A Nelson family have cancelled their health insurance with Southern Cross after having a claim denied for their 18 year old daughters breast correction surgery. When they asked for their insurer’s reasons in writing, they were told: “The procedure which you have submitted a claim for – modified mastopexy to the right breast and augmentation of the left breast- is not a treatment that is covered by Southern Cross. “It is an exclusion on all Southern Cross plans. Southern Cross only provides cover for breast reconstruction and breast surgery for symmetry that is considered medically necessary (e.g. following mastectomy for breast cancer).” Southern Cross has offered a $5000 ex-gratia contribution to the $13,500 approximate cost of the surgery.
I am always worried about the definition of ‘medically necessary’ and without declaring either Southern Cross or the family of the young woman as ‘right’ I would like to point out the difficulty of the situation. It is also worth stating that I have no idea exactly how significant the condition is for the young woman, it may be terrible. Instead, let me give a personal example: my daughter has recently started to wear braces.
The dental experts said this was a borderline case – that perhaps the situation would worsen a lot, with teeth forced out of line and requiring removal and the appearance of unsightly gaps, and perhaps not. Blessed with the resources to manage the problem, we asked Sophia what she would like to do and she has opted to wear braces. She has been insured from birth but it did not even occur to me that this could be a claimable procedure. Perhaps a worse situation would have been. My point is this. A line must exist somewhere. It actually doesn’t matter exactly where the line is drawn, provided that consumers can see clearly where it is. Preferably before they buy the cover. The market can then provide options: some products for those customers prepared to pay more for more cover, some for those that want more budget coverage.
Read the full article on NZ Herald website here.