Excluded services

If a service is excluded, you are not covered for this. There are no benefits payable.

Restricted services

For admission to Public hospital only we pay minimum benefits for restricted services. This means that we will pay the minimum default benefit rate for a shared room as set out by the Federal Government, and minimum benefits for Government approved prosthesis list items.

In a public hospital as a private patient – you may have an out-of- pocket expense to pay, in the event that the minimum benefit is less than your chosen public hospital charges.

The hospital should advise you before you are admitted or have treatment, and seek your consent about any out-of-pocket expenses you’ll need to pay. This is known as informed financial consent

* For Bare Essentials Hospital benefits, the Federal Government Default Benefit is applied. This is the amount of benefit determined by the Federal Government as the minimum amount private health insurers must pay for accommodation in public hospitals. Default Benefits are payable only towards the cost of hospital accommodation and provide no cover for other hospital charges such as labour ward or operating theatre costs. Default Benefits will not cover the full cost of treatment in private hospitals or in day hospital facilities, and you will be left with significant out-of-pocket expenses. Please call us on 1300 368 390 if you would like to know if the Default Benefit applies to any treatment you anticipate.

Other features

  • Access to the Federal Government Rebate as a reduced premium
  • Exemption from the Medicare Levy Surcharge
  • Exemption from Lifetime Health Cover penalties if joining before age 31
  • Ambulance Cover for residents of NSW & ACT in these states (for other states the ambulance cover is available under the General Treatment Products)

Waiting periods

  • Accidents requiring hospital treatment, not related to a pre-existing condition – No waiting period
  • Ambulance – No waiting period
  • Treatment relating to a pre-existing condition – 12 Months
  • All other services – 2 Months

On joining hospital cover for the first time, waiting periods must be served before benefits will be paid. If you have upgraded your hospital cover, waiting periods will apply before the higher benefits will be paid.

What’s not covered?

  • Excluded services
  • Surgeon’s fees for podiatric surgery
  • Services for which Medicare pays no benefit e.g. cosmetic surgery & laser-eye surgery
  • Restricted services in a Private Hospital
  • Services while a membership is in arrears
  • Services incurred before waiting periods are served (including any service for a pre-existing condition)
  • Services received as an outpatient, such as in the Emergency department or visit to your General Practitioner/ Specialist
  • Services where there is an entitlement under compensation insurance
  • Services claimed over 2 years after the service date
  • Services provided in countries outside of Australia

Pre-existing conditions

If you are suffering from a medical condition, illness or ailment at the time of commencing or upgrading hospital cover there will be a 12-month waiting period before hospital benefits can be paid on claims relating to that condition.

A pre-existing condition is defined as an ailment or illness where, in the opinion of a medical practitioner, the signs or symptoms existed at any time during the six months before, or on the day which a member joins private health insurance or upgrades to a higher level of cover.

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