Health Insurance - My Southern Cross policy has 80% cover meaning I pay 20% My question is that SX have a approved set

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Customer: Hi there, Health Insurance - My Southern Cross policy has 80% cover meaning I pay 20%
JA: What state are you in? And is a local attorney or other consumer protection advocate helping with this?
Customer: My question is that SX have a approved set fee with the private hospital I’m having surgery in. The expected recovery time in hospital is 3-5 days. If I stay 3 days, should I have to pay the same as the person staying 5 days ?
JA: Have you contacted the seller or manufacturer?
Customer: yes, I’ve contacted SX and the hospital, they both refer me to the other person, no one is answering my question. (I’m employed at the private hospital)My surgery is on the 13 July and I’d like to know my consumer rights
JA: Anything else you want the Lawyer to know before I connect you?
Customer: im 49 having bilateral knee replacements, this surgery is generally had by older patients than myself hence I believe I won’t by requiring the full care usually needed and don’t feel I should be paying for what I don’t use.
Answered by Chris The Lawyer in 3 hours 2 years ago
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Chris The Lawyer
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Chris The Lawyer, Expert

Hi
I am a New Zealand lawyer based in Wellington and will help you with your question today. Please give me a minute to read the question

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Chris The Lawyer, Expert

This will depend on the contract with Southern Cross and on their contract with the private hospital. The private hospital of course bills Southern Cross, and I assume you would need to either pay the 20% balance to Southern Cross or the private hospital. It would be determined on the terms of the insurance cover, as to whether they can charge for the actual time that you spend at the private hospital or whether they are entitled to charge the approved set fee. If the terms of the contract are not sufficiently clear, you could tell them you will just pay for the time actually at the private hospital and no more. The situation really hinges on the terms of the contracts however

Customer
However ??
So am I totally in the Insurance's companies hands? This doesn't appear to offer me (the client) the best deal.
So who is best to contact? the hospital (my employer) or my health insurance company to discuss this?
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Chris The Lawyer, Expert

It is the insurance company who set the rules and often to their own advantage rather than to yours. The only other alternative would be to make a formal complaint about the fee if you are not going to use the time at the hospital, which you could make to the Insurance and Savings Ombudsman. But certainly discuss it with the hospital and the insurer to see if they will adjust given that you have to pay 20%

Customer
Ok Thank you, ***** ***** be best to make the formal complaint after the surgery, once I've received the account, (at this stage, SX have provided me in writing an expected cost to me) or should I write prior to my surgery ?
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Chris The Lawyer, Expert

I think you should tell them before the surgery that you are concerned that you only pay for the time you spend in the hospital. Then they will be on notice that there is an issue if you leave a lot earlier

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