Aviva Terms & Conditions

Waiting Periods applicable for all in-patient treatment, day case treatment and out-patient PET and PET-CT scans only

Waiting periods will apply to any new health member with Aviva:

• who has never been insured under a health insurance contract,
• who is subject to a waiting period with another health insurer, or
• whose membership under another health insurance contract ended more than 13 weeks before joining the Aviva plan, or
• who upgrades their level of cover.

If a waiting period applies:
a) a person under the age of 55 on the date of becoming a health member with Aviva must wait 26 weeks before he/she is fully insured under his/her plan benefits.
b) a person over the age of 55 and under 65 on the date of becoming a health member with Aviva must wait 52 weeks before he/she is fully insured under his/her plan benefits.
c) a person over the age of 65 on the date of becoming a health member with Aviva must wait 104 weeks before he/she is fully insured under his/her plan benefits.
d) maternity or pregnancy benefits are not covered for 52 weeks from the date of becoming a health member with Aviva. The exclusion period applicable to new members for the following benefits is 42 weeks:

• Post natal home help
• Doula services
• Cord blood stem cell preservation
• Breastfeeding consultancy
• Partner benefit

If there is a break of more than 13 weeks between health insurance contracts, the application will be deemed a new application for membership.
Should you suffer an accident or injury before your waiting period ends you will be insured for medically necessary treatment resulting from the accident or injury.
If you have previously been insured, then the waiting period shall start from the commencement date of your previous or original health insurance contract as long as there has not been more than a 13 week break in cover.
If you apply to include your child on your contract within 13 weeks of his/her birth waiting periods shall not apply.

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Waiting periods for day-to-day benefits

These apply to any new health members with Aviva over 55:

• who has never been insured under an equivalent health insurance contract, or
• who is subject to a waiting period with another health insurer, or
• whose membership under another health insurance contract ended more than 13 weeks before joining the health plan with Aviva, or
• who is enhancing his or her benefits.

In such cases a one year waiting period for members over 55 and under 65 and a two year waiting period for members over 65 will apply before you are eligible to claim for any day-to-day benefits. Only eligible members can pool day-to-day benefits together maternity or pregnancy benefits are not covered for 42 weeks from the date of becoming a health member with Aviva unless switching from an equivalent plan.

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Exclusion periods for pre-existing conditions

This exclusion applies to all in-patient benefits offered under your plan and cover for out-patient scans.
If you have a pre-existing condition, as determined on medical advice, then the following exclusion periods will apply before any claim will be paid relating to that condition. Please note that these periods begin to run from the date you first become insured under any health insurance contract and do not start again on becoming a health member with Aviva unless there has been a lapse in cover of over 13 weeks.
If this exclusion for pre-existing conditions applies, the length of the exclusion period is as follows:

• persons aged under 55 on date of joining–5 years
• persons aged 55-59 on date of joining–7 years
• persons aged 60 or over on date of joining–10 years

Please note that a pre-existing condition is determined from the date the condition commences rather than the date upon which the member becomes aware of the condition. A pre-existing condition may therefore be present before giving rise to any symptoms or being diagnosed by a doctor.

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Exclusion period following an upgrade in cover

If you increase the level of cover within your plan by either changing to a more comprehensive health plan with Aviva or switching to Aviva from another insurer (without 13 weeks having elapsed since being covered under a health insurance contract) a supplementary exclusion period will apply to all increases in cover in relation to any condition that existed prior to the date of upgrade in cover.

Benefits for treatment for such conditions during this supplementary period will be paid up to the amount that would have been payable under your old health insurance contract if the benefit for the treatment would have been payable under your old health insurance contract.

The supplementary exclusion period shall be two years following the change to a higher plan but five years for people aged 65 or over.

The supplementary exclusion period for any maternity or pregnancy related conditions shall be one year. The exclusion period applicable to new members for the following benefits is 42 weeks:

• Post natal home help
• Doula services
• Cord blood stem cell preservation
• Breastfeeding consultancy
• Partner benefit

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Out-patient excess

In order to successfully claim for out-patient benefits, a member must submit invoices for out-patient expenses occurring within the term of their current policy.
The benefit payable by Aviva regarding those receipts (i.e. the out-patient benefit), without reference to the total value stated on the invoice / receipt concerned, must alone, or in addition to any other submitted invoices / receipts, exceed or equal the member’s out-patient excess. The amount payable by Aviva shall be that portion of the relevant single or combined out-patient benefit(s) which exceed(s) the member’s out-patient excess. Where a member has already been paid for out-patient expenses under their current policy the out-patient benefit shall be paid in full, subject to any other term or condition contained within this policy.
Please note, notwithstanding the value of a member’s out-patient expenses in terms of the amount listed on any invoice/receipt, only the relevant out-patient benefit will be paid according to the specific terms of a member’s plan.”

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Consultant Cover

Your cover for consultant fees is determined by the registration status of the consultant as set out below:
Part Participating – you are covered for the level of professional fees for in-patient and day case hospital treatment as set out in our schedule of benefits and you may be liable to an additional charge by your consultant(s).
Fully Participating – fully covered for all in-patient and day case consultant professional fees.
Non participating – if your consultant has not registered you may claim back the costs of your day case and in-patient treatment to the levels set out in minimum benefits, if your consultant has capacity to charge.
(NOTE: coverage for consultant fees is subject to the terms and conditions of this policy).

Applicable rules – general terms and conditions

The following rules will apply in settling any claim under your plan.

• The level of cover within your contract will at all times govern the amounts payable.
• Benefits will be paid for the medically necessary treatment that you receive and are eligible for while you are a member.
• We will pay benefits up to the level covered under the plan of which you are a member at the time you receive treatment subject to any applicable waiting period, exclusion for pre-existing conditions or supplementary exclusion period.
• We will not pay benefits for treatment which you receive while you are not an Aviva Health Insurance member.
• We will only pay fees and charges for medically necessary established treatment, services and facilities that are reasonable and customary and in any event only up to the limits shown in the schedule of benefits. By reasonable and customary we mean that what you are charged for and how much you are charged is not more than what the majority of our other members of the plan are charged in Ireland for similar treatment services or facilities.
• Where your hospital, consultant, ambulance or other provider does not have an agreement on pricing with Aviva, Aviva will only pay these benefits to specified amounts which may not cover the entire cost of your treatment. The specified amounts for non participating consultants’ fees are set out in the schedule of benefits.
• Where the amount charged is less than the cover within your policy, this lesser amount shall be paid.
• Aviva will not pay any claims for in-patient benefits where on medical advice, we determine that the treatment should have been provided as a day case or out-patient rather than as an in-patient. We will only pay the amount that would have been settled had the treatment been carried out on a day case or out-patient basis up to the level of cover your plan would have provided. This will be determined based on the established medical practice for that condition.
• Aviva will not pay any claims for day case treatment where on medical advice we determine that the treatment should have been provided as an out-patient rather than day case treatment. In such circumstances and if the relevant health services were provided in a private hospital, we will pay the rate due as an out-patient based on the level of cover provided under your plan. This will be determined based on the established medical practice for that condition.
• We will not pay any claim should we find you are breaching any of the terms of your membership. In addition, you must notify us of any other cover you may have with any other insurer that may cover all or any part of your claim.
• Where we believe that the cost of the claim can be recovered from a third party, you must do everything we ask to help us recover funds and you must permit us to commence proceedings in your name to recover any benefit paid under this policy. We may pay your claim subject to your agreeing to refund the monies provided should you subsequently recover monies from said third party.
• The amount due to be paid under your contract will be determined by reference to the date on which you receive treatment or your first day in hospital.
• We will pay benefits after deducting any withholding tax or other deductions required by law.
• If there is any other insurance or fund covering any of the benefits provided under this policy you must disclose this to us and we shall not be liable to pay or contribute more than our rateable proportion up to the specified limits.
• To help us protect your and our interests we may record telephone calls to provide an accurate record of discussions.
• In order for a claim to be paid it will be necessary to provide some of your membership details to a hospital, approved centre, doctor or consultant. Any such disclosure will be limited strictly to the purpose for which it is required under your health insurance contract and will at all times be made in strictest confidence.

If the benefits do not cover the full cost of your treatment, you are responsible for paying the remaining balance. You should request details of all costs from the hospital and consultant prior to incurring any treatment where full insurance cover may not be provided.
Any documents you forward to us will not be returned unless you specify such, at the time you send them.
It is solely at the discretion of Aviva to decide to exercise or not to exercise any legal right. Failure to exercise our rights shall not prevent us from doing so in the future.

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We will end your membership if at any time:

• We do not receive your premiums. We shall deem your membership to have ended where no premium has been paid. Membership may be resumed and made retroactive once all sums due are paid within 2 weeks from when the first default occurred.
• You make a fraudulent claim or statement to us or any other health insurer, which may have caused us or the other insurer financial loss.
• You leave Ireland for six months or more.
   

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Costs not covered under your health plan with Aviva:

• Ambulance transfer from your home to hospital or a convalescence home. Ambulance transfer from hospital or a convalescence home to your home.
• In-patient treatment or day case treatment carried out during any waiting period that may apply.
• In-patient treatment or day case treatment for pre-existing conditions during any applicable exclusion period.
• Treatment that is not medically necessary or required.
• Drug therapy which we reasonably decide, based on established medical opinion in Ireland, is experimental or unproven and not an established treatment.
• Shortfall in cover for:

(a) any treatment or provider unless we have specified that we provide full cover;
(b) any hospital that is not listed as a participating hospital;
(c) a non-participating consultant;
(d) a provider that is not listed.

• Treatment relating to any orosurgical procedures or orthodontic treatment unless it is a surgical or medical procedure listed under the schedule of benefits.
• Fees for non-attendance or late cancellation of an appointment.
• Gender reassignment treatment.
• Treatment relating to transplants except for costs covered by the Minimum Benefit Regulations and those specified in the schedule of benefits.
• Preventative or maintenance treatment unless specified in the schedule of benefits.
• Treatments not covered under your health insurance contract.
• Long-term nursing care, or long-term convalescence.
• Any form of vaccination other than stated in this handbook.
• Charges for drugs or medication unless provided as an in-patient and as agreed with the hospital.
• Family planning or contraceptive measures – this includes any form of infertility treatment or reversal thereof and assisted reproduction other than the benefit available from MTC Healthcare.
• Treatment programmes for weight reduction or eating disorders other than anorexia nervosa and bulimia.
• Participation in clinical studies or trials.
• Where injury or illness is caused by virtue of war, civil disobedience or any act of terrorism or chemical, biological or nuclear disaster.
• Where the treatment is given by a practitioner who is a member of the insured’s immediate family unless this is pre-authorised by Aviva in exceptional circumstances.
• Expenses for which the member is not liable.
• Treatment for any symptoms, which are not due to any underlying disease, illness or injury.
• Nursery fees.
• Cost of a medical certificate, medical records, or the costs associated with obtaining details of medical history.
• Cosmetic surgery unless this is needed after an accident to restore a member’s appearance or due to a genetic disfigurement at birth or due to a significant disfigurement due to disease.
• Ophthalmic procedures for correction of short-sightedness, long-sightedness or astigmatism other than benefit available under Optical Express.
• Treatment outside Ireland that is not needed as a result of an accident or emergency, unless it has been pre-authorised by Aviva.
• Accommodation charges that are not related to medically necessary treatment.
• Treatment by a consultant who is not recognised by the Irish Medical Council to have speciality in relation to the treatment received or is not recognised by the Irish Medical Council in any medical field.
• Health screening unless provided as a day-to-day benefit or as specified in this handbook.
• Any penalty charge in lieu of Health Act contributions.
• Psychology (other than psycho-oncology counselling post chemotherapy treatment).

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Residency Requirements

In order to be eligible for cover under a policy, a member must be resident in Ireland for at least 180 days in any policy year, unless given an indication to the contrary.
If a member is not resident in Ireland for 180 days or more in any policy year, their cover will cease. Where premium has been paid for a member for a period of time during which they are not resident in Ireland, this will be refunded to the policyholder, where the policyholder requests such a refund within 3 months of the member concerned ceasing to be resident in Ireland, should no in-patient claims have been made.

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Complaints and Comments

Should you have any complaints or comments about any service provided by Aviva or about your health insurance contract please contact us either by phone, in writing or via email to support@avivahealth.ie.
If you are not satisfied with any explanation or complaint resolution proposed by Aviva in relation to your health insurance contract please contact:
The Managing Director, Aviva Health Insurance Ireland Limited, P.O. Box 764, Togher, Cork.
If you remain dissatisfied with Aviva you may refer your complaint within 28 days to the Financial Services Ombudsman Bureau at the following address:
Financial Services Ombudsman’s Bureau, 3rd Floor, Lincoln House, Lincoln Place, Dublin 2. Lo Call: 1890 88 20 90. Fax: 01 6620890
Email: enquiries@financialombudsman.ie
Website: www.financialombudsman.ie
Aviva agrees to be legally bound by any decision made by the Financial Services Ombudsman Bureau.

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Changes to this agreement

Changes may be made to this agreement from time to time. Benefits may be enhanced during the year.

At no point will we impose any restriction to your cover specific only to your personal medical history that started after you joined our plan.

All changes, except those required by law (or necessitated by a change in agreement with hospitals, treatment or scan centres, or consultants), will apply with effect from the renewal date after the change was made. This contract is governed at all times by the laws and the Courts of Ireland.

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