify us of all changes in contact details of the Insured Persons covered under the Policy. Where possible, they must provide an email address. The Policyowner can advise us in writing, including by email. #### Changing the insured person's smoking status If the smoking status is not known, smoker Premiums will apply. If any Insured Person (aged 21 years or over) changes their smoking status (including any tobacco or any other substance), they must complete an nib smoking status questionnaire and send the completed questionnaire to us. We will require at least 30 days' prior notice before this change will be applied on the Policy. #### Adding or removing an option The Policyowner can add an option(s) to the Policy and/or a Cover for an Insured Person for an additional Premium, by following the relevant application process. Please call us on **0800 123 nib (0800 123 642)** for more details. The application must be completed fully and accepted by us before the Cover on the option(s) can start. We will charge any additional Premium for each Insured Person's additional option(s). The Premium will be adjusted from the next available billing date to reflect this change. The added optional Cover will start from the Effective Date or Join Date (as applicable) shown on the Acceptance Certificate or the Renewal Certificate (whichever is the later). The Policyowner can only remove an option at the next Policy Anniversary Date. The Policyowner must give us at least 30 days' prior notice in writing before the option(s) can be removed. #### We will process the change Once we have accepted the changes, we will send the Policyowner a new Acceptance Certificate or Renewal Certificate (as applicable) that will show the changes. ### Commencement of cover Any Insured Person will be able to Claim for the Benefits and/or Health Services provided by the Cover once Waiting Periods have been served and provided that all Premiums have been paid up-to-date. ### Waiting period Waiting Period means a period of time after the Commencement Date, Effective Date or the Join Date (as applicable), for which no Claim will be paid for anything that happens during this period. #### The following Waiting Periods apply to each Insured Person for this Policy: | | | |---|---| | Base Cover – Oral Surgery for extraction of unerupted or impacted teeth | 12 months | | Serious Condition Financial Support Option – Serious Conditions as specified | 90 days | | GP Option | 90 days | | Dental and Optical Option | Six months | | Proactive Health Option | Six months | #### Waiting periods when changing cover For any change in Cover, the Policyowner must follow the relevant application process. Please call us on **0800 123 nib (0800 123 642)** for more details. The application process must be completed fully and accepted by nib before the new Cover can start. We recognise Waiting Periods already served on a Cover comparable to the Ultimate Health Max Cover only. For Insured Persons changing their Cover with nib, the following Waiting Period rules apply: | New Benefits and/or Health Service | No change in Benefits and/or Health Service | |---|---| | The Waiting Period will apply from the Effective Date. | The Waiting Period applies from the Commencement Date, Effective Date or Join Date (as applicable) prior to the change. | #### Transfer to a new policy If for any reason an Insured Person needs to transfer to a new Policy with the same level of Cover, the Waiting Period applies from the Commencement Date, Effective Date or Join Date (as applicable) of the original Policy. ### Excess - The Excess amount is detailed on the Acceptance Certificate or Renewal Certificate (whichever is the later) for each Insured Person, and applies to each Insured Person every Policy Year. - The Excess will be deducted from eligible Claim payments for each Insured Person from the Commencement Date or Join Date (as applicable) until the Excess amount is reached. - The Excess will be deducted from any eligible Claim payments for each Insured Person from every Policy Anniversary Date thereafter. - The Excess is not payable by nib, and cannot be met by withdrawing from any other Benefits on your Policy. For example: The Excess amount is $500, the Insured Person submits an eligible Claim for $250. No payment is made by nib to the Insured Person. The Insured Person then submits an eligible claim for $500. $250 is paid out to the Insured Person. Any further eligible Claims submitted after the Excess amount had been reached will be paid in line with Benefit Limits until the next Anniversary Date, when the Excess amount is then deductible again. #### Changing your excess The Policyowner can request to increase or decrease the Excess for any Insured Person within six weeks prior to the Policy Anniversary Date. If the new Excess is lower than the previous Excess, the Policyowner and all the affected Insured Persons must follow the relevant application process. Please call us on **0800 123 nib (0800 123 642)** for more details. The application must be completed fully and accepted by us before the new Excess can start. Any new Excess will commence from the Policy Anniversary Date and it will be noted on the Acceptance Certificate. ### Maintaining continuous cover It is important to maintain continuous Cover with nib to ensure you are able to continue to Claim Benefits and to avoid having to re-assess all the Insured Persons' health and to re-serve Waiting Periods if they decide to re-join later (see Contract of Insurance on page 7). - If the Policy falls into arrears of Premium, no Insured Persons on the Policy will be able to Claim. - After 90 days of non-payment the Policy will be cancelled (see Cancelling the policy or cover on page 14). - It will be at nib's discretion to determine whether the Insured Persons will be covered for any Claims for Health Services carried out during a period of non-payment. ### Resuming your policy or cover from suspension - If the Policy or Cover for an Insured Person has been suspended under the Loyalty – Suspension of Cover Benefit it must be resumed within 90 days of the suspension end date, otherwise the Policy or Cover will be cancelled. - If the same Cover is resumed before the suspension period ends, we will reinstate the Cover without enquiring into the affected Insured Person's health. - If Waiting Periods have not been fully served, the remainder of the Waiting Periods must be served once the Policy or Cover is resumed. - If the Policy or Cover for an Insured Person is not reinstated at the end of the suspension period, we will write to the Policyowner at their last known address and give them 90 days within which to pay any arrears of Premium. If they do not pay the arrears within the 90 days the Policy or Cover for the affected Insured Persons will end. ### Cancelling the policy or cover Unless otherwise permitted by us, any cancellation of a Policy and/or Cover for an Insured Person must be authorised in writing by the Policyowner. The Policyowner must give us at least 30 days' notice of the cancellation. We reserve the right to cancel the Policy and/or Cover for an Insured Person, if: - the Premiums are in arrears by more than 90 days after the due date for payment; or - the Policy is not resumed following a suspension; or - an Insured Person is no longer entitled to receive Health Services funded under the New Zealand Public Health and Disability Act 2000 (or its successor under any subsequent legislation); or - the last Insured Person covered by this Policy dies; or - any Insured Person breaches the terms of the Policy; or - any information provided by, or on behalf of the Policyowner or any Insured Person when arranging this Policy or when making any changes to it, is not true, correct and complete; or - an Insured Person covered by the Policy has obtained or attempted to obtain an advantage, monetary or otherwise, whether for themselves or for any other Insured Person, to which they are not entitled under this Policy document; or - an Insured Person has engaged in offensive or intimidating behaviour towards employees of nib. If we cancel this Policy or Cover for an Insured Person, any Premiums paid may be retained by us. If we have already made any Claims payments we may recover these from the Policyowner. ### Your premiums Premiums must be up-to-date to keep the Policy active so that the Insured Persons listed on the Policy can continue to Claim Benefits. - Where the Premium rate change takes effect during the Policy Year, the change will not come into effect until the next Premium falls due. - Premiums can be paid in advance for up to a maximum of 12 months. #### Available payment methods and frequency Payment periods are set out below and must be paid in advance, unless otherwise permitted by us: - where Premiums are paid by direct debit from a bank, building society, or credit union account – weekly, fortnightly, monthly, quarterly, half yearly and yearly. - where Premiums are paid by credit card payment from a MasterCard or Visa – monthly, quarterly, half yearly and yearly. #### nib payment service agreement We will give the Policyowner at least 30 days' notice in writing if there are changes to the details of the direct debit terms and conditions. - Any information about the nominated account will remain confidential, except where required to complete direct debits with the financial institution. - When the due date is not a working day, we will debit the account on the first working day after the due date. It is the Policyowner's responsibility to: - ensure the nominated account can allow direct debit; - ensure there are enough funds available in the account to make a payment on the due date; - tell us if the account details change, or if the account is transferred or closed; - arrange a different payment method if we cancel the direct debit arrangements; - ensure all account holders of the nominated account sign the direct debit authority form; and - update us if the credit card details change, for example: new expiry date. The Policyowners can change the direct debit arrangements in line with the terms and conditions of our direct debit authority, at least 10 calendar days before the next due date. The Policyowner must give instructions to stop or alter the direct debit details in writing. We reserve the right to cancel direct debit arrangements if the nominated financial institution dishonours direct debits, and to arrange a different payment method with the Policyowner. The details of the direct debit arrangement are contained in the direct debit authority form which the Policyowner submits to us. We will rely on those details to process payments until told otherwise. Not all accounts held with a financial institution are available to be drawn on under the bulk electronic clearing system. The Policyowner should check with their financial institution if they are unsure whether their account can facilitate direct debits. The Policyowner may cancel or stop a drawing with their financial institution. If the Policyowner has a direct debit inquiry, or believes a debit has been made incorrectly, please contact us immediately on **0800 123 nib (0800 123 642)** or write to: nib nz limited PO Box 91630 Victoria Street West Auckland 1142 ### Important information about your premiums and benefits The Premiums are calculated according to the rates applying from time to time for the Policy selected. The Premiums automatically increase when an Insured Person reaches a specified age. Any changes to the Premium rates and age related steps apply across all Insured Persons with this Policy. No changes will be made to your individual Policy alone, based upon the individual claims experience of your Policy. The Premiums for this Policy are not guaranteed. We may alter the Premium rates (including any policy fee and/or the age related steps) during the life of the Policy, but only in the following circumstances and only to the extent necessary to take these circumstances into account: - if the law that applies to the Policy changes (including changes in taxation); or - if our costs increase as a result of medical inflation, as determined by us; or - in respect of any policy fee, if our costs increase as a result of increased operational expenses, as determined by us; or - in order to increase the level of cover under a Benefit or to add a new Benefit; or - to allow for an unexpected and significant increase in the type and/or level of claims under the Policy, which are not sustainable long term and which threaten its commercial viability; or - to align this Policy with a newer version of the same type of policy we subsequently offer with similar (but not necessarily the same) Premiums and/or Benefits; or - to take into account unexpected and severe public health threats e.g. a pandemic. We will give the Policyowner 30 days' prior written notice of any alteration. The Policyowner retains the right to cancel this Policy at any time. We want to ensure your valuable cover continues if a premium deduction advice is returned to us as gone/no address. In these circumstances, we will continue to make deductions in accordance with our Premium rates until we are advised otherwise and the Policyowner authorises us to stop the deductions. ### Guaranteed Benefits and Future Upgrades The Benefits (including terms of the Cover, 'What is not covered' and 'Glossary of important terms') for this Policy are guaranteed, subject to the permitted changes set out below. We may only alter the Benefits or other terms of the Cover (except for Premium rates) during the life of the Policy if: - the law that applies to the Policy changes (including changes in taxation); or - the Policyowner and/or Insured Person failed to disclose information to us (see Duty of Disclosure on page 8); or - new Benefits or increases to existing Benefits are added to the Policy. If we add new Benefits or increase existing Benefits, these changes will only apply to relevant Health Services received where the treatment date is after the date of the relevant change. --- ## Claims Benefits will only be paid for Claims which meet nib criteria. - All Claims are subject to your Contract of Insurance (on page 7) and What is not covered (on page 65). - All Claims must relate to an Insured Person. - We reserve the right to recover any money paid in error, obtained fraudulently, or by any other means contrary to the Policy or law. - It will be at nib's discretion to determine whether the Insured Person will be covered for any Claims for Health Services carried out during a period of non-payment. - Claims are only eligible for Health Services carried out by Recognised Providers. - Any Claims must have all the relevant information submitted with the Claim form (see Supporting documentation for Pre-approval and Claims on page 18). ### How to make a claim - Visit our portal at **nib.co.nz/portal** to submit a Claim. - Visit our website at **nib.co.nz** for a Claim form. - Call us on **0800 123 nib (0800 123 642)**. - Email us at **claims@nib.co.nz** - The Policy number must be quoted for all Claims. ### Pre-approval - We strongly recommend any Insured Person should seek Pre-approval prior to undertaking any Health Service to understand what is covered under your Policy. - Our aim is to process the Pre-approval within five working days from the date the request is received by us, unless further information is required or insufficient information was initially supplied. - If we issue a Pre-approval for a Claim, we will notify the Policyowner or the Insured Person and send the Policyowner a Pre-approval advice. - All Claim and Pre-approval forms are available on our portal at **nib.co.nz/portal**, our website at **nib.co.nz** or by contacting us: - Call us on **0800 123 nib (0800 123 642)**. Our opening hours are Monday to Friday 8.00am to 5.30pm. We are closed on public holidays. - Fax us on **0800 345 134** - Email us at **claims@nib.co.nz** The confirmation of the Pre-approval is valid for three months from the date of issue recorded on the correspondence, unless the Cover is cancelled with effect from a date on or prior to the treatment date. If the Cover is cancelled with effect from a date prior to the treatment date, the Pre-approval will not be valid. ### Supporting documentation for Pre-approval and Claims Supporting documentation for Pre-approval or Claims must: - be made in a format approved by nib; - be submitted with a fully completed Claim and Pre-approval form; - include a copy of the GP referral letter (if appropriate); - include a copy of the Registered Specialist Consultation letter (if appropriate); - Claims must be supported by original Recognised Provider invoices and/or itemised receipts on the Recognised Provider's letterhead showing their official stamp and GST number; and - Pre-approvals must be supported by an estimate of the cost on the Recognised Provider's letterhead showing their official stamp and GST number. We recommend all Claims be submitted within 12 months of the Health Service date, as no inflation adjustments apply. ### Novel, experimental or more expensive treatments or procedures We will not approve any novel, experimental or more expensive treatment or procedure, where a conventional or less expensive treatment or procedure is available that will provide the same, or a similarly acceptable, medical outcome. This means novel or experimental treatments, procedures or equipment are not likely to be covered unless, in nib's opinion, they provide a superior outcome at a reasonable cost. ### Medical report or assistance All costs of completing the Claim form, including providing a medical report if required by us, will be at the Policyowner's expense. If we require further information in order to assess the Claim or Pre-approval, all requests must be complied with. If we request additional information, this will be at our expense. ### Rapid refund and method Our aim is to process the Pre-approval or Claims within five working days, unless further information is required. Reimbursement must be to a Recognised Provider, Policyowner or Insured Person, regardless of whether any other person has paid the invoice. In cases where the Insured Person is deceased, Claim payment can only be made to the Recognised Provider, remaining Policyowner or the deceased Insured Person's estate. In cases where we are refunding the Policyowner or Insured Person by direct credit, please ensure your banking details are accurate on the Claim form. If we pay to an incorrect account due to an Insured Person's error, no replacement payment can be issued until the original payment has been returned to us. We will only refund to a nominated New Zealand bank account in New Zealand dollars. --- ## Usual, Customary and Reasonable Charges (UCR Charges) All costs incurred under a Benefit will be compared to our UCR Charges. This allows nib to manage the costs of Claims. Where the actual costs incurred vary significantly from our UCR Charges, we will negotiate with the Recognised Provider concerned. This process, and our success or failure in it, will not affect what we pay under this Policy. --- ## Medications provided in hospitals or at home The Policy will meet the cost of medications that are registered and approved by Medsafe, that meet the associated funding criteria, and that are prescribed by the treating Registered Specialist. If a medication is not listed under section A to H of the PHARMAC pharmaceutical schedule, the treating Registered Specialist must provide a recommendation letter detailing the reasons for the medication(s). Any administration and/or associated costs paid to administer the medications are also covered. ### Additional terms - Benefits are not payable for any medications charged in a Public Hospital. - Benefits are not payable for any medications that are listed as pending review by Medsafe. - Benefits are not payable for any medications prescribed or administered outside of the Medsafe guidelines and associated criteria. --- ## ACC ### ACC review If we believe that ACC should cover your Health Service(s), you are required to co-operate fully with our review process, which may include providing authority to our legal representative and providing us with copies of the ACC declined letter, the case summary and any other relevant information. ### ACC treatment injury In the rare instance of treatment Injury during Surgical or medical treatment, cover is payable for any additional costs involved under the ACC treatment Injury Benefit (see ACC Treatment Injury Benefit on page 40). --- ## What is covered ### Base Cover This section lists and defines the Benefits we provide under the Ultimate Health Max base Cover, and should be read in conjunction with all other parts of your nib Contract of Insurance. All Claims are subject to our general terms (see General terms of Ultimate Health Max Cover on page 8 and What is not covered on page 65). If the Policyowner has chosen an Excess for an Insured Person's Cover, this will apply to that Insured Person every Policy year (see Excess on page 13). #### 1. Hospital Surgical Benefit This Benefit covers the following for eligible Surgical Claims, upon Admission: - surgeon's operating fees; - anaesthetist's fees; - intensivist's fees; - Hospital accommodation (e.g. Admitted Patient's bed, a private room) (excludes suites); - operating theatre fees; - Surgically implanted Prosthesis (see Prosthesis Schedule on page 9); - laparoscopic disposables; - in-Hospital X-ray examination and ECG; - intensive post-operative care and special in-Hospital nursing; - in-Hospital post-operative Physiotherapy; - ancillary Hospital charges (e.g. dressings, sutures, needles, bandages); and - in-Hospital Pharmaceutical Prescriptions (see Medications provided in hospitals and at home on page 19). We also cover the costs of alternative, less invasive, procedures which, in our sole opinion, replace Surgery as the most appropriate method of treatment for any Condition that we would have otherwise agreed to accept as a Surgical Claim. Cover is under the Hospital Medical Benefit. This Benefit also applies to the Cover available under the following Benefits relating to an Admission. Claims paid under these Benefits will be deducted from the balance available in the Hospital Surgical Benefit Limit for the current Policy Year and no further claims will be paid after the Hospital Surgical Benefit Limit has been reached: - Non-PHARMAC Funded Drugs in Hospital Benefit (see Non-PHARMAC Funded Drugs in Hospital Benefit on page 25); - Non-PHARMAC Funded Drugs at Home Benefit (see Non-PHARMAC Funded Drugs at Home Benefit on page 26); - Cancer Treatment Accessories Support Benefit (see Cancer Treatment Accessories Support Benefit on page 26); - Cancer Treatment Counselling and Support Services Benefit (see Cancer Treatment Counselling and Support Services on page 26); - Cardiac Counselling and Support Services (see Cardiac Counselling and Support Services on page 27); - Follow-up Investigations for Cancer Benefit (see Follow-up Investigations for Cancer Benefit on page 28); - Breast Symmetry Post Mastectomy Benefit (see Breast Symmetry Post Mastectomy Benefit on page 29); - Major Diagnostics Benefit (see Major Diagnostics Benefit on page 29); - Hospital Diagnostics Benefit (see Hospital Diagnostics Benefit on page 30); - Hospital Specialist Consultations Benefit (see Hospital Specialist Consultations Benefit on page 30); - Hospital Specialist Second Opinion Benefit (see Hospital Specialist Second Opinion Benefit on page 30); - Travel and Accommodation Benefit (see Travel and Accommodation Benefit on page 31); - Parent Accommodation Benefit (see Parent Accommodation Benefit on page 32); - Ambulance Transfer Benefit (see Ambulance Transfer Benefit on page 32); - Home Nursing Care Benefit (see Home Nursing Care Benefit on page 32); - Physiotherapy Benefit (see Physiotherapy Benefit on page 33); - Therapeutic Care Benefit (see Therapeutic Care Benefit on page 33); - Delayed Care Benefit (see Delayed Care Benefit on page 34); - Cover in Australia Benefit (see Cover in Australia Benefit on page 34); - Medical Tourism Benefit (see Medical Tourism Benefit on page 36); - Pre-existing Cover for Newborns Benefit (see Pre-existing Cover for Newborns Benefit on page 37); - Specialist Skin Lesions Surgery Benefit (see Specialist Skin Lesions Surgery Benefit on page 38); - ACC Top-up Benefit (see ACC Top-up Benefit on page 39); - ACC Treatment Injury Benefit (see ACC Treatment Injury Benefit on page 40); - Loyalty – Sterilisation Benefit (see Loyalty – Sterilisation Benefit on page 42); - Loyalty – Bariatric Surgery Benefit (see Loyalty - Bariatric Surgery Benefit on page 43); and - Loyalty – Bilateral Breast Reduction Benefit (see Loyalty – Bilateral Breast Reduction Benefit on page 44). Individual limits and terms may apply to each of the Benefits. ##### Benefit limit - We will pay up to a total maximum of **$600,000** for each Insured Person every Policy Year under this Benefit. ##### Additional terms - Benefits are not payable if the Surgery is not performed by a Registered Specialist. ##### Oral surgery This Benefit covers the cost of oral Surgery performed by a registered oral surgeon or maxillo-facial surgeon in a Recognised Private Hospital. We will only cover the cost of removal of unerupted or impacted teeth if a registered oral surgeon, Dental Practitioner or maxillo-facial surgeon performs the Surgery. ###### Additional terms - Benefits are not payable for any extraction of teeth other than for unerupted or impacted teeth. - Benefits are not payable for any other Dental Treatments, including periodontic, endodontal procedures, Orthodontic Treatment and implants, and orthognathic surgery or exposure of teeth. ##### Specialist micrographic surgery (Mohs) This Benefit covers the cost of Mohs Surgery, performed by a Registered Specialist in a Recognised Private Hospital. ###### Additional terms - Benefits are not payable for any cryotherapy, pulse light therapy or photodynamic therapy. - For any other Skin Lesion Surgery (see Specialist Skin Lesion Surgery Benefit on page 38). ##### Varicose vein treatment This Benefit covers the cost of varicose vein treatment if it is performed by either: - a Registered Specialist; or - a Vocational GP; or - an nib Recognised Health Professional; - who is in Private Practice and holds a current annual practising certificate; - is registered with the Medical Council of New Zealand; and - is a fellow of the Australasian College of Phlebology. ###### Additional terms - Benefits are not payable for any cosmetic surgeries or treatment, including but not limited to superficial veins (for example: spider veins). #### 2. Hospital Medical Benefit This Benefit covers the following for eligible medical Claims, upon Admission: - Hospital accommodation (e.g. Admitted Patient's bed, a private room) (excludes suites); - in-Hospital X-ray examination and ECG; - intensive post-treatment care and special in-Hospital nursing; - in-Hospital post-treatment Physiotherapy; - ancillary Hospital charges (e.g. dressings, bandages); and - in-Hospital Pharmaceutical Prescriptions (see Medications provided in hospitals and at home on page 19). This Benefit also applies to the Cover available under the following Benefits relating to an Admission. Claims paid under these Benefits will be deducted from the balance available in the Hospital Medical Benefit Limit for the current Policy Year and no further claims will be paid after the Hospital Medical Benefit Limit has been reached: - Cancer Treatment in Hospital Benefit (see Cancer Treatment in Hospital Benefit on page 25); - Non-PHARMAC Funded Drugs in Hospital Benefit (see Non-PHARMAC Funded Drugs in Hospital Benefit on page 25); - Non-PHARMAC Funded Drugs at Home Benefit (see Non-PHARMAC Funded Drugs at Home Benefit on page 26); - Cancer Treatment Accessories Support Benefit (see Cancer Treatment Accessories Support Benefit on page 26); - Cancer Treatment Counselling and Support Services Benefit (see Cancer Treatment Counselling and Support Services Benefit on page 26); - Follow-up Investigations for Cancer Benefit (see Follow-up Investigations for Cancer Benefit on page 28); - Major Diagnostics Benefit (see Major Diagnostics Benefit on page 29); - Hospital Diagnostics Benefit (see Hospital Diagnostics Benefit on page 30); - Hospital Specialist Consultations Benefit (see Hospital Specialist Consultations Benefit on page 30); - Hospital Specialist Second Opinion Benefit – see Hospital Specialist Second Opinion Benefit on page 30); - Travel and Accommodation Benefit (see Travel and Accommodation Benefit on page 31); - Parent Accommodation Benefit (see Parent Accommodation Benefit on page 32); - Ambulance Transfer Benefit (see Ambulance Transfer Benefit on page 32); - Home Nursing Care Benefit (see Home Nursing Care Benefit on page 32); - Physiotherapy Benefit (see Physiotherapy Benefit on page 33); - Therapeutic Care Benefit (see Therapeutic Care Benefit on page 33); - Delayed Care Benefit (see Delayed Care Benefit on page 34); - Cover in Australia Benefit (see Cover in Australia Benefit on page 34); - Medical Tourism Benefit (see Medical Tourism Benefit on page 36); - Pre-existing Cover for Newborns Benefit (see Pre-existing Cover for Newborns Benefit on page 37); - ACC Top-up Benefit (see ACC Top-up Benefit on page 39); and - ACC Treatment Injury Benefit (see ACC Treatment Injury Benefit on page 40). Individual Benefit Limits and terms may apply to each of the Benefits. Hospital medical Cover as an alternative, less invasive procedure to Surgery is covered under this Benefit. ##### Benefit limit - We will pay up to a total maximum of **$300,000** for each Insured Person every Policy Year under this Benefit. ##### Additional terms - Benefits are not payable when the medical treatment is not managed by a Registered Specialist. - Benefits are not payable for any medical treatment where the sole or main purpose of the medical treatment is administration of an Injection. For example: pain management Injections or intravitreal Injection (except where the contrary is expressly specified in the Policy). - Benefits are not payable unless the Condition or treatment requires Admission as supported by medical evidence. - Benefits are not payable if the drug is not approved by Medsafe. #### 3. Cancer Treatment in Hospital Benefit This Benefit covers the following for eligible Claims upon Admission: - Chemotherapy; - Radiotherapy; - Brachytherapy; - Hospital accommodation (e.g. Admitted Patient's bed, a private room) (excludes suites); - in-Hospital X-ray examination and ECG; - intensive post-treatment care and special in-Hospital nursing; - in-Hospital post-treatment Physiotherapy; - ancillary Hospital charges (e.g. dressings, needles, bandages); and - in-hospital Pharmaceutical Prescriptions (see Medications provided in hospitals or at home on page 19). ##### Benefit limit - The maximum we will pay is the balance available for the Policy Year in the Hospital Medical Benefit Limit. ##### Additional terms - Costs relating to a cancer Surgery are covered under the Hospital Surgical Benefit (see Hospital Surgical Benefit on page 21). #### 4. Non-PHARMAC Funded Drugs in Hospital Benefit This Benefit covers the costs of drugs that are Medsafe approved for use in a Recognised Private Hospital (see Medication provided in hospital or at home on page 19). ##### Benefit limit - The maximum we will pay is the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). ##### Additional terms - For drugs issued for the sole purpose of use at home after Admission (see Non-Pharmac Funded Drugs at Home Benefit below). - Benefits are only payable when an associated Claim has been paid under the Hospital Surgical Benefit or Hospital Medical Benefit (whichever applies). - Benefits are not payable if the drug is not approved by Medsafe. #### 5. Non-PHARMAC Funded Drugs at Home Benefit This Benefit covers the costs of drugs that are Medsafe approved up to six months after Admission approved by us (see Medication provided in hospitals or at home on page 19). ##### Benefit limit - The maximum we will pay is the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). ##### Additional terms - For drugs issued during Admission (see Non-Pharmac Funded Drugs in Hospital Benefit above). - Benefits are only payable providing the drug are Medsafe approved and is directly relate to that Admission. - Benefits are only payable when an associated Claim has been paid under the Hospital Surgical Benefit or Hospital Medical Benefit (whichever applies). #### 6. Cancer Treatment Accessories Support Benefit This Benefit covers the costs of a wig, hat, scarf or mastectomy bras during or within six months after a cancer Surgery or Cycle of cancer treatment approved by us. ##### Benefit limits ###### Scarf/hat - The maximum we will pay for this Benefit is **$50** for each eligible cancer Condition. ###### Wig/Mastectomy bras - The maximum we will pay for this Benefit is **$500** for each eligible cancer Condition. ##### Additional terms - Benefits are only payable upon receipt of evidence of the costs incurred. - Benefits are only payable providing the cost of the scarf, hat, wig or mastectomy bras relate directly to the eligible cancer Condition. - Benefits are only payable when an associated Claim has been paid under the Hospital Surgical Benefit or Hospital Medical Benefit (whichever applies). #### 7. Cancer Treatment Counselling and Support Services Benefit This Benefit covers the cost of Counselling and support services that occur within six months after an Admission for a cancer Surgery or Cycle of cancer treatment approved by us. Claims must be received with the treating GP or Registered Specialist's written recommendation for the Counselling and/or support service. The recommended service must relate to the cancer Surgery or Cycle of treatment for cancer approved by us. The Counselling services covered under this Benefit are: - Grief Counselling; - Illness crisis Counselling; - Anxiety Counselling; - Depression Counselling; and - Anger management. The support services covered under this Benefit are: - Stop smoking; - Drug addiction; - Alcohol addiction; - Gambling addiction; - Relationship guidance; - Budgeting advice; - Career advice; and - Small business advice. ##### Benefit limits This Benefit is paid from the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). ###### Counselling services - The maximum we will pay for this Benefit is **$400** for each eligible cancer Condition. ###### Support services - The maximum we will pay for this Benefit is **$300** for each eligible cancer Condition. ##### Additional terms - Benefits are only payable if the Counselling service is provided by a GP, Clinical Psychologist, Psychiatrist or Psychologist, and is approved by nib prior to receiving the service. - Benefits are only payable if the support service is provided by an expert within their field, and is approved by nib prior to receiving the service. - Benefits are only payable upon receipt of evidence of the costs incurred. - Benefits are not payable to any family members, friends, associates or those who do not meet the criteria as determined by us. - Benefits are only payable when an associated Claim has been paid under the Hospital Surgical Benefit or Hospital Medical Benefit (whichever applies). #### 8. Cardiac Counselling and Support Services Benefit This benefit covers the cost of Counselling and support services that occur within six months after an Admission for a heart Surgery approved by us. Claims must be received with the treating GP or Registered Specialist's written recommendation for the Counselling and/or support service. The recommended service must relate to the heart Surgery approved by us. The Counselling services covered under this Benefit are: - Grief Counselling; - Illness crisis Counselling; - Anxiety Counselling; - Depression Counselling; and - Anger management. The support services covered under this Benefit are: - Stop smoking; - Drug addiction; - Alcohol addiction; - Gambling addiction; - Relationship guidance; - Budgeting advice; - Career advice; and - Small business advice. ##### Benefit limits This Benefit is paid from the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). ###### Counselling services - The maximum we will pay for this Benefit is **$400** for each eligible heart Surgery. ###### Support services - The maximum we will pay for this Benefit is **$300** for each eligible heart Surgery. ##### Additional terms - Benefits are only payable if the Counselling service is provided by a GP, Clinical Psychologist, Psychiatrist or Psychologist, and is approved by nib prior to receiving the service. - Benefits are only payable if the support service is provided by an expert within their field, and is approved by nib prior to receiving the service. - Benefits are payable upon receipt of evidence of the costs incurred. - Benefits are not payable to any family members, friends, associates or those who do not meet the criteria as determined by us. - Benefits are only payable when an associated Claim has been paid under the Hospital Surgical Benefit or Hospital Medical Benefit (whichever applies). #### 9. Follow-up Investigations for Cancer Benefit Following a cancer Surgery or treatment approved by us, we cover one Registered Specialist Consultation and relevant investigation(s) relating to that cancer every Policy Year for up to five years. ##### Benefit limits - This Benefit is paid from the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). - We will pay a total maximum of **$3,000** for each Insured Person every Policy Year. - We will pay up to five consecutive Policy Years. ##### Additional terms - This Benefit is only effective from the end of your treatment phase (Chemotherapy, Radiotherapy, Brachytherapy or Surgery). #### 10. Breast Symmetry Post Mastectomy Benefit Following a mastectomy covered under this Policy we will cover: - the cost of reconstruction of the affected breast and/or - unilateral breast reduction Surgery of the unaffected breast, to achieve breast symmetry. This benefit includes cover for any Consultations, diagnostics and subsequent treatments relating to breast reconstruction or unilateral breast reduction Surgery. Following the initial breast reconstruction or unilateral breast reduction we will not cover any subsequent treatment that is not Medically Necessary. ##### Benefit limits - The maximum we will pay is the balance available for the Policy Year in the Hospital Surgical Benefit Limit. ##### Additional terms - To claim under this Benefit, the Insured Person must submit a medical report by a Registered Specialist prior to the Surgery. - This Benefit is only payable if Insured Person has had a mastectomy covered under this Policy - No excess will be deducted from this Benefit. #### 11. Major Diagnostics Benefit This Benefit covers the cost of the following Diagnostic Investigations after referral by a GP or Registered Specialist. - arthroscopy - capsule endoscopy - colonoscopy - colposcopy - CT scan - CT angiogram - cystoscopy - gastroscopy - MRI scan - myelogram - PET scan (including PET/CT scan) ##### Benefit limits - There is no limit to the number of Diagnostic Investigations for each Insured Person every Policy Year. - The maximum we will pay is the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). ##### Additional terms If the Diagnostic Investigation results in an Admission within six months, it will be covered under the Hospital Diagnostics Benefit (see Hospital Diagnostic Benefit on page 30). #### 12. Hospital Diagnostics Benefit This Benefit covers Diagnostic Investigations up to six months before and after Admission. ##### Benefit limits - There is no limit to the number of Diagnostic Investigations during the specified timeframe. - The maximum we will pay is the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). ##### Additional terms - Benefits are only payable when an associated Claim has been paid under the Hospital Surgical Benefit or Hospital Medical Benefit (whichever applies). Cover may be available under the Specialist Option if the Policyowner has selected that option. #### 13. Hospital Specialist Consultations Benefit This Benefit covers Registered Specialist or Vocational GP Consultations up to six months before and after Admission, after a referral from a GP or a Registered Specialist. ##### Benefit limits - There is no limit to the number of Registered Specialist or Vocational GP Consultations during the specified timeframe. - The maximum we will pay is the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). ##### Additional terms - Benefits are only payable when an associated Claim has been paid under the Hospital Surgical Benefit or Hospital Medical Benefit (whichever applies). Cover may be available under the Specialist Option if the Policyowner has selected that option. #### 14. Hospital Specialist Second Opinion Benefit This Benefit covers the costs of a second opinion from another Registered Specialist or Vocational GP for the Admission. This Benefit covers the costs of Registered Specialist or Vocational GP Consultations for a second opinion, up to six months before and after Admission. ##### Benefit limits - There is no limit on the number of Registered Specialist or Vocational GP Consultations for a second opinion, for each Insured Person every Policy Year. - The maximum we will pay is the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). ##### Additional terms - Benefits are only payable when an associated Claim has been paid under the Hospital Specialist Consultations Benefit (see above). - For Diagnostic Investigations requested by another Registered Specialist (see Hospital Diagnostic Investigations Benefit on page 30 and Major Diagnostics Benefit on page 29). #### 15. Travel and Accommodation Benefit This Benefit covers the travel and accommodation costs incurred when Surgery or medical treatment recommended by a Registered Specialist is not available through a Recognised Private Hospital within 100 kilometres from the Insured Person's usual residence. Where a Registered Specialist has recommended a support person for the Surgery or medical treatment. The support person must travel together with the Insured Person to and from the Recognised Private Hospital. ##### Travel This Benefit covers the following where applicable: - air: a return economy class flight within New Zealand for the Insured Person and the accompanying support person; or - car: mileage for road travel at the amount determined by nib; or - rail or bus: a return rail or bus trip within New Zealand for the Insured Person and the accompanying support person; and - taxi: taxi fares on Admission and discharge from the Recognised Provider to/from the airport or railway station for the Insured Person and the accompanying support person. ##### Accommodation We will cover the cost of accommodation incurred by the support person whilst the Insured Person is an Admitted Patient. ##### Benefit limits - This Benefit is paid from the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). - Surgery and medical treatment: the maximum we will pay for travel is **$3,000** for each Insured Person every Policy Year. We will pay up to **$300** each night for accommodation costs. - Cancer treatment: the maximum we will pay for travel is the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). We will pay up to **$300** each night for accommodation costs. ##### Additional terms - Benefits are only payable when an associated Claim has been paid under the Hospital Surgical Benefit or Hospital Medical Benefit (whichever applies). - Benefits are not payable for any costs incurred when travelling outside New Zealand. - Benefits are not payable for any costs relating to vehicle hire. - Benefits are not payable for any costs relating to travel insurance. #### 16. Parent Accommodation Benefit This Benefit covers the cost of accommodation incurred by a parent or legal guardian accompanying an Insured Person aged 20 or under, where they are being treated in a Recognised Private Hospital. ##### Benefit limits - This Benefit is paid from the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). - We will pay up a total maximum of **$3,000** for each Insured Person every Policy Year. - We will pay a maximum of **$300** each night. ##### Additional terms - Benefits are only payable when an associated Claim has been paid under the Hospital Surgical Benefit or Hospital Medical Benefit (whichever applies). #### 17. Ambulance Transfer Benefit This Benefit covers the cost of road ambulance transfer from a Public Hospital or Recognised Private Hospital to the closest Recognised Private Hospital. The road ambulance transfer must be recommended by a Registered Specialist who has cared for the Insured Person for at least 24 hours as an Admitted Patient. ##### Benefit limit - The maximum we will pay is the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). ##### Additional terms - Benefits are only payable when an associated Claim has been paid under the Hospital Surgical Benefit or Hospital Medical Benefit (whichever applies). - Benefits are not payable on any ambulance society subscriptions. #### 18. Home Nursing Care Benefit This Benefit covers the cost of home nursing care up to six months after being discharged from a Recognised Private Hospital where the home nursing directly relates to a medical Condition, and the Insured Person requires assistance with any of the Activities of Daily Living. The home nursing care must be recommended by the Insured Person's GP or Registered Specialist and provided by a Registered Nurse or a Nurse Practitioner. This Benefit provides Cover for up to six months following each Admission as long as assistance is still required for the Activities of Daily Living. ##### Benefit limits - This Benefit is paid from the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). - We will pay up to a total maximum of **$6,000** for each Insured Person every Policy Year. - We will pay up to **$300** a day. ##### Additional terms - Benefits are only payable when an associated Claim has been paid under the Hospital Surgical Benefit or Hospital Medical Benefit (whichever applies). - Benefits are not payable for any cost in relation to providing domestic duties/house keeping or childcare. Cover may be available under the GP Option if the Policyowner has selected this option. #### 19. Physiotherapy Benefit This Benefit covers the cost of Physiotherapy up to six months after being discharged from a Recognised Private Hospital where the Physiotherapy directly relates to that medical Condition, after a referral by the treating Registered Specialist. ##### Benefit limits - There is no limit to the number of Physiotherapy treatments during the specified timeframe. - The maximum we will pay is the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). ##### Additional terms - Benefits are only payable when an associated Claim has been paid under the Hospital Surgical Benefit or Hospital Medical Benefit (whichever applies). Cover may be available under the GP Option if the Policyowner has selected that option. #### 20. Therapeutic Care Benefit This Benefit covers the cost of the following: - Osteopathic treatment; - Chiropractic treatment; - Speech Therapy; - Occupational Therapy; - Dietitian Consultations; and - Sports Physician Treatments up to six months after being discharged from a Recognised Private Hospital, where the therapeutic care directly relates to that medical Condition, after referral by the treating Registered Specialist. ##### Benefit limits - This Benefit is paid from the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). - We will pay up to a total maximum of **$1,000** for each Insured Person every Policy Year. ##### Additional terms - Benefits are only payable when an associated Claim has been paid under the Hospital Surgical Benefit or Hospital Medical Benefit (whichever applies). - Cover may be available under the Specialist Option, GP Option and Dental and Optical Option if the Policyowner has selected these options. #### 21. Delayed Care Benefit This Benefit covers the costs of Surgery or medical treatment that takes place overseas where the Surgery or medical treatment is privately available in New Zealand but cannot be provided as a direct result of insufficient medical resources, for a period of six months or more. This Benefit covers the costs of economy flights for the Insured Person and one support person to and from the destination, including transfers. This Benefit also covers the costs of accommodation for the Insured Person and one support person as agreed by nib prior to departure. ##### Benefit limits - This Benefit is paid from the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). - We will pay UCR costs that would be payable in New Zealand for the same Surgery or medical treatment. ##### Payment method and currency - All payments, Excess and Benefit Limits under this Benefit are in New Zealand dollars and will be direct credited into your nominated New Zealand bank account in New Zealand dollars. Payments can only be made to the Policyowner or Insured Person. We do not pay the Health Service provider concerned. - The exchange rate will be calculated by nib as at the date of Health Services. ##### Additional terms - Relevant Diagnostic Investigations and histology must be performed prior to departure. - Destination, travel and accommodation details are subject to nib approval, at nib's sole discretion. - All medical facilities/treatment providers/health professionals must have an equivalent accreditation/registration as per New Zealand standards approved by nib. - Benefits are not payable when Surgery or medical treatment is not available in New Zealand. - Benefits are not payable for any Surgery or medical treatment that is claimable under the overseas treatment Benefit. - Benefits are not payable for any Surgery or medical treatment not performed in an overseas private hospital. #### 22. Cover in Australia Benefit This Benefit covers the costs incurred by the Insured Person for a Surgical or medical treatment in Australia for all the Benefits listed under this base Cover with the exception of: - Travel and Accommodation Benefit; - Overseas Treatment Benefit; - Delayed Care Benefit; - ACC Top-up Benefit; - ACC Treatment Injury Benefit; and - Ambulance Transfer Benefit ##### Benefit limits - This Benefit is paid from the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). - We will reimburse up to the UCR Charges which would have been payable in New Zealand. ##### Payment method and currency - All payments, Excess and Benefit Limits under this Benefit are in New Zealand dollars and will be direct credited into your nominated New Zealand bank account in New Zealand dollars. Payments can only be made to the Policyowner or Insured Person. We do not pay the Health Service provider concerned. - The exchange rate will be calculated by nib as at the date of Health Services. ##### Additional terms - Benefits are not payable for any Surgical or medical treatment undertaken relating to an Injury which would be covered under ACC in New Zealand if the Injury had occurred in New Zealand. - All medical facilities/treatment providers/health professionals must have an equivalent accreditation/registration as per New Zealand standards approved by nib. - Surgical or medical treatment must comply with the Australian legislation. - Benefits are not payable for any type of ambulance costs. - Claims cannot be submitted for both Cover in Australia Benefit and Overseas Treatment Benefit for the same Surgical or medical treatment. If both Benefits are eligible we will pay the higher Benefit Limit. - Benefits for any medications are only provided if the medications would be covered in New Zealand (see Medications provided in hospital on page 19). #### 23. Overseas Treatment Benefit This Benefit covers the cost of an overseas Surgical or medical treatment that cannot be performed at all in New Zealand, where an application has been submitted to the Ministry of Health for funding under the 'Medical Treatment Overseas Scheme', and the Ministry of Health has declined funding. We cover the reasonable travel cost, including return economy airfares for the Insured Person requiring treatment and a support person, plus the cost of the treatment performed overseas, up to the Benefit Limit. ##### Benefit limit - We will pay up to a maximum of **$30,000** for every overseas Surgical or medical treatment for each Insured Person. ##### Payment method and currency - All payments, Excess and Benefit Limits under this Benefit are in New Zealand dollars and will be direct credited into your nominated New Zealand bank account in New Zealand dollars. Payments can only be made to the Policyowner or Insured Person. We do not pay the Health Service provider concerned. - The exchange rate will be calculated by nib as at the date of Health Services. ##### Additional terms - The treatment must be a type that cannot be performed in New Zealand. - The treatment must be recommended by the Insured Person's treating Registered Specialist. - The Surgery or medical treatment are subject to nib approval, at nib's sole discretion. - You must provide a copy of the Ministry of Health's decision regarding funding to nib. - All medical facilities/treatment providers/health professionals must have an equivalent accreditation/registration as per New Zealand standards approved by nib. - Surgical or medical treatment must comply with the local legislation and applicable law. - Benefits are not payable for any accommodation costs. - Benefits are not payable for any desensitisation, vaccinations, immunology or allergies. #### 24. Medical Tourism Benefit This Benefit covers the cost of overseas Surgical or Medical treatment in the country of the Insured Person's choice, provided the treatment is recommended by a Registered Specialist in New Zealand and can be provided in New Zealand within a period of six months. This Benefit only covers costs that would be covered under the Hospital Surgical Benefit, Hospital Medical Benefit, Cancer Treatment in Hospital Benefit, non-PHARMAC Funded Drugs in Hospital Benefit or non-PHARMAC Funded Drugs at Home Benefit. Notwithstanding the references to any other Benefits in the Hospital Surgical Benefit and Hospital Medical Benefit, this Medical Tourism Benefit does not apply to cover costs under any Benefit in this Policy except the five Benefits listed above. ##### Benefit limit - The maximum we will pay is the balance available for the Policy Year in the Hospital Surgical Benefit Limit or Hospital Medical Benefit Limit (whichever applies). - We pay up to **75%** of the Usual, Customary and Reasonable Charges that would have been payable in New Zealand. ##### Payment method and currency - All payments, Excess and Benefit Limits under this Benefit are in New Zealand dollars and will be direct credited into your nominated New Zealand bank account in New Zealand dollars. Payments can only be made to the Policyowner or Insured Person. We do not pay the Health Service provider concerned. - The exchange rate will be calculated by nib as at the date of Health Services. ##### Additional terms - Pre-approval must be obtained for this Benefit - The Surgical or medical treatment must be a type that can be performed in New Zealand and must be recommended by the Insured Person's treating Registered Specialist. - All medical reports and receipts