Your Member Guide

Your
Member Guide
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Health Insurance
Australia
2009 - 2014
April 2015
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Thanks for choosing HCF for your
private health cover.
As Australia’s largest not-for-profit
health fund, we are totally committed
to putting your needs first.
Contents
HCF member benefits
3
100% back extras cover
4
Free access to health programs
6
Our other products and services
8
Who can be covered under your HCF Policy
10
How to make a claim
12
Things you need to know 18
Waiting periods and how they affect your cover
20
The gap, what it is and what it means for you
22
Rebates, surcharges and incentives
24
Managing your policy
26
Health and wellbeing frequently asked questions
28
How your rights are protected
30
Customer Service Charter
31
Want to have your say?
32
How fraud affects you
33
Want to change your payment method?
34
Our privacy statement
36
Useful websites
37
Glossary38
Index43
2
When you’re with HCF,
it’s all about
you
Higher limits the longer you're with us
Your loyalty is rewarded when you’re with HCF. Depending on your level
of cover, your extras claim limits increase for every year you’re a member,
up to a maximum limit. It’s another way we want you to stay happy.
HCF EXTRAS COVER
Pay nothing on a range of extras
HCF includes 100% back on certain claims on selected extras cover
at participating providers (and subject to your limits). The higher
your extras cover, the more services you can claim 100% back on.
Free health and wellbeing programs
HCF knows how important your health and wellbeing is, so we provide
a range of quality health programs to you at no extra cost. See pages
6-7 for more details.
Make extras claims via our mobile app
We’ve taken the hassle out of claiming - just send us a photo of your
receipt using the HCF app. No more waiting in queues - you can claim
wherever you are, whenever you want. It’s that easy.
100% BACK
HCF EXTRAS COVER
Our 100% back on extras helps reduce your out-of-pocket costs, to help you look
after your health. You may be eligible to claim for these programs, depending on
your level of cover and available limits.
More for Teeth offers 100% back on a range of diagnostic
and preventative services
• Available at HCF Dental Centres and participating More for Teeth
providers across Australia (except NT and Tas)
• Available on selected extras and subject to your available limits
More for Eyes provides 100% back on a range of prescription glasses
per year and one free digital retinal image per year
• Available at seven HCF Eyecare Centres in Sydney and participating
More for Eyes optical providers across Australia
• Available on selected extras and subject to your available limits
HCF Eyecare Centres are independently owned and operated by Eyecare Holdings Pty Ltd ACN 054365196
More for Muscles gives you 100% back on an initial physiotherapy
consultation per year
• For a new Episode of Care
• Through participating More for Muscles physiotherapists Australia-wide
• Available on selected extras and subject to your available limits
More for Backs gives you 100% back on an initial chiropractic or osteopathic
consultation per year
• For a New Episode of Care for Eligible Musculoskeletal Conditions
• Through participating More for Backs chiropractors and osteopaths
across Australia
• Available on selected extras and subject to your available limits
More for Feet gives you 100% back on an initial podiatry consultation per year
• For a new Episode of Care for eligible conditions
• Through participating More for Feet podiatrists Australia-wide
• Available on selected extras and subject to your available limits
More for Hearing gives you 100% back or reduces the cost of high quality
hearing aids
• From our participating hearing aid provider, Blamey Saunders Hears
• Plus access to free online tools, to better understand your hearing ability
4
HCF Dental and Eyecare Centre locations:
Blacktown
Westpoint Shopping Centre, Patrick St
Dental: 02 9852 2100
Eyecare: 02 9672 9500
Hurstville
12 Butler Rd
Dental: 02 8567 3244
Eyecare: 02 8558 9800
Bondi Junction
Level 8, 1 Newland St
Dental: 02 9386 2222
Eyecare: 02 9386 2333
Parramatta
Level 6, 128 Marsden St
Dental: 02 9685 1255
Eyecare: 02 9685 0655
Brookvale
Westfield Waringah Mall
Cnr Pittwater Rd and Condamine St
Dental: 02 9907 5600
Eyecare: 02 9907 5100
Sydney
HCF House, 403 George St
Dental (Level 3): 02 9290 0555
Eyecare (Level 9): 02 9290 0199
Chatswood
Level 6, 13 Spring St
Dental: 02 8448 0144
Eyecare: 02 8448 0111
For more information on our Dental
and Eyecare Centres, please visit
hcf.com.au, call 13 13 34 or email
[email protected]
Loyalty Benefits
Higher limits the longer you're with us
We're all about giving back to our members. Depending on your level of cover, the longer you're an
HCF member the more you can claim on selected extras including dental, physio, chiro, osteo, natural
therapies and hearing aids, up to a maximum limit. And the higher your level of cover, the more you'll be
able to claim.
See hcf.com.au/loyaltybenefits for more details. Please note that when you upgrade your cover, you’ll
need to serve waiting periods before you can take advantage of the increased benefits and limits.
Health management programs
On eligible extras covers, you can claim for a range of HCF approved health programs to help you
lead a fit and healthy life. They include:
• Weight management
programs
• Healthy Weight for Life
• Childbirth education
• Lactation consultant
• Exercise and gym
membership for a
specific health problem
(doctor’s referral
required)
• Learn to swim
• Stress management and
quit smoking programs.
A six month waiting period and conditions apply.
See page 13 or visit hcf.com.au/healthmanagement for details.
Where HCF recognises a provider for benefit purposes, or appears by reference or logo or otherwise in any
advertisement or promotional material of any provider, such as advertising, reference must not be construed as an
endorsement or recommendation by HCF of that provider or their services or products. Members should make and
rely on their own enquiries and seek any assurance or warranties directly from the provider of the service or product.
5
great health
programs
Get access to
Benefits for
programs
to improve
your health
with your
HCF cover
HEALTH MANAGEMENT
PROGRAMS
Your HCF membership includes easy-to-use health and wellbeing management
tools and support for a range of specific health conditions.
HELPING YOU LEAD A
HEALTHIER AND HAPPY LIFE
Our unique program, My Health Guardian,
helps you create an easy and effective
wellbeing plan. Whether you want to lose
weight, have more energy or just feel
healthier, this innovative service helps
you take the necessary steps towards a
healthy, happy life.
My Health Guardian is provided at no cost
to members aged 18 years and over with
hospital or extras cover.
Getting started?
We recommend you see how you or
a family member can benefit.
To find out what My Health Guardian
can do for you, take the virtual tour at
hcf.com.au/mhg
WELL-BEING PLUS
MOBILE APP
To help keep you motivated
and on target to achieve
your health goals, you
can track your health and
wellbeing wherever you
are with the My Health
Guardian mobile app,
'Well-being Plus'.
Visit hcf.com.au/
mobile-apps for
information on how to use the app.
Available for iPhone and Android.
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6
GET MEDICAL ADVICE FROM
WORLD-LEADING SPECIALISTS
If you or someone on your family
membership had a serious illness, wouldn’t
it be reassuring knowing you could access a
world-leading medical expert to review your
case? My Global Specialist is an innovative
medical information service available to
members on selected levels of cover.
You’ll have access to a global network
of 50,000 medical experts to review
your medical records and report on your
diagnosis and treatment plan and answer
any questions you have. This service is
available through Best Doctors, the world’s
leading resource for specialist medical
advice, founded by doctors from the
Harvard Medical School.
On eligible extras covers, you can
claim on a range HCF approved Health
Management Programs to help you
lead a fit and healthy life.
Programs include:
• Weight management
• Healthy Weight for Life
• Exercise and gym membership fees
for specific health problems
(doctor’s referral required)
• Childbirth education
• Lactation consultant
• Learn to swim
• Stress management and quit
smoking.
A six month waiting period and
conditions apply to claims for Health
Management Programs.
Visit hcf.com.au/healthmanagement
for details.
To find out which levels of cover include
My Global Specialist, or for more information
visit hcf.com.au/mgs or contact us.
HCF reserves the right to revise, alter,
adapt or withdraw any of our Health and
Wellbeing programs from time to time.
Please consult our website for the most up
to date information about these programs.
7
Get peace of
mind from our
range of additional
products and services
Your HCF membership also provides a range of health services and options to
protect and support you and your family.
Travel Insurance
10% discount for members
Your health cover doesn’t apply when you travel
overseas. As an HCF member, you’ll receive a
10% discount on travel insurance that provides
you with worldwide emergency assistance whilst
you’re overseas.
Cover includes a range of benefits for medical
and hospital expenses, legal assistance, and
compensation for trip delays or lost luggage.
Pet Insurance
10% discount for members
As an HCF member, you also get 10% off HCF
Pet Insurance. If your dog or cat is suddenly or
unexpectedly injured or becomes ill, pet
insurance can help pay for veterinary expenses.
• Choice of two comprehensive covers
• Up to 80% of covered veterinary expenses
(less an annual excess that you choose)
Cash Assist cover
Many Australians put insurance in the too-hard
basket, leaving them exposed to potential financial
strain. To help get you back on your feet in the
event of an illness or accident we offer a range of
simple, low-cost cover options, including:
•
•
•
•
•
•
•
Kids' Accident Cover
Cash Back Cover
Medical Trauma Insurance
Personal Accident Insurance
Income Assist Insurance
Smart Term Insurance
Permanent Disability Benefit Plus.
Please consider each Product Disclosure
Statement available and your financial situation,
objectives, and needs before deciding on these
products as the information provided does not
take these into account. Call 13 13 34, email
[email protected] or visit
hcf.com.au/cashassist for details.
The Cash Assist covers are issued by our
own HCF Life Insurance Company Pty Ltd.
ABN 37 001 831 250, AFSL 236 806.
Retirement and
Aged Care Services
We also offer high quality retirement
lifestyle living and aged care services
under our subsidiary, Manchester Unity.
Retirement lifestyle
Our retirement lifestyle facilities are designed
especially for the over 55’s, offering residents
the utmost quality of life in their retirement.
We have three villages in Sydney – Hunters Hill,
North Parramatta and Westmead.
To find out more, visit hcf.com.au/racs
Aged care services
Our aged care facilities offer the best in low
care, high care, extra services and dementia
care for residents requiring more support
and security.
We have two aged care facilities in Sydney
– Courtlands Village and Northcourt, both
conveniently located at North Parramatta.
To find out more, visit hcf.com.au/agedcare
Visit hcf.com.au/travel for more information.
Visit hcf.com.au/petinsurance
for more information.
More at Home is a community care service, providing quality home support to those who need a helping
hand. Everyone has different needs, which is why our services are tailored to your personal needs and
preferences, ensuring we provide you with the perfect ‘fit’.
Visit hcf.com.au/travel or call 13 13 34 to view
the Product Disclosure Statement and Financial
Services Guide before making decisions about
this product.
Visit hcf.com.au/petinsurance or call
1800 630 681 to view the Product Disclosure
Statement and Financial Services Guide before
making decisions about this product.
We'll give you access to a compassionate professional who can assist you with domestic and/or
personal care. We’ll help with housework, shopping, meal preparation, getting you ready in the morning
and providing transport - if needed. Our nursing services may also assist you with your medical needs
following surgery and are available on a continuous basis.
HCF Travel Insurance is issued by QBE
Insurance (Australia) Limited
ABN 78 003 191 035, AFSL 239 545.
HCF Pet Insurance is issued by The Hollard
Insurance Company Pty Ltd,
ABN 78 090 584 473, AFSL 241 436.
More at Home is currently available in Northern and Western Sydney and anticipated to be available
in other areas in the future. This paid service is managed by Manchester Unity, an HCF subsidiary
with 65 years of experience providing high quality aged care services for Australians.
To find out more, visit moreathome.com.au or call 1300 550 124.
8
9
Who can be covered under
your HCF Policy
The Policyholder
Family cover
The Policyholder is the person in whose name
the health insurance policy is held (also known
as the Contributor).
The Policyholder:
• Is HCF’s main point of contact
• Nominates who’s covered by the policy
• Is entitled to access all records and claims
history relating to the membership, including
end of year tax statements
• Must advise HCF of any changes to
membership details
• Is responsible for payment of the premiums.
If you choose Family cover, the following people
can be covered under your policy:
• The Policyholder
• The Policyholder’s Partner listed under
the policy
• The Policyholder’s and/or Partner’s Child
dependant/s
• The Policyholder’s and/or Partner’s Student
dependant/s
• The Policyholder’s and/or Partner’s Adult
dependant/s with the Extended Family cover
option (this is only available on some levels
of cover - please talk to us for details).
Singles cover
Single Parent Family cover
The person covered under the Single policy is
the Policyholder only.
Couples cover
Covered under this policy are:
• The Policyholder
• The Policyholder’s Partner listed under
the policy.
('Partner' means spouse or de-facto partner).
People covered under the Single Parent Family
policy can include:
• The Policyholder
• The Policyholder’s Child dependant/s
• The Policyholder’s Student dependant/s.
• The Policyholder’s Adult dependant/s with
the Extended Family cover option (only
available on some levels of cover - please
consult HCF for further details).
New babies
To ensure your new baby will be covered
from birth make sure you upgrade to a single
parent or family membership as soon as you
fall pregnant, but no later than 2 months
prior to the birth of your child. If your child
is born prematurely and you have not held
a single parent or family membership for at
least 2 months, your child will not be covered
for procedures that occur during the initial 2
month waiting period. Waiting periods for
pre-existing conditions may also apply.
Dependants:
Child, Student & Adult
Child dependant means a person who:
a) Is less than 22 years of age; and
b) Isn’t married or in a de-facto relationship; and
c) Is primarily reliant on the Policyholder (or
Partner listed on policy) for maintenance and
support; and
d) Is related to the Policyholder (or Partner
listed on policy) as a Child, Stepchild, Foster
Child or other Child that the Policyholder
(or Partner listed on policy) has legal
guardianship over.
Student dependant means a person who:
a) Is aged between 22-24 (inclusive); and
b) I s a full time student at school, college or
university; and
c) Isn’t married or in a de-facto relationship; and
d) Is primarily reliant on the Policyholder
(or Partner listed on policy) for maintenance
and support; and
e) Is related to the Policyholder (or Partner
listed on policy) as a Child, Stepchild, Foster
Child or other Child that the Policyholder
(or Partner listed on policy) has legal
guardianship over.
Adult dependant means a person who:
a) Is aged between 22-24 (inclusive); and
b) I sn’t married or in a de-facto relationship; and
c) Isn’t a Child dependant; and
d) Isn’t a Student dependant; and
e) Is related to the Policyholder (or Partner
listed on policy) as a Child, Stepchild, Foster
Child or other Child that the Policyholder
(or Partner listed on policy) has legal
guardianship over; and
f) I s primarily reliant on the Policyholder
(or Partner listed on policy) for maintenance
and support; and
g) Is insured under an Extended Family or
Single Parent Extended Family membership.
Single Parent Family cover is only available on
certain cover options - please consult HCF for
further details.
10
11
How to make a claim
At HCF, we want the claiming process to
be as simple as possible. Here’s what you
need to know.
Before you claim
Before you claim, you must have served the
relevant waiting periods. These are detailed
on page 20.
To find out exactly what benefits are available to
you, login to the members section at
hcf.com.au/members, download the HCF
mobile app, email [email protected], visit one
of our branches or call 13 13 34. Please have the
item number for the medical or dental service, or
a description of the treatment or item. It’s also a
good idea to talk to your practitioner first about
the services you’ll be having.
Please note:
• You must have served the relevant
waiting period
• Your premiums must be paid up to the date
of service for you to make a claim
• You cannot claim for goods or a service
before it has been provided to you
• Claims must be lodged within two years of
the date on which the service was provided
(12 months from the accident for School
Accident benefit)
• The Policyholder or Partner listed on the
policy must sign the claim form or electronic
claims receipt. A dependant aged 18 years
or over who holds an HCF membership
card may also claim and sign for their own
services received
• Your healthcare provider must be recognised
by HCF.
Five ways to claim on extras
On the spot
The most convenient way to claim for some
services is when visiting your optometrist,
dentist, physiotherapist, occupational therapist,
dietician, speech pathologist, chiropractor,
osteopath, exercise physiologist or podiatrist.
12
Using the electronic claims and payment
system, you just need to pay the difference
between the cost and benefit once the claim is
approved electronically. This is called ‘the gap’,
as explained on page 22.
Make an extras claim on
your phone with HCF's
mobile app
Download the HCF app to your
personal device to submit a claim
with a photo of your receipt.
The app is available for both
Apple and Android, see
hcf.com.au/mobile-apps
Claim online
You can claim for some extras such as general
dental services, remedial massage and
naturopathy.
To claim online for these popular extras, simply:
1. Visit hcf.com.au/members and login to the
Members’ section
2.Select ‘Make an online claim’ from the menu
and follow the steps.
Please ensure that you post the original receipts,
otherwise future claims may be delayed.
Claim at any HCF branch
You can make a claim at any HCF branch
by presenting your membership card and
original receipts. The name and address of the
healthcare provider must be printed or stamped
on the receipt, not handwritten. If there is no
receipt, and only an account, a cheque will
be drawn to the service provider. Only the
Policyholder or Partner listed on the policy
may collect cash, unless written authorisation
has been provided to HCF for dependants, or a
nominee, to do so.
Dependants aged 18 years and over, presenting a
claim form for a service they have received, may
sign on their own behalf. Dependants presenting
a claim for other persons on the policy require a
claim form signed by the Policyholder or Partner.
We will pay the benefit by direct deposit to the
Policyholders' nominated account or by cheque
made payable to the Policyholder or to the
provider for unpaid accounts. Please note, no
cash or cheques are held on the premises at
HCF kiosks. You can, however, make a claim
and be paid via credit to your nominated bank
account or a cheque will be mailed to you.
Claim by post
You can download a claim form from
hcf.com.au/forms, pick one up from any HCF
branch, or call us on 13 13 34 and we’ll post or
email one to you.
Then just:
1. Complete and sign the claim form and attach
the original receipts (receipts must have the
name and address of the provider printed or
stamped on them, not handwritten)
2.Post the form to HCF at GPO Box 4242,
Sydney NSW 2001
3.We will post you a cheque, or credit your
nominated bank account if the receipt you’ve
attached shows that you paid the provider.
If there is no receipt attached to the claim
form, and only an account, a cheque will be
drawn to the person or organisation that
provided the service. We’ll also send you a
statement for your records.
Additional
information
on extras claims
Artificial appliances
Some covers have benefits for surgical and
artificial appliances like a low vision aid machine
or a blood glucose monitor. The aid or appliance
must always meet HCF’s definition of an artificial
appliance (see page 39 of the Glossary).
In addition, appliances may only be eligible
to claim when specified health professionals
prescribe them for particular health conditions,
and they provide you with a letter to support
your claim. For some particular appliances, only
a specified supplier can provide them. If your
doctor or allied health professional prescribes
a surgical or medical aid or appliance, it’s best
to call HCF on 13 13 34 to find out if you can
claim a benefit. Different waiting periods apply,
depending on your level of cover.
We will tell you what supporting information we
need from your doctor/specialist/allied health
professional to allow you to make a claim.
Combination of therapies
There is a limit of one benefit per day for therapy
services by the same provider. In addition,
where receiving a physiotherapy, chiropractic or
osteopathy therapy on the same day, a benefit
will be paid for only one of the therapies.
Health management programs
Some covers include benefits for health
management programs where you can claim
benefits towards programs like swimming
lessons, weight management programs,
exercise regimes, stress management and quit
smoking programs.
Before you start any program, please check with
us that you're eligible to claim a benefit. The
providers of the programs must be recognised
by HCF. Claims for this benefit must include
original receipts detailing the provider, the type
of program, the program location, and the start
and completion dates.
To claim towards the cost of an exercise regime,
you must complete and submit an ‘Exercise and
Gym benefits authorisation and claim form’,
available at any HCF branch, hcf.com.au/forms,
by calling 13 13 34 or emailing [email protected]
This form must include your doctor’s or
specialist’s confirmation of your specific health
condition that the program addresses.
Your physiotherapist or exercise physiologist
can complete the form if you are claiming for
a class held by a physiotherapist or exercise
physiologist. Benefits are not claimable for
recreational or competitive sports.
13
Hearing aids
Some covers include benefits for hearing aids.
If you have this type of cover, your hearing aid
limit renews every three or five years
(depending on your product), not every year.
Depending on your product, limits increase the
longer your cover is in place. Please refer to the
current brochure for the limits.
Orthodontics
Orthodontics is a branch of dentistry concerned
with the diagnosis, prevention and treatment of
problems with alignment of the teeth and jaws.
Orthodontic benefits are subject to a lifetime
limit and an annual limit depending on your level
of cover.
You’ll receive lower benefits and your overall
limit will be lower if a dentist other than an
orthodontist, provides the treatment.
Always check with HCF on 13 13 34 before
undertaking any orthodontic work.
Orthodontic treatment may involve:
• Appliances e.g. to change the jaw shape
• Braces or aligners to straighten the teeth
• The fitting of a retainer to maintain the
position of the teeth once the braces are
removed.
Orthodontic treatment can occur on either
the upper or lower jaw and teeth, or both.
How much benefit you receive depends on
your level of cover, how long you’ve had that
level of cover, whether your treatment is
provided by an orthodontist or general dentist
and what type of treatment you have.
Depending on your cover, you may receive more
benefits if you need more than one orthodontic
appliance. For example, higher benefits are paid
for braces on your upper and lower teeth than
braces for your upper teeth only.
Sequential aligners may not be claimable
when placed by a general dentist rather than
an orthodontist.
To receive the correct benefit, you need to provide
us with the dental item numbers (from the
Australian Schedule of Dental Services and
Glossary – published by the Australian Dental
Association).
When getting the orthodontic item numbers
from your provider, please note that we do
not accept the item number 881 without a
description of the services you’re receiving,
or a treatment plan.
No benefit is paid before the treatment takes
place, even if you choose to pay for your
orthodontic treatment in advance or via a
payment plan. The benefits for braces or
aligners can only be paid once the braces or
aligners are in place. Orthodontic claims are not
paid on the spot. Please post your claim to us or
visit your nearest HCF branch.
Having orthodontic work?
Please contact us on 13 13 34 so we can help
you determine what you’re covered for, and
help you minimise any gap.
Pharmacy
A benefit may be claimable for certain
pharmacy items, depending on your level of
cover. If your level of cover includes pharmacy
benefits, then please check the definition of an
eligible pharmacy item on page 40.
Before any benefit is paid, we deduct a
co-payment equivalent to the current standard
Pharmaceutical Benefits Scheme (PBS)
co-payment for general patients.
Psychology
Some covers include benefits for consultations
with an HCF recognised psychologist. On covers
that include psychology benefits, we will only pay
benefits for patients who have been referred:
• By their general practitioner
• Onto a Mental Health Plan, through Medicare
• Once the Medicare entitlements for the
calendar year are exhausted.
This benefit acts as a safety net after Medicare
and isn’t payable in any other circumstances.
14
Recognised provider
HCF has recognition criteria and requirements
for providers. If a provider isn’t recognised,
or on the rare occasion a provider is de-listed,
benefits cannot be claimed for services received
from that provider.
To find out if your service provider is recognised
by HCF, call us on 13 13 34.
School Accident benefit
If your level of cover includes School Accident
benefits, you may claim additional extras
benefits if your child has an accident in, or
travelling to or from school and the costs aren’t
recoverable from another source. Benefits
are only payable to top up services that are
included in your extras cover. This benefit does
not include medical or hospital services. Claims
must be accompanied by a detailed description
of the event and submitted within 12 months of
the accident.
Travel and accommodation
You can make a claim towards travel costs if
this benefit is included in your level of cover.
Your travel for medical specialists and/or
hospital treatment must be within Australia and
greater than a 200km round trip for treatment
that isn’t available locally.
You can claim towards hotel accommodation
costs for the patient and an attendant (if
medically necessary) before and/or after your
hospital stay if this is included in your level
of cover.
To claim, please complete and submit an
Accommodation/Travel benefits claim
form, available from any HCF branch, at
hcf.com.au/forms or on 13 13 34.
Additional
information
on insulin pump
benefits
Insulin pump benefits
The following information relates to members
of HCF who have Type 1 Diabetes and may
need, or already have, an insulin pump and do
not have benefits for insulin pumps excluded on
their hospital cover.
At the time the insulin pump is supplied, you
must have completed any relevant waiting
periods (12 months for new members or
upgrades), be paid up to date, and hold a
complying hospital product.
Initial insulin pumps
When initial insulin pumps are fitted in an
outpatient setting, HCF will pay up to 100% of
the highest costing insulin pump on the Federal
Government Prosthesis List (currently up to
$9,500) when we receive a completed insulin
pump claim form which is available at
hcf.com.au/forms
If admission to hospital is required for initiation
of pump therapy, HCF will provide a benefit,
provided the Type C certification is completed
in accordance with the legislation. Please
note that education is not a valid reason for
hospitalisation. At times, HCF may require
additional information to verify the reasons for
hospitalisation.
Replacement pumps
For a replacement insulin pump provided in
the outpatient setting, the application process
is streamlined by a standardised replacement
insulin pump claim form. Depending on your
level of cover, you will be eligible for a benefit
once every 5 years, provided you continuously
maintain your hospital cover. The replacement
cycle does not reflect the manufacturer’s
warranty period but rather the reasonable life
expectancy of an insulin pump.
15
Please contact HCF to determine if you are
eligible for a benefit for a replacement insulin
pump on your level of cover.
Please note that HCF does not replace
damaged, lost or stolen pumps. HCF also does
not pay for consumables for insulin pumps,
which are available through the National
Diabetes Services Scheme.
Hospital claims
You may be able to claim for the following
hospital expenses, depending on your level
of cover:
• Overnight (including critical care) and same
day accommodation charges, less any
applicable excess
• Operating theatre and labour ward
(not covered under Minimum Benefits cover),
less any applicable excess
• Pharmaceuticals in hospitals that are directly
associated with the reason for admission
(excluding experimental and high cost nonPBS drugs) and are consumed in hospital
• Allied health and therapy services like
physiotherapy, occupational therapy, speech
pathology and dietetics
• Surgically implanted prostheses and human
tissue items that are Government approved
for covered services
• Emergency Ambulance cover
• Medicare gap.
When it’s time for you to leave hospital, please
read the claim form carefully, answer the
questions and sign. The hospital will send us
a bill to pay on your behalf. If your policy
requires you to pay an excess, you’ll need to pay
this directly to the hospital. This usually occurs
at the time of departure, however, check with
your hospital to make sure.
Please visit hcf.com.au, any branch, or call
13 13 34 to find out your entitlements under
your current policy.
16
Claims for doctors’ & specialists’
fees during hospital admission
If your doctor or specialist treated you under
the HCF Medicover agreement, they will send
the bills directly to HCF.
If your doctor or specialist sends the bills to you,
please take it to Medicare and complete a
Medicare Two-Way form or drop into an HCF
branch and complete a Medicare claim form
and an HCF claim form.
Ambulance claims
Medicare doesn’t cover the cost of an ambulance
and these services can be very expensive.
HCF hospital and extras products include cover
for State Government emergency ambulance
services. On some levels of cover, you may also
be able to claim up to $5,000 per person, per
year for non-emergency, medically necessary
State Government ambulance transport (see
page 38 for further information).
Members with pension or social security
entitlements in NSW or the ACT just need
to complete that section on the back of
the ambulance account and return it to the
ambulance service.
Qld and Tas members
If you live in Queensland or Tasmania, you’re
covered under your state ambulance service
scheme. If you fall outside your state based
arrangement and aren’t otherwise covered for
emergency ambulance services, you can claim
under your HCF product for State Government
provided emergency ambulance services.
If your cover is for standalone extras, there is an
annual cap for emergency ambulance services.
Please see page 38 for details.
Vic, SA, NT and WA members
If you live in Victoria, South Australia, the
Northern Territory or Western Australia
and you don’t have an ambulance subscription
with your state ambulance service and aren’t
otherwise covered (including under other
state based arrangements e.g. where the State
Government has made a provision for free
ambulance services for aged pensioners),
you can claim under your HCF product for
State Government provided emergency
ambulance services.
If your cover is for standalone extras, there is an
annual cap for ambulance services. Please see
page 38 for details.
Third party and
compensation claims
Please call HCF on 13 13 34 or visit a branch
if you believe you’re entitled to claim
compensation or damages from another
insurer for:
• Personal injury
• Third party compensation e.g. car accident
• Workers compensation.
Ambulance benefits are claimable for transport
to the nearest appropriate hospital able to
provide the level of care you need.
There is a waiting period of one day for
emergency ambulance cover, two months for
non-emergency ambulance cover (where
available under your product) and 12 months for
pre-existing ailments or conditions (provided
this procedure or treatment is not listed as an
exclusion on your cover).
NSW and ACT members
If you live in New South Wales or Australian
Capital Territory, a levy is included in the
hospital component of your private health cover.
This levy entitles you to free ambulance
transport under the State Government
ambulance transport schemes. So, if you
receive an invoice for ambulance transport, just
send it to us; we will endorse the account and
send it to the appropriate ambulance transport
scheme for settlement.
17
Things you
need to know
Exclusions
What’s not covered?
If you need treatment for any procedures listed
as an Exclusion in your hospital cover, you won’t
receive any benefits from us and you may have
significant out-of-pocket expenses.
There are a number of situations where our
health insurance doesn’t cover you:
Minimum Benefits
Minimum Benefits is the rate set out by the
Commonwealth Minister for Health as the
minimum benefit for a shared room and benefits
for Government approved Prostheses List items.
In a private hospital: These benefits would not be
adequate to cover all hospital costs and are likely
to result in significant out-of-pocket expenses.
In a public hospital: As a private patient in a public
hospital, in the event these benefits are less than
what your chosen public hospital charges, you
may have out-of-pocket expenses to pay.
What happens if I choose to be a private patient
in a public hospital?
We pay Commonwealth Minimum Benefit for
a shared room and a higher rate for a single
private room. You will need to confirm with
the hospital if they will be charging you any
out-of-pocket expenses. The hospital has the
responsibility to explain to you any out-ofpocket expenses and obtain written Informed
Financial Consent (IFC), prior to admission.
What happens if I choose to go to a
non-participating private hospital?
We pay Commonwealth Minimum Benefit
towards accommodation and prostheses.
Out-of-pocket expenses may apply to
accommodation, theatre, labour ward fees and
prostheses. You need to obtain a quote from the
hospital. The hospital has the responsibility to
explain to you any out-of-pocket expenses and
obtain written Informed Financial Consent (IFC),
prior to admission.
18
• Where there are Exclusions on your policy
• Claims made two years or more after the
date of service
• When you or your dependants have the right
to recover the costs from a third party other
than us, including an authority, another insurer
(like motor vehicle or workers compensation),
or under an employee benefit scheme
• Treatment for pre-existing ailments or
conditions within waiting periods
• Goods and services received during any
period where your payment is in arrears, your
membership is suspended or you’re within
waiting periods
• Treatment that we deem inappropriate or not
reasonable, after receiving independent
medical or clinical advice
• Experimental treatments
• Any service where the treatment does
not meet the standards in the Private
Health Insurance Accreditation Rules 2011
or as amended
• Services that aren’t delivered face to face, like
online or telephone consultations, unless
you’re participating in one of our chronic
disease management or health improvement
programs like My Health Guardian
• Goods or services supplied by a provider not
recognised by us
• Goods or services provided outside Australia,
which don’t meet the requirements under the
Private Health Insurance Act (2007)
• Claims that don’t meet our criteria.
In addition, our hospital cover
doesn’t include:
In addition, our extras cover
doesn’t include:
• Medical and associated hospital benefits for
which there is no Commonwealth Medical
Benefits Schedule item number or when
the medical services are not approved for
payment by Medicare
• Private room accommodation for
same-day procedures
• Experimental and high cost non-PBS drugs
• Procedures normally performed in the doctor’s
surgery or as an outpatient
• Private hospital emergency room fees
• Respite care
• Nursing home-type patients are limited to
benefits set by the Commonwealth
Department of Health
• Special nursing, like your own private nurse
• Luxury room surcharge
• Donated blood and blood products and
donated blood collection and storage
• PBS pharmaceutical benefits in
non-participating private hospitals
• Pharmaceuticals (including PBS
pharmaceuticals benefits) and other sundry
supplies not directly associated with the
reason for admission
• Take home items e.g. crutches, toothbrushes
and drugs
• Personal convenience items e.g. phone calls,
newspapers, magazines and beauty salon
services
• Massage and aromatherapy services
• Some services provided while in hospital
by non-hospital providers
• Where a service is not covered for the
payment of benefits in a hospital, any
associated items (e.g. medical gap, prostheses,
pharmacy) are also not covered
• The gap on Government approved prostheses
in non-participating private hospitals
• The gap on Government approved
gap-permitted prostheses items.
• P
sychological and developmental
assessments. Where psychology is included
in your cover, psychology treatment is only
payable when your GP has prescribed a
mental health plan under Medicare and your
psychology entitlements from Medicare for
that year are exhausted
• Goods and services while a hospital patient,
except for eligible oral surgery
• Pharmacy items that aren’t on our approved
pharmacy list e.g. items listed on the PBS,
items prescribed without an illness, items that
are available without a prescription, items for
reproductive medicine, sexual performance,
items for weight loss, or items that are not
TGA approved
• Goods or services that had not been
provided at time of claim e.g. pre-payment
• Fees for completing claim forms and/or
reports
• Goods and/or services received overseas or
purchased from overseas, including items
sourced over the internet
• Where no specific health condition is being
treated or in the absence of symptoms,
illness or injury
• Routine health checks, screening and
mass immunisations
• More than one therapy service performed
by the same provider in any one day
• Co-payments and gaps for Government
funded health services e.g. the co-payment
for PBS items, or services where you receive
a rebate from Medicare such as the Child
Dental Benefit Schedule, or Chronic Disease
Management - Individual Allied Health
Services
• Where a provider is not in an independent private practice
• More than one of the following therapies received on the same day (physiotherapy, chiropractic and osteopathy).
Please Note
This is not a comprehensive list of items not covered under hospital or extras cover.
Please call 13 13 34 to check what you’re covered for, prior to going to hospital or for treatment.
19
Waiting periods and how they
affect your cover
When you join any health fund there are waiting
periods applied before you can start using some
services. Waiting periods apply to hospital and
extras cover but if you’ve switched from another
health fund, you may have already served the
necessary time.
If you’re transferring from another health fund,
waiting periods may be waived for the services
that were covered under your previous policy
– provided your HCF cover includes the same
benefits and you’ve served the equivalent
waiting periods with your previous fund. This
excludes hearing aids, for which a two year
waiting period will apply from the date you
join HCF. You need to have switched from
another Australian registered health insurer or
an international health insurer belonging to the
International Federation of Health Plans, and join
within 30 days of ceasing that membership.
Note: all pre-existing conditions, pregnancies
and birth related services have a 12 month
waiting period. Waiting periods apply when you
join, upgrade your cover, reduce your excess
or rejoin after a break in cover. Waiting periods
also apply to new joiners to your policy, unless
switching from another fund or policy where
they’ve served equivalent waiting periods.
If you upgrade your level of cover, waiting
periods, including the pre-existing ailment rule,
will apply to any new or higher benefits.
Pre-existing conditions or
ailments
A pre-existing condition, illness or ailment is
one where the signs or symptoms existed at
any time during the six months preceding the
day you joined HCF or upgraded your cover, even
though a diagnosis may not have been made.
HCF will appoint a medical practitioner to
examine information provided by your doctor,
Continuity of cover doesn’t apply to loyalty limits together with other relevant claim details,
for services such as hearing aids, dental services to assess whether an ailment is pre-existing.
(including orthodontic services), physiotherapy, A 12 month waiting period will apply to
chiropractic, osteopathy and exercise
members with a pre-existing condition or
physiology. If you joined during an HCF waiver
ailment, if they are a new member or an
offer, waiting periods are waived for extras
existing member that has upgraded their cover,
services with waiting periods equal to or less
or a child not previously added to the policy.
than the waiver. Hospital services are excluded
from the waiver offer.
These waiting periods are applicable where
covered under your policy.
Hospital waiting periods
Palliative care
Psychiatric services
Rehabilitation services
Pre-existing ailments or
conditions
Pregnancy & birth related services
All other hospital services
2 months
12 months
2 months
Same day hospital treatment excess
waiver (available on selected covers)
All hospital services (where not for
pre-existing ailments)
2 months
Pre-existing ailments or conditions
12 months
Extras waiting periods
Health management programs
6 months
Artificial aids (e.g. low vision aids,
blood glucose monitors)
Foot orthotics
Pre-existing ailments & conditions
Dental bleaching, crowns, bridges
and implants
Indirect fillings
Dentures
Endodontics
12 months
Occlusal therapy
Oral surgery
Orthodontics
Having a baby
If you're pregnant and on a single or couple membership, make sure you upgrade to a family or
single parent membership as soon as you fall pregnant, but no later than 2 months prior to the
birth of your child to ensure that your child is covered. If your child is born prematurely and you
have not held family or single parent scale membership for at least 2 months, your child will not
be covered for procedures that occur during the initial 2 month waiting period. For example, if
you change your cover to a family or single parent membership and you give birth 1 month after
making the change, the child will not be covered until an additional 1 month has been served.
Waiting period for pre-existing conditions may also apply. This is why we strongly encourage you
to upgrade to an appropriate membership as soon as pregnancy is confirmed.
20
Periodontics
Prosthodontics
Veneers
Hearing aids
2 years
School Accident benefit
2 - 12 months
All other extras services
2 months
Ambulance waiting periods
Emergency ambulance (where not
for pre-existing ailments)
Pre-existing ailments
1 day
12 months
21
The gap, what it is, and
what it means for you
Sometimes there’s a difference between how
much a provider charges you and the benefits
HCF pays for, so there may be an amount you’ll
need to pay. This is known as ‘the gap’.
If you’re a private patient in a non-participating
private hospital, you may incur significant
additional expenses.
At HCF, we work hard to establish agreements
with health service providers to reduce or
eliminate this gap for our members.
To check if your hospital is a participating
private hospital, please visit hcf.com.au,
drop into one of our branches or call us on
13 13 34.
The gap – what you need to
know
Medical gap
Before you receive treatment as a private
patient, you should ask your treating health
professional, HCF and hospital about any
additional money (‘the gap’) you have to
pay. Many hospital and medical services
and procedures do not incur a gap. In fact,
numerous privately insured services in hospital
are no-gap services. If any treatments do have a
gap, you should know upfront what the cost will
be. This is called Informed Financial Consent.
Please see page 40 for definition.
Hospital gap
Private hospitals charge for accommodation,
operating theatres and other hospital related
services. HCF has agreements in place with
most private hospitals and day surgeries.
These are known as participating private
hospitals. This means you won’t have to pay
additional costs for covered services (subject
to your excess and the conditions relating to
your Hospital cover).
HCF hospital products cover in-patient services
(from when you’re officially admitted to hospital
to when you’re officially discharged), however
we do not cover outpatient services (before or
after you have been officially discharged).
22
Medical services like doctors’, anaesthetists’
and surgeons’ fees are charged separately from
hospital services. Medicare covers 75% of the
Medicare Benefits Schedule (MBS) fee for these
charges and HCF covers the remaining 25%.
However, many doctors charge more than
the MBS fee and this is when you may face
additional expenses, known as the ‘medical
gap’. HCF has arrangements with a large
number of doctors Australia-wide to help
eliminate or reduce gaps for our members.
HCF Medicover is a direct billing scheme.
It allows members to receive no-gap treatment
when doctors don’t charge more than the HCF
Medicover Schedule fee, and is delivered in a
hospital or day surgery with an agreement
with HCF.
To see a list of doctors who participate in HCF
Medicover, visit hcf.com.au. Always ask your
doctor/s if they will participate, prior to each
hospital admission. Doctors can choose to opt
in or out on a patient by patient basis. If you will
incur an out of pocket expense, the doctor/s
should let you know this before any treatment.
See page 40 for definition of Informed Financial
Consent.
Prostheses
Prostheses are items used in surgery to augment or replace a part of the body e.g. pacemakers
or joint replacement devices. Government approved, non-cosmetic prostheses that have been
surgically implanted are covered by HCF. Ask your doctor which prosthesis is best for you and
if a no-gap option is available.
Your gap checklist
This checklist provides you with questions to ask before you receive treatment
in a private hospital, or as a private patient in a public hospital.
Ask your treating specialist:
• What is your fee?
• What is the item number for the procedure?
• Will you charge according to the HCF
Medicover schedule so I can receive
services at no out-of-pocket expense?
• If I have to pay a gap, how much will it be?
• If I have to pay extra costs, when and to
whom do I pay it?
• What if I can’t afford to pay this gap?
• Which other doctors and medical staff
will be involved in my treatment?
• How can I obtain information on their fees?
• What will my total costs be?
• Will I receive just one bill?
• Am I having a surgically implanted device
or prosthesis?
• What’s the product name, supplier name,
group name and billing code?
• What’s the Medicare Benefits schedule?
Ask HCF:
• Does my policy cover me for this?
• Do I need to pay an excess or any
additional charges? If so, how much?
• Do I need to pay extra for my hospital
accommodation, doctor’s fees or
anyone else involved in my treatment?
Ask your hospital:
•D
oes this hospital have an agreement
with HCF?
• Will I have a gap to pay for my
hospital accommodation?
•W
ill I incur out-of-pocket expenses
during my time in hospital?
• I f I have to pay a gap, when is it due?
•W
hat else do I have to pay for out of my
own pocket during my time in hospital?
•W
ill the cost of this be covered by my
health fund?
23
Rebates,
surcharges
and incentives
Changes to private health legislation can affect
your choice of health cover, so it’s important to
understand how to maximise your entitlements
and avoid unnecessary expenses.
Australian Government Rebate
on Private Health Insurance
To help make private health cover more
affordable, the Australian Government provides
a rebate on your health insurance premium.
The rebate is available to people with hospital,
extras or ambulance cover and who are
registered with Medicare. The rebate is income
tested, so your entitlement may change
depending on your income and also your age.
You can elect to take the rebate either as:
• A reduced premium
OR
• A tax offset credit in your annual tax return
See privatehealth.gov.au/healthinsurance/
incentivessurcharges for the list of rebate
percentages.
24
When calculating your income you need
to include taxable income, fringe benefits,
reportable superannuation contributions, net
financial investment losses and more. You may
incur additional tax payments if you nominate
the incorrect rebate tier.
We can provide you with general information
about these thresholds and the rebate tiers.
However, for personal advice specific to your
circumstances, please consult your accountant,
financial adviser or the ATO at ato.gov.au or on
13 28 65.
Medicare Levy Surcharge
The Medicare Levy Surcharge is an
Australian Government initiative designed
to encourage high-income earners to take
responsibility for their health care. It applies
to people earning above this year's income
threshold where they don’t have eligible private
hospital cover.
You can avoid having to pay this simply by
having eligible HCF hospital cover.
If you don’t have eligible private hospital cover
and you fall into these income thresholds, then
you will be charged an additional surcharge
on your Medicare levy when your tax return is
assessed.
To view this year's income thresholds and
Medicare Levy Surcharge information, go to
privatehealth.gov.au/healthinsurance/
incentivessurcharges
Lifetime Health Cover
Lifetime Health Cover (LHC) is a Government
initiative designed to encourage people to
take out hospital insurance earlier in life and
maintain their cover.
In some cases, you may be exempt or fit into
a special circumstances category.
If you do not have a product that includes
hospital cover with an Australian registered
health fund on 1 July following your 31st
birthday and then decide to take out hospital
cover later in life, you will pay a 2% loading on
top of your premium for every year you are
aged over 30.
For example, if you take out hospital cover at
age 40, you will pay 20% more than someone
who first took out hospital cover at age 30.
The maximum loading is 70%. Once you have
paid a LHC loading for 10 continuous years, the
loading is removed as long as you retain your
hospital cover.
For members transferring from another fund,
if your LHC loading differs to what was advised,
upon receipt of the transfer certificate, your
premiums may change accordingly.
The Australian Government Rebate does not
apply to the LHC component of private health
insurance. This means if you are eligible to
receive the rebate and also have a LHC loading,
the rebate will not apply to the LHC portion of
your health insurance.
For more information, visit hcf.com.au or call
13 13 34.
25
Managing your policy
If you need to update your details, change your
level of cover or suspend your policy, there are
certain rules and policies that apply.
Communication
We will communicate important information
with you (e.g. by telephone, SMS, electronically,
or mail) about our current and new products
and services, including changes, and/or
participation in any programs we develop.
Changing your details
If your contact details change, please advise us by:
Website: hcf.com.au/members
Phone: 13 13 34
Email: [email protected]
Mail: HCF, GPO Box 4242,
Sydney NSW 2001
Fax: 1800 045 563
In person: Visit any HCF branch
Your membership card
You’ll receive your membership card/s by mail,
within five business days after joining HCF.
If you lose your card, log in to the Members’
section at hcf.com.au/members, drop into an
HCF branch, email [email protected] or call
13 13 34.
Changing to a different
level of cover
Health Fund Rules
All members on the membership should be
aware of and abide by the Health Fund Rules,
which details the rules that apply to your HCF
membership. You can view a copy of the Health
Fund Rules at any branch. HCF reserves the
right to amend, delete or add to these rules
at any time, subject to the Private Health
Insurance Act 2007 and its rules.
Other conditions that apply
to your cover
• When making a claim, the Policyholder must
comply with procedures prescribed by HCF
and must supply all information required in
the form requested. HCF will not be liable for
any costs associated with the supply of such
information
• HCF reserves the right to recover any
monies obtained fraudulently or in error, or
by other means contrary to our rules
• Benefits can only be paid when we are
provided with an itemised account and receipt
from the provider and signed claim form
• If you present a claim accompanied by an
account only and no receipt, the cheque will
be made out to the service provider.
Suspending your cover
If you want to change your level of cover, just
download an application form from hcf.com.au,
call 13 13 34, email [email protected] or visit
an HCF branch. The transfer will activate on the
date your application is received by HCF. If your
new cover gives new or higher benefits, waiting
periods, including the pre-existing ailment rule,
will apply.
You can apply to suspend your membership
if you’re travelling overseas, receiving a
Newstart Allowance or Sickness Allowance
from Centrelink, or for a reason approved by
HCF. Please note that all individuals on the
suspended policy won’t be covered for the
period of suspension. Suspension is at HCF’s
absolute discretion.
Please note that changing to a different level
of cover or withdrawing from hospital cover
may have an effect on your Lifetime Health
Cover and Medicare Levy Surcharge status
(see pages 24-25).
Conditions include:
• The minimum period of suspension is 30 days
• The maximum period of suspension is 2 years,
after which time the membership will lapse
26
• No benefits are payable to a member during
the period of suspension
• The period of suspension doesn’t count
towards waiting periods and loyalty benefits
will not increase (e.g. orthodontic limit)
• The additional Medicare Levy Surcharge
may be payable for the period of suspension,
depending on your annual taxable income
• A member wishing to suspend their cover
for travel reasons must advise HCF before
leaving Australia
• Active and financial membership must be
held for more than six months before suspension
and at least six months between suspensions
• A membership cannot be suspended more
than once in a 12 month period.
Cash Assist options and life insurance policies
cannot be suspended. You can’t suspend if
you’re on Overseas Visitors Health Cover.
To maintain the cover provided, please call
13 13 34 to arrange for the premiums to be paid
while your health cover is suspended.
To resume cover
Your policy must be resumed within 30 days
of no longer receiving a Newstart Allowance or
Sickness Allowance from Centrelink, or within
30 days of your return to Australia.
An Application to Resume Membership and
Payment Authority Form (if applicable) must be
completed and submitted to us, together with
proof that benefits were being received (i.e. a
letter from Centrelink or current employer) or
proof of departure and arrival into Australia.
Forms can be downloaded from
hcf.com.au/forms
Cancelling your cover
HCF requires the Policyholder to provide notice
in writing if you want to cancel your membership.
Any premiums paid in advance of the effective
cancellation date will be refunded in full,
provided you haven’t made a claim after your
cancellation date.
If you do want to cancel your cover, we’d like to
discuss your reasons with us first and hopefully
find alternatives that won’t affect your lifetime
health cover status, so please call us on 13 13 34.
Lifetime Health Cover loading may apply if you
don’t maintain your hospital cover from age 31.
See privatehealth.gov.au or page 25 for
more information.
Termination of membership
HCF may not terminate the membership of any
member on the grounds of their health.
However, HCF may terminate any membership if:
a) Any member included in the membership has
committed or has attempted to commit fraud
b) The application for membership is
discovered to be incomplete or incorrect
c) The member has another membership with
another health fund
d) The membership is in arrears of more than
two months
e) Any member included in the membership
has, in the opinion of HCF, behaved
inappropriately toward HCF staff, providers
or other members.
HCF will give written notice of termination to
the Policyholder and will refund any premiums
paid in advance, as at the date of termination.
30 Day Guarantee
You’ll receive a 100% refund on your hospital and
extras cover if you change your mind or cancel
your policy within 30 days from the date you
joined HCF, provided you haven’t made a claim.
Recovery of monies
If HCF makes a payment to a member in error,
HCF can lawfully recover the benefit paid from
that member within 24 months of making the
payment. The amount can be recovered if it
has been paid directly to the member or to a
third party (like a hospital) for goods or services
provided to the member.
If a refund is provided to a member, benefits
paid to the member must be returned to HCF.
27
Health and wellbeing FAQs
Can I join the program?
There are two components of the program: • An online program with many tools available to
assist if you want more energy, to reach a healthier
weight, or to simply feel better within yourself
• A telephonic disease management program if
you have a chronic condition which provides
support, advice and the tools to help you
manage your condition/s.
To join the online My Health Guardian program,
you need to: • Have hospital and/or extras cover
(Ambulance Only or HCF Life only products
aren’t eligible)
• Be 18 years of age and over.
You may join via our website at
hcf.com.au/gethealthy
If you wish to join our telephonic chronic disease
program you need to:
• Have HCF hospital cover (Extras only,
Hospital Accident Only cover, Ambulance
only or HCF Life products aren’t eligible)
• Be 18 years of age and over
• Have one of a number of chronic health
conditions.
While you’re in the chronic disease program,
upon your request, your GP will be kept informed
of your health status. This program does not
replace your GP’s treatment plan. To participate in the chronic disease program or
to get more information, call Healthways on
1800 244 854 toll-free (excludes mobiles). You can also email HCF at [email protected]
or complete our online consent form at
hcf.com.au/chronic
28
How does My Global Specialist work?
• Call My Global Specialist on 1800 797 674
• My Global Specialist will assess your eligibility
to access the service. They’ll note your medical
history and document any questions you have
• After your initial call, My Global Specialist will
mail you a registration kit. You’ll need to sign
the consent form which allows them to
collect your relevant medical information
• On receipt of your medical records,
My Global Specialist will identify an appropriate
specialist from their worldwide network to
review your case
• The chosen specialist will review your records
and proposed treatment plan and answer any
questions you might have
• Once completed, a report will be sent to
you and your local doctor, including the medical
credentials of the specialist who has reviewed
your case. Prior to sending the report, a medical
professional from My Global Specialist will call
and review the key findings with you.
Which medical conditions are eligible for
this service?
Most medical conditions that have already
been assessed and investigated by your doctor.
Are there any costs associated with this service?
No, there is no charge for HCF members eligible
to access My Global Specialist.
HCF will only be aware when you have used the
service. We will use this to determine the value of
the service to our members.
Am I eligible to access My Global Specialist?
My Global Specialist is available on selected levels
of cover. You’ll not be able to access the service
for:
Who are Best Doctors?
Best Doctors was founded by doctors from the
Harvard Medical School in 1989. This organisation
now helps people in over 30 countries around the
world achieve better medical outcomes, including
the US, UK and Canada.
•
•
•
•
•
Who will have access to my personal
health information?
Only Best Doctors, with your permission, and
your existing doctor will have access to your
medical information, your reason for using the
service or the final report.
HCF reserves the right to revise, alter, adapt
or withdraw any of our Health and Wellbeing
programs from time to time. Please consult our
website for the most up to date information about
these programs.
An emergency
Pregnancy
Mental health conditions
A condition you’re already in hospital for
A condition for which you haven’t already
undertaken an initial consultation with a doctor.
When would I access the service?
My Global Specialist provides you comfort and
reassurance when:
• You want to be sure about the medical
condition you’re suffering from
• You need help deciding on treatment options
• You may be questioning why your current
symptoms don’t seem to be improving
• You want to be sure that surgery is the only
real option.
What about my own doctor?
My Global Specialist is a specialist information
service, not a clinical service. My Global Specialist
will not prescribe treatments, but may suggest
options to discuss with your treating doctor.
We encourage you to discuss the details of the
report with your doctors.
29
How your rights
are protected
Private Health Insurance
Code of Conduct
We support the Private Health
Insurance Code of Conduct by ensuring:
• You receive correct information about
private health insurance
• You’re aware of the internal and external
dispute resolution procedures
• You can make an informed decision about
your purchase through informative policy
documentation
• You’re protected in accordance with the
privacy principles.
For a full copy of the code, visit
privatehealth.com.au/codeofconduct
Private Patients Hospital
Charter
We also support the Private Patients Hospital
Charter, which outlines what members can
expect from doctors, hospitals and their
health fund.
For a copy, call 13 13 34 or visit the Private
Health Insurance section for consumers at
health.gov.au
Have a complaint?
If there's a problem with your membership,
contact HCF directly so we can assist in
resolving it as quickly as possible.
If necessary, an Internal Dispute Resolution
Officer will be appointed to independently
review the issue.
Private Health Insurance
Ombudsman
If your complaint isn’t dealt with satisfactorily,
you can also contact the Private Health
Insurance Ombudsman, an independent body
formed to help resolve complaints and provide
advice and information.
To contact the Ombudsman:
Call: 1800 640 695
Visit: phio.org.au
Write: Private Health Insurance Ombudsman
Suite 2, Level 22
580 George St Sydney NSW 2000
Customer
Service Charter
As an HCF member, you have every right to
expect excellent service from us. We are
committed to achieving this. HCF is a notfor-profit organisation, so our focus is on our
members, not shareholders.
Our mission
HCF’s mission is to satisfy the needs of
Australians for access to affordable, high quality
health care when and where they need it;
personal protection; and peace of mind.
We will:
• Be helpful;
• Assist you courteously and professionally;
• Clearly explain our answers and actions, and
your options;
• Clearly explain changes in your policy and
premium so they are easily understood;
• Let you know of any changes to your policy
conditions or cover before the change occurs;
• Provide clear, relevant information on claims
and your membership.
Making claiming and dealing with
us easy:
There are a range of ways you can claim - online,
at our branches, through the post, via our mobile
app, or at on-the-spot claims terminals at many
of our providers. Various providers will process
your claim for you.
So we can help, we ask that you:
Contacting HCF
In Person - visit a branch, Dental or Eyecare Centre
HCF has many branches, kiosks and agents
across Australia who provide a convenient
service for joining HCF, accessing advice and
making claims.
HCF Eyecare Centres are independently owned and operated
by Eyecare Holdings Pty Limited ACN 054 365 196.
By phone - when you call, you can expect that:
• Our staff will identify themselves by name;
• If we cannot help you immediately we will
arrange for someone to call you at a time
suitable to you;
• We aim to return your call within the same
working day or next working day if the
contact is received outside of business hours.
By mail - we aim to respond to mailed enquiries
within five working days of receiving them.
By email, and through our website - when we
receive your email at [email protected],
or message through the Members Section of
our website, you will immediately receive an
acknowledgement via our email management
system. This tracks your communication with us.
We aim to formally acknowledge your email and
provide a response within three working days.
For a copy of the full version of our Customer
Service Charter, please visit hcf.com.au, your
local branch, or call our Member Services team
on 13 13 34.
• Be courteous to our staff;
• Let us know when things change,
for example, your contact details;
• Give us feedback on our service.
30
31
Want to have
your say?
We believe our members should have an active
role in how HCF is managed and run. We were
the first major Australian health insurer to give
its members the right to elect the governing
body of the company.
At the Annual General Meeting in November
2011, Constituent Members voted to change
the Constitution.
Voting Policyholders
All Policyholders will be automatically
registered as HCF Voting Policyholders
once they have held HCF hospital cover for a
continuous period of at least five years. If you
were registered as a Voting Contributor (under
the ‘old’ system), you do not need to re-register.
Voting Policyholders elect the 16 Elected
Councillors of the company.
Councillors
There are up to 24 Councillors, made up of 16
Elected Councillors, and 8 Board Councillors
(who are the 8 Directors of the Board). This is
a ratio of 2:1. The 16 Elected Councillors will be
elected by Voting Policyholders.
The Councillors are Members of the Company
and can vote on the election of directors for
the Board.
32
How fraud
affects you
Becoming an Elected
Councillor or a member
of the Board of Directors
Voting Policyholders may express their
interest in becoming an Elected Councillor,
providing they meet the Elected Councillor
Eligibility Criteria. Policyholders may also
express their interest in serving on HCF’s
Board as an Elected Director, providing they
meet the Elected Director Eligibility Criteria.
Timing
You’ll be advised of elections for the Elected
Councillors before every annual general
meeting of the company. Policyholders who
wish to ‘opt out’ of being a Voting Policyholder
will be able to do so.
For more information
See the Corporate Governance section
at hcf.com.au or call us on 13 13 34.
When someone commits fraud against HCF,
we all pay the price in either higher premiums
or reduced benefits. As a not-for-profit
health fund, we exist only for the benefit of
our members. That’s why we do everything
possible to detect and prevent fraud.
What is health insurance fraud?
• Claiming for treatment or services that
haven’t been provided
• Falsifying documents or altering accounts
to increase benefits
• Withholding relevant information or
providing false information.
What are we doing to detect
and prevent fraud?
HCF combats fraud on a number of fronts.
From sophisticated software programs that
identify unlikely treatment patterns, to fraud
awareness training for all our staff, the HCF
investigations team monitors claiming patterns
and successfully prosecutes offenders.
How can I help HCF
fight against fraud?
There are four main things you can do to help.
1. Never leave your membership card with
anyone, even your healthcare provider
2.Always check the details on your receipt –
especially your electronic claiming receipt
3.Regularly check your claims history by
logging onto the Members’ section at
hcf.com.au/members
4.Report any suspicious behaviour or
irregularities to HCF.
Fraud hotline
If you suspect fraud, tell us. Even if it doesn’t
turn out to be fraud, you’ll probably have
alerted us to a potential improvement in our
system. All reports are kept strictly confidential.
Remember, when someone gets away with
health fund fraud, we all get less from HCF.
Call 1800 727 721, email us on
[email protected] or
visit us at hcf.com.au/fraud
You may report lost cards on 13 13 34.
33
Want to change your
payment method?
No problem. It’s quick and easy, and there’s
a wide range of alternative payment options
to choose from.
How do I change my payment method?
• Visit hcf.com.au/members
• Visit your nearest HCF branch
• Email [email protected]
• Call us on 13 13 34.
Seven convenient ways to pay
1. Direct debit (Ezipay) via your credit card
or bank account
2.Payroll deduction via your employer. Payroll
deductions are available only when your
employer has an arrangement with HCF
3.Phone 13 14 39 for self service and to pay
by credit card
4.Visit hcf.com.au to pay by credit card online
5.Visit hcf.com.au/bpay
6.Cheque or money order
7.Visit your nearest branch to pay by credit
card, cheque, money order or cash (EFTPOS
not available). Please note only credit card
payments are accepted at kiosks.
What if I fall behind in my payments?
Your premiums must be paid in advance.
If your premiums are more than two months
in arrears, your membership will automatically
cease. If you decide to rejoin, the normal waiting
periods will apply, including the pre-existing
conditions and ailment rule (see page 20).
Lifetime Health Cover loading may also apply
(see page 25).
34
Direct Debit Customer
Service Agreement
The Direct Debit Customer Service Agreement
applies when you pay your premiums using a
direct debit facility with your bank, building
society or credit union. Your Direct Debit
Customer Service Agreement with us is as
follows. The agreement details your rights and
responsibilities when undertaking a direct debit
arrangement with us. We guarantee to abide
by this service agreement so that a trusting
relationship is maintained between us and you.
Please read these direct debit terms and
conditions carefully:
• You should check with your financial institution
to see if direct debit is available to you
• We will advise your financial institution
to debit your selected account on your
nominated debit date. If your debit date
occurs on a non-business day, the debit will
be made on the next business day
• Your nominated debit amount will not vary
unless:
– Your premiums are not in advance of your initial debit date
– Your premiums are not owing prior to your initial debit
– You change your level of cover which has
a different premium rate
– You relocate to another state that has a different premium rate
– You change your payment frequency or payment method
– Your entitlement to the Australian Government Rebate is varied
– Your Lifetime Health Cover loading is varied
– You change your debit date
– Your premium was returned unpaid by your financial institution
– You resume your membership after a suspension period
– Your premium rates change.
• Your premiums are payable to cover periods
in advance of your nominated debit date
• We reserve the right to cancel your direct
debit if three or more consecutive debits
are returned unpaid from your financial
institution. We will advise you of alternative
payment arrangements to ensure your
health cover continues
• Where the account is not in the name of the HCF Member, the account holder is entitled
to cancel the direct debit.
Changes to your membership
and debit details
To cancel your direct debit arrangements,
change your payment frequency or request to
defer your premiums, you must notify us by
phone, email or fax no later than two business
days prior to your next debit date. To request a
change to your level of cover, you must notify
HCF no less than three business days prior to
your next debit date.
Your responsibilities
• Make sure the details on our letter of
confirmation are correct and your account
details are identical to details held by your
financial institution
• Make sure sufficient cleared funds are
available in your nominated account to meet
the debit on the due date. Where there are
insufficient funds to cover your debit, your
financial institution may charge you a fee
• Advise us promptly if you close your
account or if your account details change
• Where the direct debit payment has
previously been stopped by you at your
financial institution, you need to contact them
to re-activate your HCF Direct Debit Request.
Please visit hcf.com.au/forms to download
a direct debit form, email [email protected],
call 13 13 34 or log in to hcf.com.au/members
Our commitment to you
• New members will receive confirmation of
their direct debit details within five business
days prior to the first debit date
• If you change any direct debit details, we will
confirm the change in writing (via letter or
email), no later than five business days from
receiving your request
• If we have taken the wrong amount from your
account, please contact us on 13 13 34 during
business hours or visit a branch and one of our
staff will arrange a refund as soon as possible
• If there is still a problem, it will be resolved
in no more than seven business days after
notification. Where a problem arises with your
financial institution, we will liaise with them and
keep you informed of progress until resolution
• Your account details will be kept private
and confidential.
35
Our
privacy statement
We collect your personal information including
sensitive information such as health information
from you and/or the Policyholder who is
responsible for your policy and/or from other
third parties detailed in our Privacy Policy, so
we can:
• Comply with applicable laws
• Manage our relationship with you
• Record your treatment
• Provide health or other insurance, related
products and services to you (including
through third parties)
• Manage and pay claims and benefits
• Assess your insurance, health and related
lifestyle needs
• Investigate fraudulent or improper claims and
assess risks
• Research and develop products, services and
benefits that may better serve your needs
• Assess your possible interest in and tell you
about such products and services
• Administer our business and deal with
complaints.
The types of organisations and individuals we
disclose personal information to include:
• Third party organisations who deliver services
on our behalf or to us, some of whom may be
located overseas
• Health service providers, to improve their
ability to provide you with health services
• Research companies contracted to us to
ask your opinion on improving our service,
benefits or product offerings
• Other insurers or reinsurers, including other
health insurers if you have moved your
insurance to or from HCF
• Government, including law enforcement
agencies
36
• Related HCF companies
• The named Policyholder who has your authority
• Any other authorised individual.
If you do not provide the personal information
we request, we may not be able to provide you
with our products or services, including health
insurance.
You can ask us at any time to stop direct
marketing to you by emailing
[email protected] or calling 13 13 34
(13 14 39 for Self Service).
For more information about the personal
information we collect and how we handle it,
how to access and correct your information or
to make a complaint and how we will respond
to complaints, please read our Privacy Policy.
To view the HCF Privacy Policy:
• Visit hcf.com.au/privacy
• Visit your local branch.
All new Policyholders should ensure that all
members on the policy are made aware of the
HCF Privacy Policy.
Changes to products and
pricing
Please read and retain this brochure for
future reference. It should be read in
conjunction with our Health Insurance
brochure. We reserve the right to make
changes to prices, product specifications
and other conditions relating to our
products. Please contact us prior to
purchasing any products or health
services to make sure that you have the
latest information available.
Useful websites
The following websites provide information to help you
assess your health care needs.
hcf.com.au
health.gov.au
HCF is dedicated to delivering the best quality
healthcare to our members and providing
private health insurance cover for a full range
of health benefits including private hospital,
Australia-wide Ambulance cover and ancillary
services.
Information on Medicare Benefits Schedule
(MBS).
hcf.com.au/members
HCF provides a variety of online services to help
you get the most from your membership.
hcfeye.com.au
HCF Eyecare offers a range of fully covered
glasses, as well as savings on disposable contact
lenses and sunglasses to HCF Members.
healthdirect.gov.au
Up-to-date and quality assessed health
information.
nps.org.au
Be medicine wise. Get the most out of your
medicines and make better informed choices
about them.
phiac.gov.au
HCF Eyecare is independently owned and operated
by Eyecare Holdings Pty Limited ACN 054 365 196.
The Private Health Insurance Administration
Council (PHIAC) is an independent statutory
authority that regulates the private health
insurance industry.
privatehealthcareaustralia.org.au
phio.org.au
Private Healthcare Australia, formerly known
as the Australian Health Insurance Association,
is the Australian private health industry’s peak
representative body that represents 21 health
funds throughout Australia and collectively
covers over 95% of the private health insurance
industry.
ato.gov.au
This website provides information on the tax
benefits and issues around private health cover.
comlaw.gov.au
The Private Health Insurance Ombudsman
(PHIO) provides an independent service to help
consumers with health insurance problems and
enquiries.
privatehealth.gov.au
This website provides information on private
health insurance policies available in Australia.
seniors.gov.au
Online source for Australians over 50 years
of age.
Private Health Insurance Act 2007.
37
Glossary
This Glossary contains an explanation of words
and phrases commonly used throughout HCF
materials and which have a special meaning.
Accident means an unforeseen and unintentional
event, occurring by chance and caused solely and
directly by an external mechanical force or object
resulting in involuntary damage or injury to the
body requiring immediate and urgent medical
advice or treatment from a registered practitioner
other than the Policyholder. For determining a
benefit for hospital treatment for an Accident,
the following criteria must apply:
a) You are admitted to a hospital or transferred to another hospital as part of a continuing
admission, (each and together an Admission)
and;
b) That Admission was via that hospital’s
accident and emergency department; and
c) The hospital treatment was not for the
treatment of an illness, condition, ailment,
sickness or injury that was either known or
should reasonably have been known to you
at any time; and
d) That the damage or injury resulted in an
Admission within 24 hours; and
e) The hospital treatment was the immediate and
urgent treatment for the damage or injury; and
f) The Accident did not occur as a consequence
of your employment or professional duties.
Ambulance Transportation
HCF pays benefits towards eligible State
Government provided emergency and nonemergency ambulance services depending
on your level of cover and up to your annual
limit. The ambulance service provider must be
recognised by HCF and the transportation must
be to the nearest appropriate Australian hospital
able to provide the level of care required.
Emergency Ambulance Transportation:
Benefits are payable for emergency ambulance
services where transport to the nearest hospital
or on-the-spot treatment is required. “Emergency”
means an immediate and serious threat to
person’s health or life. Benefits are not payable:
• Where the ambulance service is not
requested because of an emergency;
• For transport on discharge from hospital
to your home or nursing home;
38
• Where you are covered by another funding
arrangement such as a State Government
scheme;
• Where you are covered by another third party
(such as a state ambulance subscription or
the ambulance charges are the subject of a
compensation claim);
• For transfers between hospitals;
• For charges raised for a medical retrieval
team escort;
• For ambulance transport providers not
recognised by HCF.
Non-Emergency Ambulance Transportation:
A limited number of HCF products include a
non-emergency ambulance benefit and eligible
members can claim up to a maximum of $5,000
in a calendar year for non-emergency ambulance
transport.
“Non-emergency” ambulance transport means
transport by a State Government provided
ambulance that is requested because your
medical condition requires a level of support
and medical monitoring in transit that only an
ambulance service can provide. Non-emergency
ambulance transport must be requested by your
treating doctor to be considered for an HCF
benefit.
Benefits are not payable for Non-Emergency
Ambulance transport:
• Where the transport does not meet the
definition above (such as for general patient
transport);
• Where the transport has been elected by the
patient or family for reasons such as choice of
doctor or hospital or closer to family;
• Where you are covered by another funding
arrangement such as a State Government
scheme;
• Where you are covered by another third party
(such as a state ambulance subscription or
the ambulance charges are the subject of a
compensation claim);
• For transfers between hospitals;
• For charges made for a medical retrieval team
escort;
• For ambulance providers not recognised by
HCF.
Ambulance service providers recognised by HCF
HCF recognises the following ambulance service
providers for the purposes of paying benefits:
- ACT Ambulance Service
- Ambulance Service of NSW
- Ambulance Victoria
- Queensland Ambulance Service
- South Australia Ambulance Service
- St John Ambulance Service NT
- St John Ambulance Service WA
- Tasmanian Ambulance Service.
Artificial appliances are those meeting the
following criteria:
a) Intended for repeated use
b) Used primarily to alleviate or address
a medical condition
c) Not useful to a person in the absence
of an illness, injury or disability
d) Supplied by a reputable supplier
e) Has been authorised by the attending doctor
or allied health professional
f) Approved by the fund’s medical Adviser.
Benefit means an amount paid or payable to a
Policyholder or provider, or provider on behalf of
a Member, in accordance with HCF’s Fund Rules.
Calendar year means a period of twelve (12)
months from 1 January to 31 December inclusive.
Contributor is also known as the Policyholder
and is referable to HCF.
Cosmetic surgery means an elective cosmetic
surgical procedure for which there is no allocated
Commonwealth Medicare Benefits Schedule
item number, or for which Medicare does not
provide benefits.
Dependants: Child, Student & Adult
Child dependant means a person who:
a)Is less than 22 years of age; and
b) Isn’t married or in a de-facto relationship; and
c) Is primarily reliant on the Policyholder
(or Partner listed on policy) for maintenance
and support; and
d) Is related to the Policyholder (or Partner
listed on policy) as a Child, Stepchild, Foster
Child or other Child that the Policyholder
(or Partner listed on policy) has legal
guardianship over.
Student dependant means a person who:
a) Is aged between 22-24 (inclusive); and
b) Is a full time student at school, college or
university; and
c)Isn’t married or in a de-facto relationship; and
d)Is primarily reliant on the Policyholder
(or Partner listed on policy) for maintenance
and support; and
e) Is related to the Policyholder (or Partner listed
on policy) as a Child, Stepchild, Foster Child
or other Child that the Policyholder (or Partner
listed on policy) has legal guardianship over.
Adult dependant means a person who:
a) Is aged between 22-24 (inclusive); and
b) Isn’t married or in a de-facto relationship; and
c) Isn’t a Child dependant; and
d) Isn’t a Student dependant; and
e) Is related to the Policyholder (or Partner listed
on policy) as a Child, Stepchild, Foster Child or
other Child that the Policyholder (or Partner
listed on policy) has legal guardianship over; and
f) Is primarily reliant on the Policyholder
(or Partner listed on policy) for maintenance
and support; and
g) Is insured under an Extended Family or
Single Parent Extended Family membership.
Direct filling (sometimes called a direct
restoration) is made in the mouth.
Eligible Musculoskeletal Condition means a
disease/health problem that is accepted under
the More for Backs program as eligible for a nogap benefit payment. Eligible Musculoskeletal
Conditions have been included in the program
because HCF is satisfied in its discretion that
there is a sufficient evidence base to support
chiropractic or osteopathy treatment of the
disease/health problem. The list of eligible
musculoskeletal conditions may be varied by
HCF from time to time.
Emergency treatment means those services
received in connection with the sudden and
unexpected onset of a serious injury or illness
requiring surgical or medical attention within 24
hours after the onset, and in the absence of such
care, the Member could reasonably be expected
to suffer serious physical impairment or death.
Excess options means a nominated amount
a Member agrees to pay when admitted to
hospital. If hospitalised, the total excess option
will apply once per person in a calendar year.
Exclusions mean if you need treatment for any
procedures listed as an Exclusion in your hospital
cover, you won’t receive any benefits from us and
you may have significant out-of-pocket expenses.
Extended Family cover means a membership
where Adult dependant/s can be covered by a
Family or Single Parent Family membership for
an additional charge (only available on some
levels of cover. Please consult HCF for further
details).
39
Foot orthotics ‘Orthotics’ are deemed in-shoe
appliances, used to aid in the management of
diagnosed conditions of the foot, ankle and lower
limb. They are only claimable if your cover includes
foot orthotics and the 12 month waiting period has
been served. The foot orthotics must be supplied
by a recognised podiatrist, pedorthist, orthotist.
Under certain products, pre-fabricated foot
orthotics can also be claimed when supplied by
a sports physician, physiotherapist, chiropractor
or osteopath. Benefits for custom made orthotics
can only be claimed for devices that have been
fabricated by a podiatrist, or by a pedorthist or
orthotist on behalf of a podiatrist following a
biomechanical examination, gait analysis, negative
cast or 3D digitised impression taken of the feet,
or when prescribed by an orthopedic surgeon or
other medical specialist.
HCF Participating Hospital means a hospital
where specific charges have been negotiated for
accommodation and other services.
Health management program means a program
approved by HCF. The program will not qualify
unless it is intended to prevent or ameliorate a
specific health condition or conditions.
Hearing aids are defined as devices that
are intended to treat or compensate for an
individual's hearing loss. They are personalised
to the user's hearing characteristics.
Hospital is any public or private facility declared
by the Minister as a hospital.
Indirect filling (sometimes called an indirect
restoration) is made outside of the mouth using
a model or digitised image.
Informed Financial Consent (IFC) is the
provision of cost information to patients,
including notification of likely out-of-pocket
expenses (gaps), by all relevant service
providers, in writing, prior to admission to
hospital or treatment.
Initial consultation in relation to the More
for Muscles, More for Backs and More for Feet
programs means the first service you receive for
a New Episode of Care.
Inpatient means any Member who is formally
admitted to hospital.
Medical adviser means a Medical Practitioner
appointed by HCF to give technical advice
from time to time on professional matters and
includes the Medical Director.
Medical Practitioner means a Medical
Practitioner within the meaning of the Health
Insurance Act.
40
Medicare benefit means a benefit payable by
the Department of Human Services (formerly
Medicare Australia).
Member means a person covered by a Policy.
Minimum Benefits is the rate set out by the
Commonwealth Minister for Health as the
minimum benefit for a shared room and benefits
for Government approved Prostheses List items.
• In a private hospital: These benefits would
not be adequate to cover all hospital costs
and are likely to result in significant out-ofpocket expenses.
• In a public hospital: As a private patient in a
public hospital, in the event these benefits
are less than what your chosen public
hospital charges, you may have out-of-pocket
expenses to pay.
Minimum Standard Supply means the smallest
commercially available pack size of a drug that is
supplied by its manufacturer to pharmacies.
Minister means the Federal Minister for the
relevant Commonwealth Department whose
portfolio includes responsibilities for matters
relating to health.
New Episode of Care in relation to the More
for Muscles, More for Backs and More for Feet
provider network means:
a)A new health condition where the symptoms are not related to a condition for
which treatment (of the program treatment
type) has previously been sought; or
b)An acute flare-up of an existing condition
where there has been no treatment (of the
program treatment type) for that condition
provided in the previous three months.
Non-participating hospital is a hospital that is
not an HCF Participating Hospital.
Partner means a spouse or de-facto partner.
PBS equivalent co-payment the Pharmaceutical
Benefits Scheme (PBS) makes subsidised
prescription medicines available to Australian
residents and requires a co-payment to be paid
towards each item. HCF requires an equivalent
co-payment for each pharmaceutical item before
a pharmacy claim is paid.
The amount of the co-payment is adjusted
around 1 January each year in line with the
Consumer Price Index.
Pharmaceutical item means an item which is
ordinarily claimable under an eligible Extras
product which meets the following criteria:
a) It is prescribed by a Medical Practitioner
or dental practitioner on prescription in
accordance with relevant state legislation; and
b)It is supplied by a pharmacist or Medical
Practitioner in private practice under relevant
state legislation; and
c)It is registered (labelled with an AUST
R number) on the Australian Register of
Therapeutic Goods (ARTG) and is prescribed
for treatment of the approved specific
indications as detailed in the ARTG; or
d) It complies with HCF’s Clinical Pharmaceutical Procedure for Ancillary Benefits as approved by the Medical Director or equivalent, provided that none of the following apply:
i) The item is listed or was listed under the PBS in any brand, formulation, strength or pack size and regardless of whether PBS availability is subject to any specified purpose or patient type; or
ii) The Minimum Standard Supply for the item is customarily charged at an amount that is less than, equal to, or within $3 of the current PBS co-payment for general patients; or
iii) The item is generally prescribed for purposes outside of illness or disease or
for reproductive medicine including contraception or for the enhancement of sporting, sexual or work performance; or
iv) The item is generally prescribed for
weight loss (some weight loss medications can be claimed under Health Management Programs);
v) The item is excluded under the HCF Clinical Pharmaceutical Procedure for Ancillary Benefits; or
vi) The item is available without a prescription.
Policy means complying health insurance
product or life insurance product, as applicable.
Policyholder means the Member whose name
the policy is held under. They are responsible
for premiums, ongoing maintenance of the
policy and receiving payment of benefits. The
Policyholder is also known as the Contributor
and is the contact person on the Policy.
Private Practice means a professional practice
(whether sole, partnership or group) that is selfsupporting. This means that its accommodation,
facilities and services are not provided or
subsidised by another party such as a hospital
or publicly funded facility.
Prosthesis means items listed on the Prosthesis
List. Prostheses are items used in surgery to
augment or replace a part of the body e.g.
pacemakers and joint replacement devices.
Prosthesis List means the list of Prosthesis in the
Private Health Insurance (Prostheses) Rules made
pursuant to the Private Health Insurance Act.
Psychiatric care means hospital treatment
received in a hospital that is licensed to provide
psychiatric treatment, and where the reason for
admission was for the treatment of a psychiatric
condition with a program approved by HCF (e.g.
treatment of drug and alcohol disorders and
mood disorders such as depression).
Recognised Provider means a provider of general
treatment in Australia who is in Private Practice,
and for each relevant class or service, satisfies all
recognition criteria, and who is recognised by HCF.
Recognition criteria and requirements include
the following:
a) The provider is registered or holds a licence
under relevant state or territory legislation to
render services for which recognition is sought
b) The provider is professionally qualified, or a
member of a professional body recognised by
HCF
c) Any other criteria that HCF considers
reasonable, such as complying with the Terms
and Conditions for HCF Recognised Providers of
General Treatment.
Rehabilitation care means hospital treatment
received in a hospital that is licensed to provide
rehabilitation treatment within a program
approved by HCF.
Same-day treatment means hospital treatment
that does not include part of an overnight stay.
Single private room is a suitable room in a
hospital which is purpose built and holds a single
bed. This room would have facility for no more
than a single admitted patient and would include
an ensuite.
Two year optical limit is available under
particular HCF covers. It means that after 12
months, the optical limit converts to a two year
limit which spans the current and previous year.
The two year limit allows you to claim the full
amount in one year, or progressively over two
years. If the full limit is claimed in one calendar
year, no benefit is payable in the next year.
An annual sub-limit for contact lenses applies.
41
Index
A Accident 38
Ambulance benefits 38, 39
Ambulance claims 16, 17
Artificial appliances 13, 20, 21, 39
C Cancelling cover 27
Cash Assist Cover 9
Changing details 26, 35
Claiming (health insurance expenses) 12, 13
Customer Service Charter 31
D Dental Centres 5
Dependants 11, 39
Direct debit 34, 35
E Exclusions 18, 39
Extended family cover 10, 39
Eyecare Centres 5
F Fraud 33
Foot orthotics 40
H Health Fund Rules 26
Health management programs 6, 7, 13, 28, 29
Hospital claims 16
Hospital gap 22
I Inpatient 40
Insulin pump 15
L Lifetime Health Cover (LHC) 25
Loyalty benefits 5
M Medical gap 22,23
Medicare Levy Surcharge 24, 25
Membership Card 26
42
Minimum benefits 18, 40
More at Home 9
My Global Specialist 7, 28, 29
My Health Guardian 6, 28
O Ombudsman 30
P Participating hospital 22
Pet insurance 8
Pharmaceuticals 14, 40, 41
Policyholder 10, 41
Privacy 36
Private Health Insurance Code of Conduct 30
Psychiatric care 41
Psychology 14
R Rebates 24, 25
Rehabilitation care 41
Retirement and aged care services 9
S Single private room 41
Suspension of cover 26, 27
T 30 Day Guarantee 27
Travel and accommodation 15
Travel insurance 8
W Waiting periods 20, 21
Please contact HCF on 13 13 34 or visit
one of our branches before purchasing
any products to make sure you have the
latest information available.
43
It’s easy
to deal with HCF
Go to
the HCF website
hcf.com.au
Visit
one of our many branches.
Find your closest branch at
hcf.com.au/branches
Claim
using our app
Take a photo of your extras claim
receipt on your phone and submit.
Available for iPhone and Android
We've made it simple for you to start
enjoying benefits only HCF can offer.
The Hospitals Contribution Fund of Australia Limited. ABN 68 000 026 746
Head Office: 403 George Street,Sydney NSW 2000
4058879 APR15_VAL0095_MG
Call
13 13 34
We’re open 8am - 8pm,
Monday to Friday,
9am - 5pm weekends (AEST)
Email
[email protected]