Important things to be aware of before you make a claim

Doctors’ Health Fund exists to support our members with their health costs. Every claim you submit is assessed against our fund rules and relevant Government legislation, so it’s important to understand the product terms and conditions before you pay for a service.

You are not eligible for benefits if:

  • the service was not covered under your policy 
  • you have not completed applicable waiting periods when the service was delivered
  • the treatment was supplied outside of Australia
  • your policy was not paid up-to-date when the service was delivered
  • the claim was lodged more than two years after the date of service
  • you have exceeded the applicable benefit limit for that service
  • you are more than 2 months behind with your contributions
  • the service was provided while your membership was suspended
  • the service provider is directly related to you or immediate family
  • the service provider is not considered to be qualified under the fund rules
  • more than one similar treatment is claimed for the same date of service (e.g. massage and physiotherapy not payable on the same day)
  • 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 a health screening, superannuation entry or employer requested health check
  • false or inaccurate information is supplied in relation to a claim
  • the date of service was prior to the patient joining the fund, or after the member left the fund
  • 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 items
  • 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 inpatient in hospital
  • an ailment, illness or condition is not being treated, managed or cured
  • the treatment has not yet been supplied
  • a legally enforceable debt was not raised for the supply of the treatment
  • the treatment is a health screening service

The above terms also apply to any products purchased, for example glasses, contacts, hearing aids or appliances.

A valid claim

Your claims must be submitted under the following rules to be accepted as a valid claim.

A valid claim can be submitted to the fund through:

  • HICAPS (electronic claiming at participating providers)
  • online by logging into our member portal
  • using Doctors’ Health Fund mobile app
  • by downloading and completing a Claims Form and
    - emailing it to; or
    - posting it to PO Box Q1749, Queen Victoria Building, Sydney NSW 1230; or
    - faxing it to 02 9260 9958.

A valid claim must include a:

  • valid claim form, authored by the claimant or other authorised person
  • itemised valid tax invoice
  • 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
  • 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'
  • itemises the name of the patient, a description or recognised item number of each treatment and the date of service of each treatment

If you have any questions about your claim, please contact us on 1800 226 126 or