Kiwi chef Simon Gault was stung by his health insurance’s changes to eligibility criteria when getting a recent cancer removed from his skin.
Earlier this month, he saw a specialist for a skin issue on his hand. During the appointment, the private specialist spotted a mark on his cheek, which was found to be cancer after a biopsy.
“[Southern Cross said] they'd cover me for a standard excision of it, and my surgeon specialist said ‘no, you shouldn't do that, you should be getting this Mohs surgery, you'll have a way greater chance of removing all the cancer with that’,” Gault told RNZ.
“But he [the specialist] said you won't meet the criteria, but they put an application in anyway, and Southern Cross declined it.
“So then I said, ‘okay, well if you'll cover the standard excision, how about you pay that portion of it and I pay the difference’, and they said no to that - and I think that's disgraceful, you know, they just leave you on your own.”
Mohs surgery is a highly specialised treatment for skin cancer, offering the highest cure rates while maximising preservation of healthy tissue, the NZ Dermatological Society says.
Gault says he ended up paying for the Mohs surgery because he did not want to wait on the public health system - his specialist had also told him to get it done quickly. He also had skin cancer surgery on his hand.
Southern Cross’ Mohs surgery criteria changes in December last year stated that, to get coverage, the lesion needs to be a basal cell carcinoma or squamous cell carcinoma.
Additionally: “At least one (a or b) of the following apply to the skin lesion.
“a) The lesion has either recurred, has aggressive histopathology, or is clinically justified as high risk AND the lesion is on the head and neck OR site of previous radiation or burn scarring.
“b) The lesion is on eyelids, periorbital skin, ears, pre and post auricular, lips, nose, chin, mandible, temple, fingers, toes, or genitals ONLY, AND tissue preservation is critical for maintaining function (as evidenced by clinical photography which must be retained for audit purposes).”
Southern Cross said it could not comment on individual cases without a privacy waiver but added they were in contact with Gault and offered to meet with him to discuss the questions he has raised.
Southern Cross Health Insurance spokesperson Regan Savage told RNZ the eligibility criteria focus Mohs cover on circumstances where there is a clinical need for the procedure, and are intended to ensure members for whom the surgery is most clinically important continue to have access to the specialised treatment.
“Where the Mohs eligibility criteria are not met, standard surgical excision remains available as an established treatment for skin cancer, subject to the member’s policy.”
Savage said eligibility criteria are regularly reviewed as practice, technology and evidence change, to ensure they remain clinically appropriate and reflect current practice.
“These reviews are not about restricting cover. They can result in criteria being removed where they are no longer required, cover being expanded, or criteria being updated as clinical practice evolves. The aim is to ensure our cover keeps pace with changes in healthcare.
“Eligibility criteria also help us make funding decisions fairly and consistently across our membership, while balancing access to healthcare with the need to keep health insurance sustainable and as affordable as possible.”
Asked about allowing the cost of a standard excision to go towards Mohs surgery for ineligible members, Savage said it could mean members in similar circumstances received different outcomes depending on their ability to pay the additional cost.
“Our policies are designed to fund eligible healthcare services rather than provide a dollar contribution towards a different service that does not meet the applicable eligibility criteria.”
Gault says he has had health insurance with Southern Cross since the 1970s, when his parents started paying for it before he took over. He had been raised with the message drilled into his head about the importance of having health insurance.
“I thought paying all those years would mean I’d be looked after when I needed it.”
While he says he is not discouraging people from having private health insurance, he wants young people to be more aware of the fine print.
“If you’ve got health insurance, especially if you’re younger, have a really good look at what you’ve actually signed up for.
“And if your work provides you health insurance - some people are lucky enough that they do that for them - find out exactly what you’ve got because here’s the question I’d be asking: ‘Can you change what I’m covered for later?’
“I never thought to ask that question - and I sure as hell wish I had.”
Gault says he did not want to move to another insurance provider in case they would not cover him for other health issues.
On how changes are communicated, Savage said policy documents direct members to check the eligibility criteria that apply when treatment is being considered.
“When we communicate with policyholders about changes to their policy document, we also remind them that eligibility criteria are kept up to date online, and encourage members to check these if they are considering or planning treatment.”
