Eligibility for Claiming

To keep premiums affordable, we need to ensure that members’ claims are eligible for reimbursement. Our health insurance plans have been designed to provide cover for a wide range of private healthcare services and treatments whilst sitting alongside and complementing the services available through ACC and the public health system.

We provide cover for many medical conditions and their associated treatments, but not for all. For a medical condition to be eligible, it must meet certain criteria. A different set of eligibility criteria applies for the healthcare service, or surgical procedure. Both these sets of criteria must be met before a claim can be reimbursed.

Please see below checklists of eligibility criteria and other factors that need to be taken into consideration for your treatment (as a guide only). You will also need to consult your Membership Certificate to see if you have any relevant endorsements to be taken into consideration. Full wording is in the Conditions of Membership and our Claims Team would be pleased to check your specific situation and confirm the extent of cover.

We also aim to ensure that the healthcare services we pay for will result in a successful outcome for our members and we do this by requiring that healthcare service providers and facilities are appropriately accredited or registered in New Zealand.

Checklist for eligible healthcare services

The healthcare service is listed in the Benefit Schedule for your plan,
For surgical procedures, the procedure is listed in the ‘List of Approved Surgical Procedures’,
The healthcare service or procedure not included is in the ‘List of Non-Approved Healthcare Services,’
The medical condition is not acute,
The treatment is medically necessary,
The treatment or healthcare service is not excluded under the Conditions of Membership,
You don’t have an applicable exclusion or endorsement on your Membership Certificate,
The healthcare service is being delivered by an appropriately qualified and registered Medical Practitioner,
The healthcare facility is approved by us, and
You have a referral from a GP, a Specialist or a Consultant Physician.

Checklist for eligible medical conditions

You don’t have an exclusion or endorsement on your policy for the medical condition,
It’s not excluded in the Conditions of Membership which apply to all UniMed members,
The condition, the treatment, and who/where the treatment is being delivered comply with any requirements set out in your plan’s Benefit Schedule, and
UniMed considers the condition to be detrimental to health.

List of Approved Healthcare Services

This is a document that we modify from time to time and which includes all the different surgical procedures we approve for cover. You should read the List in conjunction with any personal endorsements you might have on your Membership Certificate.

You can get a copy of the current list from the ‘Important Documents’ section on this page. If you have any concerns about whether your proposed procedure is approved, you can give us a call or send an email.

Further information

The information on this website is intended as a general guide. Please read your Benefit Schedule, Membership Certificate and Conditions of Membership for the full terms and conditions of your policy.