What's not covered by Health Insurance?

So often we are so focused on what our products do cover, but understanding the importance of these insurance products also means having a good understanding of what they don’t especially in a country like Aotearoa where we have a public health care system. In this article we look at a few key areas where private health cover is not designed to be used. As always products and policies vary so this may not be the case for all that is available on the market but does give you a good picture of what you should be seeking for from our health insurance.

ACUTE CARE

This is generally excluded by your health insurance and for good reason. Acute care means that you are experiencing a medical event that require immediate treatment, that is exactly what the public health system does best. When you are in immediate need of help you head the hospital and to A&E. This is simply not what you are seeking private health insurance for, you want to make sure that you can skip public waiting lists for surgical needs and treatments, as well as access treatments beyond the public funded treatments for critical illnesses.

COSMETIC

This is probably an obvious one but generally reads as “anything that is not necessary” with covers cosmetic procedure or any surgery, procedure or treatment that improves, alters or enhances appearance, whether or not undertaken for medical, physical, functional, psychological or emotional reasons.

EXPERIMENTAL TREATMENTS

Treatments generally need to be approved by the insurer, and for the most part they are following the guidance of Medsafe. So experimental and unproven treatments will not be covered by your health policy, however if you are suffering from a critical condition and have Trauma Cover you will paid out your sum insured in a lump sum and it is yours to do with as you see fit. It is a key reason I really like Trauma Cover having been involved in a serious accident myself and the flexibility to have the funds to do what you feel you need to is a game changer.

CONTRACEPTION, INFERTILITY & PREGNANCY

There are often exclusions around all of these on the core health insurance product, although there are often some benefits available with the better products on the market and if you add the Special & Tests portions of health insurance. But I did want to put this here so that you check your specific policy, and to show we probably need much better supports from the public sector in this area.

Outside of these common exclusion are around : CRIMINAL ACTIVITIES, DRUGS, MENTAL ILLNESS, NUCLEAR CONTAMINATION, OBESITY, HIV/AIDS, ORGAN DONATION, PREVENTATIVE TREATMENTS, SELF-INFLICTED INJURY, WAR/TERRORISM.

So what are common benefits: Surgical Care ($300k per annum up to Unlimited), Cancer Care ($100k per annum up to $600k can include non-PHARMAC treatments), Major Diagnostics ($100k +), Overseas Treatments (where is not available at all or within a timeframe in NZ) and a host of other minor benefits like home nursing, return home benefits, kids cover, public hospital credits, transfer benefits, support person benefits, accommodation benefits, medical misadventure benefit, sterilisation, recovery and hospice benefits.

Thoroughly review the benefit sheets to see what is covered before applying for cover. Private Health Insurance is a real must if it is accessible and affordable to you as paying for these treatments yourself could cost you thousands. But knowing what you can and cannot expect to claim on is paramount, and what you can expect from ACC and the public system.