We’re committed to supporting our members as patients and practitioners, so we structure our hospital cover to ensure it covers more of the medical gap.  That means that we outperform the biggest funds in terms of medical services provided with NO gap incurred by our members – so we minimise the potential out-of-pocket expenses you may pay for treatment.

In Western Australia, we cover 90.8 per cent of medical services provided with NO gap

Wa gap map

Privatehealth.gov.au - Health Insurers Performance 'Medical services with No Gaps'

What is the hospital and medical gap?

The hospital and your doctor both charge for their services when you are admitted into in hospital. The gap is the difference between the fees charged by the hospital, the amount your doctor charges, and the amount covered by both Medicare and your private health insurer. It is the out-of-pocket expenses you may pay for your treatment.

There are 5 situations in which you will be charged for the gap:

  1. You have chosen hospital insurance with an excess, exclusions or benefit restrictions
  2. You have chosen a hospital that does not have an agreement with your private health insurer for that treatment
  3. Your doctor doesn’t participate in or bill you under the Access Gap Cover Scheme, where a participating doctor agrees to bill for their services. Under the Access Gap Cover scheme, you will pay a gap of no more than $400 for each medical service item or $800 on the management of labour and delivery
  4. Your doctor’s fee is more than the Access Gap Schedule or the AMA list of medical services and fees, depending on your level of cover;
  5. You have incurred inpatient charges for items not covered under your health insurance hospital policy, such as newspapers, telephone calls or prescribed medication.

Doctors’ Health Fund offers unique Top Cover Gold hospital cover – with benefits based on the AMA List of medical services and fees, meaning you will have no out-of-pocket expenses when the doctor charges the AMA List of medical services and fees or less.

Or you can choose from our Prime Choice Gold and Smart Starter Bronze Plus hospital covers that include medical gap cover paying benefits according to the Access Gap Cover scheme.  

For more information on the gap or to get a quote, speak to our expert Member Services team today on 1800 226 126.

Don't settle for an ordinary health fund, join the health fund where doctors belong.