Other terms used in our policy documents or on this website are defined below:
ACC means the Accident Compensation Corporation referred to in the Accident Compensation Act 2001 (or its successor).
Accident means an accident as defined in the Accident Compensation Act 2001 (or its successor).
Acute care means care provided in response to a sign, symptom, condition or disease that requires immediate treatment or monitoring.
Adult means a person 21 years of age and over.
Affiliated Provider means a health services provider who has entered into a contract with Southern Cross to provide certain healthcare services at agreed prices.
Allowance means the fixed amount that we will contribute towards the cost of certain eligible healthcare services as specified in the Coverage Tables.
Ancillary hospital charges means anaesthetic supplies, dressings, drugs (which are prescribed and taken in hospital), intravenous fluids, and irrigating solutions, used whilst the member is hospitalised for an eligible healthcare service.
Annual limit(s) means the maximum amount in respect of any one person that can be reimbursed in any 1 claims year.
Approved facility means a certified private facility or other healthcare facility approved by Southern Cross.
Approved treatment means a healthcare service that is necessary for treatment of the health condition involved, is not experimental or unorthodox, and is widely accepted professionally as effective, appropriate and essential based upon recognised standards of the healthcare specialty involved.
Certified private facility means a private surgical or medical facility certified as such by the Ministry of Health.
Chemotherapy drugs means prescription medicines for the treatment of cancer or neoplastic disease, that are prescribed or recommended by a registered oncologist or haematologist in private practice, Pharmac approved, and not otherwise excluded by the terms of your policy.
Child means a person under 21 years of age.
Chronic conditions means cystic fibrosis, polycystic kidney, marfans syndrome, Loeys-Dietz syndrome, spina bifida, scoliosis, kyphosis, pectus excavatum and pectus carinatum.
Claims anniversary date means the date 12 months following the date the policyholder started on the current plan and the anniversary each 12 months thereafter as specified on the current Membership Certificate.
Claims year means the first 12 months following the policy start date and each successive 12 month period from your claims anniversary date.
Complaints procedure means the complaints procedure and process available to you as set out on page 30.
Congenital condition(s) means congenital anomalies or defects which are present at birth and for which the policyholder or dependant had either:
(a) signs or symptoms of the condition prior to the original date of joining, or
(b) signs or symptoms of the condition within 3 months of birth, as reasonably determined by Southern Cross.
Continuous cover means that the person covered by the policy must have had no break in cover for the particular healthcare service in this plan to which the continuous cover qualification relates for the specified minimum period.
Cosmetic treatment means any surgery, procedure or treatment that improves, alters or enhances appearance, whether or not undertaken for medical, physical, functional, psychological or emotional reasons.
Coverage Table(s) means the table(s) set out on pages 15 to 22 of the policy document, and any subsequent changes we make to those Coverage Tables.
Dependant means the husband/wife or partner (including any former husband/wife or partner) of the policyholder and any child and or any adult dependant (including any stepchildren or adopted children) of the policyholder (or the policyholder’s husband/wife or partner) who are listed on the Membership Certificate.
Detrimental to health means a medical condition that is causing significant problems for the physical health of an individual.
DHB means a District Health Board established under the New Zealand Public Health and Disability Act 2000, or its successor.
Diagnostic tests means ambulatory blood pressure monitoring, ankle brachial index, anorectal physiology study (anorectal motility study), bone marrow aspiration, breath nitric oxide test, caloric reflex/vestibular caloric stimulation test, colposcopy and biopsies (in rooms), compartment pressure study, corneal pachymetry test, corneal topography, electroencephalogram, electromyogram, electrooculogram, electroretinogram, endometrial biopsy (in rooms), full urodynamic assessment, fundus fluorescein angiography, fundus photography, GDx retinal scanning, H. pylori breath test, Heidelberg retinal tomography (HRT), hydrogen breath test, intraocular pressure test (IOP), laryngoscopy (in rooms), lumbar puncture, lung diffusion study, lung function test, matrix screen, nasendoscopy (in rooms), oesophageal 24hr pH monitoring (gastric function study), oesophageal manometry test, optic disc photos, optical coherence tomography (OCT), overnight pulse oximetry, proctoscopy, retinal photography, segmental pressure test, sigmoidoscopy (in rooms), simple urinary flow study, sleep study, specular microscopy test, spirometry with or without flow volume loops, ultrasounds of the eye, urea breath test, vascular laboratory testing, vestibular evoked myogenic potential, videonystagmography, visual evoked potential, visual fields, or vulvoscopy with or without biopsy (in rooms).
Disability support service(s) means support service(s) provided where a condition, disability or illness has been, or is likely to be, present for 6 months or more excluding surgical or medical treatment.
Drug(s) means subsidised prescription medicines, (and non-subsidised diabetic test strips and needles only), that are Pharmac approved, and not otherwise excluded by the terms of your policy.
Easy-claim means Southern Cross Health Society Easy-claim which is made available to members via participating health services providers.
Eligibility criteria means any additional terms and conditions we put in place from time to time in respect to a particular procedure, the then current version of which will be available at southerncross.co.nz/eligibilitycriteria or upon request.
Eligible means those private healthcare services which are:
(a) covered under or listed in the Coverage Tables and comply with any applicable terms and conditions (including any eligibility criteria we may specify from time to time); and
(b) approved treatment; and
(c) performed in private practice by a health services provider with registration applicable to the healthcare service; and
(d) a healthcare service for which costs are actually incurred or to be incurred; and
(e) not otherwise excluded under the terms of your policy.
Exclusion(s) means conditions, treatments or situations that are not covered by this policy, as listed in this policy document and /or as specified in the Membership Certificate.
General Practitioner means a Medical Practitioner vocationally registered in General Practice or who has general or provisional general registration and is practising in general practice.
Health screening means diagnostic test(s), investigation(s) or consultation(s) in the absence of any sign or symptom suggesting the presence of the illness, disease or medical condition the screening is designed to detect.
Health services provider means a General Practitioner, Specialist or registered practising member of certain professions allied to medicine practising in private practice who we approve for the provision of healthcare services under this policy.
Healthcare service(s) means any private surgery or other procedure, treatment investigation, diagnostic test, consultation or other private healthcare service including hospitalisation provided by a health services provider or an approved facility.
Hospital fees means hospital costs for accommodation (single room basis excludes suites), operating theatre fees, anaesthetic supplies, intensive care and special in-hospital nursing, in-hospital x-rays and ECG, ancillary hospital charges, laparoscopic disposables and in-hospital post-operative physiotherapy.
Internal medicine means internal medicine, cardiology, clinical immunology, clinical pharmacology, endocrinology, gastroenterology, geriatric medicine, haematology, infectious diseases, medical oncology, nephrology, neurology, nuclear medicine, palliative medicine, respiratory medicine and rheumatology, as defined by the Medical Council of New Zealand (MCNZ).
Lifetime means the duration of a policyholder or dependant’s relationship with Southern Cross whether or not continuous.
List of Prostheses and Specialised Equipment means the document published by Southern Cross from time to time which details the prostheses, specialised equipment and consumables, donor tissue preparation charges and associated levels of cover provided under this policy, the latest copy of which is available at southerncross.co.nz/plans or by calling us.
Long term care means hospitalisation which is expected to last or lasts more than 90 days.
Medical Practitioner means a medical practitioner who has a current practising certificate, is practising in accordance with any restrictions placed on them by the Medical Council of New Zealand (MCNZ), is in private practice and whose scope of practise is relevant to the applicable healthcare service.
MedSafe means the New Zealand Medicines and Medical Devices Safety Authority, a division of the Ministry of Health, responsible for the regulation of therapeutic products in New Zealand.
Membership Certificate is the document we issue to the policyholder from time to time which details the key dates in respect of the policy, the people covered and the level of cover and plans applicable, the policyholder’s Southern Cross membership number, any specific exclusions from cover for pre-existing conditions applicable to the people covered under the policy known to Southern Cross at the date of issue of the certificate, and any other information specific to the policy.
Multiple procedures means two or more surgical procedures performed simultaneously, sequentially or under the same anaesthetic.
Nurse means a Nurse who is registered with the Nursing Council of New Zealand (NCNZ), has a current practising certificate, is practising within their scope of practice and in accordance with any restrictions placed on them by the NCNZ.
Operation means all surgical procedures performed under one anaesthetic.
Original date of joining means the most recent date of joining Southern Cross for each person covered by the policy as shown on your Membership Certificate.
Palliative care and treatment means any home nursing performed by a Nurse, healthcare equipment (excludes home alterations), private hospital fees for pain management or nursing care, General Practitioner visits (including home visits), nutritional support prescribed by a General Practitioner, Specialist, Nurse or Nutritionist, counselling consultations, or pharmacy and pain management costs, which provide support and comfort when diagnosed with a progressive terminal illness. Excludes entertainment, leisure, travel expenses or any costs which are covered under another policy benefit.
Pharmac means the Pharmaceutical Management Agency, a Crown entity established by the New Zealand Public Health and Disability Act 2000 (or its successor).
Pharmac approved means any drug that is specifically identified by Pharmac on the Pharmac Schedule as being approved for subsidy by the Government for use in your particular treatment. In determining this, we may take into account any criteria, prescribing guidelines, rules, conditions and/or restrictions published by Pharmac.
Pharmac Schedule means the New Zealand Pharmaceutical Schedule managed by Pharmac, which lists prescription medicines and related products subsidised by the Government.
Policy means the contract between Southern Cross and the policyholder. The policy comprises the Membership Certificate, this policy document (including any document that is incorporated by reference ie eligibility criteria), the List of Prostheses and Specialised Equipment and any amendment or variation made to them from time to time.
Policy anniversary date means the date specified in the Membership Certificate, and:
(a) in relation to a policy which is not part of a work scheme or association scheme, each anniversary of the policy start date, and is the date from which your policy will be renewed for the following year; and
(b) in relation to a policy which is part of a work scheme or association scheme, the anniversary of the commencement date of the scheme under which your policy is provided and the date from which your policy will be renewed for the following year.
Policyholder means the person in whose name the policy is issued and who is responsible for the payment of premiums and to whom claims relating to the policyholder and any dependants are paid.
Policy limits means in relation to any eligible healthcare service the maximum amount payable by Southern Cross per operation, per procedure, per item, per day, per lifetime, or as an annual limit as specified in the Coverage Tables and List of Prostheses and Specialised Equipment, or as specified in our contract with an Affiliated Provider and advised to you by Southern Cross or your Affiliated Provider when you seek treatment.
Policy start date means the date your policy commences as shown on your Membership Certificate.
Policy year means in relation to the first year of the policy the period from the policy start date to the first policy anniversary date and thereafter means the period from one policy anniversary date to the next.
Pre-existing condition means any health condition, sign, symptom or event occurring or existing:
(a) in relation to the policyholder and each dependant named in the Application Form, before the policy start date; and
(b) in relation to any dependant added to the policy after the policy start date, before the date the relevant dependant was added to the policy; and
(c) in relation to any upgrade after the original date of joining, before the date of upgrading; where the policyholder or the dependant was aware, or ought reasonably to have been aware, of the health condition, sign, symptom or event.
Prophylactic healthcare services means healthcare service(s) provided in the absence of any relevant sign or symptom suggesting the presence of an illness, disease or medical condition, that seek to reduce or prevent the risk of an illness, disease or medical condition developing in the future.
Prostheses means surgically implanted items, specialised equipment and consumables and donor tissue preparation charges as set out in the List of Prostheses and Specialised Equipment.
Reasonable charges are charges for healthcare services that are determined as reasonable by us (acting reasonably) based on our review of our data.
Southern Cross means Southern Cross Medical Care Society trading as Southern Cross Health Society, having its registered office at Level 1, Te Kupenga, 155 Fanshawe Street, Auckland City 1010.
Specialist means a Medical Practitioner who is vocationally registered in one of the following scopes:
anaesthesia, cardiothoracic surgery, clinical genetics, dermatology, diagnostic & interventional radiology, general surgery, intensive care medicine, internal medicine, musculoskeletal medicine, neurosurgery, obstetrics & gynaecology, occupational medicine, ophthalmology, oral & maxillofacial surgery, orthopaedic surgery, otolaryngology, paediatric surgery, paediatrics, pain medicine, palliative medicine, plastic & reconstructive surgery, psychiatry, radiation oncology, rehabilitation medicine, sexual health medicine, sport & exercise medicine, urology, vascular surgery, or
has provisional vocational registration with the MCNZ and is under the supervision of a Medical Practitioner vocationally registered in one of the above scopes, or
holds a special purpose (locum tenens) scope of practise with the MCNZ and is under the supervision of a Medical Practitioner vocationally registered in one of the above scopes, or
is a Medical Practitioner who has been admitted to the Fellowship of the Australasian Society of Breast Physicians, or
is an oral surgeon, oral medicine specialist or oral and maxillofacial surgeon registered with the Dental Council of New Zealand.
Sports event means involvement in an organised and competitive sporting event or tournament that requires human activity capable of achieving a result requiring physical exertion and/or physical skill which, by its nature and organisation, is competitive and is generally accepted as being a sport.
Treatment injury means a treatment injury as defined in the Accident Compensation Act 2001 (or its successor).
Varicose vein procedures means unilateral endovenous laser treatment, unilateral ultrasound guided sclerotherapy, unilateral varicose vein surgery, or unilateral radiofrequency (RF) endovenous ablation. Where a member has 1 varicose vein procedure on each leg during a single operation, the procedures are counted as separate procedures for the purposes of the per leg per lifetime limit.
We/us/our means Southern Cross.
You/your means the policyholder and any dependant named on the Membership Certificate (unless otherwise specified).