Are you covered for the treatment?
The first thing to do is find out if you’re covered for the category of treatment you need. Check your Hospital Product Sheet or call us on 1300 727 538 (with your membership number) to find out if your treatment is covered, restricted or excluded.
- Covered – Great! Move on to Can you claim for it now?
- Restricted – You can choose your specialist but are likely to have significant out-of-pocket costs if they treat you at a private hospital. With public hospitals it depends on what the hospital charges private patients. Your other alternative is to be treated as a public patient at a public hospital. Learn more about restricted cover.
- Excluded – You won’t be able to claim anything for this one. Your options are to go through the public system, or upgrade and serve the relevant waiting periods. If the treatment is for an existing health issue, it’s likely to be 12 months.
Can you claim for it now?
If you’re planning to use your Hospital cover, next check you’re eligible to claim right away.
- Have you served any applicable waiting periods?
- Could the rules around pre-existing conditions affect your timeline?
Either can be an issue if you’re new to hospital cover or have recently upgraded to a higher level of cover.
If you have any doubt about either of the above, please call us on 1300 727 538 before you book your treatment, so we can check it out.
What you definitely can’t claim for
Australian health funds can’t cover outpatient hospital services – medical care you get when you’re not formally admitted to hospital (even if they happen at the hospital). Examples can include specialist consultations, tests and scans.
This is a big source of confusion, and frustration, for many Aussies, who (understandably) assume that if hospital insurance includes a certain treatment it’ll cover all the bills.
Unfortunately, government legislation means we can’t. And neither can any other fund.
On a brighter note, if you’re eligible for Medicare the government may pay part of the cost of standard outpatient services (for medically necessary treatment).
When you call to give us a precise breakdown of your treatment (which we’ll get into in step 3), we’ll let you know if there’s anything else you can’t claim for.