Can NZ Health Insurance Cover Treatment in China?
People who hold private health insurance in New Zealand may sometimes consider receiving surgery or other medical treatment in China. This may be due to language preferences, family support, access to a particular specialist or differences in waiting times and costs.
The important question is whether a New Zealand health insurance policy will pay for that treatment.
The answer is: it may be possible under some policies, but approval is not automatic. Eligibility depends on the policy wording, the medical condition, the proposed treatment, the overseas provider and the insurer’s written assessment.
Is China an eligible treatment destination?
A reference to “overseas treatment” in a policy does not necessarily mean that treatment can be obtained in any country or at any hospital.
An insurer may have requirements relating to:
The country in which treatment takes place;
The legal status and standards of the hospital;
The specialist’s registration and qualifications;
The type of treatment proposed;
The availability of treatment in New Zealand;
The proposed cost; and
Prior written approval.
Before making any booking, ask the insurer to confirm whether China and the proposed medical provider are acceptable under the relevant benefit.
The treatment must still be covered
Receiving treatment overseas does not normally expand the underlying policy.
The condition and procedure must first qualify for cover. A claim may be affected if the condition is excluded, relates to a pre-existing condition, falls outside the policy’s treatment definitions or involves an experimental or otherwise excluded treatment.
The insurer will generally assess whether the treatment itself is eligible before considering where it can be provided.
Obtain written approval before treatment
Prior approval is one of the most important parts of an overseas treatment application.
A general telephone discussion should not be treated as a guarantee of payment. Before paying a deposit, booking flights or undergoing treatment, ask the insurer to confirm in writing:
The approved condition and procedure;
The approved hospital and specialist;
The expenses that will be eligible;
The reimbursement basis and maximum approved amount;
Any excess, co-payment or benefit limit;
The documents required after treatment;
Whether follow-up care is included; and
How complications will be handled.
Proceeding without approval can create difficulties because the insurer may not have had an opportunity to assess medical necessity, provider credentials or the reasonableness of the proposed cost.
How might the claim be calculated?
Approval for treatment in China does not necessarily mean that the insurer will reimburse the full hospital invoice.
Payment may be limited by:
The actual eligible cost;
A policy benefit limit;
An excess or co-payment;
The reasonable cost of equivalent treatment in New Zealand;
The amount approved before treatment; or
Other conditions in the policy wording.
An itemised quotation is therefore important. It should separate the costs of surgery, hospital services, medical devices, medicines, diagnostic tests, accommodation upgrades and any non-medical services.
The insurer should also be asked how foreign-currency payments and exchange rates will be handled.
Are travel and accommodation covered?
Airfares, hotels, visas, local transport, translation, meals and support-person expenses should not be assumed to be covered.
These costs may remain the patient’s responsibility even when the medical procedure has been approved. Every expense category should be confirmed separately.
Documents to prepare
An overseas treatment application may require:
A diagnosis from a New Zealand doctor or specialist;
A referral and recommended treatment plan;
Relevant test and imaging reports;
Details of the proposed hospital in China;
The treating specialist’s qualifications;
A detailed treatment plan;
An itemised quotation;
Proposed admission and treatment dates;
A follow-up and rehabilitation plan; and
English translations where required.
Additional medical evidence or an independent clinical opinion may also be requested.
Overseas treatment is not the same as travel insurance
Planned treatment overseas is different from emergency medical treatment during a trip.
Travel insurance generally focuses on unexpected illness or injury while travelling. It should not be assumed to cover a condition when the main purpose of the trip is to obtain planned medical treatment.
Both the health insurance and travel insurance terms should be checked before departure.
Final considerations
Treatment in China may be considered under some New Zealand health insurance policies, but the decision depends on much more than the destination.
The safest process is to obtain a diagnosis and treatment recommendation, collect the overseas provider’s information and quotation, apply for written approval, and confirm the payment conditions before making any financial or travel commitment.
One Step Finance can assist with reviewing the relevant policy provisions and identifying the questions and documents required for an overseas treatment application.
This article provides general information only and is not personalised insurance or medical advice. Cover remains subject to the policy wording, medical assessment and the insurer’s written decision.