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About Private Health Insurance

What is Private Health Insurance?

New Zealand’s  health and disability system is mainly funded from general taxation. The Ministry of Health allocates more than three quarters of the public funds it manages via Vote Health to DHBs, who then use this to purchase and provide public health services.

Other funding sources include the Accident Compensation Corporation (ACC) and other government agencies. But the public health system does not cover all healthcare and private health insurance covers a wider variety of healthcare options.

More than 1.3 million New Zealanders have private health insurance, according to the Health Funds Association of New Zealand. Having private health insurance means New Zealanders can access treatment without the often-lengthy wait of the public health system. It also gives the policy holder some more control over their healthcare, such as the option of getting cover for extra treatments, such as dental, optical, chiropractic or physiotherapy.

These are a general explanation of the meaning of terms used in relation to health insurance.

Policy wording may use different terms and you should read the terms and conditions of the relevant policy to understand the inclusions and exclusions of that policy.

Annual limit: The maximum benefit payable for a particular service within a 12-month period.

Benefit: The dollar amount paid to you by your health fund when you make a claim with your hospital cover or extras cover.

Benefit limitation period: Benefit limitation periods are a period of time after taking out your health insurance policy where you will only be able to claim a restricted amount of benefit for nominated conditions. This time period usually commences after standard waiting periods have been served.

Claim: When you request that your health funds contributes to the cost of health services provided by a hospital, doctor, or other healthcare provider. If you have already paid the invoice in full, you can make a claim with your health fund afterwards and they will reimburse you with some or all of the cost via a direct payment such as electronic funds transfer or cheque. If the invoice has not yet been paid, the health fund will pay this invoice in full, and then request that you pay them the balance owing (the difference between the actual bill and the amount the health fund will cover).

Compensation or Damages: Fund benefits are not payable when compensation and/or damages may be claimed from another source, such as Workers’ Compensation, Compulsory Third Party (CTP) car insurance, Common Law, Sports Insurance, Travel Insurance, Litigation, or Crimes Compensation.

Default Benefits: The minimum level of benefits private health insurers must pay, as set down by the Government. These cover claims for treatment provided in public hospitals, non-contracted private hospitals and day surgeries.

Elective surgery: Surgical treatment of a condition that, according to your doctor, does not require immediate attention. Elective surgery waiting lists are one reason why it’s great having health insurance.

Excess: Much like with a car insurance policy, your health insurance policy charges an excess when you make a claim. It is an amount of money you agree to pay for hospital admission or medical services before you can claim anything back from your health fund. An excess does not apply to extras cover. Learn more about the health insurance excess.

Exclusions: Any medical procedure, treatment, or health service that is not covered by your policy. You cannot make a claim for these items with your health insurance.

Pre-existing condition: An ailment, illness, or health condition is considered to be pre-existing if, in the opinion of a doctor appointed by the health fund, it existed at any time during the 6 months prior to the member joining a hospital cover or upgrading to a higher level of cover. Health funds can impose a maximum 12-month waiting period for hospital treatment for ailments, illnesses, or conditions that are considered to be pre-existing. Learn more about health insurance pre-existing conditions.

Premium: The annual payment or monthly payment (or other regular periodic payment) that a policyholder makes to a health insurance company to pay for having health cover.

Restriction: Some hospital cover policies have procedures that are restricted, meaning they will only pay the Public Hospital Benefit for that procedure. Policyholders would pay a considerable gap fee if they chose to be treated for a restricted procedure.

Waiting periods: The time you need to wait after buying health insurance, before you can start claiming benefits on the policy. Learn more about health insurance waiting periods.