Emergency department visits and ambulance cover

Medical emergencies are unexpected events that can be extremely distressing. While no one plans to have a medical emergency, you can be prepared to know what to expect with your private health insurance. We address two of our most common questions from our members relating to emergency department visits and ambulance cover, after the event of a medical emergency.

I have outstanding accounts from my visit to the emergency department; can I claim these with my health insurance?

Private health insurance in general is unable to pay benefits towards services received in a public or private emergency department. This is because you are treated as an outpatient during this time and not an admitted patient in hospital.

Emergency departments are hospital units that accept and treat patients who experience a medical emergency and require urgent medical care. While you are on a hospital site, these departments operate independently from the main hospital and its admission processes.

If you call an ambulance for a medical emergency, you will usually be taken to the nearest public hospital emergency department (read more about our ambulance cover below).

But if you go by private vehicle, you might be able to choose whether you attend a public or private hospital emergency department. Knowing more information about each can help if you can make this decision, especially regarding any additional costs you may be prepared to pay.

The difference between public hospital and private hospital emergency departments

Most public hospitals across the country have emergency departments, with many open for 24 hours a day. They are usually larger and look after more serious emergencies. As these departments are often busy, your triage category is a major factor for how long your waiting time will be. The triage system is designed to ensure those who need help most urgently are treated first.

Services received in public hospital emergency departments will be generally covered by Medicare in full, provided you are eligible for Medicare. This can include treatment by doctors, specialists and nurses, and any tests you may be required to undergo as part of your emergency treatment.

Not every private hospital has an emergency department, but for those that do, patients should expect to be more out-of-pocket if choosing this option.

While private hospital emergency departments are generally quieter, many charge a facility fee. This fee can’t be claimed with private health insurance or Medicare, meaning it is an out-of-pocket cost covered by the patient.

For any medical services received in a private emergency department, a portion of these may be covered by Medicare, however out-of-pocket costs or gaps are highly likely. Depending on your required treatment, this can include a specialist assessment and/or services such as radiology or other tests.

Your private health cover begins if you become an inpatient

Your private health cover begins if your treating doctor makes the assessment that you require ongoing hospital care, and formally categorises you as an inpatient. This means you are moved out of the emergency department and are admitted into hospital.

On average, only 1 in 3 patients are admitted to hospital after a visit to an emergency department.¹ This means more often than not; the illness or injury can be managed and/or treated entirely in the emergency department.

I had to call an ambulance for a medical emergency; am I covered?

Ambulance cover is a standard inclusion of all our hospital products. This means, if you are covered by Top Cover Gold, Prime Choice Gold or Smart Starter Bronze Plus, you are covered nationally for emergency and medically necessary ambulance services, including transfers between hospitals. There is no limit on the benefit we pay per service, or number of ambulance services required per year.

You will be covered if -

• An ambulance is called to attend to you, but you are not subsequently taken to hospital.
• It is medically necessary for you to be transported by an ambulance to an emergency department.
• 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.

Each state and territory operate their own arrangements for funding ambulance services. The services respond differently depending on your state of residence, and your eligibility for a concession. More information on this can be found at privatehealth.gov.au

However, where a state or commonwealth scheme doesn’t provide a benefit, this is when your Doctors’ Health Fund hospital cover will ensure you pay no out-of-pockets for ambulance services. You can have complete confidence that you will be fully covered in the event you need an ambulance for an emergency. 

Due to this comprehensive cover, you don’t need to also maintain a membership or subscription with state-based ambulance services.

Members who hold only an extras policy are not covered for ambulance services.

How to make an ambulance claim

If you receive an invoice for your ambulance services, simply send this to us to process. If you have paid for the account upfront, ensure you include proof of payment (a receipt), to ensure we can reimburse you directly. Otherwise, we will pay any outstanding accounts to the ambulance service.

Claims can be made -

• using the Doctors' Health Fund mobile app for Android or iPhone
• online through Online Member Services
• by email to info@doctorshealthfund.com.au
• by post - PO Box Q1749, Queen Victoria Building, Sydney NSW 1230
  

¹Health Direct. Hospital Emergency Departments, source: https://www.healthdirect.gov.au/hospital-emergency-departments