Making Insurance Claims After a Diagnosis in New Zealand

Insurance can be one of the most important financial resources after a serious diagnosis — but the process of finding policies, understanding what triggers a claim, and navigating a declined decision is not always clear. This guide walks through each stage. If you'd rather have a plan built around your situation, answer a few questions and we'll build one around you →

Types of policy to check

Several types of insurance can respond to a serious illness diagnosis. Check each category, not just the policies you remember holding:

• Life insurance — pays a lump sum on death, but many policies also include a terminal illness benefit that can pay out early if you're diagnosed with a terminal condition and given a short life expectancy. Check the policy wording.
• Trauma or critical illness cover — pays a lump sum on diagnosis of a specific listed condition (cancer, heart attack, stroke, and others). This pays regardless of whether you can still work — purely triggered by the diagnosis itself.
• Total and permanent disability (TPD) — pays if you're permanently unable to work. Some policies cover inability to work in your own occupation; others require inability to work in any occupation. The definition matters enormously — check yours.
• Income protection — replaces a portion of your income (usually around 75%) while you're unable to work due to illness. Has a waiting period (often 4, 8, or 13 weeks) before payments begin.
• Mortgage protection cover — meets your home-loan repayments while you're unable to work. Usually sold alongside a mortgage and easy to forget about.
• Employer group schemes — many employers hold group life, trauma, and income protection cover on behalf of their employees. You may have cover you don't know about. Ask your HR department or payroll team.

Finding policies you may have forgotten

It's common to hold cover you've lost track of. Check these sources:

• Old payslips — group scheme premium deductions often appear as a small line item. Check payslips from current and previous employers.
• Your KiwiSaver provider — some KiwiSaver schemes include bundled life or disability cover. Call your provider and ask specifically whether any insurance is attached to your account.
• Your mortgage lender — mortgage protection is frequently sold at the time of a home loan. Contact your bank or lender and ask what insurance you took out alongside the mortgage.
• Previous employers — group cover typically lapses when you leave a job, but individual conversion rights sometimes apply. It's worth asking a previous employer's HR team whether any continuing entitlements exist.
• Your insurance broker or financial adviser — if you've used one, they'll have records of policies arranged on your behalf.

What "trauma" and "critical illness" actually mean

This is where many claims run into difficulty. A trauma or critical illness policy does not simply pay out because you have been diagnosed with a serious illness — it pays when your diagnosis matches the specific clinical definition written into the policy for each listed condition.

For example, most policies define "heart attack" using specific cardiac enzyme or ECG criteria. A diagnosis of a minor cardiac event may not meet the definition even if your doctor uses the same term. Similarly, "cancer" definitions in many policies exclude early-stage, non-invasive, or in-situ conditions.

This does not mean you won't qualify — it means the wording matters. Ask your specialist to provide a diagnosis letter that includes the specific clinical details: the type and staging of the condition, the diagnostic criteria met, and relevant test results. A letter that just states the common name of the condition may not be enough for an insurer to assess your claim.

If you're unsure whether your diagnosis meets the policy definition, an insurance broker or financial adviser can help interpret the wording before you lodge a claim.

How to make a claim

Once you've identified a policy that may respond to your diagnosis:

• Notify the insurer promptly. Most policies require you to notify within a certain timeframe after diagnosis. Don't wait until you feel ready — a late notification can complicate a claim.
• Get your diagnosis in writing. Ask your specialist for a letter setting out the clinical diagnosis, the specific type and stage of the condition, and the diagnostic criteria. This is the core document for your claim.
• Gather your policy documents. If you've lost them, the insurer holds copies. Call their claims team and they'll send them. IRD may also hold records of historical group scheme deductions if you need to trace past cover.
• Submit the claim form. The insurer will send or direct you to a claim form. Complete it accurately and attach your specialist letter and any other requested documents. Keep copies of everything you send.
• The insurer appoints an assessor. For larger claims, an insurer may appoint an independent medical assessor to review the information or request a medical examination. You have the right to know the assessor's findings.

What insurers can and can't do

Insurers in New Zealand are regulated by the Financial Markets Authority (FMA) and must meet conduct standards under the Financial Markets Conduct Act.

• They can request access to your medical records (with your written consent) and appoint an independent medical examiner.
• They can take a reasonable time to assess a claim — but they cannot delay indefinitely or without reason.
• They cannot use genetic information to discriminate against you in life, health, or disability insurance — the Human Rights Act 1993 protects against this.
• They must have an internal dispute resolution process and tell you about it if your claim is declined or disputed.

If your claim is declined

A declined claim is not necessarily final. There is a clear process to challenge it:

Step 1 — Internal dispute resolution (IDR). Every insurer must have an IDR process. Write to the insurer formally requesting a review of the decision. Ask for the specific reasons the claim was declined in writing, and respond to each point. This step is mandatory before escalating further.

Step 2 — Insurance and Financial Services Ombudsman (IFSO). If the insurer's IDR process doesn't resolve the dispute, you can take the complaint to IFSO — a free, independent service that reviews disputes between consumers and insurers. Call 0800 888 202 or visit ifso.nz. IFSO can direct an insurer to pay a valid claim. They require you to have gone through the insurer's IDR process first.

If the amount in dispute is large, or the policy wording is genuinely ambiguous, a lawyer experienced in insurance law can advise on your options before or after the IFSO process.

A note on ACC

ACC (the Accident Compensation Corporation) is often mentioned in conversations about illness and injury, so it's worth being clear: ACC covers accidental injury, not illness. A diagnosis of cancer, heart disease, MS, or any other medical condition is not covered by ACC.

There is one exception worth knowing: if a medical procedure causes an accidental injury during treatment — known as a treatment injury — ACC may cover the costs of that specific injury. But the underlying illness itself is not covered.

This distinction matters because New Zealand's no-fault ACC scheme means there is no personal injury litigation culture here. Unlike some other countries, you cannot sue for compensation if an illness affects your ability to work. Your own insurance is the primary financial protection — which is why checking every policy you hold is worth doing thoroughly.

Getting help with policy wording

Insurance policy documents are written in legal and medical language that can be genuinely difficult to interpret. A licensed financial adviser or insurance broker can read the policy against your specific diagnosis and give you a view on whether a claim is likely to succeed before you lodge it.

Many advisers offer a free initial consultation for this kind of review. To find a licensed financial adviser in New Zealand, search the Financial Service Providers Register at fsp-register.companiesoffice.govt.nz — look for someone who holds a licence for life and health insurance advice.