Health and medical insurance
This domain covers private medical cover: what it reimburses, what it excludes, and how it sits alongside ACC and the public system.
What the products do
- Hospital and surgical cover: pays for eligible private hospital treatment and surgery.
- Specialist and diagnostic cover: consultations, imaging and tests, often with an annual limit per person.
- Major medical / comprehensive: adds non-Pharmac drugs, cancer treatment and higher limits.
- Everyday or extras cover: dental, optical, physiotherapy - frequently excluded from core hospital policies.
Structural settings
Excess (per claim or per year), co-payment percentages, annual and lifetime limits, network versus open-provider policies, pre-approval requirements, and non-Pharmac drug caps. Cover is indemnity: it reimburses actual cost up to the limit, it does not pay a lump sum.
Timing rules
New conditions typically face a stand-down (often three months); pre-existing conditions face a longer stand-down (commonly up to three years) or exclusion. Disclosure of symptoms and past treatment at application is critical.
The ACC boundary
ACC funds treatment for injury. Health insurance is valuable for illness and elective procedures - a cardiac condition, cancer, or a knee damaged by disease rather than accident.
Worked example
A 48-year-old discloses knee osteoarthritis. The insurer may exclude the knee or impose a three-year stand-down. A new cardiac event arising after the general stand-down is still covered. Recommending the policy without flagging the knee exclusion would mislead the client about what they are buying.
Traps
Assuming health insurance pays GP visits; assuming ACC covers illness; forgetting the difference between pre-existing conditions and new conditions; and treating the cheapest excess as best when the client could not fund a large unexpected bill.