Plan guide
11
application and a
claim
is made that
we
believe is for a
pre-existing medical
condition
:
•
we
will reject the
claim
if
your
underwriting terms are
moratorium
or
CPME previously moratorium
;
•
we
will reject the
claim
if
your
underwriting terms are
FMU
or
CPME
previously FMU
and
you
did not tell
us
about the
medical condition
when
we
asked about it on the application, or we have not accepted it.
This
benefit
condition does not apply if
your
underwriting terms are
MHD
.
BC6
Only
reasonable
costs will be paid for
claims
. Any costs above the relevant
limits shown in
your
Table of
benefits
will not be paid. If the
costs are not
reasonable
, or are above the limits shown in
your
Table of
benefits
,
you
will have
to pay the difference.
BC7
If
you
choose to use a
visiting doctor
instead of an
in-house doctor
, in a
hospital
, clinic or any other facility where direct billing or cashless arrangements
are in place, only
reasonable
costs will be paid. If the
visiting doctor’s
costs are
not
reasonable
and not in line with the
in-house doctor’s
costs,
you
will have to
pay the difference.
BC8
If
you
move to a
plan
where a
lifetime
limit
applies to a
benefit
, any amount
previously paid under the same, or equivalent
benefit
:
•
on any one or more
plans
;
•
regardless of any previous
benefit
limit; and
•
whether or not there has been a break in
your
cover;
will be deducted from the current
lifetime limit
on the
benefit
.
BC9
Physiotherapy must be referred by a
medical practitioner
or
specialist
. If
more than six physiotherapy sessions are needed for any
medical condition
,
your
therapist
must provide the reasons in the
Claim
form so
we
can consider cover.
BC10
Complementary
treatment
must be referred by a
medical practitioner
or
specialist.
If more than four osteopathic, chiropractic, homeopathic, podiatry,
Chinese traditional medicine or acupuncture sessions are needed for any
medical
condition
,
your therapist
must provide the reasons in the
Claim
form so
we
can
consider cover.
BC11
All
psychiatric treatment
and psychotherapy must be given by
medical
practitioners
, psychiatrists or qualified and registered psychotherapists or
psychoanalysts.
BC12
The normal pregnancy and childbirth
benefit
covers no more than one
routine antenatal 2D ultrasound scan in each trimester of a normal uncomplicated
pregnancy. If any more ultrasound scans are needed,
your medical practitioner
must confirm the reasons in the
Claim
form so
we
can consider cover. The
benefit
also covers 12 routine antenatal visits during a normal uncomplicated pregnancy.
If any more antenatal visits are needed
your medical practitioner
must provide
the reasons in the
Claim
form so
we
can consider cover.
The
benefit
covers the following for the newborn child:
•
one physical examination;
•
vitamin K, hepatitis B and BCG vaccinations;
•
routine blood tests for PKU, congenital hypothyroidism and G6PD;
•
one hearing examination; and
•
reasonable
accommodation costs for no more than four nights, if the
mother is admitted and not suffering any complications.
BC13
If
we
receive new information that shows a
claim we
have already
approved is not eligible, no costs will be paid. If any costs have already been paid,
we
will recover these from
you
or the
planholder
and no further costs will be
paid. Any approval
we
have given during the
pre-authorisation
process may also
be withdrawn.
Benefit exclusions
The
UltraCare plan
and Maternity add-on
plan
do not cover
claims
for, arising
from or connected with the following
benefit
exclusions unless shown on
your
Table of
benefits
, or agreed by
us
in writing.
Some of these
benefit
exclusions also apply to the Personal accident and Travel
add-on
plans
. See the ‘Extra
benefit
conditions and
benefit
exclusions for add-on
plans
’ section for more information.
Extra
benefit
exclusions also apply to the Personal accident and Travel add-on
plans
. See the ‘Extra
benefit
conditions and
benefit
exclusions for add-on
plans
’
section for more information.
BE1
(This
benefit
exclusion applies if
your
underwriting terms are
moratorium
or
CPME previously moratorium
, as shown on
your
Certificate of insurance. See
benefit
exclusion BE2 if
your
underwriting terms are
FMU
or
CPME previously
FMU
, as
benefit
exclusion BE1 does not apply to these underwriting terms.
Benefit
exclusions BE1 and BE2 do not apply if
your
underwriting terms are
MHD
.)
A
pre-existing medical condition
or
related medical condition
that, within a
24-month period before the
date of joining
or the date shown on the special
terms section of
your
Certificate of insurance, has one or more of the following
characteristics:
•
was
foreseeable
;
•
clearly showed itself;
•
you
had signs or symptoms of;
•
you
asked for advice about;
•
you
received
treatment
for;
•
to the best of
your
knowledge,
you
were aware
you
had.
Pre-existing medical conditions
or
related medical conditions
may be covered
after
you
have had 24 months’ continuous cover under the
plan
and within that
time
you
have not:
•
experienced symptoms;
•
asked for advice; or
•
needed or received
treatment
, medication, or a special diet.
If
you
have:
•
experienced symptoms;
•
asked for advice; or
•
needed or received
treatment
, medication, or a special diet;
then
you
will have to wait until
you
have completed a continuous 24-month
period when none of these apply to
you
.
Pre-existing medical conditions
or
related medical conditions
may then be covered. This is the rolling part of the
moratorium
.
BE2
(This
benefit
exclusion applies if
your
underwriting terms are
FMU
or
CPME
previously FMU
, as shown on
your
Certificate of insurance. See
benefit
exclusion
BE1 if
your
underwriting terms are
moratorium
or
CPME previously moratorium
,
as
benefit
exclusion BE2 does not apply to these underwriting terms.
Benefit
exclusions BE1 and BE2 do not apply if
your
underwriting terms are
MHD
.)
A
medical condition
or symptom that
you
were aware of before
your start date
unless
we
were given all the information
we
asked for in the application and
we
have not specifically excluded the
medical condition
or symptom as shown on
your
Certificate of insurance.
BE3
Costs that exceed a limit shown on
your
Table of
benefits
.
BE4
A
benefit
not included on
your plan
.
BE5
A
benefit
not included on
your plan
at the time the costs are incurred, even if
the
benefit
was included in any previous
plan year
.
BE6
A
benefit
included on
your plan
,
if
you
have not completed the waiting
period shown on
your
Table of
benefits
.
BE7
Pregnancy, childbirth or postnatal costs, whether complicated or not.
BE8
Any journey made specifically for the purpose of receiving medical
treatment
,
unless
you
have
r
equested
pre-authorisation
and
we
have given
our
approval.
BE9
Non-
emergency
transportation.
BE10
Burial, cremation, or the costs of moving
your
body or mortal remains, if
you
die in
your home country
.
BE11
Any journey, activity, action or pursuit carried out against the advice of a
medical practitioner
,
specialist
,
nurse
or
therapist
.
BE12
Treatment
given, or referrals made by, a
medical practitioner
,
specialist
,
nurse
or
therapist
who is in any way related to
you
, and self-prescribed
treatment
or self-referral
if
you
are a
medical practitioner
,
specialist
or
therapist
.
BE13
Alcohol, drug or any other intoxicating substance
abuse
, any addictive
condition of any kind and any
medical condition
arising directly or indirectly from
any such
abuse
or addictive condition.
BE14
You
being under the influence of alcohol, drugs or any other intoxicating
substance.
BE15
Male to female or female to male gender reassignment.
BE16
Tests or
treatment
for, or because of, sexually transmitted infections.
BE17
Experimental or unproven
treatment
, unless
you
have requested
pre-
authorisation
and
we
have given
our
approval.
