We like to think our policies are straightforward and this guide has the same approach. This policy guide is designed to be easy to use and navigate. After reading the guide, if you still have any questions, jump on a chat, drop us an email or call us on 1300 199 802.
You’ll be able to find information on the following:
1. Fund Rules
2. Who can take out a policy
3. Policy categories
4. Managing your policy
5. Your health.com.au Claims Card
7. Hospital cover
8. Extras cover
9. Pre-existing conditions
10. Waiting periods
11. Making a claim
12. Government private health insurance measures
13. Your access to us online
14. Contacting Us
1. Fund Rules
health.com.au is registered under the Private Health Insurance Act 2007. This Act governs all private health insurers in Australia, and under the Act we’re required to have Fund Rules which set out how we operate. All policyholders (and persons covered) are subject to the Fund Rules. From time to time, the Fund Rules may change. If any changes have a detrimental effect on your entitlement to benefits, we’ll give you reasonable notice before the date the changes take effect.
This Policy Guide is a summary of the Fund Rules.
2. Who can take out a policy
Anyone may take out a health insurance policy regardless of their health status. That said, there are some basic requirements you have to meet.
These are similar regardless of insurer:
- you must be aged 16 years or more to take out your own policy. People under 16 years are dependants under a family or single parent family policy;
- you cannot have the same sort of policy with us and another health insurer concurrently;
- your policy must reflect your state of residence; and
- you must meet the residency and eligibility requirements of Medicare.
3. Policy categories
We cover people under a number of policy categories.
- Singles policy — one person only;
- Couples policy — two adults only;
- Single Parent policy — two or more people, one of whom is an adult; or
- Family Policy — three or more people, two of whom are adults.
Not all policy categories are available for all our products.
4. Managing your policy
If you’re new to health.com.au and decide that the policy you have chosen isn’t for you, we’ll give you a refund if you contact us within 30 days of signing up. If you have made any claims under the policy we ‘ll deduct the amount that we have paid, and refund any difference. After 30 days, you can cancel at any time, but you may not be entitled to a refund of any amounts already paid (see section 6 below).
The policyholder is responsible for managing the policy. This means that they are the only person who can:
- change any details on the policy;
- change the level of cover;
- apply to add a person from the policy;
- apply to remove a dependant who is under 16 from the policy;
- receive a benefit; or
- cancel the policy.
It is the policyholder’s responsibility to ensure that the policy premiums are paid by the due date. The policyholder may nominate another person to manage the policy; however, this nominated person may not cancel the policy.
Dependants are the policy holder’s spouse/partner or children. Dependent children are covered:
- until 21 years of age; or
- between the ages of 21 and 25 years of age if the dependant is in full time study, in a family or single parent family policy.
When a child turns 21, stops studying full time or turns 25, they have two months to arrange their own policy. They won’t have to serve any waiting periods if they take out the same or lower level of cover within two months.
Adding a child
If you’re planning to start a family and your hospital cover doesn’t include pregnancy related services, you’ll need to upgrade your hospital cover to include this. Be aware that waiting periods are applicable for pregnancy and assisted reproduction related services. It’s probably best to contact us to discuss these, or download a policy information statement from our website.
A new born baby is usually not admitted to hospital as a patient unless they require neonatal intensive care, or is the second or later child of a multiple birth. If this were to happen, your baby will not be covered for accommodation or medical services unless your child has served the appropriate waiting period. If you already have a Family or Single Parent policy ,you need to contact us to add your newborn baby to your policy within 3 months to the day of your baby's birth — furthermore, the baby's addition must be backdated to the date of birth. This may result in an arrears amount being generated if you’re currently on a single policy.
Suspension of your policy
In some cases, like overseas travel or when you are in receipt of an Australian Government unemployment or sickness allowance, you may apply to health.com.au to suspend your policy. The whole of your policy must be suspended. If you have hospital and extras cover, you cannot suspend just the extras part of your policy and keep the hospital portion.
There are some key points to note:
- a policy cannot be suspended unless premiums have been paid to the date of suspension;
- the minimum period of suspension is two months;
- whilst the policy is suspended no premiums are payable by you and no benefits are payable by us; and
- the period of suspension does not count toward any waiting period.
health.com.au policies provide benefits for treatment you receive in Australia only. Policy holders who travel overseas should obtain suitable travel insurance. Do ask us about suspension of your policy if you are going away for a considerable length of time.
5. Your health.com.au Claims Card
When you become a policyholder, we’ll send you a Claims Card. You'll need this card to make a claim, arrange an admission to hospital or visit an extras provider, such as a dentist.
Your health.com.au Claims Card is important to you and to us. Please let us know if you have misplaced or lost it.
Your premiums are to be paid in advance. We do not accept payments that will take your premiums to more than 30 months in advance.
Payments are to be made by direct debit from your nominated bank account or credit card. Debits may be made on any day of the month except the 29th, 30th or 31st. Premiums may be deducted fortnightly, monthly, quarterly.
health.com.au’s premium increases are subject to approval by the Minister for Health and Ageing under the Private Health Insurance Act. We’ll give you at least 14 days notice if your policy’s premiums are to change.
If you haven’t paid your premium for a period that ends after the date of any premium change, we won’t change the date you have paid up to. The new premium will apply from your next payment.
health.com.au will not pay any benefits for any treatment you receive while your policy is in arrears. If your policy is more than two months in arrears, we may terminate your policy.
Termination and refunds
If you decide to end your policy, we will refund any premium that you have paid in advance. We will calculate your refunds from the date you specified us to terminate your policy.
A small fee may apply for the processing of these refunds.
Premiums vary by state. We ask that you pay the premium for the state in which you live. You need to tell us if you move interstate.
The Australian Government Rebate on private health insurance can decrease your premium costs and Lifetime Health Cover loading can increase them. Please see Section 12 Government Private Health Insurance Measures for more information on these.
7. Hospital cover
With health.com.au hospital policies, you have the best cover at our contract hospitals and all public hospitals across Australia. There are a few private hospitals which we don’t have a contract with. These hospitals should inform you of any out of pocket expenses you may face as part of your admission. These out of pocket expenses are separate to any excess you may have chosen as part of your policy.
When admitted to hospital, you will be covered for all in-hospital charges raised as part of your treatment. These include:
- bed fees;
- operating theatre fees;
- intensive care fees;
- labour ward fees;
- pharmaceuticals covered by the Pharmaceutical Benefit Scheme;
- ancillary health services such as in-hospital physiotherapy;
- consumables such as dressings;
- pathology and radiology services; and
- surgically implanted prostheses up to the Federal Government approved benefit on the Government prostheses list.
Before you confirm your hospital booking, please check with us to discuss any excess that may be applicable on your policy. You should also ask the hospital if they anticipate any out of pocket expenses you may face as part of your admission. These out of pocket expenses are separate to any excess you may have chosen as part of your policy with us. We’ll also be able to tell you if your chosen hospital is one of our contract hospitals.
A contract hospital is a private hospital with which health.com.au has an agreement relating to direct billing of fees and benefits. These agreements aim to maximise your cover and minimise your out of pocket expenses. (Both good things.)
We have a hospital agreement with nearly every private hospital in Australia. If your chosen hospital doesn’t have an agreement with us, you’ll be covered up to a default rate (set by the Government) and you‘ll incur significant out of pocket expenses.
The best thing is to check our website or give us a call us to make sure that the hospital you’re using is contracted. You can also ask the hospital directly: they’re required to advise you of any out of pocket expenses. You’re always covered you if you choose to go to a public hospital as a private patient.
Hospital benefit exclusions
There are some services that have no hospital benefits payable under all health.com.au policies. These are:
- outpatient services (including hospital substitute treatments);
- some same day procedures determined by the Government as not requiring hospitalisation unless your medical practitioner has certified that the treatment does have to be provided to you as an admitted hospital inpatient;
- ancillary health services not covered by our hospital contract or under any extras cover you may have;
- services excluded under your policy;
- cosmetic surgery;
- personal items such as newspapers not covered by our hospital contracts; or prostheses not listed on the Commonwealth Government’s prostheses schedule.
You may have chosen a policy that excludes some services. The general conditions on your policy also apply. For example, a policy in arrears will not pay benefits, nor will benefits be paid if you are still serving a waiting period.
Hospital benefit restrictions
A small number of services only attract a minimum level of benefits. Some health.com.au products pay a minimum level of benefits for psychiatric, rehabilitation and podiatric surgery (when performed by an accredited podiatrist). Best to check your policy to ensure your level of cover.
The minimum level of benefits is the amount set by the Federal Government as the minimum level health insurers must pay for hospital accommodation costs in both public and private hospitals. This level doesn’t include any cover for theatre fees, intensive care or labour ward costs. Also, the minimum level isn’t sufficient to fully cover you for private hospital charges, but you’ll be covered if you choose to be treated as a private patient in a shared ward of a public hospital.
Our Access Gap Cover scheme allows you to reduce or eliminate your out of pocket expenses. Medical practitioners can decide if they will participate in our scheme on a case by case basis. Almost 9 out of 10 medical services under the Access Gap Cover scheme have no out of pocket expenses. If your medical practitioner chooses not to participate, then health.com.au is only able, by law, to pay 25% of the Medicare Benefits Schedule (MBS) fee. Medicare pays 75% of the MBS fee. However medical practitioners are able to charge what they like. If your bill is more than the MBS fee, you’ll have to pay the difference.
Surgically implanted prostheses
The Commonwealth Government Prostheses List details the minimum benefits a health fund has to pay to policyholders who have cover for these prostheses in their product.
If you’re going to have an operation and need a surgically implanted prosthesis, you should ask your medical practitioner for a cost estimate of the prosthesis they’re planning to use. If you’re happy with the cost, then provide your medical practitioner with informed financial consent — in writing is best. Then contact us. We can tell you what out of pocket expenses, if any, are related.
So you can lower the cost of your policy, health.com.au gives you a choice of excess. An excess is the amount you pay if you go to hospital before your benefits are paid.
With our products are excesses to vary from: $250 and $500. Our High products also include the option of a nil ($0) excess. They apply per person (other than a dependant child) for each hospital admission. There’s a cap to the amount of excess you pay each calendar year. The cap depends on the excess you choose, and whether your policy covers just one person or more than one person. For example: a single policy with a $250 excess has an annual cap of $250. A couples policy with a $250 excess has an annual cap of $500.
The excess doesn’t apply to claims made for prostheses, medical treatment or ambulance services.
If you have children on your policy, there is no excess payable for them — unless they have transferred from another health fund that had excess applicable to children. If this is the case, the 12 month pre-existing waiting period would be applicable for the no excess rule, as this is classified as an upgraded service.
There is no excess to pay when making a claim with Extras cover.
health.com.au pays for emergency ambulance transport under every policy we sell. Emergency ambulance transport means that you need immediate attention, and your condition or injury is such that you can’t be transported to hospital by any other way except ambulance.
Each state has its own ambulance arrangements. In New South Wales and the Australian Capital Territory the Government asks health insurers to collect a levy on behalf of everyone who pays for a hospital policy. Payment of the levy means you get free emergency ambulance transport. If you receive an account for emergency transport, send it to us for endorsement and then send it back to your ambulance service. In Queensland and Tasmania, the Government does not charge its residents for ambulance services. In Victoria, South Australia, Western Australian and the Northern Territory there are various subscription schemes, each of which operate slightly differently. You may choose to subscribe to one of these schemes. If you do subscribe and subsequently receive ambulance care. then you probably won’t need our ambulance cover.
Health.com.au pays for emergency ambulance transport under every policy we sell, regardless of the state you live in. Some state schemes have reciprocal arrangements with other states, but not all. Again you don’t need to worry about which scheme applies where, as all health.com.au policies cover emergency ambulance transport regardless of where you live.
Being admitted as a private patient in a public hospital means you have a choice of which doctor treats you. In some cases, this could be the same doctor who would have treated you anyway if you were a public patient at the same public hospital.
health.com.au will pay minimum benefits for any treatment you receive as a private patient in a public hospital. These minimum benefits are determined by the Government. We also pay for surgically implanted prostheses up to the default benefit in the Government Prostheses List. All hospitals should let you know what expenses you will be liable for before you choose to be treated as a private patient in a public hospital. These expenses are the difference between what the hospital decides to charge and what the Government sets as the minimum default payment to be paid by health insurers like us. You’ll have to cover the difference between what the hospital charges and what the minimum default benefit is.
Hospital benefit restrictions
A small number of services only attract a minimum level of benefits. The minimum level of benefits is the amount set by the Federal Government as the minimum level health insurers must pay for hospital accommodation costs in both public and private hospitals. This level doesn’t include any cover for theatre fees, intensive care or labour ward costs. Also, the minimum level is not sufficient to fully cover you for private hospital charges, but is sufficient if you choose to be treated as a private patient in a shared ward of a public hospital.
8. Extras cover
Medicare does not cover services such as physiotherapy, dental examinations and spectacles. This is where health.com.au extras cover can help. We have a wide range of extras cover: Pulse, Basic, Middle, Active and High. Within each range, we pay a set percentage - 50%, 60%, 65%, 75% or 85% of the fee charged, respectively - by your provider as a benefit. Some of our products use a combination of percentage back and set benefits. Each cover has a distinct range of services that are covered. Benefits are paid up to an annual cap, which applies over a calendar year, for every person covered by a policy. The annual caps vary by policy.
You may choose to see any provider you wish, as long they’re in private practice and recognised as such by us.
Extras cover is only available when you take out hospital cover.
9. Pre-existing conditions
If you have a pre-existing condition, all Australian health insurers will require you to serve a waiting period before you can claim. (That is, unless you are transferring from a policy that would have covered that condition at the time you transferred.)
A pre-existing condition is any ailment, illness or condition that you had signs or symptoms of during the six months before you joined or upgraded to a higher level of cover with health.com.au. It is not necessary that you or your doctor knew what the condition was, or whether the condition was diagnosed.
A condition can still be classed as pre-existing even if you didn’t see your doctor about it before joining health.com.au. If you weren’t well, or had signs of an ailment that a doctor would have detected had you seen one during the six months prior to taking out cover, then the ailment would be considered as pre-existing.
By law, a medical referee appointed by health.com.au will decide whether your condition is pre-existing. The decision is not yours or your doctors’. The medical referee must consider your treating doctors’ opinions on the signs and symptoms of your ailment, but is not obliged to agree with them.
As a new policy holder with a pre-existing condition, you’ll have to wait 12 months before you can receive benefits for the services related to the pre-existing condition. This is also true if you have upgraded your cover to receive the higher benefits, including benefits for those services not previously covered.
health.com.au reserves the right to determine whether the pre-existing condition waiting period applies on an individual claim basis. This may mean that even if a first claim is not considered to be subject to the waiting period, then a subsequent claim may be.
Psychiatric and rehabilitation services are not considered to be pre-existing conditions and are only subject to a two month waiting period.
In an emergency, we may not have time to determine if you are affected by the pre-existing condition waiting period before you are admitted. Consequently, if you have been a health.com.au policyholder for less than 12 months and you are admitted as a private patient, and we determine that the condition for which you were admitted was pre-existing, you may have to pay for some or all of the hospital and medical costs remaining after Medicare benefits have been paid.
10. Waiting Periods
You will have to serve waiting periods before some benefits can be paid. Our waiting periods are as follows:
- All services, including psychiatric, rehabilitation and palliative care, except the ones listed below;
- pre-existing conditions;
- pregnancy related services;
- major dental services;
- hearing aids;
- blood glucose monitors;
- other health appliances.
Policy holders transferring from an Overseas Visitors Health Insurance product or an Overseas Student Health Cover product will have to serve all waiting periods applicable to their health.com.au policy.
We have talked about what we mean by pre-existing conditions in the previous section, Section 9.
Transferring from another fund
If you are transferring from another health insurance fund, you will have continuous coverage. This means that you’ll be covered for services on your new policy from the date you join if those services were also included on your previous policy, and you had already served any relevant waiting periods. You just have to join health.com.au within two months of leaving your former fund. If you haven’t served all of the relevant waiting periods, you’ll need to serve the balance with health.com.au before you’re eligible for benefits. Waiting periods will apply if you have switched to a higher level of cover with health.com.au for services not previously covered, or if you waited more than two months between leaving your former fund and joining health.com.au.
Extras benefits paid under your previous policy with your old fund will count against any benefit limits of your new health.com.au policy.
11. Making a claim
Compensation and damages
Benefits aren’t payable for services or treatments where you are, or may be, entitled to compensation and/or damages. This includes Government workers’ compensation schemes, traffic accident schemes, public liability claims or third party claims.
health.com.au pays hospital claims directly to the hospital (if they are a hospital we have a contract with). Just hand over your health.com.au Claims Card when you’re admitted, and we’ll pay the bill directly. Once we have paid your claim to the hospital, we’ll let you know.
Each of the medical practitioners and other healthcare professionals involved in your care will probably charge a fee. Medical practitioners and health care professionals may include medical specialists, surgeons, anaesthetists, pathologists and radiologists. These fees are additional to the fees the hospital may charge for accommodation and other hospital specific charges.
You should always ask your hospital and your medical practitioner (and their colleagues involved in your care) about the expected costs of your treatment, and any out of pocket expenses you may be liable for. You’re entitled to this information before any treatment begins, and you may be able to lower you out of pocket expenses by being fully informed.
There are two ways you can claim for extras services, such as dental and optical.
We use an electronic system - HICAPS - that lets you claim your extras benefit directly after your consultation with more than 45,000 providers across Australia. This operates very much the same way as EFTPOS machine and your claim will be processed in seconds. If there’s a difference between what your provider charges and what your policy benefit is then you will have to pay the balance on the pot.
You can also claim at health.com.au. Complete your claim details, and we’ll pay your benefits into your nominated bank account.
For audit purposes, we ask that you keep your accounts and receipts for two years.
Medical benefits available from health.com.au go towards the fees raised by a medical professional (for example, a surgeon or an anesthetist) who will bill you separately from the hospital you have been admitted to.
If your medical practitioner doesn’t use our medical Access Gap Cover scheme, claims can only be paid after Medicare has assessed your claim for medical services. We do not pay benefits for services provided if you were not a hospital inpatient.
If your medical practitioner does use our medical Access Gap Cover scheme, the medical practitioner will bill health.com.au directly, and we then pay the medical practitioner.
Access Gap Cover scheme
Our Access Gap Cover scheme allows you to reduce or eliminate your out of pocket expenses. On a case by case basis, medical practitioners can decide if they will participate in our scheme. Almost 9 out of 10 medical services under the Access Gap Cover scheme have no out of pocket expenses. If your medical practitioner chooses not to participate then health.com.au is only able by law to pay 25% of the Medicare Benefits Schedule (MBS) fee. Medicare pays 75% of the MBS fee. However, medical practitioners are free to charge what they like. If your bill is more than the MBS fee, you’ll have to pay the difference.
12. Government private health insurance measures Federal Government Rebate
Australian Government Rebate on Private Health Insurance
If you’re a member of a registered health fund, no matter what your level of cover, you may well be eligible for a rebate on your premium costs. The Government introduced an income test on the rebate. Here’s how it works/
The easiest way to claim your rebate is by asking us to provide you with a premium reduction. Just let us know which tier your income falls into. We don’t want to know your actual income — just the tier. You can nominate or change your income tier at any time, and the applicable rebate will be applied to future payments. This way, you can lower the risk of incurring a higher tax liability than you need to.
You can also claim your rebate through the taxation system, but we find most people like the idea of a premium reduction.
Medicare Levy Surcharge
The Medicare Levy is a tax every Australian personal income tax payer pays regardless of whether they have private health insurance or not. It’s 2% of taxable income.
The Medicare Levy Surcharge (MLS) is an additional tax. It’s applied to high income earners who do not have an appropriate level of private hospital insurance. It’s to encourage higher earning Australians to take out private health insurance so as to reduce the burden on the public health system.
It starts at 1% of your taxable income for singles earning more than $90,000 and for families with a combined income of more than $180,000. After that, the surcharge is 1.25% if your income is in income tier 2 and 1.5% for income tier 3. The same income tiers apply for the surcharge as for the rebate. Please see table below:
For more information about the MLS contact your taxation advisor, the Australian Taxation Office or see the website of the Department of Health and Ageing: www.health.gov.au
Lifetime Health Cover (LHC)
The Federal Government introduced the Lifetime Health Cover scheme in July 2000. Under the scheme, if you don’t take out a private health insurance hospital policy by the 1st of July following your 31st birthday, you’ll pay higher premiums for the following 10 years. Your premiums will be 2% more than the base rate for every year that you are over 31 that you have not had a hospital policy. This extra amount, or LHC loading, can go as high as 70% of the base rate for hospital cover.
You pay the LHC loading for a continuous period of 10 years, after which it will no longer apply. During the time a LHC loading might apply, you’re permitted to have periods of absence adding up to three years without affecting your loading.
The LHC loading does not apply to the Extras part of your premium.
From 1 July 2013 the Government changed the Private Health Insurance Act so that any LHC loading that might apply to your premium is no longer eligible for the Government rebate.
The LHC scheme has a number of special rules that apply to Australians returning from overseas, Norfolk Islanders, former members of the Australian Defence Forces, staff of the Australian Antarctic Division and some other particular groups of people.
Private Health Insurance Ombudsman
Free independent advice is available from the Private Health Insurance Ombudsman on Freecall 1800 640 695 or online at www.phio.gov.au
13. Your access to us online
Our website always has the most current information available. Whenever there’s a change in policy details, premiums or even government legislation surrounding private health insurance, you will find the most up to date information at health.com.au.
Making a complaint
If you make a complaint to us, it will be logged. We will also confirm that we have received it. Then we will make every effort to resolve your complaint, in writing, within two working days.
If you believe that we have not resolved your complaint to your satisfaction, we’ll escalate it to our General Manager who will address the complaint within seven working days.
Instead, you may contact the Private Health Insurance Ombudsman. This is a free, independent service to help consumers with health insurance problems and enquiries. You can contact them via Freecall 1800 640 695 or online at www.phio.gov.au
14. Contacting us
We’ll keep you up to date as best we can through our website and social feeds. But if you have any questions, concerns, suggestions, or even just need a new friend, hit us up however you want. We can be contacted via Livechat, email, facebook, twitter, Instagram, or even an old school phone call.