Barrister takes health insurer to court over refusal to pay for ADHD diagnosis

A Waikato barrister is taking Southern Cross Health Insurance (SCHI) to the disputes tribunal after it refused pay out $1000 for his ADHD assessment.

The lawyer, who doesn't want to be identified as someone with ADHD, had health insurance which included cover for psychiatrist consultations.

He booked a consultation with Psychiatry NZ, which provides consultations by telehealth.

The assessment was done by a doctor at the practice who was in training to become a psychiatrist. RNZ has agreed not to name him.

But, he was supervised by Dr Han Chung Lim, a registered psychiatrist, who then signed off on the assessment.

Despite this, Southern Cross declined the claim because the assessment was not done by a registered psychiatrist. Instead it categorised the consult as a GP visit, and paid $65 for the hour-and-a-half long, $1000 appointment.

"If I had gone to my GP, and they had done this, the cost would be much lower, and would be appropriate for SCHI to apportion it this way," the barrister said. "My GP did not offer this service."

GPs have recently gained the ability to conduct ADHD assessments - but the doctor who performed the assessed was not technically a GP, either.

The Medical Council's register lists them as having a "general scope of practice" which is not the same as being a GP.

"General practice is a specialty area of practice," it said. "Doctors registered in the general scope of practice can work in any area of medicine. They are required to participate in an approved recertification programme to assist them in maintaining their competence."

The barrister told RNZ it wasn't about the money - rather, he thought Southern Cross had denied the claim in bad faith.

"Working as a criminal barrister, I see the significant impact the lack of access to affordable, and timely psychiatry care has on my clients, particularly those remanded in custody and sentenced prisoners," he said.

"The benefit for me, as someone very privileged, to have access to psychiatry care has been life changing. SCHI's approach limits, rather than improves access across the board."

If his case was successful, he intended to donate the money to ADHD NZ.

Southern Cross Health Insurance chief sales and marketing officer, Regan Savage, told RNZ in a statement the policy only provided cover for psychiatrist consultations with vocationally registered psychiatrists.

"The member was informed of the policy terms and extent of cover before undertaking the assessment but chose to proceed with receiving the service from a GP.

"In this case, the provider was not registered as a psychiatrist, so the claim did not meet the benefit criteria."

Savage said it was important that Southern Cross applied policy terms consistently for all members to promote fairness. "The policy terms are clear that, for specialist benefits such as psychiatrist consultations, providers must hold the relevant vocational registration."

The company regularly reviewed products and policy settings to make sure they remained appropriate for members and sustainable over time, but "we are not currently considering changes to enable cover for GP consultations under the psychiatrist consultations benefit".

Dr Lim from Psychiatry NZ said his doctors had been providing telehealth assessments for ADHD under his supervision for the past two to three years.

He said they always advised people to get pre-approval, or check with their insurer that the appointment would be covered, at the time of booking, as they knew some insurers would refuse cover.