Managing yourself or a loved one through medical treatment can be overwhelming, and you may find yourself having to navigate through processes you have never encountered before.
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At Aynsley & Associates we have a bespoke claims service dedicated to helping you in your time of need.
Our Team are able to guide and support you through the claim process, from the first step and all the steps that follow.
What is a Medical Claim?
Most medical policies will provide cover for private medical and surgical costs, cancer surgeries/treatment (chemotherapy and radiotherapy), joint replacements, major diagnostic tests, and more.
Some policies have optional coverages which can provide additional benefits such as Specialist Consults and Tests, General Practice or Health & Wellness Checks, Dental & Optical, Day-to-Day benefits, or even Non-PHARMAC Cover.
In the first instance check your most recent Acceptance Certificate to know exactly what benefits you have.
If you cant find or are not sure about what cover you have, get in touch - we have access to your policy information and can provide clarity on what may or may not be covered under your benefits.
How to Make a Claim
As soon as you are aware you may need a claim, it is best to start the claim process. All insurers have a Pre-Approval process in order to provide clarity and peace of mind on what costs will be covered before your or your loved ones treatment commences.
For all insurers you can complete a claim form and then email in your request direct to their claims teams. Please refer below to access the claims form and email addresses for your insurer.
We understand having to coordinate between different systems and forms can get overwhelming. We're here to help. Get in touch with us today and we can work with you to get the right documents over to your insurer for your claim.
Claim Forms and Email Addresses
Submitting Your Claim
To help your claim proceed as smoothly as possible, make sure you have the following information:
Your Letter Needs to Include:
Symptoms and date they first started
Reason why GP has referred you to a specialist
The type of specialist you are being referred to
Your Letter Needs to Include:
Symptoms and date they first started
Recommended treatment and date of procedure
Incurred or Estimate of Costs
Specialists can provide you with an estimate of costs which may include: doctor fees, hospital costs, anesthetist costs, radiology fees, prosthesis costs, and more.
OR if you have already had the procedure completed, provide an invoice of the costs you have incurred
Complete Medical Insurance Form
Click on your insurer in order to download the appropriate claim form
Your insurer will review the information submitted against the benefits and clauses on your policy. Everyone's situation is different, and depending on the complexity of your or your loved ones treatment will impact how long it will take for your claim to be assessed.
If you have concerns about the length of time it is taking for your claim to be assessed, let us know. We can utilize our experience to get in touch with your insurer and find out what needs to happen to get things moving.
We understand not everything in life happens according to plan, or with consideration for business processing times. If your treatment is urgent, or was arranged last minute, let us know. We can work with you and your insurer in order to escalate your claim application.
Your Insurer will notify of the outcome of your claim as soon as they have made a decision. Your claim will either be Approved or Declined.
If your claim is approved, you will have 2 options in how your or your loved ones treatment costs are covered:
Option 1 – Direct Payment
Pass on your outstanding invoice to your insurers once costs are approved
Make sure to let your medical provider know who is due to pay the bill
Option 2 – Reimbursement
Pass on the invoice illustrating that the costs have been paid (include a receipt) along with your preferred bank account and the insurer will organize reimbursement of the approved costs.
Your insurer will confirm what excess will be applied when they approve your costs. Normally you will pay your excess directly to the medical provider, or it will be deducted from your reimbursement.
Unfortunately, not everything can be covered. Every medical policy has different benefit levels, definitions, wordings, and exclusions. While we can do our best to interpret policy wordings to determine if something will be covered, ultimately the insurance company assessing the claim will make the final decision, which may be an unsatisfactory result.
These can occur for multiple reasons - some common examples include:
Policy Exclusions - these may have been applied when applying for medical cover or is a general exclusion built into the policy.
Standdown Periods - an insurer may place a standdown period before something can be claimed on (e.g. wisdom teeth).
Benefit Limits - you may have already reached a certain benefit limit for the current policy year.
Medically Necessary - an insurer may decline a claim if the procedure isn't deemed medically necessary (e.g. cosmetic surgery such as nose reshaping).
Specialist Consultations - if you don't have specialist cover on your policy (often an additional benefit), most insurers will cover you for specialist consultations only if you end up having a hospitalisation or medical procedure. Cover for these specialist consults can either be 6 or 12 months on either side of the hospitalisation or medical procedure taking place.
At any stage, if something doesn't feel right about your insurers response to your claim submission, or you would like some additional guidance, let us know.
Is my excess per claim or once per policy year?
Every policy is different - your excess may be applied per claimable event or once per policy year. For information on this please refer to your policy document or contact Aynsley and Associates.
What happens if I have an accident?
ACC is the primary insurer for any treatment relating to an accident. If ACC declines your claim, please enclose a copy of the letter from ACC with your claim form. If ACC is paying a part of the claim, the insurer may be able to top this up.
How long will my prior approval be valid for?
These are generally 6 months, however, some policies will allow for 12 months.
Can I change my insurance company?
Changing medical insurers can be risky - if you have had any changes in your health since your policy was first issued, these may be excluded under a new policy. If changing insurers, ensure you leave the current cover in place until you completed the underwriting process and have been offered satisfactory terms.
Can I modify my cover?
You can increase your excess and/or remove additional benefits (such as specialists) at any time. If you want to add benefits and/or reduce your excess, you will need to be underwritten. This is where the insurer will ask questions about your health and may apply exclusions if you have any 'pre-existing conditions'.