(1) The amount that an insurer, except the manager, is liable to pay under clause 1(2)(b) of Schedule 1 of the Act for treatment other than elective surgery is calculated by—

• (a) Determining the amount that the treatment provider who treated the insured for a personal injury charges for treating personal injuries of the kind suffered by the insured; and

• (b) Determining the amount that is payable under these regulations; and

• (c) Selecting the lesser of the amounts determined under paragraphs (a) and (b).

(2) For the purposes of subclause (1)(b), the amounts that are payable under these regulations are in—

• (a) Column 2 of the Schedule, which specifies the amount payable for the treatment, opposite the amount, in column 1 of the Schedule; and

• (b) Regulations 6 to 12, some of which prescribe amounts that are payable without reference to the Schedule and others of which modify the amounts specified in the Schedule.

(3) The amount that an insurer, except the manager, is liable to pay under clause 1(2)(b) of Schedule 1 of the Act for elective surgery is calculated under regulation 13.

(4) [Revoked]

(1) The amount that the manager is liable to pay under clause 1(2)(b) of Schedule 1 of the Act for treatment other than elective surgery is,—

• (a) If the manager has not made a contract that deals with the kind of treatment given to the insured by the treatment provider, the amount calculated under subclause (3):

• (b) If the manager has made a contract that deals with the kind of treatment given to the insured by the treatment provider, the amount calculated under subclause (4).

(2) For the purposes of subclauses (3)(b) and (4)(b), the amounts that are payable under these regulations are in—

• (a) Column 2 of the Schedule, which specifies the amount payable for the treatment, opposite the amount, in column 1 of the Schedule; and

• (b) Regulations 6 to 12, some of which prescribe amounts that are payable without reference to the Schedule and others of which modify the amounts specified in the Schedule.

(3) For the purposes of subclause (1)(a), the amount is calculated by—

• (a) Determining the amount that the treatment provider who treated the insured for a personal injury charges for treating personal injuries of the kind suffered by the insured; and

• (b) Determining the amount that is payable under these regulations; and

• (c) Selecting the lesser of the amounts determined under paragraphs (a) and (b).

(4) For the purposes of subclause (1)(b), the amount is calculated by—

• (a) Determining the amount that the treatment provider who treated the insured for a personal injury charges for treating personal injuries of the kind suffered by the insured; and

• (b) Determining the amount that the manager is liable to pay under payment method A, that is, payment under these regulations; and

• (c) Determining the amount that the manager is liable to pay under payment method B, that is, payment under the contract. (To avoid any doubt, nothing in regulations 6 to 12 or the Schedule applies to treatment to which such a contract applies); and

• (d) Determining—

  • (i) Whether the insured would be liable to pay anything to the treatment provider if payment method A were used and, if so, how much; and

  • (ii) Whether the insured would be liable to pay anything to the treatment provider if payment method B were used and, if so, how much; and

• (e) If the insured would be liable to pay something to the treatment provider under either payment method A or payment method B, selecting whichever payment method results in the insured being liable to pay the least to the treatment provider; and

• (f) If the insured would not be liable to pay anything to the treatment provider under either payment method A or payment method B, selecting payment method B.

(5) The amount that the manager is liable to pay under clause 1(2)(b) of Schedule 1 of the Act for elective surgery is calculated under regulation 13.

(6) The power of the manager to make, under section 329 of the Act, contracts of the kind referred to in subclause (1)(b) is affected by section 339 of the Act, as to both the ability to enter into the contract and the contents of the contract.

(1) An insurer is not liable to pay anything to the insured for a public health acute service that—

• (a) The insured receives; or

• (b) The insured does not receive but is entitled to receive.

(2) Subclause (1) applies even though the public health acute service is—

• (a) A treatment of a kind to which regulation 4 or regulation 4A applies; or

• (b) Elective surgery of a kind to which regulation 4 or regulation 4A applies; or

• (c) [Revoked]

(1) This regulation relates to the treatments under the heading “Counsellors' Costs”.

(2) The insurer is liable to pay $78.75 an hour for the treatment described in item 5 of the Schedule.

(3) The insurer is liable to pay $56.25 an hour for the treatment described in item 6 of the Schedule.

(4) The insurer is liable to pay only the rate specified in this regulation, no matter how many people the counsellor treats in the session for which payment is sought.

(5) The insurer is liable to pay only for counselling provided on a face-to-face basis. This subclause is subject to subclause (6).

(6) The insurer is liable to pay for 1 session of counselling provided on other than a face-to-face basis if the counselling is provided because the insured needs it urgently for a mental injury the insured suffered in the circumstances described in section 40 of the Act.

(1) This regulation relates to the treatments under the heading “Dentists' Costs”.

(2) If the insured is given both a treatment and a more comprehensive treatment at the same visit, the insurer is liable to pay only the cost of the more comprehensive treatment.

(3) If the insured is given an implant, the insurer is liable to pay the amount specified in the Schedule for whichever of the following would otherwise have been given:

• (a) Crown:

• (b) Bridge:

• (c) Metal denture.

(4) If an insured is given a treatment on a tooth that has previously been heavily restored, and no insurer was liable to pay for the previous restoration, the insurer is liable to pay 75% of the amount specified in the Schedule for the treatment.

(5) If an insured is given a treatment on a tooth that has previously been crowned, and no insurer was liable to pay for the previous crowning, the insurer is liable to pay 50% of the amount specified in the Schedule for the treatment.

(1) This regulation relates to the treatments under the heading “Hyperbaric Oxygen Treatment Costs”.

(2) If the insured is given such a treatment, the insurer is liable to pay—

• (a) $57.40 an hour for the use of a hyperbaric oxygen chamber; and

• (b) The amount specified in the Schedule for the treatment.

(1) This regulation relates to the treatments under the heading “Radiologists' Costs”.

(2) If the insured is given a treatment by a radiologist whose scope of practice does not include the branch of medicine known as diagnostic radiology, the insurer is liable to pay 60% of the amount specified in the Schedule for the treatment.

(3) If the insured is given a treatment by a radiologist whose scope of practice includes the branch of medicine known as diagnostic radiology, the insurer is liable to pay the amount specified in the Schedule for the treatment.

(1) This regulation relates to the treatments under the heading “ Medical Practitioners' Costs”.

(1A) This regulation applies if the insured visits, or is visited by, a medical practitioner who either—

• (a) is not a registered specialist; or

• (b) is a registered specialist but, during the consultation, is not practising within a recognised branch of medicine that is included in his or her scope of practice.

(2) If this regulation applies, the insurer is liable to pay—

• (a) The following rates for each consultation that the insured has:

  • (i) $35.00, if the insured is under 6 years when the consultation takes place:

  • (ii) $26.00, if the insured is 6 years or over when the consultation takes place; and

• (b) The amount specified in the Schedule for any treatment the insured is given.

(3) If the insured is given both a treatment and a more comprehensive treatment at the same visit, the insurer is liable to pay only the cost of the more comprehensive treatment.

(4) If the insured is given 2 or more separate treatments at the same visit, the insurer is liable to pay—

• (a) The amount specified in the Schedule for the more or most expensive treatment the insured is given; and

• (b) 50% of the amount specified in the Schedule for each other treatment the insured is given.

(5) If a medical practitioner referred to in subclause (1A) travels to an insured and gives him or her emergency treatment, the insurer is liable to pay—

• (a) A travelling fee at the rate of 82 cents per kilometre, if the cost of travel in the same circumstances is payable under the New Zealand Public Health and Disability Act 2000; and

• (b) $47.80 an hour for any part of the emergency consultation that exceeds 30 minutes, if the insurer is liable to pay a travelling fee under paragraph (a); and

• (c) The amount payable under subclause (2).

(1) This regulation relates to the treatments under the heading “Registered Specialists' Costs”.

(2) This regulation applies if the insured visits, or is visited by, a medical practitioner who—

• (a) is a registered specialist; and

• (b) during the consultation, is practising within a recognised branch of medicine that is included in his or her scope of practice.

(3) If this regulation applies, the insurer is liable to pay—

• (a) The following rate for a first consultation that the insured has:

  • (i) $97.55, if the consultation was with a registered specialist who, during the consultation, was practising within any of the following recognised branches of medicine:

    • (A) Internal Medicine:

    • (B) Neurosurgery:

    • (C) Occupational Medicine:

    • (D) Paediatrics:

    • (E) Psychological Medicine or Psychiatry:

    • (F) Rehabilitation Medicine; or

  • (ii) $76.50, if the consultation was with a registered specialist who, during the consultation, was practising within any other recognised branch of medicine; and

• (b) $38.25, for any later consultation that the insured has with a registered specialist; and

• (c) The amount specified in the Schedule for any treatment the insured is given.

(4) If the insured is given both a treatment and a more comprehensive treatment at the same visit, the insurer is liable to pay only the cost of the more comprehensive treatment.

(5) If the insured is given 2 or more separate treatments at the same visit, the insurer is liable to pay—

• (a) The amount specified in the Schedule for the more or most expensive treatment the insured is given; and

• (b) 50% of the amount specified in the Schedule for each other treatment the insured is given.

(1) This regulation relates to the treatments under the heading “Specified Treatment Providers' Costs”.

(2) A specified treatment provider may elect not to be paid the amount specified in item 249 of the Schedule for any treatments that he or she gives any insured.

(3) The specified treatment provider must then give the insurer a written notice of election.

(4) The specified treatment provider may revoke such an election by giving the insurer a written notice of revocation but may then give another written notice of election only if the insurer first gives written consent.

(5) An insurer that receives a written notice of election is liable to pay the cost of the treatment given by the specified treatment provider at the lesser of—

• (a) The rate of $47.80 an hour; or

• (b) The rate the specified treatment provider would have charged the insured if the insurer were not to pay the cost.

(1) In this regulation, nurse means a nurse working in a general practice to which the practice nurse subsidy is payable under terms and conditions agreed under the New Zealand Public Health and Disability Act 2000.

(2) If the insured visits, or is visited by, a nurse, the insurer is liable to pay—

• (a) $11.00 an hour for each consultation that the insured has; and

• (b) The amount specified in the Schedule for any treatment the nurse gives the insured and that could be given by a medical practitioner.

(3) If the insured is given both a treatment and a more comprehensive treatment at the same visit, the insurer is liable to pay only the cost of the more comprehensive treatment.

(4) If the insured is given 2 or more separate treatments at the same visit, the insurer is liable to pay—

• (a) the amount specified in the Schedule for the more or most expensive treatment the insured is given; and

• (b) 50% of the amount specified in the Schedule for each other treatment the insured is given.

(1) In this regulation,—

(2) This regulation applies if an insurer is liable to pay for elective surgery for the insured.

(3) The insurer may nominate a provider to perform the insured's elective surgery.

(4) The insured does 1 of the following:

• (a) Decides to accept the nominated provider:

• (b) Decides not to accept the nominated provider and to choose a provider:

• (c) Chooses a provider, if the insurer does not nominate a provider.

(5) Before the insured decides whether to accept the nominated provider, the insurer must tell the insured the amount that the insurer would be liable to pay if the surgery were performed by the nominated provider.

(6) The insurer is liable to pay the full cost of the surgery if it is performed by—

• (a) A district health board, whether it is the chosen provider or the nominated provider; or

• (b) The nominated provider; or

• (c) The chosen provider, if the insurer does not nominate a provider.

(7) The insurer is liable to pay 60% of the amount that would have been payable had the surgery been performed by the nominated provider, if—

• (a) The insurer nominated a provider; and

• (b) The surgery is performed by the chosen provider; and

• (c) The chosen provider is not a district health board.

All amounts specified or referred to in these regulations are inclusive of goods and services tax.