Terms and Conditions of Claiming

How to submit a valid claim:

  • A valid claim can be submitted to the fund through:
    • HICAPS;
    • Doctors' Health Fund smartphone app;
    • Via email to
    • fax (02 9260 9958);
    • post (PO Box Q1749, Queen Victoria Building, Sydney NSW 1230); or
    • in person at the chief administration office.
  • A valid claim must include a:
    • valid claim form, authored by the claimant or other authorised person;
    • itemised valid tax invoice; and
    • receipts of any monies paid toward the supplied tax invoice.
  • A valid claim form is:
    • a HICAPS transaction;
    • a Doctors' Health Fund smartphone app claim; or
    • the claim form available on the Doctors' Health Fund website at the date of making a claim.
  • A valid tax invoice:
    • is on the treating practitioners official letterhead (or endorsed with his/her official stamp);
    • includes the treating practitioners' ABN, practice address, contact details and name;
    • is endorsed with the invoice date and, where a reprint of the original, the date of printing and the word 'duplicate'; and
    • itemises the name of the patient, a description or recognised item number of each treatment and the date of service of each treatment.

Terms and Conditions of Claiming

Claims are not payable where:

  • it is submitted more than 2 years after the date of service of the claimed treatment;
  • the provider is not qualified to supply the treatment under the Fund Rules;
  • more than one like treatment is claimed for the same date of service (e.g. massage and physiotherapy not payable on the same day);
  • the patient and the treating practitioner are related;
  • the policy is unfinancial or suspended at the date of service;
  • the relevant waiting periods have not been served at the date of service;
  • an amount is, or a right exists for an amount to be, paid or payable from a third party in relation to the claim;
  • the service was for health screening, superannuation entry or employer requested health check;
  • false or inaccurate information is supplied;
  • the service is excluded or restricted on your cover;
  • you have exceeded the relevant claims limits on your cover;
  • the date of service was prior to the patient joining the fund, or after the patient left the fund;
  • the treatment was supplied outside of Australia;
  • aids, appliances, glasses, contacts, pharmaceuticals or hearing aids are not accompanied by a prescription from the patient's ordinary practitioner;
  • the cost does not exceed the co-payment payable on pharmacy treatments;
  • the treatment does not meet the standards and requirements of the Private Health Insurance Act 2007 or its associated instruments;
  • the treatment was not delivered in person;
  • a treatment was supplied whilst an in-patient in hospital;
  • an ailment, illness or condition is not being treated, managed or cured;
  • the treatment has not yet been supplied;
  • there was not legally enforceable debt raised for the supply of the treatment; or
  • the treatment is a health screening service.