Starting a family

Hospital cover allows you to be treated as a private patient in either a private or public hospital, whereas extras cover offers benefits for a range of general health services provided outside of a hospital and not covered by Medicare.

If you are planning for your child and wish to be covered as a private patient for your delivery, you will need to have a hospital policy that includes cover for Pregnancy and Birth. Pregnancy and Birth is the specific clinical category that covers inpatient hospital services related to the birth of your baby. 

Extras cover include benefits for pregnancy care, where benefits are paid towards a range of services including midwifery, pre-natal and post-natal classes, and pelvic floor physiotherapy.

It is important to note that you’ll need to have served the 12-month waiting period to access hospital cover and a 2-month waiting period to access extras cover.

Doctors’ Health Fund offers two gold hospital polices that cover Pregnancy and Birth: Prime Choice Gold and Top Cover Gold. 

Both policies provide comprehensive cover for Pregnancy and Birth. Please contact our expert Member Services Team on 1800 226 126 to discuss the right level of cover for you.

It’s important to know that Doctors’ Health Fund, and private health insurance in general, is unable to cover the costs of healthcare visits to your specialist during your pregnancy when you are not an admitted patient in hospital. This includes regular scans and check-ups performed in a doctors’ surgery or clinic. Most of the time, a portion of these fees can be claimed with Medicare.

In addition, you may be charged a Pregnancy Management Fee if you engage a private obstetrician to manage your pregnancy and be available for your birth. This is charged as an out-of-pocket fee and is not covered by private health insurance. It is a one-off fee and is separate from the fees you pay for consultations. Medicare rebates are available to subsidise some of these costs.

If you have Smart Starter Hospital Cover, you will need to upgrade to Prime Choice Gold or Top Cover Gold to be covered for the delivery of your baby.

It is important to note that on upgrading you’ll need to serve the 12-month waiting period to access hospital cover so it’s essential you upgrade before becoming pregnant.

Please reach out to our expert Member Services Team on 1800 226 126 for more information on how to upgrade your cover.

If you’re new to health insurance, or are upgrading your cover, there is a 12-month waiting period to access pregnancy services, so it’s essential that you upgrade your health cover before becoming pregnant.

No. Doctors’ Health Fund, like most health funds, has a 12-month waiting period for Pregnancy and Birth cover.

Waiting periods, which are set by the Australian Government, are necessary to help to discourage people from signing up for health cover, claiming and leaving soon after, which drives premiums up.

During this 12-month period, you will not be eligible to claim for pregnancy services. Waiting periods are necessary to help to discourage people from signing up for health cover, claiming and leaving soon after, which drives premiums up.

If your baby is due within the time you’re still serving your 12-month waiting period, or you give birth prematurely within your waiting period, you will not be covered by your insurance policy.

We have partnered with online resource tool, Nourish Baby, to provide members on any level of hospital cover complimentary access to antenatal and early parenting classes and courses.

Our Essential Extras and Total Extras both include benefits for pregnancy care, where benefits are paid towards midwifery, pre-natal and/or post-natal classes or consultations for services such as pelvic floor physiotherapy, breastfeeding consultations or parenting classes performed by a nurse, midwife or physiotherapist.

Essential Extras has an annual sub-limit of $500 and Total Extras offers an annual sub-limit of $600.

It is especially important to add your baby to your policy within 60 days, in the event they are admitted to special care nursery due to any health complications after birth. You can have peace of mind knowing your baby will be covered for any inpatient hospital and medical services received while admitted.

You will need to notify us of your baby’s arrival within 60 days of their birth date, to ensure your baby is covered straight away under your level of cover with no waiting periods. Otherwise, if your baby is not added within 60 days of birth, full waiting periods will apply.

If you are on a single or couples' policy, you will also need to upgrade to a family policy.

Cover for assisted reproductive services, like other clinical categories, is based on whether a doctor determines that a particular procedure is medically necessary. Doctors’ Health Fund does not make this determination – only a qualified medical professional can. 

Yes. Doctors’ Health Fund offers two hospital options which cover you for assisted reproductive services for infertility: Prime Choice Gold and Top Cover Gold. Both cover medically necessary hospital treatment for infertility, for example the retrieval of eggs or sperm, in-vitro fertilisation and gamete intra-fallopian transfer.

The most common item numbers Doctors’ Health Fund covers include the following three item numbers under our Prime Choice Gold and Top Cover Gold policies:

• 13212 - Oocyte retrieval for the purpose of assisted reproductive services;
• 13215 - Transfer of embryos or both ova and sperm to the uterus or fallopian tubes, excluding artificial insemination;
• 13218 – Preparation of frozen or donated embryos (ONLY if related to a valid inpatient hospital admission).

These procedures must be conducted as an inpatient. Doctors’ Health Fund is unable to pay benefits toward outpatient IVF and assisted reproductive services.

To check your cover, please provide the Medical Benefits Schedule item number(s) from your doctor for the relevant procedure(s) to our expert Member Services Team and they will be able to assist you further.

Doctors’ Health Fund offer two hospital options which cover you for assisted reproductive services for infertility: Prime Choice Gold and Top Cover Gold. While the waiting period for both these policies is set at two to twelve months, it should be noted that given assisted reproductive services are likely to be a pre-existing condition, a waiting period of 12 months would apply.

If you do need treatment within the first 12 months of taking out or upgrading your policy, Doctors’ Health Fund will assess whether your condition is a pre-existing condition and therefore, whether benefits are payable.

Under the Private Health Insurance Act 2007, a health insurer may impose a 12-month waiting period on benefits for hospital treatment for a pre-existing ailment (PEA) or pre-existing condition.

This is defined as any ailment, illness, or condition where, in the opinion of a medical adviser appointed by the health insurer, the signs or symptoms of that illness, ailment or condition existed at any time in the period of 6 months ending on the day on which the person became insured under the policy. The pre-existing condition waiting period applies to new members and members upgrading their policy to any higher-level benefits under the new policy. The fund medical practitioner must consider any information regarding signs and symptoms provided by your treating medical practitioner(s).

The Commonwealth Ombudsman explains:

"As infertility is generally defined as the inability to conceive after one year, assisted reproductive services will usually be subject to the twelve-month waiting period for pre-existing conditions. This means you need to complete twelve months of membership on an appropriate hospital policy prior to the commencement of IVF treatment in order to be eligible for benefits.”

Please note that the definition of infertility applies to both women and men.

If you have held cover for assisted reproductive services for between two and 12 months and wish to claim benefits for a procedure, your GP and specialist will need to complete a pre-existing condition form to confirm that the condition is new. You will also need to verify each Medicare Benefits Schedule item number to check if pre-existing condition waiting periods apply. Once these forms are submitted to Doctors’ Health Fund, a third-party medical professional will determine whether the admission is related to a pre-existing condition.

If there is no medical case to review, then normal waiting periods would stand for 12 months (from time of joining).

IVF and assisted reproductive services involve a series of procedures, some occurring in hospital, and others out of hospital.

For services performed when you are admitted as a patient in a registered hospital or day facility (where you are an inpatient), private health insurance can provide cover for these procedures. Benefits are paid towards your hospital costs, including accommodation and theatre fees, and your medical bills, if you are on the right level of cover and any waiting periods have been served*.

For services received outside of hospital, Medicare can cover some of these costs and any remaining fees are out-of-pocket costs covered by the patient. It’s important that you speak with your GP or specialist before you begin your IVF journey to discuss any conditions for Medicare benefits.

We will always do our best to help you navigate through this area and encourage you to contact our Member Services team to discuss your situation and understand more about your cover options.

*Assisted reproductive services not covered under our Smart Starter Bronze Plus cover. Waiting periods apply when upgrading to a level of hospital cover that includes assisted reproductive services, being Top Cover Gold or Prime Choice Gold.

Please note, no health insurer can pay benefits for outpatient services.