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"Standard Plan Terms And Conditions as at July 2010"

(A)	RULES FOR ADMISSION AND PAYMENT OF CONTRIBUTIONS
1	PREREQUISITES FOR ADMISSION
1.1	(a) An applicant must be a financial member of, or be employed by one of the following organisations:
TEU	Tertiary Education Union - (formerly known as ASTE and AUS)
AUSNZ	Association of University Staff of NZ (Inc)
NZEI	NZ Educational Institute (Inc)
PPTA	Post Primary Teachers Association (Inc)
TIASA	Tertiary Institutes Allied Staff Association (Inc)
PSA	NZ Public Service Association (Inc) - University and Education Services Group
ISEA	The Independent Schools Education Association Inc. (Formerly ISTANZ)
(b)	Any employee in, or former employee of, the education sector who is a member of an approved union relevant to that employment is also eligible for admission.
1.2	Enrolment applications which do not comply with 1.1 above should be referred to the General Manager for consideration.
1.3	These people CANNOT join EBS Health Care: any person who is not a financial member of a member organisation; employees in private schools or institutions.
2	SPECIAL CATEGORIES
2.1	The Board may admit applicants who do not meet the above requirements [Constitution, Clause 8] as follows:
2.1.1	Trainee teachers who will be employed within the New Zealand education service at the end of their training and who have been accepted by a recognised organisation are eligible for limited EBS Health Care benefits applicable only to themselves.
(a)	Trainee teachers do not pay contributions to EBS Health Care.
(b)	Trainee teachers are eligible for all benefits except Sick Leave Without Pay and Orthodontic and cannot claim the Birth Benefit in the first 12 months of training. Other benefits can be claimed after the requisite qualifying periods.
(c)	Trainee teachers are only eligible for events occurring during the academic year.
(d)	On commencing employment as a teacher, former trainees must apply to join EBS Health Care as a full contributor and pay the appropriate rate of contribution.
2.2	Any contributor who leaves employment within the education sector may continue to contribute to EBS provided they retain membership of their education sector union i.e. honorary or associate membership
3	CONTRIBUTIONS
3.1	The level of contributions is set by the board of EBS Health Care from time to time and is reviewable without reference to contributors.
3.2	Contributions can be by regular salary deduction or by direct debit. Where this is impractical, approval for alternative means of payment may be sought from the General Manager.
3.3	Contributions received by EBS Health Care in good faith may not be refunded.
3.4	Where leave without pay has been approved for a specific period up to 12 months, a contributor may pay EBS Health Care contributions for the full period in advance before the leave commences while still a financial member of a member organisation.
3.5	From 1 April 1992 the main contributor must register a partner and/or/child/ren and pay the appropriate subscription in order for them to be covered. Refer to GENERAL CONDITIONS [C18].
4	CESSATION
4.1	Eligibility for benefits ceases on resignation from a member organisation. Contributions to EBS Health Care must be terminated by the contributor. Benefits will be paid up to the date of the last union deduction/contribution.
4.2	Qualifying periods for benefits must be re-served after any break in contributions (except for those people who resume within 12 months of the start of approved sick leave without pay).
5	ELIGIBILITY FOR BENEFITS
5.1	The initial qualifying period for new contributors is 3 months for the Bereavement, Hospital, Medical, Medical Appliance, Complementary Medical Benefits. The qualifying period for the Major Diagnostic and Optical Benefits is 6 months. The qualifying period for the Birth, Orthodontic and Sick Leave Without Pay Benefit is 12 months. Benefits may be claimed for events which occur after the requisite qualifying period has been completed in full.
5.2	Contributions must be regular and continuous for at least 3 months prior to any event for which a benefit is claimed. This is extended to 6 months for the Major Diagnostic and Optical Benefits and to 12 months for the Birth, Orthodontic and Sick Leave Without Pay Benefits.
5.3	Contributors receiving the Sick Leave Without Pay Benefit are eligible for all benefits until contributions resume, up to a maximum of 12 months from the start of leave.
5.4	Contributors who do not pay in advance to cover periods of approved leave without pay must re-serve the requisite qualifying periods when payments to EBS Health Care resume.
5.5	Contributors on maternity or parental leave who do not pay contributions in advance may apply for the Birth Benefit (and Bereavement Benefit if the child dies) but eligibility for all other benefits ceases until contributions recommence and the requisite qualifying periods must be re-served.
5.6	Where relevant, the above restrictions also apply to a registered partner or dependent child/ren.
(B)	SCHEDULE OF BENEFITS FOR THE STANDARD PLAN
	The General Conditions for Benefits [C] should be read in conjunction with the following guidelines.
6	BEREAVEMENT
6.1	$1000 on the death of a contributor, registered partner or child (including still birth).
6.2	Where the contributor dies, the benefit is payable to the surviving partner or to the person who is the accredited next of kin.
6.3	In the event that the deceased has no accredited next of kin a discretionary application may be made by the person responsible for the funeral expenses and arrangements but it should be noted that the benefit is not payable to an estate.
6.4	The benefit is payable within 12 months of the death.
6.5	All applications must be supported by the original or a certified copy of the death certificate or an original newspaper notice.
7	BIRTH
7.1	$200 for each live child born to a contributor or partner.
7.2	An adoptive parent may claim this benefit, but the benefit application must be made within 12 months of the date of adoption.
7.3	A contributor on approved maternity or parental leave may apply for the benefit (see A 5.4 & 5.5 above).
7.4	Applications must be supported by an original or certified copy of the child's birth certificate or a statement of adoption issued by the adoption agency or solicitor.
7.5	Contributors must have contributed continuously for 12 months prior to the birth (and/or initial date of adoption) to be eligible for the benefit.
8	HOSPITAL
8.1	50% of the net cost of hospital expenses up to a maximum of $700 a year (see table of entitlements).
8.2	The benefit covers expenses related to an operation or treatment from the first day in hospital up to and including post-operative consultations. Consultations prior to admission to hospital may be eligible for the Medical Benefit.
8.3	Fees of a surgeon (registered medical practitioner), anaesthetist, as well as theatre and hospital charges are eligible. Documentation for all parts of the procedure must be submitted with the application even if they are not being claimed at that time.
8.4	Travel, newspapers, television, telephone and any extras are excluded.
8.5	The excess refund available on the EBS Hospital Cover is 50% of the total procedure cost to a maximum of $500 (regardless of the size of the Hospital Plan excess) per calendar year each for contributor, partner, and children collectively on the policy*. This excess is available to linked and approved EBS Hospital Plans only. The word policy* referred to in this benefit is Standard Plan Policy only. (Dental related oral surgery excluded)
9	MAJOR DIAGNOSTIC (effective from 1 March 2008)
9.1	50% of the net cost of CAT scans, MRI scans and Angiograms, up to a maximum of $600 a year (see table of entitlements).
9.2	This benefit is only available providing subscriptions have been paid for six months prior to the date of the procedure.
9.3	Contributors who have a linked and approved EBS Hospital Cover Plan may find that major diagnostic procedures are subject to a full, or partial reimbursement under their EBS Hospital Cover Plan. If an excess applies, refer to clause 8.5 above.
10	MEDICAL
10.1	50% of the net cost of medical treatment up to a maximum of $750 a year (see table of entitlements).
10.2	The maximum refund per prescription item or laboratory fee is $10. The prescription number, name of patient and pharmacist must be clearly shown on the prescription receipt. Similar details must be provided for laboratory fee receipts.
10.3	The benefit covers consultations with or treatment provided by a registered medical practitioner, x-rays, prescription and laboratory fees arising from visits to a registered medical practitioner.
10.4	The benefit excludes treatment covered by the Complementary Medical Benefit even if performed by a registered medical practitioner.
11	MEDICAL APPLIANCE
11.1	50% of the cost of specified items prescribed by a registered medical practitioner or supplied by a hospital up to a maximum of $300 a year (see table of entitlements).
11.2	Any aid prescribed by a medical practitioner within the scope of the Medical Benefit will be considered. These would include mastectomy prosthesis, hearing aid, aids for the control of diabetes or lung-related diseases, specially made footwear (but not inserts for shoes provided by a podiatrist), baby monitor or any equipment essential for the disabled. Hire costs are not claimable.
11.3	Any subsidy payable or assistance available from another source must be claimed first and stated on the application.
11.4	A medical referral or supporting letter must be supplied.
12	COMPLEMENTARY MEDICAL
12.1	50% of the net cost of specified expenses to a maximum of $375 a year (see table of entitlements).
12.2	Specified treatment includes:
12.2.1	Fertility and sterilisation procedures whether in the public or private system;
12.2.2	Treatment, consultations provided by persons registered with: Chiropractic Board New Zealand; New Zealand Psychologists Board; The Psychotherapists Board of Aotearoa New Zealand; Podiatrists Board of New Zealand; The Physiotherapy Board of New Zealand; Osteopathic Council Of New Zealand. All of the above are required by statute to be registered in order to practice in New Zealand.
12.2.3	The NZ Register of Acupuncturists Inc; New Zealand Acupuncture Standards Authority Inc. (NZASA)Naturopaths of New Zealand (Inc) and the Natural Health Council (NZ) Inc.; NZ Society of Naturopaths Inc (NZSN); NZ Council of Homeopaths Inc; NZ Register Of Homeopaths Inc; NZ Physiotherapy Acupuncture and Pain Modulation Association; NZ Association of Counsellors ;Drug and Alcohol Practitioners’ Association of Aotearoa – New Zealand
12.2.4	Treatment, consultations provided by a full member of the New Zealand Audiological Society (MNZAS); Occupational Therapy Board of NZ; New Zealand Speech-Language Therapists Association (NZSTA).
12.2.5	Any of the therapies included in 12.2.1, 12.2.2, 12.2.3 and 12.2.4 above, performed by a registered medical practitioner; and
12.2.6	Chelation therapy, allergy testing or consultations and treatment related to allergies performed by a registered medical practitioner.
12.3	Medication, remedies, aids, food supplements or other items relating to any of the above are excluded.
13	OPTICAL
13.1	50% of the net cost of glasses, multifocal or contact lenses plus examination fee, to a maximum of $200 a year. (see table of entitlements).
13.2	The Optical Benefit is only applicable if new lenses/glasses are purchased due to a change in vision.
13.3	Prior to 1 July 2010, an optometrist's examination fee on its own was not covered; new lenses/glasses needed to be purchased to qualify. New Optometrist examination fees occurring from 1 July 2010 are covered without the need to purchase lenses/glasses.
13.4	Original receipted accounts must be itemised. The date of the eye examination must be supplied as clauses 16.5 and 17 B12 relate to this.
13.5	One benefit only is payable irrespective of the number of lenses/glasses purchased as a result of a change in vision
13.6	The effective date for the optical benefit is the date of the eye examination, NOT the date the lenses/glasses are purchased or supplied.
13.7	This benefit is only available providing that subscriptions have been paid for six months prior to the date of the eye examination. Documentation verifying the date of the eye examination must be provided to EBS Health Care.
14	ORTHODONTIC
14.1	30% of orthodontist and associated fees to a maximum of $750 per registered child.
14.2	The maximum benefit payable for the duration of a contributor's membership is $1500.
14.3	The benefit covers registered children only.
14.4	A treatment plan and estimate of the expected total cost is required from the orthodontist with the first application for the orthodontic benefit.
14.5	Preliminary consultation and extraction costs will be considered only when a brace or appliance for the straightening of the dental arch(es) has been fitted.
14.6	Permanent fixtures or devices for other purposes e.g. dentures, thumb crib are excluded.
14.7	Where a consultation or treatment occurred prior to the end of the qualifying period for eligibility (12 months) for this benefit, all subsequent orthodontic expenses in relation to that child are ineligible. Click here for full guidelines for the orthodontic benefit.
15	SICK LEAVE WITHOUT PAY
15.1	$50 per week plus $5 for each registered child up to a maximum of $60 per week for 26 weeks.
15.2	The benefit is payable for sickness of the contributor only.
15.3	The qualifying period for this benefit is 12 months.
15.4	The period may be extended by up to 26 weeks provided a full Income Support Services sickness benefit is being received and the EBS Health Care benefit does not prejudice the right to additional assistance from Income Support Services benefits.
15.5	The minimum recognised period which can be claimed is 5 consecutive working days' approved sick leave without pay.
15.6	A medical certificate must be supplied stating the nature of the illness and specifying the period of absence from work.
15.7	A letter from the contributor's pay office stating the start date of approved sick leave without pay and proposed finish date must be supplied. Once the contributor resigns, this benefit is no longer claimable.
15.8	A contributor absent from duty on approved sick leave without pay is not required to pay subscriptions in respect of any complete fortnight of absence for which a salary payment is not received. However, Hospital Cover payments must be continuous.
15.9	Persons in receipt of this benefit may continue to apply for other mandatory benefits for up to 12 months from the start of the period of approved sick leave without pay.
15.10	This benefit is not applicable to employees who have sick leave with pay available.
15.11	Contributors who return to work on reduced hours cannot claim this benefit.
15.12	A contributor receiving payments under the Accident Rehabilitation & Compensation Insurance Corporation Act 1992 (ACC) is not entitled to this benefit, except for the first week of a non-work related accident if salary is not received.
15.13	Contributors on maternity or parental leave, teacher trainees, relieving teachers and contributors who are free to take up other employment cannot apply for this benefit.
C	GENERAL CONDITIONS FOR BENEFITS FOR THE STANDARD PLAN
16	ELIGIBILITY - CONTRIBUTIONS
16.1	Applicants must be financial within the rules of EBS Health Care [see A].
	ELIGIBILITY - BENEFITS
16.2	The minimum aggregation for claims is $10. The aggregation can be a combination of any type of benefit e.g. medical, hospital, complementary medical. The cost of events within a family can be combined to reach the required minimum needed to claim benefits.
16.3	The maximum refund per event is 50% unless otherwise stated.
16.4	Benefits are calculated on the net amount actually paid by a contributor (see 19.5c , 19.6 & 20).
16.5	Any costs related to events which occurred more than 12 months prior to the date a claim is received by the Society will be declined. This also applies to costs resubmitted.
16.6	Subsequent expenses cannot be aggregated with previous paid claims.
16.7	Claims must be submitted on EBS1 claim forms. All sections of the form must be completed to avoid delays in processing. Incomplete forms will be returned unprocessed.
16.8	Costs incurred outside New Zealand are ineligible except for any contributor on approved overseas exchange or study leave who continues to have NZ$ salary paid to them and continues to make contributions to EBS Health Care. Costs within the country of exchange only are eligible.
16.9	One benefit only is payable per event (even where there are two contributors).
17	TABLE OF ENTITLEMENTS
	The entitlements for benefits 8, 9, 10, 11, and 12 are for the calendar year. See full guidelines above for the other benefits. Click here for Table

18	PERSONS COVERED
18.1	The contributor must register a partner and/or children and pay the appropriate subscription in order to apply for benefits for them.
18.2	A parent or other adult who is not recognised as the contributor's partner, cannot be registered as a partner for the purpose of obtaining benefits as a family.
18.3	Registered dependent children are eligible for benefits up to the end of the year in which they become 21, i.e., to 31 December in any year. Note: students, although living with a parent, may be eligible for the Community Service Card and this should be used where appropriate before claiming EBS Health Care benefits.
19	CERTIFICATION
19.1	The date of an event is the date of birth or death, or the date of the eye examination, treatment, consultation or supply.
19.2	Receipted accounts or receipts bearing an official stamp showing the name and qualifications of the practitioner, as well as the name of the patient treated, the date of the event and other relevant details must be submitted with all claims.
19.3	A receipt for $100 or more must be accompanied by an itemised account.
19.4	A receipt in payment of more than one charge, i.e. treatment/consultation must be accompanied by an itemised account.
19.5	Original receipts/accounts must be firmly attached to claims. Copies, duplicates, replacement receipts, Eftpos, cash register or altered receipts are not acceptable. (See also C19.6 below.)
19.6	Reimbursement should be claimed from other sources first. In these instances only, copies of receipts/accounts are acceptable. All claims must be accompanied by evidence of the amount received from the other society. Note: a copy of the list of events claimed from another society may be sent with the EBS form to reduce form filling. Note exclusions at point 20.
19.7	Claims subject to Accident Rehabilitation & Compensation Insurance Corporation (ACC), Health Department, Income Support Services, other government refunds or assistance, must be settled before applying to EBS Health Care. In these cases a maximum of 50% of the balance less other medical insurance refunds will be paid.
19.8	No contributor may receive an aggregated refund of more than 100% of original costs.
20	EXCLUSIONS
	The following are excluded: Excesses charged by other insurers (apart from approved EBS Hospital Cover Plans linked to an EBS Standard Plan policy); Expenses arising from and/or associated with: oral surgery dental or periodontal treatment pregnancy and birth accommodation and travel related expenses dietitians/ nutritionists /food supplements non-health related consultations e.g. examinations for employment or insurance purposes preventative treatment / vaccinations cosmetic surgery/elective treatments over the counter medication treatment for obesity / weight reduction hire fees Contact EBS Health Care for further information on restrictions.
21	PAYMENT OF BENEFITS
21.1	Payment is payable by direct credit to the contributor's nominated bank account.
21.2	Payments received by contributors are not subject to income tax and are inclusive of GST.
22	CHANGES TO CONDITIONS
	The Board of EBS Health Care reserves the right to interpret, alter or amend the conditions for payment of benefits generally as it deems necessary.
	Orthodontic Benefits: Guidelines for applicants
	May 2005 The Society financially assists subscribers whose children are undergoing lengthy and costly orthodontic treatment to straighten dental arches or crooked teeth, to improve breathing, eating or speaking difficulties. The Orthodontic Benefit covers registered children only, i.e. up to the end of the year in which they turn 21. The General Conditions for all benefits should be read in conjunction with these guidelines.
1.0	30% of orthodontist and associated fees to a maximum of $750 per child. The maximum benefit payable for the duration of a contributor's membership is $1500. The benefit covers registered children only (i.e. up to the end of the year in which they turn 21).
1.1	This is the amount payable provided all conditions are met.
1.2	“Associated fees” would include dental surgery for extractions, anaesthetic and clinic fees. These fees are not eligible for other EBS benefits. “Associated fees” does not include anything arising from the orthodontic procedures such as treatment for decaying teeth, gum disease, repairs or restoration of any kind.
1.3	Eligible orthodontist and associated fees may be aggregated and submitted in one claim.
1.4	Do not wait until the end of the treatment to make a claim. Applications for the benefit should be made progressively as the accounts are paid. Expenses incurred over 12 months prior to the claim being received will be declined.
1.5	The recognised date of events for these claims is the earlier of the date of treatment/consultation or the date of the account if periodic payments are made.
2.0	A treatment plan and estimate of the expected total cost is required from the orthodontist.
2.1	The first application for an orthodontic benefit must be accompanied by a description of the proposed treatment, approximate total cost and expected duration. Please ask the orthodontist to supply the information in writing.
2.2	These estimates are kept on file for future reference. A separate estimate is required for each child.
2.3	Where necessary we contact the orthodontist to verify details.
2.4	Any expenses not included in the original estimate will be declined.
2.5	If further treatment is required after the estimated duration, the subscriber must obtain an additional estimate from the orthodontist.
3.0	Preliminary consultation and extraction costs will be considered only when a brace or appliance for the straightening of the dental arch(es) has been fitted.
3.1	After the brace is fitted the previous expenses will be considered if they were incurred within the 12 months prior to the receipt of the claim containing confirmation of the fitting.
3.2	Sometimes in the early stages, the orthodontist recommends extraction of some teeth and there is no subsequent fitting of a brace. These extractions and any related consultations would be excluded.
3.3	The extraction of wisdom teeth at any stage of treatment is excluded.
4.0	Permanent fixtures or devices for other purposes e.g. dentures, thumb crib are excluded.
4.1	False teeth, partial plates, crowns, bridges for a purpose other than straightening of the dental arches are excluded.
4.2	A thumb crib or any other mouth appliance designed to stop a child persisting with a habit which may or may not have a detrimental effect on the teeth or shape of the mouth or anything in the mouth is excluded.
5.0	Where a consultation or treatment occurred prior to the end of the qualifying period for eligibility (12 months) for this benefit, all subsequent orthodontic expenses in relation to that child are ineligible.
5.1	Treatment is deemed to have commenced from the initial consultation with the orthodontist whether or not further treatment was proposed.
5.2	This does not exclude the treatment of other children in the family who may consult an orthodontist after the subscriber's initial qualifying period.
6.0	Claims
6.1	We do not accept copies or duplicates of receipts or accounts.
6.2	An account is required with each receipt and must show the date the instalment/s was/were due. The date of payment is not relevant and, except for the preliminary consultations, accounts are rarely linked directly to dates of visits.
6.3	“Other Society” regulations apply if the subscriber or the spouse of the subscriber is intending to make a claim on another organisation and evidence of the amount received must be provided before the EBS payment can be calculated. Generally, the percentage refunded from any similar society will be 50% or less. Some medical insurance companies have introduced packages which include orthodontic benefits for families. These must be stated on any applications sent to EBS.
6.4	Benefits cannot be claimed in advance. As with all benefits the bills must be paid in order to claim.
6.5	Benefits are paid at the rate current at the time of the treatment or account date, not the claim processing date.
	NOTE: The rules for all benefits are subject to change without notice. These guidelines have been compiled from material provided by claims processors and enquiries from contributors and are correct as at May 2005. It is impossible to predetermine every facet of the benefit but we hope these guidelines are sufficiently comprehensive for most situations.
	Disclosure of information*(see end of page)
	All statements made through EBS Health Care to approved underwriters must be truthful and frank. All relevant information must be disclosed to us otherwise we may not pay your claims. Also, if any relevant circumstances change between the time you sign the proposal and we accept your insurance, then you must immediately tell us.
	Termination of cover
	Cover under this policy will terminate immediately after you have:
(a)	Been continuously residing outside New Zealand for six months or more;
(b)	Failed to pay the premium or any premium instalment within thirty days of the due date for payment;
(c )	Specifically requested cancellation.
(d)	If this policy is terminated by condition (b) above it may, at our sole discretion, be reinstated on such terms and conditions as are imposed by us. Cover for dependent children insured under this policy will expire at the end of the year in which they turn 21 years of age.
	Cancellation
	Provided you comply with the policy conditions, we cannot cancel your policy.

*Disclosure of information.

All statements made through EBS Health Care to approved underwriters must be truthful and frank. All relevant information must be disclosed to us otherwise we may not pay your claims. Also if any relevant circumstances change between the time you sign the proposal and we accept your insurance, then you must immediately tell us. Cover under this policy will terminate immediately after you have:

(a) Been continuously residing outside New Zealand for six months or more, unless covered by 16.8.

(b) Failed to pay the premium or any premium instalment within thirty days of the due date for payment;

(d) If this policy is terminated by condition (b) above, it may, at our sole discretion, be reinstated on such terms and conditions as are imposed by us Cover for dependent children insured under this policy will expire at the end of the year in which they turn 21 years of age.