It's been ten years since insurers started adding breast reconstruction after cancer surgery to medical insurance. At the time, insurers had a hard time with the subject, but over the last ten years, all insurers, with the exception of some older employer plans, now have the benefit.

The article, which you can read here, only mentioned four of the 10 providers of medical insurance benefits in the New Zealand market at the time, which does the market a disservice as it does provide valuable benefits to policyholders in need with 8 out of 10 at the time having some response to breast reconstruction after surgery.

We now have 6 medical insurers plus the NZ Police Scheme. This is due to the consolidation of providers, with Sovereign and AIA merging and the Tower and OnePath policies becoming nib. nib provides the cover distributed under the State and BNZ brands. Accuro and UniMed are also presently working through merging, so it's soon to be 5 retail medical insurers in New Zealand

What do you need to know?

I mentioned in the first paragraph not all policies with the same provider are alike, in the case of Sovereign, now AIA, who had one primary medical insurance policy with lots of variations on the basic theme.

When you purchased, your policy will determine which flavour you have.

• For example, if you took a Sovereign MajorCare policy before 2001, you have preventative screening included, something you generally won't find on a modern policy purchased today.
• If you took it prior to 2003 you have coverage for Non-Pharmac medications and guaranteed wordings.
• Those who purchased cover before 2019 also have access to a second opinion service called Best Doctors.

Loyalty benefits on the policies have varied as well.

• Some have the typical sterilisation option after having the policy for 2 or 3 years, varicose vein treatment, and even breast reduction surgery.

My point: your policy with most providers will have variations, minor on the surface but can be significant when applied to your specific requirements at claim time.

• Southern Cross is another that has a wide variety of policy terms and conditions, unlike Sovereign they take an approach of a wide range of policy options too.

Back to breast reconstruction

What is interesting with the article that was written, is the commentary about who covers what.

• You might be interested to know that some nib policy wordings specifically exclude Breast reconstruction or reduction, gynaecomastia and revision of breast implants unless approved by nib.
• The article indicates that in the situation of breast reconstruction after mastectomy for breast cancer, they do cover it.
• It makes it a little difficult for you, the consumer, to really understand what your policy will do for you.

In the same vein, Sovereign's policies (Were) also quite specific to excluding breast reconstruction across all of their policy documents, but they (Had) a $15,000 allowance for reconstruction, which isn't in most of their existing policy wordings.

• Again makes it difficult to understand what cover you do have when you get to the finer points of what's in and what's out.
• On 1 June 2014, Sovereign, now AIA, removed the specific $15,000 reconstruction benefit and now includes breast reconstruction under the main surgery benefit of the policy. 

The best thing you can do is have an adviser involved. As I wrote in an earlier article, it helps at claim time to have an adviser involved in the application.

Likewise, if you have questions or specific requirements for your cover, asking an adviser to source or clarify gives you the best chance of getting the type of cover you want.

If you go directly to the provider, you will only get answers on their product, which may not identify a better option elsewhere for you.

The week the NZ Herald article was published, two medical insurance providers issued communications to clarify the issues raised.

• Both would cover the reconstruction within the surgery limits of their standard cover.
• At the time when I talked to one of these providers' claims people directly, they would see the later problem of a breast implant issue following a reconstruction as medically necessary and come to the party to pay for the necessary follow-up treatment, too.

What does this mean for you?

Check your policy documents to see what you do have covered.

If you have questions or need assistance understanding what you do have, or you find you need advice on getting covered, get in touch. We would be glad to help.