Two eyes, two excesses
Mr Kereama wanted his wife's two cataract surgeries treated as one procedure, with the second excess waived.
Mr Kereama wanted his wife's two cataract surgeries treated as one procedure, with the second excess waived.
Mr and Mrs Kereama* had health insurance that had a $2,000 excess per person each policy year.
In October 2022, Mr Kereama informed their insurer that Mrs Kereama would need cataract surgery on her right eye. The insurer explained that they would need to pay the $2,000 excess. Then, in November 2022, Mr Kereama told the insurer that Mrs Kereama would also need cataract surgery on her left eye. Because this fell into a new policy year, he was told they would need to pay another $2,000 excess for the second surgery.
Mr Kereama was unhappy with this, saying that if he’d known they would need to pay two separate excess amounts, they would have delayed both surgeries until after the policy renewed, to avoid the second excess. He said that Mrs Kereama’s doctor had wanted to decide on the second surgery after seeing the results of the first one. Mr Kereama wanted the surgeries treated as one procedure, and the second excess waived.
The case manager reviewed the complaint. The case manager believed the surgeries were two separate procedures, because they were performed at different times and, unfortunately, within different claims years. The policy stated that the $2,000 excess was payable once each policy year, and a new policy year started at the anniversary date. The IFSO Scheme could only consider whether the insurer had correctly applied the terms and conditions of the policy to the claim, which it had. The IFSO Scheme could not require the insurer to waive the second excess.
Complaint not upheld
* Names have been changed
The IFSO Scheme can only consider whether an insurer has correctly applied the terms and conditions of a policy. To avoid any surprises at claim time, consumers should check their policies for when they need to pay an excess and the amount/s to be paid.