Terms & Conditions
There is an extra cost to become a Healthcare99 member. Details can be found here.
Gallagher Bassett are the administrators of our Mutual Fund. Our Administrators will need to collect personal information from our Healthcare99 members so their claims may be considered.
No benefit shall be payable in respect to any event either directly or indirectly related to:
- Any pre-existing condition, unless the symptom or condition was disclosed on your Healthcare 99 application and accepted as covered by the plan in writing.
- Anything related to pregnancy or childbirth (including caesarean sections, costs associated with hospital stays, birthing and after birth care units) except for the initial consultation with a Registered GP.
- All types of infertility or treatment and investigations thereof, termination of pregnancy and sexual dysfunction.
- All types of contraception unless recommended by a doctor for non-contraception use i.e. migraines, menorrhagia.
- All types of sterilisation other than that on recommendation by a Specialist where the health of the member or spouse would be seriously affected by pregnancy. Letter from Specialist required for confirmation of diagnosis and confirming treatment is medically necessary.
- All forms of preventative treatment, for example (without limitation), mole mapping, screening and surveillance procedures (including as a result of family history) where the life assured has no medical symptoms, genetic testing, Covid testing (including pre-operation and pre-departure tests, or where free access to tests is available), medicals for any licenses or occupations, life and travel insurance except where expressly covered by a benefit in this policy.
- All types of cosmetic plastic/reconstructive treatment, prophylactic treatment, elective treatment and anything which is not medically necessary or detrimental to the immediate health of the member, where, without treatment, the member’s physical health would not deteriorate.
- All types of obesity or the treatment and the arising consequences. i.e. any weight reduction consultations, investigations, equipment or surgery for any condition including but not limited to obesity, diabetes and sleep apnoea.
- All types of Psychiatric or Psychological conditions, including Mental Stress, Anxiety or Depression and all types of Autism Spectrum Disorder, Asperger’s, Attention Deficit/Hyperactivity Disorder, Learning and Speech disorders, Behavioural Disorders, Learning disabilities, and Geriatric care, Senile illness or Dementia.
- All types of chronic and congenital conditions i.e. Cystic fibrosis, polycystic kidney, Marfans syndrome, Loeys-Dietz syndrome, spina bifida, scoliosis, kyphosis, pectus excavatum and pectus carinatum; disease or physical abnormality present from birth whether it was recognised or diagnosed at birth or not.
- Correction of refractive visual errors or astigmatism by surgery, glasses, contact lenses or laser treatment.
- All types of organ transplants or the treatment and the arising consequences (recipient and donor).
- Any medical provider that is not registered within their scope of practise, dietician, homeopath, podiatrist, occupational therapist, naturopath, alternative treatment provider or any other non-hospital or specialist treatment provider costs.
- All types of dental treatment including dental repair or implants, orthodontic treatment, orthognathic, periodontal, or endodontic procedures, oral surgery and other associated treatments except where expressly covered by a benefit in this policy.
- All types of orthotics, appliances & aids and/or external artificial devices, cochlear implants & heart pacemakers.
- All types of vaccinations.
- Treatments and procedures which are considered experimental and have not entered or completed trial phases, or which, in the Claims Manager & Trustees sole opinion, are not recognised as appropriate for the underlying medical condition.
- Palliative care and Hospice care.
- Investigations and Treatment provided in a public hospital unless admitted as a Private fee paying patient.
- Any expense recoverable from any other source – such as ACC (including surcharges), other medical insurance or benefits including all types of in hospital treatment for any accident related conditions as defined by the Accident Compensation Corporation Act (ACC) and its amendments and any Accredited Employer Scheme.
- Costs of administration (e.g. charges incurred between the prescribing doctor, specialist or pharmacy) associated with prescriptions, completing reports and late payment penalties.
- All types of investigations and treatment outside of New Zealand.
- Any health condition arising as a consequence of a criminal act committed by the member that results in a conviction under the Crimes Act.
- The misuse of prescribed or non-prescribed drugs, including where they have not been taken in accordance with the manufacturer’s or registered medical practitioner’s directions.
- Any injury, illness, condition or disability arising from, caused or contributed by intoxication or misuse of alcohol or drug taking.
- Any self-inflicted illness, disability, injury or any accident or illness, condition or disability arising from or caused by nuclear contamination.
- The use, existence or escape of nuclear weapons material or ionising radiation from or contamination by radioactivity from any nuclear fuel or nuclear waste from the combustion of nuclear fuel.
- Injuries of war or resulting from any terrorist act (whether war is declared or not).
|ACC||Means the Accident Compensation Corporation, set up by the New Zealand Government to provide comprehensive, 24-hour, no-fault personal injury cover for all New Zealand residents and visitors to New Zealand. Accident Compensation Corporation being a crown entity established by the Accident Compensation Act 1972 or its successor under any subsequent legislation.|
|Accident||Means a violent, external and visible event that results in physical Injury.|
|Acupuncture||Means Treatment by an acupuncturist registered with the Acupuncturist Board of New Zealand (or its successor).|
|Alternative Treatment Provider||A provider who practises in Alternative therapies which reside outside medical science. This includes but is not limited to Traditional medicine and Holistic medicine providers.|
|Bankruptcy/Bankrupt||Means a situation where the member, is adjudged Bankrupt in Australia or New Zealand.|
|Care Provider||Means an employee whether indirectly or directly employed by a Private or Public Hospital.|
|Chiropractor||Means Treatment by a Chiropractor registered with the Chiropractic Board of New Zealand (or its successor).|
|Chronic||Cystic fibrosis, polycystic kidney, Marfans syndrome, Loeys-Dietz syndrome, spina bifida, scoliosis, kyphosis, pectus excavatum and pectus carinatum.|
|Condition||Means any Injury, illness or disease which would have caused any ordinary prudent person to seek treatment, diagnosis, care, medical advice or treatment.|
|Congenital||Means a non-acute medical condition, disease or physical abnormality present from birth, whether it was recognised or diagnosed at birth or not.|
|Cosmetic||Any elective or cosmetic investigation, procedure or any surgery, or treatment that improves, alters or enhances appearance, whether or not undertaken for medical, physical, functional, psychological or emotional reasons and there is no medical necessity for the investigation, procedure or any surgery, or treatment to occur.|
|Criminal Act||Means participation in an action that constitutes an offence under the Crimes Act 1961 (or its equivalent in the country that the crime was committed if that country is not New Zealand), whether or not that action results in a conviction on indictment or on summary conviction.|
|Diagnostic Procedures||Means investigative procedures ordered by a Medical Doctor to diagnose a medical condition.|
|Hospice||Means any facility or home providing care for the sick or terminally ill.|
|Endorsement||Means the amended terms and conditions of the policy. The endorsement will override any other terms issued on the Healthcare 99 Plan.|
|Hospital||Means any facility or home providing care for the sick or terminally ill.|
|Illness||Means any sickness or disease, which has not been caused by an Accident.|
|Injury||Means a physical impairment which has been caused by an Accident.|
|Lawyer||Means a Lawyer who holds a current practising certificate in New Zealand as a barrister or a barrister and solicitor.|
|Medical Doctor||Means any medical practitioner registered with the New Zealand Medical Council as being able to practice medicine in New Zealand, holds a current practising certificate, and is working within the New Zealand Medical Council stated scope of practice (or the Australian equivalent). That person must not be:
|Medically necessary||Means a service, treatment or procedure where without that service, treatment or procedure, the member’s physical health will not improve and may lead to further deterioration in their physical health.|
|Medsafe||Means the New Zealand Medicines and Medical Devices Safety Authority. It is a business unit of the Ministry of Health and is the authority responsible for the regulation of therapeutic products in New Zealand.|
|Medical Treatment||Means a course of prescribed medicine or a therapeutic procedure required to treat, arrest or cure a medical condition.|
|Nurse Practitioner||Means any nurse registered with the Nursing Council of New Zealand who holds a current practising certificate as a Nurse Practitioner, and is working within the Nursing Council of New Zealand stated scope of practice (or the Australian equivalent). That person must not be:
|Oral Surgeon||Means a person registered with the Dental Council of New Zealand and who holds an Annual Practising Certificate qualified in this surgical specialty (or the Australian equivalent).|
|Osteopath||Means Treatment by an osteopath registered with the Osteopathic Board of New Zealand (or its successor).|
|Pallative||Means a drug or medical treatment that reduces pain without curing the cause of the pain.|
|Pharmac||Means the Pharmaceutical Management Agency of New Zealand which manages funding of community pharmaceuticals on behalf of the District Health Boards. The Pharmaceutical Management Agency being a Crown entity established by the New Zealand Public Health and Disability Act 2000 or its successor under any subsequent legislation.|
|Physiotherapy Treatment||Means treatment by a physiotherapist registered with the Physiotherapy Board of New Zealand (or its successor).|
|Pre-existing condition||Means Any disease, injury or medical condition for which, prior to the risk commencement date, the member knew they had or should on reasonable grounds to have known they had, or for which they had experienced a symptom, consulted a registered medical practitioner or alternative treatment provider, received treatment or services from a registered medical practitioner or alternative treatment provider or took prescribed drugs or medication.|
|Private Hospital||Means any registered hospital not administered, operated, controlled, or funded by any District Health Board established by or under Section 19 of the New Zealand Public Health and Disability Act 2000 or any subsidiary of such a District Health Board (or the Australian equivalent) including Day Stay Facilities.|
|Prophylactic Procedures||Means Procedures undertaken as preventative measures that do not improve the members physical health.|
|Reasonable charges||Means Charges, costs and fees that The Trustees have determined are reasonable for the treatment, procedure, consultation, test, diagnostic imaging or care when carried out.|
|Registered Nurse||Means any nurse registered with the Nursing Council of New Zealand who holds a current practising certificate as a Registered Nurse, and is working within the Nursing Council of New Zealand stated scope of practice (or the Australian equivalent). That person must not be:
|Specialist||Means any health provider who is a Member or Fellow of an appropriately recognised Specialist college and has Medical Council of New Zealand vocational registration in the speciality that directly relates to the medical condition suffered by the member, in the Trustees sole opinion (or the Australian equivalent). That person must not be:
|Surgery||Means an invasive procedure, which involves physical intervention on human tissues involving cutting of a patient’s tissues or closure of a previously sustained wound. Surgery would be expected to require the use of a sterile environment, anaesthesia or sedation, antiseptic conditions, the use of surgical instruments and suturing or stapling.|
|Trustees||Means any person appointed as Trustee pursuant to Rule 16 of the New Zealand Firefighters Welfare Society rules.|
|Welfare Society||Means New Zealand Firefighters Welfare Society registered under the Friendly Societies and Credit Unions Act 1982.|
AIMS AND OBJECTIVES
1. To provide members of the New Zealand Firefighters’ Welfare Society and their families with assistance in health care during any illness by providing a mutual fund to assist in meeting medical costs
TRUSTEESHIP AND CLAIMS MANAGEMENT
2. The Trustee of Healthcare ’99 shall be the New Zealand Firefighters’ Welfare Society.
3. The Claims Manager of Healthcare ’99 shall be determined from time to time by the Trustee but shall initially be Gallagher Bassett NZ Ltd.
4. All members of the New Zealand Firefighters’ Welfare Society are eligible to become members of Healthcare ’99 upon completion and submission of the application form to the Trustee provided no pre-existing medical conditions exist. If pre-existing medical conditions exist applicants will only be accepted for membership if approved by the Trustee.
5. Existing members of Healthcare ’99 may terminate their own membership from the fund by giving fourteen (14) days’ notice in writing to the Trustee of that member’s intention to cease membership of the fund.
6. Membership of the fund shall cease immediately upon that member’s termination of membership of the New Zealand Firefighters’ Welfare Society.
7. The Trustee may give notice to any member that their membership shall be terminated by the Trustee if arrears of contributions are not paid in full to the Trustee within fourteen (14) days of the date such notice is sent to the member by ordinary post to the last known address of the member. In the event that the member fails to pay all arrears of contributions within the time allowed the Trustee may terminate that member’s membership at any time from expiry of that date and notify the member accordingly by notice in writing to the last known address of the member.
8. The level of contributions shall be determined from time to time by the Trustee after obtaining professional advice. The level of contributions is set out on the back page.
9. The contributions may be made to provide benefits for the member, his or her spouse and dependent children, which shall be based upon the option chosen by the member.
10. Contributions are deducted fortnightly, monthly or annually in advance from wages, salary or by direct debit from a bank account.
CONSIDERATION OF CLAIMS AND PAYMENT OF BENEFITS
11. After payment of all expenses and other charges related to the fund the Trustee may in its absolute discretion, at any time or times:
11.1 Accumulate all or any part of the contributions as an addition to the capital of the fund;
11.2 Retain out of, or charge against the contributions for a financial period any reserves or other provisions that the Trustee thinks fit against any liabilities of the fund;
11.3 Consider claims by financial members for assistance with the costs of medical treatment and determine in its absolute discretion whether to accept any claim and the amount of any benefits to be paid.
12. In exercising its discretion, the Trustee may obtain and consider
Professional advice and may be guided by:
12.1 The contributions available;
12.2 The nature and extent of the claims received; and
12.3 The advice of the Claims Manager
13. A member is not a financial member If contributions are in arrears
14. Members must claim within 30 days of the date of the treatment or event.
15. Claims will only be considered upon receipt of a full completed official claim form. Please download a form from www.firefighters.org.nz and email to firstname.lastname@example.org. Alternatively, you can complete your claim online.
16. For small reimbursement claims, the member is expected to pay for the service and seek reimbursement. For higher value claims, Gallagher Bassett can pay the provider directly on your behalf.
17. Whenever a member expects the cost of medical treatment or hospitalisation to exceed his or her own financial resources the member may apply for urgent consideration of the member’s claim.
18. In the event that the Trustee or the Claims Manager acting as the Trustee’s agent declines a claim made by a member, that member may appeal by notice in writing to within twenty-eight (28) days of the decision, to the Trustee for reconsideration of the member’s claim.
Upon receiving notice of such an appeal, the Trustee shall reconsider the claim of the member and either declines it or accepts in whole or in part as the Trustee in exercise of its absolute discretion deems appropriate. The decision of the Trustee shall be final.
Unless any dispute or difference is resolved by mediation or other agreement the same shall be submitted to the arbitration of one arbitrator who shall conduct the arbitral proceedings in accordance with the Arbitration Act 1996 and any amendment thereof or any other alternative statutory provision then relating to arbitration.
TERMS AND CONDITIONS
Consideration for benefits under this mutual fund are available only to persons who have been accepted and remain acceptable by the Society for participation in Healthcare 99 and at all times during the currency of the fund are current with all contributions required.
Contributions are payable in advance.
All benefits are payable in New Zealand currency.
- Healthcare 99 is Self-Funded and operates under a Trust Deed (NOT an insurance plan. You (the members) own it. The NZFF Welfare Society are the Trustee.
- After operating costs ALL of the contributions are available for assisting the medical welfare needs of the members and their families.
- Regular Actuarial reviews are undertaken
- All claims submitted are subject to reimbursement at the sole discretion of the Trustee. (Rules 11 and 19).
- Members have right of appeal according to the rules.
- No claim/s shall be payable to any Member or any Dependant for a period of 12 weeks starting from the date of members first contribution payment received.
- You only pay for two children (dependants under 19 years of age). Dependant children upon reaching 19 years of age may continue participation as an adult under their parents’ membership or institute their own membership. All of your dependants must come under the same Option as you, there cannot be variations in the Options i.e. you are all Option A, or Option B.
- Please check the Information Brochure for Terms & Conditions before making any claim.
- Existing conditions at the time of application will be considered only following full Disclosure by the applicant.
- Check that the receipts/invoices are less than 30 days old before sending to claims manager.
Members wishing to change options
When a member elects to move downwards from one option to another that has lesser benefits, then there will be a waiting period of twelve (12) weeks before the member can make a claim on their new option.
The member continues to pay the higher contribution rate until the 12 week period has been completed. Any claim during that time will be for the lesser amounts.
When a member elects to move upwards from one option to another that has greater benefits, then there will be a waiting period of twelve (12) weeks before the member can make a claim on their new option, e.g. the member will continue to pay the higher amount until the 12 week period has ended and during that time any claims made will be for the lesser amounts.
If you are to change your Healthcare Option to an Option that has increased benefits, during your 12 week stand down you will be charged a the higher Option contribution rate.
Please note until your 12 week stand down has been completed you still have the ability to claim medical expenses against your former Healthcare option.
Once a member has elected to move upwards they cannot elect to move downwards to a lesser option for two (2) years. The member must declare any material facts or changes that may influence the decision to accept the change of cover.
The Trustee has the sole discretion to decline any member’s request to move from one option to another.
Check the Terms and Conditions. (See Page 5 of this Information Brochure October 2019).