Southern Cross health insurance — what's not covered

61 exclusions from wording effective 2026-04-01 · source PDF ↗

• Pre-existing conditions unless clearly stated otherwise on your membership certificate
• Cystic fibrosis
• Dementia
• Kyphosis
• Loeys-Dietz syndrome
• Marfan syndrome
• Pectus carinatum
• Pectus excavatum
• Polycystic kidney disease
• Scoliosis
• Spina bifida
• Any congenital conditions except for umbilical hernia, inguinal hernia, undescended testes, hydrocele, tongue tie, phimosis, and squint
• Gynaecomastia
• Illnesses, injuries, conditions or disabilities that are caused or contributed to by the abuse of substances such as alcohol or drugs
• Self-inflicted illnesses or injuries
• Injuries or disabilities from war, or any act of war (whether declared or not)
• Injuries or disabilities from active duty in the military of any country or international authority
• Injuries or disabilities from terrorism
• Unapproved healthcare services
• ACC covered healthcare services except for the Accident and treatment injury top-up benefit
• Any surgery, procedure or treatment that changes, improves, or enhances appearance, regardless of whether it was done for medical, physical, functional, psychological, or emotional reasons
• Pregnancy and childbirth except for prescriptions and physiotherapy under the Day-to-day treatment benefit for RegularCare
• Termination of a pregnancy
• Infertility or assisted reproduction
• Contraception, including the insertion or removal of intrauterine devices, except when used for medical reasons
• Sterilisation or its reversal, for example, vasectomy
• Treatment of obesity (including weight loss surgery) except for the Gastric banding or bypass allowance
• Breast reduction except for the Breast reduction allowance
• Subsequent breast reconstruction surgery (including replacing prostheses) or breast symmetry surgery except as covered under the Surgical procedures benefit for breast reconstruction or the Breast symmetry allowance
• Gender affirmation (confirmation) surgery
• Correction of refractive visual errors or astigmatism by surgery, or by surgically implanted intraocular lenses, or by laser treatment
• Healthcare services performed by a dentist, periodontist, endodontist, or orthodontist
• Implantation of teeth, including titanium dental implants
• Extraction of teeth, which includes the complete extraction or partial removal of any part of a tooth, tooth root or tooth remnant
• Surgery that's designed to assist or allow for orthodontic healthcare services
• Health screening except for mammography, breast screening ultrasounds, and colonoscopy
• Maintenance examinations or medical check-ups
• Any examination required by a third party (including preparing reports) such as physical examinations for life insurance, travel insurance and driver licence
• Vaccinations
• Prophylactic healthcare services except for the Prophylactic treatment allowance
• Treatment for any medical condition that's not causing significant problems to your physical health
• Healthcare services that are not approved treatment
• Healthcare services provided at a public facility directly or indirectly controlled by Health NZ Te Whatu Ora except where approved in writing before treatment
• Healthcare services provided outside of New Zealand except for the Overseas treatment allowance
• Healthcare services provided by a person who is not a health services provider
• Healthcare services for skin using digital imaging technology such as mole mapping
• Pathology and laboratory tests except for the Laboratory tests benefit
• Organ transplants
• Transfusion or injection of autologous blood or blood products, except when used as part of eligible chemotherapy treatment, or where cell saver is used as part of eligible surgical treatment
• Autologous chondrocyte implants
• Stem cell transplants
• Healthcare services provided for the diagnosis, management, or treatment of developmental or congenital abnormalities of the facial skeleton and associated structures
• Healthcare services for mental health except for Psychiatrist consultation, Psychiatric hospitalisation, and Day-to-day treatment benefits
• Healthcare services provided to manage or treat snoring, or upper airways resistance, or both
• Treatment of HIV
• Appliances or equipment (surgical, medical, or dental), for example, CPAP machines, hearing aids, orthotics, crutches, surgically implanted lenses (except monofocal lenses) except as part of eligible surgical treatment on the list of prostheses and specialised equipment
• Acute care
• Administrative charges such as statement fees, cancellation fees, or nonattendance fees
• Personal costs related to a stay in hospital such as newspapers, meals for your family, alcohol, and TV rental
• Long-term care where hospitalisation lasts, or is expected to last, more than 90 days
• Respite and convalescent care

65 exclusions from wording effective 2026-04-01 · source PDF ↗

• Pre-existing conditions unless clearly stated otherwise on your membership certificate (this exclusion doesn't apply to cover provided under the 'Day-to-day treatment' benefit if you have the RegularCare plan)
• Cystic fibrosis
• Dementia
• Kyphosis
• Loeys-Dietz syndrome
• Marfan syndrome
• Pectus carinatum
• Pectus excavatum
• Polycystic kidney disease
• Scoliosis
• Spina bifida
• Any congenital conditions except for umbilical hernia, inguinal hernia, undescended testes, hydrocele, tongue tie, phimosis, and squint
• Gynaecomastia
• Illnesses, injuries, conditions or disabilities that are caused or contributed to by the abuse of substances such as alcohol or drugs
• Self-inflicted illnesses or injuries
• Injuries or disabilities from war, or any act of war (whether declared or not)
• Injuries or disabilities from active duty in the military of any country or international authority
• Injuries or disabilities from terrorism
• Specific drugs, devices, techniques, tests, and other healthcare services that haven't been approved by us before you receive the treatment
• Healthcare services related to, or incurred as a consequence of, any accident, treatment injury, or work-related gradual process injury, except for what you're entitled to under the 'Accident and treatment injury top-up' benefit
• Any surgery, procedure or treatment that changes, improves, or enhances appearance, regardless of whether it was done for medical, physical, functional, psychological, or emotional reasons
• Pregnancy and childbirth, except for what we cover under the 'Day-to-day treatment' benefit for prescriptions and physiotherapy if you have the RegularCare plan
• Termination of a pregnancy
• Infertility or assisted reproduction
• Contraception, including the insertion or removal of intrauterine devices, except when used for medical reasons
• Sterilisation or its reversal, for example, vasectomy
• Treatment of obesity (including weight loss surgery), except for what we cover under the 'Gastric banding or bypass allowance'
• Breast reduction, except for what we cover under the 'Breast reduction allowance'
• Subsequent breast reconstruction surgery (including replacing prostheses) or breast symmetry surgery, except for what we cover under the 'Surgical procedures' benefit for breast reconstruction and the 'Breast symmetry allowance'
• Healthcare services directly related to, or incurred as a consequence of, gender affirmation (confirmation) surgery
• Correction of refractive visual errors or astigmatism by surgery, or by surgically implanted intraocular lenses, or by laser treatment
• Healthcare services performed by a dentist, periodontist, endodontist, or orthodontist
• Implantation of teeth, including titanium dental implants
• Extraction of teeth, which includes the complete extraction or partial removal of any part of a tooth, tooth root or tooth remnant
• Surgery that's designed to assist or allow for orthodontic healthcare services
• Health screening, except for mammography and breast screening ultrasounds, and colonoscopy
• Maintenance examinations or medical check-ups
• Any examination required by a third party (including preparing reports) such as physical examinations for life insurance, travel insurance and driver licence
• Vaccinations
• Prophylactic healthcare services, except for what we cover under the 'Prophylactic treatment allowance'
• Treatment for any medical condition that's not causing significant problems to your physical health
• Healthcare services that are not approved treatment
• Healthcare services provided at a public facility that is directly or indirectly controlled by Health NZ Te Whatu Ora, except where we've approved it in writing before you receive the treatment
• Healthcare services provided outside of New Zealand, except for what we cover under the 'Overseas treatment allowance'
• Healthcare services provided by a person who is not a health services provider
• Healthcare services using technology (such as digital computer images) to help monitor and diagnose skin cancers and other skin lesions – for example, mole mapping
• Pathology and laboratory tests, except for what we cover under the 'Laboratory tests' benefit
• Organ transplants
• Transfusion or injection of autologous blood or blood products, except when used as part of eligible chemotherapy treatment, or where cell saver is used as part of eligible surgical treatment
• Autologous chondrocyte implants
• Stem cell transplants
• Healthcare services provided for the diagnosis, management, or treatment of developmental or congenital abnormalities of the facial skeleton and associated structures
• Healthcare services for mental health, except for what we cover under the 'Psychiatrist consultation' benefit, the 'Psychiatric hospitalisation' benefit, and the 'Day-to-day treatment' benefit if you have the RegularCare plan
• Healthcare services provided to manage or treat snoring, or upper airways resistance, or both
• Treatment of HIV
• Appliances or equipment (surgical, medical, or dental), for example, CPAP machines, hearing aids, orthotics, crutches, surgically implanted lenses (except monofocal lenses), except when specifically included in the list of prostheses and specialised equipment as part of eligible surgical treatment
• Acute care
• Administrative charges such as statement fees, cancellation fees, or non-attendance fees
• Hospital charges incurred for your personal convenience related to a stay in hospital, such as newspapers, meals for your family, alcohol, and TV rental
• Long-term care where hospitalisation lasts, or is expected to last, more than 90 days, including geriatric in-patient care and disability support services
• Respite and convalescent care
• Drugs that are not Pharmac approved (except as specifically permitted under chemotherapy benefits and the IV infusions non-cancer benefit for Medsafe-indicated drugs)
• Ultrasound when related to obstetrics and varicose veins (legs)
• X-ray when performed by a dentist or chiropractor
• Family history of cancer (specific cancer excluded) under Cancer Cover Plus upgrade, where two or more biological siblings or parents diagnosed with colorectal, breast, ovarian, or prostate cancer before age 55

63 exclusions from wording effective 2026-04-01 · source PDF ↗

• Pre-existing conditions (unless clearly stated otherwise on membership certificate, and does not apply after 3 years of continuous cover on this plan, or to Day-to-day treatment or Vision and Dental benefits)
• Cystic fibrosis
• Dementia
• Kyphosis
• Loeys-Dietz syndrome
• Marfan syndrome
• Pectus carinatum
• Pectus excavatum
• Polycystic kidney disease
• Scoliosis
• Spina bifida
• Any congenital conditions except for umbilical hernia, inguinal hernia, undescended testes, hydrocele, tongue tie, phimosis, and squint (exclusion does not apply after 3 years of continuous cover on this plan)
• Gynaecomastia
• Illnesses or injuries caused or contributed to by the abuse of substances such as alcohol or drugs
• Self-inflicted illnesses or injuries
• Injuries or disabilities from war, or any act of war (whether declared or not)
• Injuries or disabilities from active duty in the military of any country or international authority
• Injuries or disabilities from terrorism
• Unapproved healthcare services (specific drugs, devices, techniques, tests, and other healthcare services that haven't been approved by us before you receive the treatment)
• Healthcare services related to any accident, treatment injury, or work-related gradual process injury that ACC is legally responsible for (except for Accident and treatment injury top-up benefit)
• Cosmetic treatments and procedures (any surgery, procedure or treatment that changes, improves, or enhances appearance)
• Pregnancy and childbirth (except Obstetrics allowance and Day-to-day treatment for prescriptions or physiotherapy)
• Termination of pregnancy
• Infertility or assisted reproduction
• Contraception, including the insertion or removal of intrauterine devices (except when used for medical reasons)
• Sterilisation (except as covered under Surgical procedures benefit) and reversal of sterilisation
• Treatment of obesity including weight loss surgery (except Gastric banding or bypass allowance)
• Breast reduction (except Breast reduction allowance)
• Subsequent breast reconstruction surgery (including replacing prostheses) or breast symmetry surgery (except as covered under Surgical procedures benefit or Breast symmetry allowance)
• Gender affirmation (confirmation) surgery
• Correction of refractive visual errors or astigmatism by surgery, or by surgically implanted intraocular lenses, or by laser treatment
• Healthcare services performed by a dentist, periodontist, endodontist, or orthodontist (except Vision and dental benefit for UltraCare 400 plan)
• Dental implants including titanium dental implants (except Vision and dental benefit for UltraCare 400 plan)
• Extraction of teeth (except as covered under Surgical procedures benefit or Vision and dental benefit for UltraCare 400 plan)
• Surgery designed to assist or allow for orthodontic healthcare services (except Vision and dental benefit for UltraCare 400 plan)
• Health screening (except mammography and breast screening ultrasounds, colonoscopy, and annual health checks)
• Maintenance examinations or medical check-ups (except annual health checks)
• Any examination required by a third party such as physical examinations for life insurance, travel insurance, and driver licence
• Vaccinations (except flu vaccination under Day-to-day treatment)
• Prophylactic healthcare services (except Prophylactic treatment allowance)
• Treatment for any medical condition that's not causing significant problems to your physical health
• Healthcare services that are not approved treatment
• Healthcare services provided at a public facility that is directly or indirectly controlled by Health NZ Te Whatu Ora (except where approved in writing before treatment)
• Healthcare services provided outside of New Zealand (except Overseas treatment allowance)
• Healthcare services provided by a person who is not a health services provider
• Healthcare services using technology (such as digital computer images) to help monitor and diagnose skin cancers and other skin lesions, for example, mole mapping
• Pathology and laboratory tests (except Laboratory tests benefit)
• Organ transplants
• Transfusion or injection of autologous blood or blood products (except when used as part of eligible chemotherapy treatment, or where cell saver is used as part of eligible surgical treatment)
• Autologous chondrocyte implants
• Stem cell transplants
• Healthcare services for the diagnosis, management, or treatment of developmental or congenital abnormalities of the facial skeleton and associated structures
• Healthcare services for mental health (except Mental health consultations, Psychiatric hospitalisation, and Day-to-day treatment benefits)
• Healthcare services to manage or treat snoring or upper airways resistance
• Treatment of HIV
• Treatment of cleft palate
• Appliances or equipment (surgical, medical, or dental) such as CPAP machines, hearing aids, orthotics, crutches, surgically implanted lenses (except monofocal lenses) (except when included in list of prostheses and specialised equipment as part of eligible surgical treatment)
• Acute care
• Administrative charges such as statement fees, cancellation fees, or non-attendance fees
• Personal costs related to a stay in hospital such as newspapers, meals for your family, alcohol, and TV rental
• Long-term care where hospitalisation lasts or is expected to last more than 90 days
• Respite and convalescent care
• Family history of cancer (as defined) excluded under Cancer Cover Plus upgrade only, for the specific cancer type; does not apply to Chemotherapy for cancer (base) benefit

1 exclusion from wording effective 2026-04-01 · source PDF ↗

• excludes cover for drugs that are not Pharmac approved

32 exclusions from wording effective 2026-04-01 · source PDF ↗

• We don't cover any costs related to, or incurred as a consequence of, any pre-existing conditions unless we've clearly stated otherwise on your membership certificate.
• We don't cover any costs related to, or incurred as a consequence of, the following chronic conditions: Cystic fibrosis, Dementia, Kyphosis, Loeys-Dietz syndrome, Marfan syndrome, Pectus carinatum, Pectus excavatum, Polycystic kidney disease, Scoliosis, Spina bifida.
• We don't cover any costs related to, or incurred as a consequence of, any congenital conditions except for umbilical hernia, inguinal hernia, undescended testes, hydrocele, tongue tie, phimosis, and squint.
• We don't cover any costs related to, or incurred as a consequence of, gynaecomastia.
• We don't cover any costs related to, or incurred as a consequence of: illnesses, injuries, conditions, or disabilities that are caused or contributed to by the abuse of substances such as alcohol or drugs; self-inflicted illnesses or injuries.
• We don't cover any costs related to, or incurred as a consequence of, injuries or disabilities from: war, or any act of war (whether declared or not); active duty in the military of any country or international authority; terrorism.
• We don't cover any costs related to, or incurred as a consequence of, specific drugs, devices, techniques, tests, and other healthcare services that haven't been approved by us before you receive the treatment.
• We don't cover any costs for healthcare services that are related to, or incurred as a consequence of, any accident, treatment injury, or work-related gradual process injury, except for what you're entitled to under the 'Accident and treatment injury top-up' benefit.
• We don't cover any costs related to, or incurred as a consequence of, any surgery, procedure or treatment that changes, improves, or enhances appearance, regardless of whether it was done for medical, physical, functional, psychological, or emotional reasons.
• We don't cover any costs related to, or incurred as a consequence of, pregnancy and childbirth, except for what we cover under the 'Obstetrics allowance' if you have the Wellbeing Two plan, the 'Keeping Well Module' for prescriptions, or the 'Day-to-day Module' for prescriptions or physiotherapy.
• We don't cover any costs related to, or incurred as a consequence of, termination of a pregnancy.
• We don't cover any costs related to infertility or assisted reproduction.
• We don't cover any costs related to, or incurred as a consequence of: contraception, including the insertion or removal of intrauterine devices, except when used for medical reasons; sterilisation or its reversal, for example, vasectomy.
• We don't cover any costs related to, or incurred as a consequence of, treatment of obesity (including weight loss surgery), except for what we cover under the 'Gastric banding or bypass allowance'.
• We don't cover any costs related to, or incurred as a consequence of, breast reduction, except for what we cover under the 'Breast reduction allowance'.
• We don't cover any costs related to, or incurred as a consequence of, subsequent breast reconstruction surgery (including replacing prostheses) or breast symmetry surgery, except for what we cover under the 'Surgical procedures' benefit for breast reconstruction or the 'Breast symmetry allowance'.
• We don't cover any costs for healthcare services directly related to, or incurred as a consequence of, gender affirmation (confirmation) surgery.
• We don't cover any costs related to, or incurred as a consequence of, correction of refractive visual errors or astigmatism by surgery, or by surgically implanted intraocular lenses, or by laser treatment.
• We don't cover any costs related to healthcare services performed by a dentist, periodontist, endodontist, or orthodontist, except for what we cover under the 'Keeping Well Module' or the 'Vision and Dental Module' for dental services.
• We don't cover any costs related to, or incurred as a consequence of, implantation of teeth, including titanium dental implants, except for what we cover under the 'Keeping Well Module' or the 'Vision and Dental Module' for dental services.
• We don't cover any costs related to, or incurred as a consequence of, extraction of teeth, which includes the complete extraction or partial removal of any part of a tooth, tooth root or tooth remnant, except for what we cover under the 'Surgical procedures' benefit for tooth extraction or the 'Keeping Well Module' or the 'Vision and Dental Module'.
• We don't cover any costs related to, or incurred as a consequence of, surgery that's designed to assist or allow for orthodontic healthcare services, except for what we cover under the 'Keeping Well Module' or the 'Vision and Dental Module'.
• We don't cover any costs related to: health screening (with specified exceptions); maintenance examinations or medical check-ups (except annual health checks under the 'Day-to-day Module'); any examination required by a third party.
• We don't cover any costs related to vaccinations, except for what we cover under the 'Keeping Well Module' or the 'Day-to-day Module' for flu vaccinations.
• We don't cover any costs related to, or incurred as a consequence of, prophylactic healthcare services, except for what we cover under the 'Prophylactic treatment allowance'.
• We don't cover any costs related to, or incurred as a consequence of, treatment for any medical condition that's not causing significant problems to your physical health, except for what we cover under the 'Keeping Well Module' or the 'Day-to-day Module'.
• We don't cover any costs related to, or incurred as a consequence of, healthcare services that are not approved treatment.
• We don't cover any costs for healthcare services provided at a public facility that is directly or indirectly controlled by Health NZ Te Whatu Ora, except where we've approved it in writing before you receive the treatment.
• We don't cover any costs related to, or incurred as a consequence of, healthcare services provided outside of New Zealand, except for what we cover under the 'Overseas treatment allowance'.
• We don't cover any costs related to healthcare services provided by a person who is not a health services provider.
• We don't cover any costs related to healthcare services using technology (such as digital computer images) to help monitor and diagnose skin cancers and other skin lesions – for example, mole mapping.
• We don't cover any costs for pathology and laboratory tests (subject to exceptions stated in the policy).

34 exclusions from wording effective 2026-04-01 · source PDF ↗

• Pre-existing conditions unless clearly stated otherwise on your membership certificate
• Chronic conditions: Cystic fibrosis, Dementia, Kyphosis, Loeys-Dietz syndrome, Marfan syndrome, Pectus carinatum, Pectus excavatum, Polycystic kidney disease, Scoliosis, Spina bifida
• Any congenital conditions except for umbilical hernia, inguinal hernia, undescended testes, hydrocele, tongue tie, phimosis, and squint
• Gynaecomastia
• Illnesses, injuries, conditions, or disabilities that are caused or contributed to by the abuse of substances such as alcohol or drugs
• Self-inflicted illnesses or injuries
• Injuries or disabilities from war, or any act of war (whether declared or not)
• Injuries or disabilities from active duty in the military of any country or international authority
• Injuries or disabilities from terrorism
• Unapproved healthcare services
• Healthcare services related to any accident, treatment injury, or work-related gradual process injury (except Accident and treatment injury top-up benefit)
• Any surgery, procedure or treatment that changes, improves, or enhances appearance, regardless of whether it was done for medical, physical, functional, psychological, or emotional reasons
• Pregnancy and childbirth (except Obstetrics allowance on Wellbeing Two, and prescription/physiotherapy cover under optional modules)
• Termination of a pregnancy
• Infertility or assisted reproduction
• Contraception, including the insertion or removal of intrauterine devices, except when used for medical reasons
• Sterilisation or its reversal, for example, vasectomy
• Treatment of obesity (including weight loss surgery), except for what is covered under the Gastric banding or bypass allowance
• Breast reduction, except for what is covered under the Breast reduction allowance
• Subsequent breast reconstruction surgery (including replacing prostheses) or breast symmetry surgery, except as specified
• Gender affirmation (confirmation) surgery
• Correction of refractive visual errors or astigmatism by surgery, or by surgically implanted intraocular lenses, or by laser treatment
• Healthcare services performed by a dentist, periodontist, endodontist, or orthodontist, except under Keeping Well Module or Vision and Dental Module
• Implantation of teeth, including titanium dental implants, except under Keeping Well Module or Vision and Dental Module
• Extraction of teeth, except under Surgical procedures benefit or optional modules
• Surgery designed to assist or allow for orthodontic healthcare services, except under optional modules
• Health screening (with limited exceptions)
• Maintenance examinations or medical check-ups, except for annual health checks under Day-to-day Module
• Any examination required by a third party (including preparing reports) such as physical examinations for life insurance, travel insurance, and driver licence
• Vaccinations, except for flu vaccinations under Keeping Well Module or Day-to-day Module
• Prophylactic healthcare services, except under the Prophylactic treatment allowance
• Treatment for any medical condition that is not causing significant problems to your physical health, except under optional modules
• Healthcare services that are not approved treatment
• Healthcare services provided at a public facility