Eligibility criteria to make health claims

As specified in Southern Cross’ policy documents, certain healthcare services have eligibility criteria which need to be met before a healthcare service will be covered under your policy. In exceptional circumstances, we may choose (in our absolute discretion) to waive the requirement to meet certain eligibility criteria.

The eligibility criteria for each of these healthcare services can be found in the links below.

If you are unsure about any of the medical terms in the eligibility criteria, please discuss these with your medical practitioner to understand how they apply in your particular circumstance.

Please note that the general exclusions set out in your policy documentation apply to all healthcare services, including those listed below.

Cardiac services (heart disorder diagnosis & treatment)

• Catheter based cardiac procedures
• CT coronary angiogram (CTCA)
• Electrophysiology studies
• Left atrial appendage occlusion
• Transcatheter aortic valve implantation/replacement (TAVI/TAVR)
  • TAVI/TAVR for intermediate to high risk patients
  • TAVI/TAVR for low risk patients

Gastroenterology (digestive tract examination)

• Balloon enteroscopy
• Bravo pH monitoring
• Colonoscopy (in adults)
• Endoscopic ultrasound
• Endoscopy services (gastroscopy, colonoscopy, and flexible sigmoidoscopy) under general anaesthesia or deep sedation
• Gastroscopy with RFA for Barrett's oesophagus
• Paediatric colonoscopy
• Wireless capsule endoscopy

General surgery (breast, gall bladder, hernia)

• Breast reduction allowance
• Biofeedback and electrostimulation for faecal incontinence
• Breast revision surgery
• Fat grafting following an eligible mastectomy
• Gastric banding / bypass allowance
• Gastric bypass for gastro-oesophageal reflux disease
• Hernia repair
• Surgical treatment of hyperhidrosis

Gynaecology (reproductive system)

• Labiaplasty
• Periurethral bulking agent
• Removal of submucosal fibroids or uterine polyps using a hysteroscopic morcellation device (eg MyoSure, TruClear)

Imaging (scans)

• Breast screening ultrasounds for dense breast tissue
• Cone beam computed tomography (CBCT)
• Gastrointestinal ultrasound
• Positron emission tomography / computed tomography (PET/CT)

Internal medicine

• Radioactive iodine therapy

Interventional radiology 

• Adrenal vein sampling
• Basivertebral nerve ablation
• Image-guided ablation for bone tumours or metastases (including cementoplasty)
• Percutaneous renal cryoablation
• Radiofrequency ablation of bone lesions
• Radiofrequency ablation of thyroid nodules
• Vascular malformation sclerotherapy and embolisation – simple

Neurosurgery

• Endoscopic third ventriculostomy ETV
• Single level lumbar disc replacement

Oncology (cancer diagnosis & treatment)

• Peripheral sensory nerve ablation
• Prognostic breast gene testing
• Radiotherapy treatment

Ophthalmology (eyes)

• Blepharoplasty and ptosis surgery
• Cataract surgery
• Corneal cross-linking
• Lens extraction for narrow anterior chamber angles

Oral & maxillofacial

• Bite splints
• Temporomandibular joint (TMJ) total joint replacement (TJR)
• Tooth extraction under general anaesthesia

Orthopaedic

• Single level lumbar disc replacement
• Surgical ligament or tendon repair with a synthetic augmentation device or Neoligaments synthetic ligament prosthesis

Other

• Percutaneous medial branch thermal radiofrequency neurotomy
• Prophylactic treatment allowance

Otolaryngology (ear, nose & throat)

• Balloon sinuplasty
• Cochlear implant internal device
• Endonasal septoplasty
• Endoscopic modified Lothrop
• Eustachian tube balloon dilation
• Exostoses removal
• Open septoplasty and septorhinoplasty
• Transoral robotic surgery
• Video-assisted head impulse test (vHIT) and caloric test

Skin

• Skin lesion removal or closure under general anaesthesia or IV sedation
• Removal of lipoma
• Mohs surgery
• Skin lesion removal and minor skin surgery
• Surveillance consultations for non-melanoma skin cancers

Urology (kidney, bladder, and prostate)

• Periurethral bulking agent
• Prostate cryotherapy
• Prostate saturation biopsy
• Robotic sacrocolpopexy

Vascular surgery (artery & vein surgery)

• Treatment of varicose veins (legs)

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 S&P Global Ratings Australia Pty Ltd. 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 S&P Global Ratings. S&P Global Ratings Australia Pty Ltd is an approved rating agency under the Insurance (Prudential Supervision) Act 2010.