Hospital Cover

When you purchase HCI hospital cover, you have the confidence to say 'yes' to treatment in a private hospital or treatment as a private patient in a public hospital.

HCI Premier Hospital does not have exclusions or benefit limitations for treatment that is clinically necessary and eligible for Medicare benefits. If you have served the relevant waiting periods and any other standard conditions - you're covered.

When deciding what level of hospital cover is best for you, you should consider the following information about treatment options:

A public patient in a public hospital

As an Australian resident, Medicare entitles you to free treatment in a public hospital by a doctor appointed by the hospital at a date and time suitable to the hospital.

A private patient in a public hospital

If you decide to be treated as a private patient in a public hospital, you have the right to choose the doctor who treats you but there is no guarantee you will be able to avoid the public hospital waiting lists.

A private patient in a private hospital

As a private patient in a private hospital, you will usually gain immediate access to hospital services and be able to choose the doctor who treats you at a time that is convenient to you.

Agreement Hospitals

HCI has entered into agreements with over 500 private hospitals, same day and day hospital facilities around Australia.

To search for contracted hospitals please click here.

What is covered:

  • Up to 100% of the cost of hospital accommodation and theatre fees in all contracted hospitals and day surgery facilities in Australia.
  • Up to 100% of the cost of surgically implanted prostheses (as listed by the Federal Government).
  • Private room accommodation (if available).
  • Up to 100% of the cost of most hospital prescriptions relating to the admission. (Subject to hospital agreement details).
  • Dental theatre costs for surgical tooth extraction by an oral surgeon.
  • 100% of the cost of the difference between the Medicare refund and the Commonwealth Medical Benefit Scheme (CMBS) fee for medical services provided during a hospital admission.
  • Up to 100% of the cost of medical services provided during a hospital admission where the doctor charges above the Commonwealth Medical Benefit Scheme (CMBS) fee and chooses to use Access Gap Cover.

What is not covered:

  • Cosmetic surgery.
  • Charges for extra services such as physiotherapy not included in the hospital agreement.
  • Personal expenses such as phone calls.
  • Hospital benefits where the professional service performed is not eligible for Medicare benefits.
  • Pharmaceutical items supplied or prescribed on discharge.
  • Medical Gap.
  • Surgically Implanted Prosthesis Gap.
  • Medical treatment provided to you whilst you are not in hospital, such as surgical procedures conducted in a doctors' room.

Hospital Cover Excess Options

By choosing to include an excess in your hospital cover, the amount you pay will be reduced. The larger the excess, the lower the premium.

Please note the following features about HCI’s excess options.

  • There is no excess payable on day only admissions.
  • There is no excess payable for dependant children under the age of 18 years who are admitted to hospital.
  • The excess per adult is the maximum payable in any calendar year.

 

If a person covered is under the age of 18 on a single or couple policy they will be required to pay the excess.

The following excess options are available with Premier Hospital or Premier Package:

Membership Category

Per adult excess

Application of Hospital Treatment Excess

 $250

$500

$1000*

Note the maximum excess per policy for all categories except Single is double the adult excess.

Single

Yes

Yes

Yes

The excess payable when admitted to hospital overnight.

Couple

Yes

Yes

Yes

The excess for each person admitted to hospital overnight.

Family

Yes

Yes

Yes

The excess for each of the first two adults admitted to hospital overnight.

Family Dependant Plus

Yes

Yes

Yes

The excess for each of the first two adults admitted to hospital overnight.

Single Parent

No

Yes

No

The excess for each of the first two adults admitted to hospital overnight.

The excess is restricted to $500 per adult.

Single Parent Plus

No

Yes

No

The excess for each of the first two adults admitted to hospital overnight. 

The excess is restricted to $500 per adult.

* Not exempt from Medicare levy surcharge

 

Waiting Periods

What are waiting periods?

A waiting period is an initial period of health insurer membership during which no benefit is payable for certain procedures or services. Waiting periods can also apply to any additional benefits when you change (upgrade) your health insurance policy.

 

Why do waiting periods apply?

In Australia, all health insurers are required by law to provide health insurance for Australian residents regardless of their health status and cannot charge higher premiums based on whether a person is more likely to require treatment. If there were no waiting periods, people could take out hospital insurance or upgrade to a higher policy only when they knew or suspected they might need hospital treatment. Their hospital costs would then have to be paid by the long-term members of the insurer. This would lead to much higher premiums for all insurer members and would not be fair.

 

Do all health insurers apply the same waiting periods?

 Most insurers apply the same waiting periods for hospital policies, but waiting periods do differ between insurers for general treatment (extras).

 

Benefit limitation periods

Some insurers also apply Benefit Limitation Periods for some types of treatment on some of their hospital policies. These are initial periods of membership during which only a minimal benefit is paid for some types of treatment. HCI does not have any Benefit Limitation Periods included in its hospital products.

 

First-time health cover

If you are taking out private health insurance for the first time, you will be required to serve full waiting periods before benefits can be paid.

 

Transferring from another health fund (portability)

If you already have health cover with another health fund, you can transfer to HCI at any time.

If you join within 2 months of the expiration of your cover with your previous fund, you will not have to serve any new waiting periods for the same or lower level of cover with HCI.

HCI’s normal waiting periods will be applied, including the pre-existing ailments rule, to benefits not covered by your previous fund cover. Under the Federal Government’s Lifetime Health Cover initiative, your “certified age at entry” with your previous fund will be recognised by HCI if you join immediately after the expiration of your cover with your previous fund.

 

Accidents

There is no waiting period for treatment as a result of an accident sustained after joining us. An accident is categorised as an unforeseen event or incident which results in an injury and requires immediate treatment.

 

Changing your HCI cover

You can vary  your  level  of  cover  to  meet  your  changing  needs at any time. If you increase your level of cover by adding a new benefit type, or by increasing your benefit level, or moving from an excess product to a lower or excess free product, waiting periods will apply to the higher benefits of your new cover. You will, however, be entitled to the benefit levels of your previous cover.

 

Psychiatric services and rehabilitation

Psychiatric services and rehabilitation only  require  a  2  month waiting period, even if the condition is pre-existing. This means you can be covered 2 months after commencing a policy.

 

Pre-existing conditions

If you have less than 12 months membership on your current level of cover, you should contact us on 1800 804 950 before arranging hospital treatment to find out whether the pre-existing condition rule applies to you.

A pre-existing condition is defined as any ailment, illness, or condition where, in the opinion of a medical adviser appointed by the health insurer, the signs or symptoms of that illness, ailment or condition existed at any time in the period of 6 months ending on the day on which the person became insured under the policy. The pre-existing condition waiting period applies to new members and members upgrading their policy to any higher level benefits under the new policy.

The test applied under the law relies on the presence of signs or symptoms of the illness, ailment or condition; not on a diagnosis. It is not necessary for the member or their doctor to know what their condition is, or for it to be diagnosed. In forming an opinion about whether or not an illness is a pre-existing condition, the health insurer appointed medical practitioner who makes the decision must take into account information provided by the member’s treating doctor.

 

Why is there a waiting period for pre-existing conditions?

If there were no waiting period for pre-existing conditions, people could take out hospital cover or upgrade to comprehensive cover only when they knew or suspected that they might need hospital treatment and immediately make a hospital claim. If these new members then ceased their membership or downgraded to a lower level policy, their hospital costs would have to be paid for by the long-term members who remain on their previous hospital policy. This would not be fair to long-term members.

New and upgrading members who do have pre-existing conditions can still seek treatment for these conditions in a public hospital under Medicare.

 

Key Points for pre-existing conditions

  • Only applies to hospital tables.
  • It is the health insurer’s medical practitioner who decides if an ailment, illness or condition is pre-existing, NOT the member’s treating doctor. The insurer’s medical practitioner must also consider any information regarding signs and symptoms provided by the treating medical practitioner(s).
  • Whether or not a member has a pre-existing condition must always be assessed in relation to that person’s individual circumstance. It is not allowable to say that certain conditions are always pre-existing.
  • The medical practitioner appointed by the health insurer must be satisfied that there is a direct link between the ailment, illness or condition that requires hospital treatment and the signs and symptoms that existed in the 6 month period prior to the member joining or upgrading hospital cover.
  • It is not necessary for the ailment, illness or condition, to have been diagnosed in the 6 month period – only that signs or symptoms were, or would have been, evident.
  • These signs and symptoms should have been reasonably apparent to either the member, or a reasonable general practitioner had the member been examined in this 6 month period.

 

Obstetrics (pregnancy and birth related services - including IVF and assisted reproductive services)

  • A 12 month wait applies to any obstetric related services.
  • Services which occur outside of a hospital admission, including consultations and tests, may be claimable on Medicare or paid out of your own pocket.
  • A person with single membership is eligible for obstetric benefits provided she has been a member of a hospital table for 12 months or more.
  • Always check with the hospital, HCI and your doctor before proceeding with a hospital booking to ensure you will be covered and to discuss what costs you may incur.

 

IVF and assisted reproductive technology

In vitro fertilisation (IVF) treatment is a process to treat infertility. IVF and other assisted reproductive services aren’t automatically covered on policies that cover natural births and obstetrics. Even on policies which include IVF, the treatment has several steps and only the component which involves an admission to hospital can be covered under private hospital insurance.

Check with HCI before proceeding with IVF or similar treatments to confirm what services you will be required to pay for and that you have completed any required waiting periods. The standard waiting period of IVF treatment is 12 months. Check with your doctor and IVF clinic for more information and quotes.

 

Waiting periods for new born babies

When a newborn child is added to a family or single parent policy, the child is deemed to have served the same waiting periods as the policy holder, providing that:

  • the  child  is  added  to  the  policy  within  2  months  of  their date of birth; and
  • all contributions with respect to that policy are paid up-to-date and effective from the date of birth.

Note: Where the policy is a single or couples policy prior to the birth, the addition of the newborn child will require the policy to be upgraded to a family or single parent policy from the date of birth.

If you haven’t been covered by family hospital cover for 12 months prior to becoming pregnant, we suggest you give us  a  call  on 1800 804 950 to check you and your baby’s benefit entitlements.

 

Waiting periods

Health Care Insurance applies the following waiting periods: 

 

Hospital treatment or Hospital substitute

 

 

Services

 

Waiting Period (months)

Pre- existing conditions

12

Obstetrics (pregnancy related services)

12

IVF and assisted reproduction technology

12

Sterilisation including reversal

12

Psychiatric Care, rehabilitation or palliative care

2

All other hospital treatment services

2

 

Extras cover

 

 

Services

 

Waiting Period (months)

Acupuncture

2

Ambulance

2

Audiology (Hearing Tests)

2

Chiropractic

2

Dental – General

6

Dental – Major (incl. Orthodontics)

12

Diabetes Education

2

Diabetes Australia Membership

2

Dietetics

2

Eye Therapy (Orthoptics)

2

First Aid Training

2

Funeral + (eligible members only)

120

Health Screening Checks

2

Hearing Aids

24

Home Nursing

2

Hydrotherapy

2

Laser Eye Surgery

12

Medical Appliances

12

Natural Therapy

2

Non-surgical Prostheses

12

Occupational Therapy

2

Optical

6

Orthodontics

12

Orthotics

2

Osteopathy

2

Pharmacy

2

Physiotherapy

2

Podiatry / Chiropody

2

Psychology

2

Quit Smoking Programs

2

Speech Therapy

2

Surgical Footwear

2

Travel & Accommodation *

6

Weight Loss Programs

2

 

 

*When taken with a hospital cover (for full details refer to page 9 of our Guide to Cover)

+Please refer to page 9 of our Guide to Cover for special conditions relating to the funeral benefit

Doctors' Fees and Access Gap Cover

Doctors’ fees, medical gap, out of pockets and Access Gap Cover

Other than the items listed above under “What is not covered“ if you are a private patient in a public or private hospital, HCI pays benefits for treatment provided to you by a doctor whilst you are in hospital. However the Federal Government’s Commonwealth Medical Benefits Schedule (CMBS) specifies how much both Medicare and HCI pay for that treatment. Indicatively Medicare pays 75% of the amount specified in the schedule and HCI pays 25%.

If your doctor chooses to charge above the CMBS fee you may have to pay the medical gap or “out of pockets” which is the difference between the total fee charged by the doctor and the CMBS fee. HCI does not pay a benefit on out of pockets.

It is in your interest to discuss the issue of fees with your doctor to determine whether they will use HCI’s Access Gap Cover which will minimise or eliminate your medical out-of-pocket costs.

 

Access Gap Cover for cover for medical care in hospital

Should you ever need specialist care in hospital, your doctor can now provide a much simpler billing system by choosing to use HCI’s Access Gap Cover.

If your Doctor uses the scheme, you will either:

  • Have no out-of-pocket expenses; or
  • You will know exactly how much you will have to pay before treatment begins.

Also, your doctor can bill HCI direct, saving you from having to claim from Medicare and HCI yourself.

It is your doctor’s choice to use Access GAP Cover. Your special relationship with your doctor and the treatment you receive will not change.

Questions to ask each Doctor…

  • Will you treat me under Access Gap Cover?
  • Will I have any out-of-pocket expenses, and if so, can you provide a written estimate of how much?
  • Will any assisting doctors also use Access Gap Cover and if so, how can I obtain a quote for their services?
  • Are you prepared to send the bill to HCI directly?

See http://www.hciltd.com.au/doctors-search for registered participating doctors. Lists are  subject  to  change  and  are updated regularly.

Surgically Implanted Prostheses 

A prosthesis is an artificial substitute for a missing body part, used for functional or cosmetic reasons or both. Surgically implanted prostheses are sometimes required during a medical procedure, such as a replacement lens for a cataract surgery, an artificial hip joint, a pacemaker, or a heart valve.

For medical procedures covered by the Medicare Benefits Schedule (MBS), HCI will fully cover the cost of at least one prosthesis, if required (called a ‘no gap’ prosthesis).

In some cases, an alternate prosthesis may be available which costs more than the ‘no-gap’ version. If one of these prostheses is used, you will have to pay the difference between the ‘no gap’ amount and the total amount charged by the supplier for the prostheses.

The Prostheses Schedule lists prosthetic items, the costs of which will be covered 100% by health funds (no gap) and items that may require you to meet part of the cost (gap).

It is recommended that if you require surgery involving a surgically implanted prosthesis, discuss with your specialist doctor the option of using the prosthesis listed as a no gap item.