Your Member Guide ntil 2014 15 lid u Va Re Health Insurance Australia 2009 - 2014 April 2015 g . N o. 5 0 3 7 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. HEALTHY HEALTHYWEIGHT WEIGHTFOR FORLIFE LIFE HCF HCFbelieves believeshealthy healthyliving livingstarts startswith with awareness awarenessand andeducation. education.Our OurHealthy Healthy Weight WeightFor ForLife Lifeprograms Programsare aredesigned designed to topromote promoteand andteach teachskills skillstotoachieve achieveand and maintain maintaina ahealthy healthyweight, weight,for foreligible members members with Typewith 2 Diabetes, Type 2 Diabetes, Cardiovascular Cardiovascular conditions andconditions Osteoarthritis. and Osteoarthritis. The Theprograms programshave haveshown shownpositive positiveresults, results including includingmajor majorimprovements improvementstotothe thehealth and wellbeing of participants. health and wellbeing of participants Visit hcf.com.au/hwfl forfor more information. Visit hcf.com.au/hwfl more 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]
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