Over the past 12 months more than 1,000 claims were declined for health screening. While this is a small percentage of the 3.1 million claims we processed, having a claim declined can be a costly experience for our members.
Health screening is a general exclusion on all Southern Cross policies so understanding what it means can help avoid disappointment when the time comes to claim.
Health screening is considered to be diagnostic tests, investigations or consultations in the absence of any sign or symptom of a medical condition.
Southern Cross policies cover members for medically necessary eligible healthcare services. What this means is the treatment must be necessary for the health condition involved and be widely accepted professionally as effective, appropriate and essential based upon recognised standards of healthcare. Members also need to have signs and symptoms to be considered for cover. We make an exception to this rule for mammography and screening colonoscopy for familial risk on a case by case basis.
Recent examples of claims declined for health screening include a member who requested cover for a colonoscopy because of their age. The member had turned 65 years old and wanted a full health assessment. Unfortunately the claim could not be covered because the member did not have any symptoms that required medical investigation.
Another example was a member who had been recommended to have a cardiac assessment after their sibling had suffered a heart attack. The claim was declined because the member was not experiencing any symptoms that required testing.
Our members are encouraged to check their policy documents or call our Claim Approval team prior to seeking treatment. All policy documents are available online here.