Hospital cover provides you benefits when you are treated as an admitted private inpatient in a contracted hospital or contracted day-only facility, if your policy covers the procedure.
Inpatient vs outpatient
When determining what services may be covered under your chosen hospital cover, it is important to understand whether you received those medical services as an ‘inpatient’ or ‘outpatient’.
Hospital cover provides benefits only when you receive treatment as an inpatient in a hospital or day-only facility and only if your chosen hospital policy covers the procedure.
You are an inpatient when you are admitted into a hospital or day-only facility to receive medical treatment and care.
According to the Private Health Insurance Act of 1973 (Cth) Section 3, an inpatient, in relation to a hospital, does not include:
- a member of the staff of the hospital who is receiving treatment in his or her own quarters
- a newly-born child whose mother also occupies a bed in the hospital (a newly-born child is regarded as a child nine days old or less - however, a newly-born child who occupies an approved bed in an intensive care facility in a hospital shall be deemed an inpatient of the hospital)
Further, according to the Private Health Insurance Business Rules 2017 (Cth), inpatient treatments do not include:
- treatment provided to a person at an emergency department of a hospital
- other treatments that do not meet the requirements of the Private Health Insurance (Benefit Requirements) Rules such as procedures the Commonwealth has identified as ordinarily not requiring an inpatient admission
Services provided outside of the hospital admission such as visits to a general practitioner or specialists are known as outpatient services and are not covered by your hospital cover. You may be able to claim a rebate from Medicare for outpatient services.
With all our levels of hospital cover, the hospital may ask you for payment on admission and/or discharge and you will be responsible for these expenses, if your hospital stay involved:
- the payment of an excess
- any personal expenses such as telephone calls or newspapers
- take home prescribed medication
- non health-related charges applied by the hospital
If you are in hospital continuously for more than 35 days, you can expect to pay part of the cost of your hospital accommodation, unless you are an acute care patient.
Extras cover includes healthcare services not covered by Medicare such as dental, optical and physiotherapy.
Depending on your level of cover, we pay benefits on a wide range of services and treatments including:
- general dental
- major dental
- optical appliances
- remedial massage
- mental health
- health management
- pregnancy care
Our extras benefits are paid per calendar year, except for optical, orthodontic and aids/appliances benefits.
All our hospital products cover you for ambulance nationwide*, whether it’s for an emergency or otherwise medically necessary, including when;
- an ambulance is called to attend but you are not subsequently taken to hospital
- it is medically necessary for you to be transported by an ambulance to be admitted to hospital
- you need immediate medical attention at a hospital or other approved facility
- you are an admitted patient and need to be transferred to another hospital
*Doctors' Health Fund does not pay ambulance cover where a State or Commonwealth scheme provides a benefit.
In order to be eligible for the benefit entitlement under your hospital cover, you must first serve any waiting periods that apply. Waiting periods apply to what excess you will pay, your level of hospital benefit entitlement and your level of medical benefit entitlement.
The waiting periods are:
- None for accidents
- 1 day for ambulance
- 2 month waiting period on psychiatric services when getting cover for the first time
- None on psychiatric services when upgrading cover. Waiting period can be waived only once a lifetime.
- 2 months for rehabilitation and palliative care, and all other treatments
- 12 months for pre-existing conditions
- 12 months for obstetrics
These waiting periods apply when someone purchases a hospital cover with Doctors’ Health Fund that has better benefits and conditions than available under their previous hospital cover (or if they previously had no hospital cover).
If this is the first time you have purchased health insurance, you will receive no benefit for any treatments during the corresponding waiting period.
If you have not held cover for the treatment for more than 12 continuous months, you may not be eligible to access our benefit entitlements for pre-existing conditions and obstetrics.
If you have purchased cover with better benefits and conditions with us, compared with your previous hospital cover from another fund or with us, you will receive a benefit entitlement equivalent to your old hospital cover for any treatments during the corresponding waiting period.
Once the waiting periods have been served, you will be eligible to access our better benefits and conditions under your new hospital cover with us.
If you have transferred from another health fund, we request a transfer certificate from them which details your previous cover.
You should note that if you are switching from comparable benefits and conditions, you may not need to re-serve waiting periods for those previously covered and served.
We will contact you once we have received the transfer certificate, which usually takes around 14 days.
A waiting period applies to new members with pre-existing ailments.
This waiting period also applies to existing members who have recently upgraded their level of hospital cover.
If the ailment, illness or condition is considered pre-existing:
- new members must wait 12 months for any hospital benefits
- members transferring/switching to a hospital cover with better benefits or conditions must wait 12 months to access the better benefits and conditions
A pre-existing ailment is one where signs or symptoms of your ailment, illness or condition, in the opinion of a medical practitioner appointed by the health fund (not your own doctor), existed at any time during six months preceding the day on which you purchased your hospital insurance.
The only person authorised to decide if the ailment is pre-existing is the medical practitioner appointed by Doctors’ Health Fund. The fund medical practitioner must however consider any information regarding signs and symptoms provided by your treating medical practitioner(s).
Please ensure that you understand whether or not inclusions, restrictions or exclusions apply to your chosen level of cover. Here's a quick explanation what they mean:
Inclusions – this is the most comprehensive benefit we offer, providing you with access to one of the largest networks of contracted private hospitals. You will have the freedom to choose single or shared rooms, your choice of doctor and more. You will also be eligible to access benefits towards your medical bills.
Restrictions – sometimes referred to as minimum benefits, we will provide a limited benefit for these treatments. Whilst you can be treated in any hospital, the benefit available is equivalent to a shared room in a public hospital. If receiving a private room, or treatment in a private hospital, you may have to make a significant contribution to the hospital bills. You will also be eligible to access benefits towards your medical bills.
Exclusions – when a service is excluded, there is no benefit entitlement. This means you will be responsible for the payment of all medical and hospital bills, which could run into the thousands. You should discuss treatment options with your clinical team, such as being treated as a public patient.
This is the amount you agree to pay before your health insurance starts to pay for your hospital costs. Excess is paid per admission up to the yearly excess you have chosen. Consider whether you will be able to manage the cost of the excess if you go to hospital. An excess on health insurance will reduce its cost.
Your excess (if you have one) will vary depending on your cover. If you have an excess, it will apply to same day procedures as well as overnight admissions. If you are unsure how your excess applies please give us a call on 1800 226 126.
If you are planning to have children, you should check that your hospital cover includes obstetrics. This refers to the inpatient services associated with pregnancy and the birth of a baby.
All our hospital covers have a 12-month waiting period for making claims for all inpatient services related to an obstetrics admission unless you are switching from another fund to a comparable cover with us and have already served your waiting period.
You will need to contact Doctors’ Health Fund to add each child to your membership within two months from the date of their birth. This also means moving to a family membership if you are not already on that level of cover. This will ensure your child does not need to serve any waiting periods.
The gap is the difference between the fee charged by the hospital or the amount the doctor charges for services in hospital, and the amount covered by Medicare and your private health insurer. It is the out-of-pocket expenses you may pay for your treatment.
Read more about the gap here.