Health insurer ordered to pay customer after declining to cover ADHD diagnosis

Southern Cross Health Insurance has been ordered to pay a customer $355 after the Disputes Tribunal found it had wrongly declined to cover a portion of his ADHD diagnosis.The dispute arose after the man, who works as a barrister and wished to remain anonymous, sought cover for a psychiatry appointment for an ADHD assessment, in which he was seen by two doctors with different registration statuses.The man's policy included cover up to $600 per year for consultations with a vocationally registered psychiatrist.In order to get treatment for ADHD, he had a consultation with a doctor, who was in training to become a psychiatrist but was not yet vocationally registered, and then the report and prescriptions were signed off by their supervising doctor, Dr Han Chung Lim, who was registered.Southern Cross argued as the doctor who did the assessment and the report was not a registered psychiatrist, the customer was only covered for a GP visit, to the amount of $45.The tribunal accepted that point, but ruled the portion of the work done by the registered psychiatrist should also qualify for cover.The man sought $1000.01, but ultimately the tribunal determined $400 was a reasonable amount for the qualifying portion of the consultation, and deducted the $45 Southern Cross had already paid, for a total of $355 to be paid.In a statement, Southern Cross said: "We are currently reviewing the decision and considering our next steps, including those outlined by the Disputes Tribunal in its decision."The barrister told RNZ he was pleased with the decision."It vindicates my view that Southern Cross are out of step with the needs of its customers."Being treated remotely, particularly post-Covid, should be embraced. In this case, seeing [the doctor], remotely, who is supervised by Dr Lim, a psychiatrist, allowed improved access, without reducing the quality of care."He hoped the decision would prompt Southern Cross to work on improving, rather than restricting, access to psychiatry care.