Plan guide
17
Date of joining
– when
you
first became a
member
on the
plan
.
Daycare treatment
–
treatment
at a
hospital
or daycare unit when medical
supervision is needed for four or more hours for recovery, but
you
do not stay
overnight.
Deductibles
– any
co-insurance
or
excess
that applies to
your plan
.
Dental
– that which affects the teeth and gums.
Dependant
– a
planholder
, employee or affinity
member’s
:
•
husband, wife or partner;
•
unmarried child, stepchild or legally adopted child under the age of 18;
•
unmarried child, stepchild or legally adopted child aged 18 to 24 who is
in continuous full-time education.
We
may need written proof from the
educational facility where they are enrolled.
Diagnostic tests and procedures
– a
medically necessary
test or examination to
investigate the cause of
your
symptoms.
Emergency
– a sudden, unexpected
acute medical condition
or an unexpected
acute
episode of a
chronic medical condition
that, without
treatment
within 48
hours of onset, could result in death or serious damage to bodily functions.
End date
– the last day
you
have cover under a
plan
.
Excess
– the amount
you
must pay towards the cost of a covered
claim
as shown
on
your
Table of
benefits
. The different types of
excess
are:
•
Excess
for each visit -
you
must pay this
excess
for each consultation
with a
medical practitioner
or
specialist
, no matter how many
medical
conditions
are treated by them during one consultation.
•
Excess
for each
medical condition
- this
excess
applies to each
medical
condition
claimed in each
plan year
. For example, if
you
make four
claims
for two
medical conditions
,
you
must pay two
excesses
in the
plan year
.
•
Excess
for each
member
- this
excess
applies to
you
once every
plan year
,
no matter how many
claims you
make in each
plan year
.
•
Excess
for each
claim
-
you
must pay this
excess
for each
claim you
make.
FMU
– see
Full Medical Underwriting
.
Foreseeable –
a
medical condition
that could be reasonably anticipated.
Full Medical Underwriting
–
the process that
we
use to assess
your
medical
history and decide the special terms
we
offer
you
. Cover will still be governed
by the
benefits
, terms and conditions of
your plan
with
us
except for
benefit
exclusion BE1.
Hazardous pursuit
– any activity or sport that places
you
at an increased risk of
suffering a
medical condition
or making an existing
medical
condition
worse.
Home country
– the country
you
are from as given to
us
on
your
application.
Hospital
– a legally licensed facility providing
treatment
under the laws of the
country in which it is located.
Immediate family
– a blood relative.
Inherited –
a
medical condition
which is hereditary.
In-house doctor
– a doctor who is employed by the
hospital
, is considered a
permanent member of staff and charges in line with
hospital
tariffs.
In-patient treatment
–
treatment
at a
hospital
where
you
need to stay in a bed
for one or more nights.
Intrinsic value
– the actual cash value of an item at the time of loss or damage,
including appropriate deductions for wear and tear.
Lifetime limit
– the total amount that will be paid for any eligible costs incurred
during any time
you
are covered on any one or more
plans
with the same, or
equivalent
benefit
, even if there is a break in
your
cover. See
benefit
condition
BC8 for more information.
Main member –
the person who is named first on a valid Certificate of insurance.
Material fact
– information, as follows, which is likely to influence
us
in the
assessment, acceptance or renewal of a
plan
, or in making any
changes to it:
•
about
you
,
your
lifestyle, health or
medical conditions
, that
we
have
asked
you
questions about;
•
about the
planholder
and any
members
,
including
dependants
, where
we
have asked the
planholder
or
plan administrator
questions;
•
that
you
, the
planholder
or
plan administrator
have chosen to give to
us
;
or
•
that
we
have not asked the
plan administrator
or
planholder
of a group
plan
any questions about, but which the
plan administrator
or
planholder
must disclose to
us
.
Medical condition
– signs or symptoms, injury, illness, sickness or disease.
Medical History Disregarded
–
we
will cover
pre-existing medical conditions
suffered by
you
, subject to the
benefits
, terms and conditions of
your plan
.
Benefit
condition BC5 and
benefit
exclusions BE1 and BE2 will not apply.
Medical necessity
,
medically necessary
–
treatment
prescribed by
your medical
practitioner
or attending
specialist
, which is appropriate for
your medical
condition
and is in line with accepted medical standards.
Medical practitioner
– a person who is registered and licensed to practise
medicine in the country where
treatment
is provided and has obtained the
primary degrees in medicine and surgery following attendance at a recognised
medical school listed within the World Directory of Medical Schools published by
the World Health Organisation.
Member
– see
you
,
your
,
yourself
.
MHD
– see
Medical History Disregarded
.
Moratorium
– a waiting period of 24 months from
your date of joining
, or the
date shown on the special terms section of
your
Certificate of insurance, that
must have passed before
claims
for
pre-existing medical conditions
or
related
medical conditions
may be eligible under the
UltraCare plan
. See
benefit
exclusion BE1 for more information. The
moratorium
also applies to the Maternity
add-on
plan
.
Natural teeth
– any teeth that are original and organic, not artificial implants or
replacements.
Nurse
– a person who is qualified in nursing, currently practising and on the
professional register of nursing in the country where
treatment
is provided.
Orthodontic
– that which affects the structure, function, development or
appearance of the teeth, upper or lower jaw or the oral cavity.
Our
– see
us
.
Out-patient treatment
–
treatment
in a
hospital
, consulting room or clinic when
you
do not need a bed.
Palliative treatment
– any surgical or medical services aimed to relieve the
symptoms rather than to cure, stop, reverse or delay progression of the
medical
condition
causing them.
Personal effects
– personal belongings, including clothing worn and baggage
owned by
you
,
that
you
take with
you
on
your trip
.
Physiotherapist
– a person who is qualified to practise physiotherapy and is
licensed in the country where
treatment
is provided.
Plan
– the contract between the
planholder
,
you
and
us
.
Plan administrator
– the person who acts as co-ordinator with
us
for
your
group
plan
, as chosen by the
planholder
.
Planholder
– the person or organisation
we
have issued the
plan
to as named on
a valid Certificate of insurance.
Plan start date
– the date the
plan
begins each year.
Plan year
– a period of 12 months from the
plan start date
, as shown on a valid
Certificate of insurance.
Pre-authorise
,
pre-authorised
,
pre-authorisation
– the process
you
must follow
to obtain approval from
us
before receiving
treatment
or services, or incurring
costs.
Pre-existing
– any
medical condition
or
related medical condition
which 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.
Preventative services
– medical services where no
medical condition
or
symptoms are present.
Professional sports
– any sport that
you
are paid to engage in and where any
payment received is the main source of
your
income.
Psychiatric
– that which affects
your
mind, mental function or emotions, whether
the cause is organic, traumatic or reactive.
Public transport
– any paid and licensed form of transport.
