NEW ZEALAND RAILWAYS STAFF WELFARE TRUST - EXTENDED HEALTH PLAN
Underwritten by Southern Cross Ltd
Summary:
The NZR Staff Welfare Trust Extended Health Plan has been designed for members to manage their own and their family’s future health needs when admission to a hospital is required.
Features of the plan are:
- $75,000 Surgical Cover
- Generous cover for non surgical Hospital admissions
- Up to 100% payment of the costs
- Costs paid direct by the underwriter if prior approval is obtained
- Easy pay deductions
HOW TO JOIN
Simply contact the Trust’s office and an application form including a health declaration will be sent to you – telephone (04) 498 3043 or FREEPHONE 0800 806 444 – or fill out the Southern Cross Extended Health Plan Form
The NZR Staff Welfare Trust Extended Health Plan (Southern Cross)
This policy provides 100% reimbursement off expenses for medically necessary procedures on reasonable charges, up to the maximums stated below. Reasonable charges are determined from the Underwriter’s claims statistics.
- General Surgery - performed in a Registered Private Hospital or other Southern Cross approved facility
- Surgeon’s Fees, Anaesthetist’s Fees, Hospital Charges, Accommodation, Operating Theatre Fee
- Ancillary - includes anaesthetic supplies, dressings, pathology tests, medication (prescribed and taken in hospital), special in-hospital nursing, X-ray examination, ECG, in-hospital post operative physiotherapy
- Disposable Laparoscopic Equipment
- Prostheses (surgically implanted Prostheses - schedule applies)
$75,000 per operation
Oral Surgery
For surgery performed in a registered Surgical Hospital or a private facility approved by Southern Cross Health, by an Oral and Maxillofacial Surgeon on the NZ Dental Council Register, or a General Surgeon on the NZ Register of Specialists. Surgery should be on referral from either a Registered Dentist or Registered Medical Practitioner.
- Surgeon’s Fees, Anaesthetist’s Fees, Operating Theatre Fee, Ancillary Hospital Charges (including anaesthetic supplies), Hospital Accommodation
- Reimbursement for Oral Surgery relates to all procedures undertaken during one session. Removal of teeth is restricted to impacted and unerupted teeth only. No cover for implants and also excludes periodontal, orthodontic and endodontal procedures.
$75,0000 per operation
Cardiac Surgery - performed in a Registered Private Surgical Hospital
- Surgeon’s Fees, Anaesthetist’s Fees’, Perfusionist’s Fees, Hospital Charges, Accommodation, Operating Theatre Fee, Intensive Post Operative Care (including special nursing)
- Ancillary -includes anaesthetic supplies, ECG and specialised X-ray, intravenous fluids, irrigating solutions, dressings, in-hospital post operative physiotherapy and medication (prescribed and taken in hospital)
- Prostheses (surgically implanted Cardiac Prostheses - schedule applies)
$75,000 per operation
- For the cost of care by a Registered Nurse recommended by a Specialist on the NZ Register of Specialists immediately following General, Oral or Cardiac Surgery
$100.00 per day - $2,000 per year
Overseas High Technology Treatment
- Reimbursement is available for medical expenses (not accommodation or transport) for the cost of overseas high technology treatment including organ transplants. Eligibility for reimbursement follows successful application for Regional Health Authority funding under the Overseas Patient Fund. The reimbursement is for medical expenses incurred over and above the Regional Health Authority assistance.
$10,000 per trip
- Angioplasty performed in a Registered Private Hospital
- Angioplasty Operator
- Anaesthetist Fees
- Hospital Charges
- Accommodation
- Operating Theatre Fee
- Ancillary - including anaesthetic supplies, Angioplasty Catheters, ECG and specialised X-ray intravenous fluids, irrigating solutions, dressings, medication (prescribed and taken in hospital)
$75,000 per procedure
- Referred by a Specialist Medical Practitioner for treatment, convalescence or observation in a Registered Surgical, Medical or General Hospital and under the control of a Specialist Medical Practitioner. Includes reimbursement for Hospital accommodation (on a single room basis, excluding suites) and ancillary hospital charges.
Note - excludes Hospice, Geriatric and Psychiatric Hospital care
$25,000 per admission
$60,000 per year
Psychiatric Hospitalisation
- Referred by a Specialist Psychiatrist for treatment, convalescence or observation in a Registered Surgical, Medical or General Hospital and under the control of a Specialist Psychiatrist. Includes reimbursement for Hospital accommodation and ancillary hospital charges.
$330 per day
$200 for drug/ancillary
$1,650 per admission
- Following a General Practitioner’s referral, pre and post-operative consultations three (3) months before or after hospitalisation.
Initial consultation $175
Follow-up consultation $125
Cover is excluded where the specialist consultation does not relate to hospitalisation
Oncology (Chemotherapy/Radiotherapy)
- Performed by a Specialist on the NZ Register of Specialists in a Registered Surgical or Medical Hospital. Includes the cost of materials and medication, Hospital accommodation (on a single room basis, excluding suites) and ancillary hospital charges.
$25,000 per admission
$60,000 per year
- Performed by a Specialist on the NZ Register of Specialists in a Registered Surgical or Medical Hospital or a private facility approved by Southern Cross
$25,000 per admission
$75,000 per year
- Sterilisation - after two years of continuous cover, reimbursement for treatment from a Registered Medical Practitioner for Sterilisation
General Surgery reimbursement levels apply
OTHER BENEFITS
Public Hospital Cover
Crown Health Enterprises
If applicable, treatment in a Crown Health Enterprise will be covered up to the stated maximums in this Policy, as long as the “Protocols for the Treatment of Private Patients in Crown Health Enterprises (Public Hospitals)” has been followed.
Public Hospital Benefit - Cash Grant
For overnight admissions - other than for accident or maternity conditions
| Child | Adult | |
| per day | $25 | $50 |
| per admission | $250 | $500 |
| per year | $1200 | $2400 |
Note - The above Cash Grants do not apply if the treatment in a Crown Health Enterprise is reimbursed under another section of this Policy
For the payment of receipted costs incurred in overnight admissions for other than accident conditions
| Child | Adult | |
| per day | $25 | $50 |
| per admission | $250 | $500 |
| per year | $1200 | $2400 |
Upon the death of the Policyholder named on the Extended Health Plan prior to attaining age 60 years, where the cause of death is not excluded under the General Terms and Conditions of the Underwriter’s Policy, the surviving partner and dependants named on the Plan will continue to qualify for the cover provided by the existing Plan free of charge for 24 months.
Note - this provision does not apply to standard NZR Staff Welfare Trust benefits.
Parent Accommodation Allowance
For hospital expenses incurred when accompanying children 5 years or under where accommodation is provided in a Registered Hospital.
$50 per night
$500 per year
If the ARCIC refuses to cover the cost of treatment in a private hospital or in the event that your ARCIC refunds are less than those that apply for non-accident conditions under this Policy, the underwriter will make up the difference, if any, between the ARCIC contribution to the cost of the treatment and the maximum payable under this Policy. The total refunded by the underwriter, together with the payment made by the ARCIC will not exceed the maximum payable under this Policy.
Start of Cover
Cover will commence from the first available pay date upon acceptance of the completed application form by Southern Cross.
Policy Variables
Members joining the Extended Health Plan are required to (a) elect to receive 100% reimbursement of allowable costs under the policy or (b) elect to meet the initial $250.00 or $500.00 on the first claim in the year (from 1 April to 31 March) for any person covered under the Plan. By taking the $250.00 or $500.00 deductible option the premiums rates required to support the Plan are reduced and members may be able to claim the $250.00 or $500.00 through the Trust’s Medical Benefit provided all criteria of that benefit are met.
Premium Rates
The Trust will supply members with details of the premium rates that apply to cover individuals under the Extended Health Plan on request. If you require this information or an application form send an email to the Trust.
The Trust’s Extended Health Plan has a review date of 1 April each year. On that date any policyholder with an individual person included in their policy, who has changed their age bracket for premium charging prior to or on that date, will have their premium deduction adjusted to the higher rate. In addition should the underwriter impose a general change to premium charges at the time of the yearly review or at any other time, all policyholders will have their premiums adjusted to reflect the change imposed by the underwriter.
How to Claim on the Extended Health Plan (Southern Cross)
If a person, who is covered under the Plan, is to be admitted to a private hospital for surgical or medical treatment that is provided under the Plan, it is in the interests of the policyholder to contact the Southern Cross Prior Approval Centre to make sure that the proposed treatment is covered by your policy.
At that time arrangements can be made for a “direct pay facility” which will make it easier to settle the accounts received from the hospital and various specialists who will be involved in providing the treatment.
Please note that prior approval is required for all claims that are likely to be $1,000.00 or greater.
Claims for hospitalisation, or claims which may cause any member financial difficulty, can be approved with the hospital by Southern Cross Health on your request. Full details on the claims procedure and a personalised claim form are contained in the information pack received once the application to join the Plan has been finalised.
Health Questionnaire
All members completing an application to join the Plan are required to complete the health questionnaire to the best of their ability. This information will assist Southern Cross Health in future should the member cease to eligible to continue to be part of the Trust Group Scheme and wish to take out a policy on an individual basis.
It is not normal practice to accept amendments to an existing policy except at the time of review/renewal on 1 April each year. However there are the following exceptions -
- Marriage/Partnership
If a member marries during the year the member can add his/her spouse to the policy by completing a Policy Alteration Form (which will be provided by Southern Cross Health at the time of joining) and attaching a copy of the marriage certificate within 30 days of the event. All papers are to be forwarded to Southern Cross Health NZ Ltd for processing.
Similarly should a member wish to add a de facto partner to their policy this can be done within 30 days of establishing a recognised de facto partnership by providing a signed declaration to Southern Cross Health to affirm the de facto status and completing a Policy Alteration Form. - Birth
Newborn children are covered from the date of birth with all group concessions provided the member notifies Southern Cross Health within 90 days of birth by completing a Policy Alteration Form.
Southern Cross Health will provide the Trust with details of each new member added to a member’s policy and will take appropriate action to adjust premium deductions from the payroll. This will also occur should additional family be added to a member’s policy at the time their policy is reviewed/renewed each 1 April.
What Happens if Group A Membership Ceases
If members cease to be eligible for Group A membership their eligibility to retain their Extended Health Plan under conditions applying to the Trust’s Group Scheme will be determined by their eligibility to become Group B members of the Trust and if so their decision in that regard. The following applies -
- Group B members
Should eligible members become Group B members they will be eligible to retain their Extended Health Plan under the same conditions which applied as a Group A member. Any eligible member will be advised by the Trust of their eligibility to retain their existing Plan should they so desire together with details as to the date premiums are paid through the deduction taken from their final pay from their employer. Members wishing to continue with their Plan will be required to complete a new application form for Southern Cross Health’s benefit plus provide a “direct debit “ authority to allow Southern Cross Health to deduct future premiums direct from a nominated bank account. Group B members are given the opportunity by Southern Cross Health to include within their new policy coverage for “Medical Specialists” (includes x-ray imaging and scans) with the additional premium being calculated having regard to group conditions.
These forms when completed are returned to the Trust’s Wellington Office for onward transmission to Southern Cross Health with additional information regarding their changed status.
Former Group A members who do not wish to take up the offer of continuing their Extended Health Plan as a Group B member are requested to advise the Trust’s Wellington Office and action is then taken to cancel their existing policy - Other members
Should members who are not eligible for Group B membership, wish to continue with their Extended Health Plan this can be arranged with Southern Cross Health who will determine the conditions (and premium levels) that will be applicable. Provided members have had continuous cover with the Extended Health Plan for the preceding two years, OR a combined period of cover with the Extended Health Plan and a recognised insurer who provided cover for existing medical conditions for the preceding two years they will be eligible to continue with the type of cover held under the Extended Health Plan although the premium rates will be set as an individual policyholder not as part of the Trust Group.
If the member does not meet the two year continuous cover period as defined in the preceding paragraph any existing medical conditions that the member was aware of or ought reasonably to have been aware of prior to being covered will no longer be covered. Any member will also be able to look at additional cover options to meet their individual family circumstances.