Insure? Not Sure?

Topics in this Section

Introduction

Contents

General Information

Surcharges and Incentives

About Private Health Insurance

Types of Cover

Questions You Should Ask

Common Terms

Insurer Contact Details

About Private Health Insurance

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Ineligible claims

Benefits will generally not be paid:

• if you will be paid compensation by a third party
• for certain general treatment (previously known as ancillary or extras) services provided by someone not recognised by your insurer or if you are not covered for general benefits
• if you put false or inaccurate information on your claim form
• if you are more than two months behind with your contributions
• if you claimed benefits for services provided while your membership with the insurer was suspended
• if the service provider is directly related to you - that is, if he or she is your spouse, parent, child or sibling, or
• if your claim is made two or more years after the date of service.

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Prostheses

Surgically implanted prostheses, such as a lens for a cataract surgery, a stent for cardiac surgery or an artificial hip or knee component during a hip/knee replacement, are sometimes required during a medical procedure. For every medical procedure covered by the Medicare Benefits Schedule (MBS) requiring a surgically implanted prostheses, clinicians have determined at least one clinically suitable prostheses that must be covered by health insurers at no additional cost to you (called a ‘no-gap’ prostheses).

There may be some prostheses available which cost more than the ‘no-gap’ ones. If you choose to use one of these prostheses, you will have to pay the difference between the ‘no-gap’ amount and the total amount charged by the supplier for the prostheses.

For each procedure, you should ask your health insurer how much it will pay for a particular prostheses, and whether you will have any ‘gap’ to pay.

Don’t forget that if your private health insurance policy has exclusions – where you can’t claim for some services, for example joint replacements – then you won’t be able to claim for any prostheses provided as part of these services either.

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Private Health Insurance Administration Council

Suite 16, Level 1, 71 Leichhardt Street, KINGSTON ACT 2604
Telephone 02 6215 7900 | Facsimile 02 6215 7977 | Email phiac@phiac.gov.au

Last modified: 22 July, 2005