FAQs

Hospital insurance - When you look at a hospital policy, keep in mind it primarily covers services provided by two suppliers - the hospital and the doctors. The cover for Doctors' services will be described as medical gap cover schemes or contracts. Some hospital policies will also include ambulance cover. Also, read the following topics on this page What is covered?  What is not covered in hospital products?

Extras insurance - Extras product descriptions tell you what types of services are covered, it will include details about the amount of cover and benefits paid. Also, read the following topics on this page What is covered?  What is not covered in extras product?

Click on the link and email us your contact details, if you haven't already received an email from us providing information which you need to consider.

Hospital insurance will only pay benefits for treatments which are recognised by Medicare Australia. Surgical treatment which is experimental and plastic surgery which is not medically necessary are two examples of items Medicare would not recognise for payment of benefits.

Extras insurance products cover the categories of services included in the product descriptions. Where the description tells you that more information can be sought from the Fund, it is an indication that there is more detail you need to know about, such as which services or providers are covered for that type of service. Medicare doesn't play much of a role in funding extras services, however when Medicare does pay you a benefit for an extras service, your private health insurance cannot also pay a benefit for that service.

Every health fund has to maintain an administration document of fund 'Rules' which together with federal legislation governs how they manage their policies. You can request a copy of any fund's rules.

In a hospital insurance product the following terms indicate that something is not covered or has limited cover. If you are considering a lower cost policy check carefully for these terms and consider both your family's history as well as your own health before taking a policy which excludes or limits treatment coverage. See also 'When do I serve waiting periods and what are they served for?', 'Which hospitals can I use?' and 'Will I have out-of-pocket expenses if I go to hospital?'

Exclusions or excluded - this type condition and its treatment will not be covered at all

Benefit restrictions or restricted benefits - this means that benefits might be paid for only part of the services used to have the treatment. It is most commonly used to indicate that benefits for hospital accommodation will only cover treatment in a public hospital, if you were treated in a private hospital these benefits would not cover the cost of your hospital accommodation bills.

Benefit limitation periods - effectively these add to the length of the waiting period or the amount of time before you would be paid a benefit if you had the treatment which has a benefit limitation period. As The Doctors' Health Fund doesn't use benefit limitation periods the following example of a benefit limitation is from the product description for a hospital insurance product from a well known large fund which costs over $850 per year. These benefit limitations mean while you are paying for the policy you wouldn't be fully covered for treatment in a private hospital for pregnancy services for 3 years, and for the other services it would be 2 years and 2 months before full benefits would be payable.

An example of a benefit limitation period from another fund

'During your first 24 months of cover (but after the standard hospital waiting periods have been served) the services below are subject to ‘Benefit Limitations’. This means that the benefits payable on these services are limited to Public Hospital Benefits only.

• Pregnancy & birth related services 
• Assisted reproductive services For example: IVF Infertility investigations  
• Heart surgery For example: stents, open heart surgery 
• Major joint replacement For example: artificial knee/hip 
• Psychiatric conditions For example: depression, eating disorders 
• Gastric banding & obesity surgery 
• Rehabilitation programs 
• Renal dialysis 
• Major eye surgery

Service and therapy types which are not listed in an extras product description won't be covered by that product. For instance, in the major dental category if it doesn't mention orthodontic services there won't be benefits for these services.

Extras policies generally do not cover unlimited claims for use of the services covered. The maximum amount of benefits you can be paid for at service each will be listed as a limit or sub limit. Sometimes limits are not monetary, they can be based on frequency, such as a bone density test benefit being paid once per year. Limit amounts on our extras policies are per person, unless otherwise indicated.

Product descriptions provide some information about the amount of the benefit which will be paid for each service allowing you to assess the amount of services you will be covered for or the proportion of the cost of the service that will be covered.

An example

$100 per visit to a psychologist with a sub limit of $500 would cover up to  5 visits. $30 per visit to a physiotherapist with a sub limit of $500 would cover up to 16.6 visits. These two services share a limit of $900 with some other therapies, if you had already been paid $500 in benefits for psychology services you would only have $400 of benefits left for your physiotherapy visits, or 13.3 visits.

Waiting periods are served when you have not previously had health insurance or when you have not previously been covered for specific types of treatment or services. When you transfer from one health fund to another or one policy to another, all the waiting periods you have served transfer with you. You only serve waiting periods on any higher levels of cover in your new policy. For example, you change over from a policy with a $500 excess on which you had served your pregnancy waiting period to one with no excess, if you made a pregnancy hospital claim prior to completing the 12 month waiting period you can still be charged the excess on that hospitalisation.

Hospital insurance waiting periods

The maximum waiting periods allowed in health insurance policies are:

• 12 months for pregnancy services
• 12 months for pre-existing conditions
• 2 months for other conditions
• None for accidents

Extras insurance waiting periods are more variable:

• 2 month waiting periods are used by The Doctors’ Health Fund for most services
• 6 month waiting periods are used by other funds for some services
• 12 month waiting periods are usually applied to major dental services and aids & appliances
• 24 month waiting periods are usually applied to hearing aids

A few things relevant to choosing cover ‘just in case of emergencies’:

First, treatment in the emergency department of a hospital is not covered by hospital insurance, it is an out patient service. Once you are an admitted patient your hospital insurance becomes effective. In a public hospital emergency department you won't be charged, but private hospital emergency department charges can be quite high.

Second, an emergency might mean you get admitted and treated as a public patient with no need to worry about waiting lists at this stage. However, if your injury requires further treatment, for instance a broken bone which didn't set well, you will no longer be an emergency patient and to receive publicly funded treatment you would probably be put on a waiting list. Private hospital insurance overcomes the need to wait for treatment.

Third, if you are looking for cover only for emergencies, look at the budget priced hospital insurance products. However, check the detail carefully. Our Smart Starter hospital product has some exclusions and benefit limitations, but offers a whole lot more for about $100 less per year than a product offered by a leading health insurer which they present in way that will appeal to someone looking for 'just emergency cover'.

Good value means different things to different people. For most people it means not paying too much for what they need.

Thinking about your needs is the first step - are you someone who likes to have the most complete cover, or are you looking for something economical which covers your likely health risks? If you fall into the second group you might be happy to choose hospital insurance with an excess or which has some treatment exclusions or limits - Read 'What is not covered in hospital products' too.

One view of good value 

Prime Choice with a $500 excess - was recently recognised by the AFR Smart Investor magazine as one of the 'best hospital-only policies' for a family. Its equivalent for singles is Prime Choice with a $250 excess. AFR Smart Investor recognised it because it has a low excess, no co-payments, no exclusions, the lowest possible out-of-pocket expenses on hospital-related and medical services and price. The also checked the number of private and day hospitals in our coverage, that we had good members retention and low member complaints.

To prevent having out-of-pocket expenses for your hospital accommodation, use a contract hospital. Contract hospitals include all public hospitals and all the private hospitals and day surgeries listed in our contracted hospital search facility. Look for your local 'Contracted hospitals' the link to this search facility can also be found on the Products menu in the website.. We have contracts with over 95% of private hospitals and day surgeries. All major private hospitals have contracts with us.

You can have out-of-pocket expenses or have to pay for some things when you go to hospital, but there are ways to avoid these costs.

By choosing a hospital product with no excess you can avoid having to pay for some of your hospital accommodation costs when you get admitted. But you might prefer to have an excess, and pay less for your policy because you think your risk of needing hospital treatment is pretty low.

To avoid out-of-pocket expenses on your doctors' bills, ask your treating specialist if they will treat you under the gap scheme in your hospital insurance. Also, ask them if other doctors involved in your treatment such as assistant surgeons and anaesthetists will also treat you under your gap scheme. You can choose another doctor if they provide you with Informed Financial Consent which shows you will have out-of-pocket expenses.

Ask to be treated in a contract hospital. Our contracts with hospitals mean the Fund has agreed prices for our members' accommodation, theatre and other services that are part of your treatment in that hospital, which we pay on your behalf. Occasionally a member's treatment requires something which is not within the contract, most often this will be high cost pharmaceuticals, the hospital will contact the Fund to seek approval for out of contract items to be covered. Contract hospitals include all public hospitals and all the private hospitals and day surgeries listed in our contracted hospital search facility. Look for your local 'Contracted hospitals' the link to this search facility can also be found on the Products menu in the website.

Prostheses benefits are based on a federal government system of approved prostheses which includes the setting of minimum and maximum prices for those prostheses.  If the maximum price is charged or an unapproved prostheses is used you will have an out-of-pocket expense for the difference between the minimum price of the approved prostheses and the maximum price or the price charged for the unapproved prostheses. Talk to your doctor about using approved prostheses in your treatment to avoid out-of-pocket expenses.

The reason most extras products include a range of services in their coverage is because this is an effective way to manage the claims risk and the costs of providing cover for a variety of services. More than 70% of the cost of offering an extras product lies in covering the optical and dental services.  

Members would end up paying more for less cover of extras services, if more individual choices were allowed.

If circumstances in your life change you may need to adjust your health insurance, but you should also plan ahead and anticipate some of your changing needs. Consider any change in your life, and whether it changes your health risks or what you need from your health insurance

Plan ahead where you will need services in the future and there are waiting periods to be served:

• Starting a family means if the mother doesn't have obstetrics cover they will need to serve the 12 month waiting period before the baby is born
• Starting a family means the mother should be on a family policy 2-3 months before the birth so the child will be covered at birth
• Getting older means the likelihood of optical and dental care needs increases; you need to serve the 2 month waiting periods before benefits can be paid
• Getting older means reconsidering having a hospital policy with exclusions, as your risk of being affected by them increases

When other circumstances in your life change:

• Moving, let the Fund know your new contact details.
• Moving to another State may mean a change in the cost of your policy
• Getting married or living together, you may choose to take a policy to cover you both, but it isn't necessary to have couples cover you can each have singles cover until children come into the picture.
• Someone in the family is affected by a hereditary disease, you should consider what your personal risk is and whether you need to change your level of cover.

As a not for profit fund we price our products to cover our members, not generate profits. When we compare our pricing with the major funds, we find that for comparable products our price falls at the lower end of the range of their prices.

Our gap cover schemes offer higher levels of benefit payment with 92% or more of services being paid a benefit, compared to the major funds which range between 77% and 89%.

Also, read the second paragraph under How can I get a good value product with a low price?

The product descriptions for Total Extras and Essential Extras both include a column which shows the limits for each type of service. Also, read the second, third and fourth paragraghs at What's not covered in extras products?

The difference between the Top Cover and Prime Choice hospital products lies in the medical gap cover and the excess options. Top Cover provides the highest level of hospital cover available in Australia, the benefits paid on medical services are based on AMA List fees and your treating doctor does not need to agree to participate in the gap scheme for a benefit to be paid for your treatment. Top Cover has one pricing level while Prime Choice has three because two of those pricing levels mean you are choosing to have an excess which reduces the price you pay for your policy.

The key difference between Prime Choice and Smart Starter is the coverage exclusions and restrictions on treatment for some conditions in Smart Starter. Smart Starter also has only one price which includes an excess of $500 for a single policy and $1000 for a family or couple.

Both Prime Choice and Smart Starter offer the same high performing medical gap cover scheme.

Top Cover is our highest level of hospital insurance, and offers a higher level of cover than other funds hospital products. Our Prime Choice hospital insurance is comparable to the top hospital cover offered by other funds.

Total Extras is our highest level of extras cover.

As a not-for-profit health insurer we try to operate on the most economical basis we can, but still provide members with a range of choices of cover which meet a variety of needs.

By allowing members to choose from individual hospital and extras products, whether you are looking for single or family cover, we are able to provide a choice of 17 different cover options but we only need to manage 7 products.

If you don’t have private hospital insurance and your income exceeds the threshold you will be charged a Medicare levy surcharge, in addition to the standard 1.5% Medicare levy. To be exempt from the surcharge your hospital insurance must not have a yearly excess greater than $500 for a single policy, and not greater than $1000 for a couple or family policy.

The surcharge is currently 1% of your total income. The income thresholds for the 2010-2011 tax year have increased from $73,000 to $77,000 for singles, and from $146,000 to $154,000 for couples.