New Zealand has a public healthcare system that treats acute health conditions and provides some elective surgery. We also have a public, no-fault accident insurance scheme (ACC) covering accidental injury.
These are effective in providing healthcare support for accidents and acute and urgent care. But public hospitals cannot do everything for everyone.
Private health insurance complements these public services by making private healthcare available.
Southern Cross cares about the health and wellbeing of our members. In an effort to support you when you undertake an ACC review, the Southern Cross Member Advocacy team is there to help.
One of the ways Southern Cross helps is by offering all our members an advocacy service to review an ACC decline from either a personal injury caused by an accident, treatment injury or a work-related gradual process. There is no charge for this service for our members.
If the medical evidence shows that your ACC decline may be incorrect, and your treating specialist is willing to provide a supportive opinion, the Southern Cross Member Advocacy team may be able to assist. We can guide you through the process of an ACC review, providing knowledge of the system and support with the goal of having the ACC decline overturned and the treatment funded by ACC. If successful, you may be able to request backdated compensation and other entitlements from ACC.
We generally assist members who have recently received an ACC decision declining funding for surgery, or a decline of cover for a physical injury related to this. If you have received an ACC decision about something else, we may not be able to assist.
John's story
Southern Cross member John is grateful for the help he received with his declined ACC claim from the Southern Cross Member Advocacy team. To see how the Member Advocacy team can help you, watch John's story here.
ACC has two categories of cover: personal injuries caused by an accident or gradual work-related stresses, and personal injuries caused by medical treatment (treatment injuries). The different categories of cover are treated differently by ACC and therefore by Southern Cross.
Southern Cross Health Insurance policies do not cover treatment for injuries which ACC has agreed to cover. If your treatment relates to an injury or health condition which is covered by ACC, you or your doctor must, therefore, apply to ACC for treatment funding in the first instance.
In circumstances where ACC does not pay the full amount charged for treatment you may be able to claim the remainder under your Southern Cross policy. These may include ACC surcharges and partial payments.
If your claim is declined by ACC and the treatment you require is covered under your Southern Cross policy, Southern Cross may agree to cover the cost of that treatment. The Southern Cross Member Advocacy team may also work with you to apply for a review of ACC’s decision. A review can take place either before or after treatment is provided and will not delay your access to treatment.
If you or your doctor think that ACC’s decision is incorrect, and your treating specialist is supportive of your case, please contact the Southern Cross Member Advocacy Team. We will review the decline documentation and offer advice as to whether a review of ACC’s decision is worthwhile. If there is a case for review of the decision, the Southern Cross Member Advocacy Team can work with you to guide you through the review process.
Please find the personal injury caused by an accident (PICBA) process below:
Occasionally, a patient suffers an unexpected injury during medical treatment or surgery. If a registered health professional was treating you and the treatment directly caused your injury and is not a normal side effect of your treatment, you may be eligible for ACC cover for a treatment injury.
As in the case of an injury caused by accident, you need to first lodge a claim with ACC for a treatment injury (see chart below). For more information visit the ACC website.
Unlike a personal injury caused by accident, ACC does not require a claim to be lodged or a decision on cover or treatment funding to be made before you can undergo treatment for your treatment injury. This reflects the fact that treatment injuries often need urgent treatment and it would not always be possible or appropriate to lodge a claim or request for prior approval prior to treatment. However, if ACC has already accepted cover for your treatment injury, approval for treatment funding must then be sought from ACC before treatment can take place.
Treatment injuries can be complex, and it is often difficult to determine whether a particular injury meets ACC’s criteria for cover. If you have any questions about whether you may have a treatment injury, you can contact the Southern Cross Member Advocacy team for advice.
If your ACC decline is overturned, you may be eligible for ACC entitlements that may include the following:
If you have any questions about this process, please contact the Southern Cross Member Advocacy team at advocacy@southerncross.co.nz or on 0800 800 181
Southern Cross Medical Care Society (trading as Southern Cross Health Society) is a licensed insurer and a licensed financial advice provider. For more information about the financial advice service we provide and a copy of our public disclosure statement please visit southerncross.co.nz/disclosure-statement.
Southern Cross Medical Care Society (trading as Southern Cross Health Society) has an A+ (Strong) financial strength rating given by Standard & Poor’s (Australia) Pty Limited. The rating scale is: AAA (Extremely Strong), AA (Very Strong), A (Strong), BBB (Good), BB (Marginal), B (Weak), CCC (Very Weak), CC (Extremely Weak), SD or D (Selective Default or Default). Ratings from ‘AA’ to ‘CCC’ may be modified by the addition of a plus (+) or minus (-) sign to show relative standing within the major rating categories. Full details of the rating scale are available at www.spglobal.com/ratings/en/about/intro-to-credit-ratings. Standard & Poor’s is an approved rating agency under the Insurance (Prudential Supervision) Act 2010.
