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Insurance policy exclusions put kids at risk

08/08/2018By Matthew Woodley
Many children with congenital cataract are currently being excluded from private health insurance coverage due to improper policy assessments, a prominent ophthalmologist has said.

The head of ophthalmology at the University of Sydney’s Save Sight Institute, Professor John Grigg, says the policy restrictions are placing families under undue stress during a particularly challenging time and putting children at risk of unnecessary vision loss.

Grigg told Insight the issue has arisen because even though Medicare has a separate item number for juvenile cataract (under 16 years), insurance companies tend to categorise all cases within the same policy.

“Young people with families take out health insurance, but don’t pick up the cataract option without realising this includes their kids as well,” he said.


“It’s a loophole that flies under the radar.”
John Grigg, SSI

“I’ve seen three families this year who have been referred with childhood cataract under the age of two who believe they had private health cover, only to discover they don’t because cataracts are specifically excluded. It’s a loophole that flies under the radar.”

The specific timing required to properly treat children’s cataract complicates the issue, as ophthalmologists have only a 2–4 week window within which to complete the surgery without risking further damage to the child's still developing visual system.

Because of this, additional strain is placed on the public health system and other patients, as waiting lists need to be rearranged to accommodate the most serious cases.

“A challenging aspect of these really young cataracts is trying to get them in at the appropriate time. They’re competing on a list for children with glaucoma, who are also going to go blind if you don’t do something – so they often take priority over the cataracts – but it’s a really challenging battle to try and fit these in,” Grigg explained.

“Unfortunately, you end up having to try and manage who’s going to lose vision most. We already have to juggle lists between all the different consultants at the Children’s Hospital Westmead, just to try and see these children in a timely manner.”

Grigg has called on the private health insurers to close the loophole and suggested the rare nature of the disease – 1/2,000 – means it should not be particularly expensive. However, he is not confident that this will occur under the new classification system that is being brought in, and has called on the Federal Government to take action if the status quo remains.

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The president of the Australian Society of Ophthalmologists, Dr Peter Sumich, has also supported Grigg’s position and said he will raise it with the Assistant Minister for Children and Families, Mr David Gillespie, at a meeting in Canberra next week.

More reading: Australian discovery gives hope to children with cataracts

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