Claims

We all need Insurance to cover those risks which we hope will never happen. Unfortunately they sometimes do, and it is very important that at this time the cover you have purchased works for you. We have staff who have had years of experience in ensuring your claims are processed quickly and met fairly. We are proud of our record and are here to help you. (See Case Studies). You may contact us to help. See Contact Us

Our Insurance provider, Sovereign has an excellent record in Claims processing and satisfaction. You may contact the Sovereign claims team on 0800 166 377 for assistance.

Simple prior approval service

Sovereign provides an exceptional claims service. You can apply for approval for your proposed treatment in advance and, if approved and covered by the plan, they will arrange payment directly with the health providers. You have the certainty of knowing, before the treatment commences, whether the claim will be paid in full.

If you think you may have a claim but are uncertain, check the policy Wording which provides information on the cover provided, and/or contact Sovereign. If a claim is justified, Sovereign will send you a appropriate claim form. You may also download and print a claim form from this site here.

Below is detailed information required for an Private Health claim. The more information that can be provided, the quicker the processing. Sovereign is under no obligation to pay a benefit until they have received all the information requested.

How to claim a benefit

For any claim enquiries or before incurring any costs in respect of a claim the life assured or the policy owner should first call the Claims Hotline on 0800 166 377.

There are two ways to claim a benefit:

1. You can seek prior approval from Sovereign and they will arrange to pay the life assured's registered medical practitioner directly, less any excess; or
2. you can pay for the medical costs incurred yourself and then submit your claim to Sovereign for reimbursement in accordance with section 3b below.

Sovereign strongly recommends that you utilise the prior approval service at all times. This will ensure that Sovereign approves or declines your claim before you incur any costs.

Prior approval and direct payment process for claims

Sovereign has preferred provider relationships with a number of registered medical practitioners, private hospitals and day stay clinics. Prior approval and direct payment processes to these registered medical practitioners and facilities are streamlined.

The policy owner must comply with the following requirements when seeking Sovereign's prior approval and direct payment of any claims:

Prior approval requests should be made as soon as you are aware of a pending private hospital admission, MRI or CT scan. We need a minimum of five working days to process a claim prior to the actual private hospital admission or procedure. Failure to notify Sovereign within the required timeframe may result in a prior approval authorisation being declined or delayed until Sovereign has had the opportunity to fully assess the claim.

The policy owner should provide Sovereign with:

• details of the planned medical treatment or procedure; and
• a copy of the registered medical practitioner's referral letter and any other relevant clinical notes that may be requested by us in order to assess that the medical treatment or procedure being contemplated is medically necessary and falls within the terms and benefits of this policy.

Where possible you should provide Sovereign with an estimate of the costs for the medical treatment or procedure.

Allow Sovereign in its sole discretion to:

• contact the registered medical practitioner and obtain an estimate of the costs associated with the medical treatment or procedure under the claim;
• negotiate the proposed costs; and
• request that a second opinion is sought.

Subject to you requesting otherwise, Sovereign can nominate alternative registered medical practitioners to perform the medical treatment or procedure under the claim.

If your claim is approved, Sovereign will allocate a prior approval reference number to the claim and will fax or post to you or the life assured a letter confirming that the claim has been approved.

You must ensure that the prior approval number is quoted on all of the invoices/accounts relating to the pre-approved claim that are sent to Sovereign.

When you pay for treatment yourself and then submit a claim for reimbursement

You should give Sovereign notice of a claim as soon as possible by calling our Claims Hotline. On such notification Sovereign will send you a claim form. You should complete the claim form and send it together with the registered medical practitioner's referral letter and/or medical certificate and all of the original receipts and itemised invoices to us.

For any claim to be admissible regardless of payment method:

• the medical treatment or procedure must be medically necessary, as evidenced by the registered medical practitioner's referral letter and/or medical certificate and any other documentation requested by Sovereign to satisfy itself that the medical treatment or procedure is medically necessary; and
• premiums must be fully paid at the time the medical treatment or procedure takes place.

Subject to the terms of the policy, Sovereign will pay all reasonable charges for medically necessary treatment up to the respective maximum cover. If the costs of the medical treatment or procedure are greater than the lesser of the maximum cover or the reasonable charges, the balance of the costs remaining after Sovereign has paid the lesser of the reasonable charges or the maximum cover will be your responsibility.

If this policy is cancelled for any reason and there are outstanding claims relating to any medical treatment, procedure or other event covered under this policy that occurred before the date of cancellation, Sovereign must receive the relevant claim forms within 30 days of the cancellation date, otherwise the claim will not be payable.

Sovereign is not under any obligation to consider a claim unless all of the required information is provided to us. All claims are paid in New Zealand dollars.

You must submit all claims or all invoices/accounts relating to pre-approved claims to Sovereign within 12 months of the registered medical practitioner performing the medical treatment or procedure.

Claims on other insurers

Where another insurer, including but not limited to ACC, may have responsibility in respect of a claim the following provisions apply:

• It is the policy owner's or the life assured's responsibility to advise Sovereign that another insurer is involved in a claim that has been submitted to Sovereign.
• Before Sovereign accepts a claim under this policy, you or the life assured must firstly make a claim to the other insurers for any expense recoverable from a third party or under any contract of indemnity or insurance. Any expenses recoverable in this way will be deducted from the reimbursement provided by Sovereign under this policy.
• For the purposes of this policy, ACC is defined as another insurer.

For claims involving ACC

1. It is the life assured's or the policy owner's responsibility to submit any accident related claim to ACC in the first instance. Where surgery is indicated, the life assured or policy owner must seek or obtain prior approval from ACC for private hospital costs.
2. In respect of any accident related hospital treatment, Sovereign will not pay for MRI or CT scans required within seven days of the injury occurring.
3. If, due to the policy owner's or life assured's failure to comply with ACC's requirements, ACC refuses to cover the claim or ceases claim cover, the policy owner or life assured will be deemed by Sovereign to not have made a reasonable effort to secure cover and will therefore be ineligible to claim under this policy.
4. If ACC declines cover for private hospital treatment of an accident related condition, Sovereign reserves the right to insist that the policy owner or life assured applies to ACC for a review of that decision before Sovereign accepts any claim. Where ACC reverses a decision for a previously declined claim, Sovereign reserves the right to seek reimbursement from ACC or the policy owner of any related claims paid by Sovereign.
5. Where ACC agrees to contribute to the policy owner's or life assured's private hospital costs, Sovereign may cover additional costs up to the reasonable charges or as specified in the benefits sheet.
6. Sovereign will not be liable for any additional costs where a lead care provider of ACC is used to provide private hospital medical treatment or procedures.