1 Police Health enjoy the benefits Quality Health Cover for Queensland Police
2 Why Police Health? Police Health is Australia's only private health insurer run by police for police. We are not-for-profit with straightforward health insurance products. All funds go to ensuring our members receive the best health cover at the best possible price. It is a unique service exclusive to the police community and their families. Around half of Queensland s police are now with Police Health, making us the most popular choice among police. In South Australia, where Police Health started in 1935, about 90 per cent of serving officers are members*. This extraordinary support is an indication of the reputation we enjoy among police ranks. Member research shows we are one of the highest rating health insurers for customer satisfaction. And the reason is simple - our policies are easy to understand, our service is of the highest quality and, most importantly, we offer value-for-money. Police Health is conscious that a multitude of private health insurance products can be confusing. Therefore, we have only four: Top Hospital and SureCover Extras, which are combined at a discounted rate to make Platinum Health, or Platinum Plus for families with older independent children. All four are premium quality products with a high level of health cover. Police Health is readily available to the policing communities across Australia. More information Please read the information contained in this brochure carefully and retain it for future reference. It contains detailed information on our products, why we are the best health insurance choice for police and how to become a member. We welcome all new members so if you have any questions please contact our office or visit Full contact details are on the back page of this brochure. The information contained within this brochure is provided for information purposes only and is subject to change without notice. (*For an explanation of the terms membership and member as used in this brochure see page 19.) 1
3 Who can join Police Health? Police Health is a restricted access health insurer primarily for current employees of a State, Territory or Federal police department, service or association. Additionally all former police and employees of police services or associations in Australia who resigned or retired after 1 January 2001 are able to join Police Health. Others eligible for membership* include their partners (spouse or defacto), former partners, dependent children and their adult children (as well as partners and dependent children of these adult children). Contact us for clarification if you are not clear on whether you and your family are eligible to join Police Health. Who is covered by my Police Health policy? Single Policy - just yourself. Family Policy - yourself, partner and all your children until they reach 21 years, or 25 if they are full-time students. Police Health Platinum Plus covers all children until they reach 25. Children who are married or in a defacto relationship are not covered. Single Parent Family Policy - yourself and all your children as described above. (*For an explanation of the terms membership and member as used in this booklet, see page 19.) The Police Health difference Police Health has one objective - looking after the health insurance needs of the police community and their families. No other health insurance provider in Australia has that single-minded focus. Our activities are overseen by people who understand and care about your requirements. We are managed by a team of health insurance professionals under the direction of a board from both police and health insurance backgrounds. There are many other reasons why about 9 out of 10 serving police officers in South Australia - the home of Police Health - have joined us: Not-for-profit - There are no shareholders. All premiums are used to benefit members. Value-for-money - Top cover at a great price. Police Health premiums are usually lower than those offered by other insurers for similar cover. Generous rebates - When you make a claim for extras with Police Health, our cover tends to be higher. For extras we pay 80% of the service fee in most cases, even though the charge from service providers may vary. If you are not with Police Health, you could end up paying more. Our dental cover, for instance, is hard to match. Efficient claims system - At Police Health we pride ourselves on a rapid and efficient turnaround on claims. Freedom to choose - You can choose your preferred hospital, doctor and any other service provider, such as your physiotherapist and dentist. Professional advice and friendly service - Police Health is a quality health insurer managed by industry professionals. We provide accurate, practical unbiased advice to ensure the highest level of individual service. Our staff are friendly and well trained in providing excellent customer service. Easy to understand - We keep it simple. You are not bewildered with complex, multiple options and left with niggling questions about the extent of your cover. At Police Health you only have to choose between quality extras, top hospital or both. Quality, value, simplicity At Police Health, we make your private health insurance choices as simple as possible to ensure maximum value. Essentially, we offer four high quality covers: Top Hospital and SureCover Extras, which you can have separately or combined as either Platinum Health or Platinum Plus. There are several reasons why we offer such a defined product range. For a start it is less confusing for members and it enables us to keep your costs down. Furthermore, we only offer top-of-the-range products, which means our members are not caught out with an inappropriate level of cover. Member feedback has repeatedly shown that police prefer to have a comprehensive policy that looks after them and their family through all stages of their lives: One cover fits all One cover for life The premiums shown in this brochure reflect our endeavour to give you the best in quality at a price that offers true value. When you compare our premiums and level of cover with other insurers, it soon becomes apparent that Police Health is one of the most competitive. 2
4 Why private health insurance There are many compelling reasons why it pays to have private health insurance. The obvious ones are peace of mind and freedom of choice - knowing that you can be treated when you want, by the doctor or specialist you prefer and in the hospital of your choice. There is also a cost consideration - the security of not being faced with large fees resulting from unexpected treatment. Then there are the following financial incentives introduced by the Australian Government - three schemes that make private health insurance an obvious choice. Government incentives 1 The Australian Government provides a Rebate on private health insurance to most Australians*. The Rebate is means tested against your income, and is reduced on a Tier basis. You can choose to receive your Rebate as a reduced premium, making your health insurance instantly cheaper, or claim any eligible Rebate when you lodge your tax return. 2 As the government encourages all Australians to take out private health insurance, it likewise penalises those who do not. The government charges an additional Medicare Levy Surcharge* if you earn over the set threshold and do not hold appropriate hospital cover. 3 Government legislation requires health funds to apply a loading to hospital cover for those who postpone taking out hospital cover until they are older. Avoid the loadings by simply taking out and maintaining hospital cover by 30 June following your 31st birthday.* * Please read more about how these Rebates, levies and loadings may affect you on pages 21 and 22. Helping you choose There are resources available to help you choose the best health insurer and policy to suit your particular requirements. Standard Information Statements (SIS) are available on all private health insurance products in Australia. These are designed to assist you in reviewing and comparing different health insurance policies. This is a Federal Government initiative and all health insurers are required to provide such statements by law. Police Health SIS are available on request or can be found on our website For further information on SIS and other detailed information on private health insurance in Australia visit the Federal Government website 3
5 Top Hospital Hospital Cover Top Hospital provides cover for treatment in any recognised hospital or day-surgery (public or private) anywhere in Australia. It is designed to give you and your family complete freedom of choice in your health care. Compare the benefits and premiums of Police Health Top Hospital - you will find they are comprehensive and offer excellent value. Choice of hospital Top Hospital cover does not restrict you to any particular hospital - full benefits apply in all registered hospitals for recognised services. In the unlikely event that we cease to recognise a hospital for full benefits, Police Health will advise members likely to be affected. Details of hospitals not recognised are listed on our website Choice of doctor Police Health has no interest in directing you to a particular doctor or any other health care provider. Our aim is to give you the freedom to make true choices about who treats you and where. Access Gap Cover Under Police Health Access Gap Cover you may never have to pay a doctor's bill. Your doctor can forward all accounts to us and we pay them on your behalf. When private patients are admitted to hospital, Medicare pays a benefit that is 75% of its Schedule Fee for medical services such as doctors, radiology and pathology. Police Health pays the remaining 25%. Note: Police Health does not pay benefits for medical services where Medicare does not pay a benefit. It is reasonably common for doctors to charge fees over and above the Medicare Benefits Schedule Fee. To help members avoid these additional costs, in the majority of cases Police Health is able to pay higher benefits through our Access Gap Cover scheme. Under this scheme, Police Health has arrangements with more than 25,000 doctors Australia-wide. When doctors bill under this arrangement we can pay higher benefits to eliminate or at least reduce your Top Hospital Premiums Oldest Person Under Policy is Under 65years* Payment method Base Tier Tier 1 Tier 2 Tier 3 (27.820%*) (18.547%*) (9.273%*) (0%) FULL REBATE NO REBATE Family (& Couples) Fortnightly Direct Debit $ $ $ $ Fortnightly Payroll $ $ $ $ Quarterly $ $ $1, $1, Half Yearly $1, $1, $2, $2, Yearly $3, $3, $4, $4, Single Parent Family Fortnightly Direct Debit $ $ $ $ Fortnightly Payroll $ $ $ $ Quarterly $ $ $ $1, Half Yearly $1, $1, $1, $2, Yearly $3, $3, $3, $4, Single Fortnightly Direct Debit $65.40 $73.80 $82.20 $90.60 Fortnightly Payroll $67.25 $75.90 $84.55 $93.20 Quarterly $ $ $ $ Half Yearly $ $ $1, $1, Yearly $1, $1, $2, $2, yrs & older! * Premiums based on oldest person under policy being under 65yrs, for those 65yrs or older you may be entitled to a higher Rebate please see page 21 for more information. For premiums that apply to over 65yrs go to or call ** Premiums available on lodging the Australian Government Rebate on private health insurance application form with Police Health. See page 21 to determine which level of Rebate applies to you. Important Note: The premiums shown in this table are based on rates applying to those having an existing hospital cover with a certified age of entry of 30 or, who join hospital insurance by June 30 following their 31st birthday. If neither of these apply, contact Police Health for the Lifetime Health Cover premiums that will apply to you. 4
6 out-of-pocket costs. Also where a gap does exist, members are informed by their doctor prior to treatment. Access Gap Cover means our members have even more flexibility when choosing a doctor, because there is an increased likelihood their fees will be covered. While all doctors can be involved in Access Gap Cover, it is up to individual doctors to participate. You can alert your doctor to the scheme and request that they take part. If you are unsure if your doctor or specialist has agreed to participate, please call Police Health or check the list on our website Choosing a prosthesis Prostheses include screws and plates, intraocular lenses, replacement joints, cardiac stents, defibrillators and other devices that are surgically implanted during your stay in hospital. There are often a multitude of brands and types available for a particular use, all designed to achieve the same result, but they can vary in cost and comparative benefits. The Federal Government together with a panel of health specialists issues a listing for prostheses detailing the benefit that health insurers must pay. While the surgeon or hospital providing the prothesis can determine what they will charge for them, it is intended that the government required benefit should fully cover the cost of at least one of the items available that meet your surgical requirements. To make an informed decision ask your doctor the following questions: Which prosthesis will be the best one for you and is there a gap to pay for it? If a gap is payable, is there a gap free option available? What are the costs of the surgery, including the prosthesis? Request a written cost estimate if there are any gaps to pay and contact Police Health to confirm what is covered and the amount of any gaps you may have to pay. Hospital 35-day rule Hospital benefits are payable 365 days a year. However, if your hospital stay exceeds 35 days you must obtain an Acute Care Certificate to continue receiving benefits. If you are not classified as an acute hospital care patient and your stay exceeds 35 consecutive days, you may become a "nursing home type patient". In this case a Government restriction requires that you make a personal (and uninsurable) contribution to your care. In our experience this is rare and does not apply where acute hospital care is required. 5
7 What is covered Police Health Top Hospital General hospital costs Please refer to page 4; 100% covered for: Private or shared room accommodation Same day hospitalisation and day surgery Intensive/coronary care, etc Theatre fees/labour ward 100% covered Drugs supplied Surgically implanted prostheses Doctor's fees (for hospital treatment) Hospital at home Additional health care services Travel and accommodation cost 100% covered when related to the reason for admission in hospital and covered under the agreement with the hospital. Public hospitals generally supply medication without charge. Cover as defined in the Federal Government s Prostheses List. (see page 5) If your doctor chooses to use the Access Gap Cover schedule of fees, Police Health can cover up to 100% of the doctor's fee. At a minimum, Police Health will cover the difference between the Medicare rebate and the Medicare Benefits Schedule (MBS) Fee. (see pages 4, 17) Police Health has agreements with some hospitals to deliver out-of-hospital care to patients for services such as wound management, intravenous therapy and post-natal care. Aids and appliances - benefits vary (contact Police Health). Home Nursing - attractive benefits apply (contact Police Health). Up to $500 per year, per policy. (see page 16) Our Top Hospital Cover is comprehensive and covers all procedures where Medicare pays a benefit, with no exclusions or restrictions and no excess to pay when admitted as an in-patient. Some example services that you are covered for under Top Hospital are listed below; this is not an exhaustive list. Should you require information about a particular treatment please contact Police Health. Examples of hospital services Covered by Police Health Top Hospital Examples of hospital services Covered by Police Health Top Hospital Intensive care & operating theatre Pregnancy & birth related services Heart surgery, bypass, stents Assisted reproductive services (IVF) Removal of tonsils Gastric banding, stomach surgery Removal of appendix Dialysis for chronic renal failure Hernias Back surgery Chemotherapy and cancer Psychiatric services Rehabilitation services Cataract and lens replacement (eyes) Hip and knee reconstruction and joint replacement Surgically implanted prostheses 6
8 What is not covered (non exhaustive list*) Services incurred before waiting periods have been served. (see page 14) Treatment for which Medicare does not pay a benefit, including cosmetic surgery. (Some benefits may be payable for hospital treatment following this surgery. Contact Police Health for more details.) Services that are provided outside the Commonwealth of Australia. Services where an entitlement exists or may exist under any compensation, sports club or third party insurance. A claim for a service that is submitted more than two years after the date of service. Outpatient services unless there is an agreement between Police Health and the hospital. Pharmaceuticals not related to the reason for hospitalisation or not covered under the agreement with the hospital or provided on discharge. Exceptional high cost drugs that may be excluded or limited. Prostheses items that are not included on the Federal Government approved list. Charges greater than the benefit defined in the Federal Governments Prostheses List. Personal and take-home items, eg newspapers, toiletries, television, hairdressing, manicure, etc. Treatment provided to a person in a hospital emergency department. Aged care and accommodation in an aged care facility. If you are in hospital for more than 35 consecutive days and not classified as an acute care patient, your benefits will significantly reduce. (see page 5) * This provides a general description of what is not covered. Should you require information about a particular treatment or benefit please contact Police Health. 7
9 SureCover Extras Extras Cover With Police Health SureCover Extras you are covered for an extensive range of health services at highly competitive premiums. Few health insurers can match our extras benefits for value or the number of services available. Our extras table is designed exclusively for the benefit of the Queensland police community. You won t be left wondering how much your health insurer will repay on your extras claims. For the majority of services provided by recognised providers, Police Health pays a generous 80% of the cost. Equally important, we let you visit the health provider of your choice and in most cases will still provide our high level of cover. Because of our generous benefits limit (explained later), you can choose your provider and still be confident that in most cases you will receive back 80% of their fee. Our Annual Maximum - the benefits allowable in any one calendar year per person are also generous (exercise physiology also has a family limit). To ensure even greater security and value, Police Health also provides Rollover Benefit. Rollover Benefit In many service areas, any unused Annual Maximum benefit that is not claimed during one calendar year can be rolled over to be available the following year. Claims are always paid from the current year's Annual Maximum before your Rollover Benefit is accessed. New members are eligible for Rollover Benefit after just 12 months (2 years for major dental). The combined Rollover Benefit and the Annual Maximum are shown as the Rollover Maximum in the following tables (on pages 10, 11). Limit to services Health insurers have restrictions on frequency of use and the way some services are combined. This helps ensure equity among members. The benefit structure developed by Police Health means we have fewer restrictions. Our limits on regular services such as dental for example are generous by comparison. For extras services such as physiotherapy, chiropractic or podiatry, we limit claims to one consultation per person per day per service type. Benefits limit Health insurers generally calculate an average charge for services and set their benefit limit based on that amount. Police Health goes further and in the majority of cases recognises charges up to 15% higher than the calculated average. This means that when members make a claim for extras with Police Health, they tend to get more back - 80% in the majority of cases. SureCover Extras Premiums Oldest Person Under Policy is Under 65years* Payment method Base Tier Tier 1 Tier 2 Tier 3 (27.820%*) (18.547%*) (9.273%*) (0%) FULL REBATE NO REBATE Family (includes Couples & Single Parent Families) Fortnightly Direct Debit $64.65 $72.95 $81.25 $89.60 Fortnightly Payroll $66.55 $75.10 $83.65 $92.20 Quarterly $ $ $ $ Half Yearly $ $ $1, $1, Yearly $1, $1, $2, $2, Single Fortnightly Direct Debit $32.30 $36.45 $40.65 $44.80 Fortnightly Payroll $33.25 $37.55 $41.80 $46.10 Quarterly $ $ $ $ Half Yearly $ $ $ $ Yearly $ $ $1, $1, yrs & older! * Premiums based on oldest person under policy being under 65yrs, for those 65yrs or older you may be entitled to a higher Rebate please see page 21 for more information. For premiums that apply to over 65yrs go to or call ** Premiums available on lodging the Australian Government Rebate on private health insurance application form with Police Health. See page 21 to determine which level of Rebate applies to you. 8
10 If the service charge is higher than the fee we recognise, the percentage amount you receive will reduce accordingly. Our 80% benefit applies to the net amount payable on an account, inclusive of any discounts the provider might be offering; this may vary where, for the benefit of our members, Police Health has negotiated specific agreements with selected providers. Optical discounts Police Health has arrangements with OPSM and Laubman & Pank for our members to receive 20% off all frames*, lenses, contact lenses and treatments. You can take advantage of these discounts simply by showing your Police Health Membership Card at any of these outlets throughout Australia. With this 20% discount and our 80% benefit, you can obtain lenses at no cost providing you are within your Annual Maximum. Police Health Members can also receive 10% off sunglasses* at these outlets, Bright Eye s and Sunglass Hut. * Based on standard store pricing and excludes Chanel, Bulgari, Oliver Peoples, Paul Smith, Tag Heuer and Tiffany & Co brands. 9
11 What is covered SureCover Extras The following list is an example of the services covered under SureCover Extras with details of our benefit limit and Annual Maximums, which is based on a calendar year. New members have a waiting period before they can make a claim for extras benefits and these are marked in the list. Waiting periods may not apply if they have been served with another insurer prior to joining. Service Type Example of Benefits Annual Maximum per person Rollover Maximum per person* General Dental Oral exam (2 every calendar year) 80% up to $47.30 (2 months waiting period) Scale and clean (2 every calendar year) 80% up to $ Includes checkups, X-rays, Filling - adhesive posterior 3 surface 80% up to $ Unlimited N/A simple extractions, fillings and root canal Mouth Guard (1 every calendar year) 80% up to $ Major Dental Full crown - veneered 80% up to $1, (12 months waiting period) Complete upper & lower 80% up to $1, Includes crowns and dentures dentures (1 every 3 yrs) $1,300 $2, month waiting periods may be waived where it has been served with previous fund. Rollover Maximum available after 2 years membership. Orthodontic Lifetime limit - $ % up to Annual Maximum 1st yr $0 (12 months waiting period) 2nd yr $800 We recognise your time served with other health insurers and N/A Benefits apply to specialist in many cases new members can go direct to our $1,500 3rd yr $800 orthodontists only Annual Maximum. 4th yr $1,500 Optical Standard single vision lenses 80% up to $ (2 months waiting period) Standard progressive lenses 80% up to $ Contact lenses, disposable - spherical 80% up to $ Contact lenses, rigid 80% up to $ Frames $ At OPSM and Standard single vision lenses 100% Laubman & Pank: Standard progressive lenses 100% Contact lenses, disposable - spherical 100% Contact lenses, rigid 100% Frames $ Physiotherapy Initial consult 80% up to $77.20 (2 months waiting period) Subsequent consult 80% up to $68.50 Exercise Physiology Initial consult 80% up to $73.60 (2 months waiting period) Subsequent consult 80% up to $55.20 Chiropractic Initial consult 80% up to $73.60 (2 months waiting period) Subsequent consult 80% up to $46.00 Naturopathy Initial consult 80% up to $96.60 (2 months waiting period) Subsequent consult 80% up to $64.40 Acupuncture Initial consult 80% up to $69.00 (2 months waiting period) Subsequent consult 80% up to $62.10 Osteopathy Initial consult 80% up to $82.80 (2 months waiting period) Subsequent consult (16-30 mins) 80% up to $73.60 Complementary Therapies Therapies consult $25.00 (2 months waiting period) Note: While many therapies are covered, some are not. Please refer to our special Complementary Therapies Brochure for more information. $330 $660 $850 Combined Sub-limit for Exercise Physiology $400 per person, or $800 per family $700 Combined $1700 N/A $1,400 N/A 10
12 Service Type Example of Benefits Speech Therapy Initial consult (46-90 mins) 80% up to $ (2 months waiting period) Subsequent consult (46-90 mins) 80% up to $ Occupational Therapy Initial consult (76-90 mins) 80% up to $ (2 months waiting period) Subsequent consult (46-60 mins) 80% up to $92.00 Eye Therapy Initial consult 80% up to $43.20 (2 months waiting period) Subsequent consult (< 30 mins) 80% up to $38.60 Dietary Initial consult 80% up to $ (2 months waiting period) Subsequent consult 80% up to $64.40 Podiatry Initial consult 80% up to $66.20 (2 months waiting period) Subsequent consult (< 20 mins) 80% up to $54.20 Annual Maximum per person Rollover Maximum per person* $850 $1,700 $600 $1,200 $600 $1,200 $600 $1,200 $700 $1,400 Psychology (2 months waiting period) Consultation (46-60 mins) 80% up to $ $850 $1,700 Pharmaceutical (excludes government subsidised PBS prescriptions) (2 months waiting period) Per script Up to $50 after you pay first $20 Available at any pharmacy Note: While many medicines are covered, some are not. $600 $1,200 $20 may increase for dispensings greater than the minimum standard packaged quantity. Please refer to our special Pharmaceutical Benefits Brochure for more information. Health Appliances Hearing aids 80% $1200 per 5 yrs (12 months waiting period) Nebulisers 80% up to $200 1 unit per 3 yrs (Doctor's referral required Blood glucose monitors 80% up to $250 1 unit per 3 yrs N/A on all appliances) Blood coagulation monitor (INR) 80% up to $400 1 unit per 3 yrs School Accident Additional benefits apply to clinically required services (2 months waiting period) resulting from an accident whilst at or travelling to or from $500 N/A school. (Some restrictions apply.) 100% *Rollover Maximum available after 12 months membership with extras cover, except Major Dental which require 2 years membership. Note: All the benefits shown here are payable only on services and at health providers recognised by Police Health. (see page 16 for details) What is not covered (non exhaustive list**) Claims for a service that has exceeded the Annual Maximum & Rollover Maximum. The second and subsequent consult with the same profession on the same day. Where the service charge exceeds the fee recognised by Police Health, the benefit you receive may be less than 80% of your cost. Where the service provider is a partner, dependent or parent of the person being treated. Business partners within the practice are also excluded. Services incurred before a waiting period has been served. Services where a Medicare benefit is payable. Services that are provided outside the Commonwealth of Australia. Services where an entitlement exists or may exist under any compensation, sport club or third party insurance. A claim for a service that is submitted more than two years after the date of service. Services provided by practitioners not registered or recognised by the fund. ** This provides a general description of what is not covered. Should you require information about a particular treatment or benefit please contact Police Health. 11
13 Platinum Health This is Police Health's most popular health cover and the reasons are obvious - it is all-inclusive and is offered at a discounted premium that provides even more value. About 80% of our members choose Platinum Health because it is the total health package, combining the security of Top Hospital and the extra protection of SureCover Extras. In addition partial benefits are available for corrective laser eye surgery for Platinum Health Cover which is not available for extras only or hospital only policies. Furthermore the premium is lower than having the two products separately and means all your health needs are covered under one convenient package. If you have non-student dependent children who have turned 21 but not yet 25, please consider the benefits of Platinum Plus on the following page. Platinum Health Premiums Oldest Person Under Policy is Under 65years* Payment method Base Tier Tier 1 Tier 2 Tier 3 (27.820%*) (18.547%*) (9.273%*) (0%) FULL REBATE NO REBATE Family (& Couples) Fortnightly Direct Debit $ $ $ $ Fortnightly Payroll $ $ $ $ Quarterly $1, $1, $1, $1, Half Yearly $2, $2, $3, $3, Yearly $4, $5, $6, $6, Single Parent Family Fortnightly Direct Debit $ $ $ $ Fortnightly Payroll $ $ $ $ Quarterly $1, $1, $1, $1, Half Yearly $2, $2, $2, $3, Yearly $4, $5, $5, $6, Single Fortnightly Direct Debit $95.75 $ $ $ Fortnightly Payroll $98.50 $ $ $ Quarterly $ $ $ $ Half Yearly $1, $1, $1, $1, Yearly $2, $2, $3, $3, yrs & older! * Premiums based on oldest person under policy being under 65yrs, for those 65yrs or older you may be entitled to a higher Rebate please see page 21 for more information. For premiums that apply to over 65yrs go to or call ** Premiums available on lodging the Australian Government Rebate on private health insurance application form with Police Health. See page 21 to determine which level of Rebate applies to you. Important Note: The premiums shown in this table are based on rates applying to those having an existing hospital cover with a certified age of entry of 30 or, who join hospital insurance by June 30 following their 31st birthday. If neither of these apply, contact Police Health for the Lifetime Health Cover premiums that will apply to you. 12
14 Platinum Plus Platinum Plus provides the same total health package available in Platinum Health (including the partial benefits for corrective laser eye surgery) but also includes all your children until they reach the age of 25, unless they are married or in a defacto relationship. This is a true family cover specifically designed to suit members with older children. It does not matter if they are employed or unemployed, or living at home or away, they are still covered under Platinum Plus. All this is available for just a small increase in your premium. If the children you wish to cover are aged under 21, or under 25 and studying full-time, Platinum Health provides all the cover you need (refer to previous page). Platinum Plus Premiums Oldest Person Under Policy is Under 65years* Payment method Base Tier Tier 1 Tier 2 Tier 3 (27.820%*) (18.547%*) (9.273%*) (0%) FULL REBATE NO REBATE Family (& Couples) Fortnightly Direct Debit $ $ $ $ Fortnightly Payroll $ $ $ $ Quarterly $1, $1, $1, $2, Half Yearly $2, $3, $3, $4, Yearly $5, $6, $7, $8, Single Parent Family Fortnightly Direct Debit $ $ $ $ Fortnightly Payroll $ $ $ $ Quarterly $1, $1, $1, $1, Half Yearly $2, $3, $3, $3, Yearly $5, $6, $6, $7, yrs & older! * Premiums based on oldest person under policy being under 65yrs, for those 65yrs or older you may be entitled to a higher Rebate please see page 21 for more information. For premiums that apply to over 65yrs go to or call ** Premiums available on lodging the Australian Government Rebate on private health insurance application form with Police Health. See page 21 to determine which level of Rebate applies to you. Important Note: The premiums shown in this table are based on rates applying to those having an existing hospital cover with a certified age of entry of 30 or, who join hospital insurance by June 30 following their 31st birthday. If neither of these apply, contact Police Health for the Lifetime Health Cover premiums that will apply to you. 13
15 Claiming Information Making a claim Lodging claims with Police Health is easy. Hospital bills are usually sent direct to us by the hospital and we pay them on your behalf. With the majority of extras claims, such as dental and optical, most service providers will process invoices on the spot using eftpos-style electronic claiming facilities. All you have to do is swipe your membership card and sign to validate the service. Your claim will be automatically lodged with Police Health and we will pay the provider direct, leaving you to pay only the gap. The majority of providers offering on the spot claiming can be searched for on the Police Health website. Alternatively give us a call or ask your health service provider to see if they offer this facility. Please note Police Health does not provide on the spot claiming for orthodontic, complementary therapies, occupational therapy, psychology, dietician, acupuncture and naturopathy. If on the spot claiming is not available, simply post, or fax your account and completed claim form to Police Health and we will do the rest. Claims lodged manually - Payments covering medical gap or extras services will be made payable to you if you have already paid the account. If you have not paid the account, you will receive a cheque made out to the health service provider and you must forward this together with your part of the payment. Access Gap Cover - Doctors billing under our Access Gap Cover will normally forward their account direct to Police Health. We then claim your Medicare entitlements and pay that, together with your Police Health benefit, direct to the doctor. Your doctor will inform you of any out-of-pocket expenses you may need to pay. PromptPay - If you have already paid the account from your medical or extras provider, Police Health offers PromptPay to ensure fast payment of your claim. With PromptPay your benefit is paid direct to your financial institution account as an automatic direct credit. Simply tick the appropriate box on the claim form and provide your account details. Claims - your receipts/accounts with a completed claim form to (Please include your membership number in the subject line). Fax claims - Fax your receipts/accounts with a completed claim form to Two-year limit - Claims must be lodged with Police Health within two years of the date of service. Claims for services older than two years will not be accepted. Orthodontics - Orthodontics can vary considerably in the period of treatment, cost and how you are billed. Before agreeing to commence orthodontic treatment determine your payment plan with the provider. This may involve an upfront payment followed by instalments during the expected treatment period. Ask the provider what options are available and for a written plan once it s agreed to. Should you choose to pay for the total treatment up front, please be aware Police Health benefits will be spread over the treatment period and are subject to Annual and Lifetime Maximum limits and waiting periods. For more information please call us, or refer to our website. Please note electronic claiming is not available for Orthodontic services, you will need to submit your claim form to Police Health and we recommend you attach a copy of your treatment plan with this claim so we can give a detailed outline of the benefits you can expect. Waiting periods Waiting periods are designed to protect the interest of our members. Without waiting periods it would be easy for people to simply join at the time they need cover and receive benefits. This would lead to much higher premiums for all fund members. Waiting periods for: Hospital benefits of Top Hospital, Platinum Health and Platinum Plus: 2 months membership for all benefits, excluding accidents. 12 months membership for obstetric treatment. 12 months membership for pre-existing conditions, excluding psychiatric care, rehabilitation or palliative care. 12 months membership for aids and appliances. Extras benefits for SureCover Extras, Platinum Health and Platinum Plus: 2 months membership for all benefits, excluding accidents. 12 months membership for major dental (such as crowns, bridges, inlays, indirect fillings and dentures), orthodontic, hearing aids, nebulisers, blood glucose & blood pressure monitors, blood coagulation monitor and for pre-existing conditions. 12 months membership for Rollover Benefit and access to Rollover Maximum (2 years Major Dental). 14
16 Platinum Health & Platinum Plus 3 years membership for corrective laser eye surgery. For Hospital Substitute Treatment the same waiting periods apply as for Hospital cover. Pre-existing conditions - A pre-existing condition is one where signs or symptoms of your ailment, illness or condition, in the opinion of a medical practitioner appointed by Police Health (not your own doctor), existed at anytime during the six months preceding the day on which you purchased your health insurance or upgraded to a higher level of hospital cover. The medical practitioner appointed by Police Health must consider any information regarding signs and symptoms provided by your own treating doctor or specialist. If a new member has a pre-existing condition before joining Police Health, they may need to serve a 12 month waiting period under the terms of our policy before benefits are payable for the particular condition. This does not apply for psychiatric care, rehabilitation or palliative care. New members - Like all private health insurers, Police Health has waiting periods for people joining our private health insurance who do not have existing cover. These periods may also apply to people transferring from another insurer where their cover was lower than Police Health's and to members upgrading their policy. Naturally, new members do not need to serve waiting periods for services for which they were eligible prior to transferring to Police Health. Transfer from another insurer - New members who were covered by another insurer at the time of joining will receive continuity of cover. Credit is even provided for any waiting periods you served with the previous insurer. If you are transferring from another insurer and increase your level of cover, you will be required to serve waiting periods for new services or higher Annual Maximums, for which you were not previously covered. This also applies to other people who transfer to your existing Police Health cover. Services incurred during the waiting period will, of course, still be honoured for the lower level of cover. From time to time waiting periods may be reduced or waived in the case of special offers by Police Health. Newborn cover - Mothers with a single hospital policy are covered for the cost of a birth but not for any treatment for the baby. For a baby to be eligible for benefits immediately upon birth, a parent must have held a family or single parent family policy for at least two calendar months prior to the baby's birth, regardless of whether or not the baby is premature. We recommend that a single member upgrades to a family or a single parent family policy as soon as pregnancy is confirmed to ensure a premature baby is covered. Doing this also reduces the chance of the 15
17 12 month waiting period for a pre-existing condition being applied to the baby for a congenital condition. This can occur when you suspect or are aware of such a condition at the time of changing your cover. We recommend that you add your newborn to your policy as soon as you can, but within two months of birth. Ambulance No matter which policy you hold, Police Health members have full ambulance cover when transport is required for clinical reasons, or if treatment is required with no transport provided. Cover is not provided for ambulance transport where you do not require treatment by the ambulance officers. Police Health benefits will also not apply if ambulance transportation costs are covered by a third party arrangement, such as an ambulance subscription scheme or a State/Territory ambulance transportation scheme. Benefits may be payable, however, for any ambulance treatment costs not fully covered by those arrangements or schemes. Travel and accommodation assistance The Patient Travel Subsidy Scheme (PTSS), a government sponsored scheme operating in Queensland, provides assistance to a patient who, because of their locality, must travel long distances to access specialist medical services. In addition to the benefits available through PTSS, under certain circumstances Police Health also offers travel and accommodation benefits to members who need to travel more than 200 kilometres from their home to receive in-patient hospital treatment. Please contact Police Health prior to admission. Recognised health providers Recognised health providers are those who are in private practice in Australia and recognised by Police Health. We only pay benefits for services by these providers. If you wish to ensure that your provider is covered by Police Health please contact us prior to treatment. Recognised fees Police Health has agreements with most hospitals and recognise their fees for rebate. benefits start with our calculated average fee and are then increased by a further 15%. This ensures there are few surprises and that the majority of our members will receive a full 80% rebate on claims. In determining your claimed benefit, Police Health will use the net amount payable of any account inclusive of discounts the provider might be offering at the time. This may vary where, for the benefit of our members, Police Health has negotiated specific agreements with selected providers. Australia-wide coverage Members are covered anywhere in Australia but not overseas. Police Health does not provide cover to insured persons while outside of Australia or for internet or mail order purchases from providers not based in Australia. It is strongly recommended that people travelling overseas consider purchasing travel insurance to cover their emergency needs (see page 20). Services not recognised by Medicare Police Health is limited in the benefits it can pay for services that are not recognised by Medicare, including some types of cosmetic surgery and sterilisation reversal. If you are intending to undergo this kind of surgery, please check with us first. Compensation or damages If you are eligible for compensation or damages from WorkCover or other insurance claims, including compulsory third party, public liability or an accident, your medical and hospital expenses may be postponed until the third party pays. If this does not occur, Police Health may agree to pay your benefits subject to conditions. Under these circumstances you will be required to reimburse Police Health for any fund benefits you receive for services subsequently covered by the other insurance provider. Any compensation you receive for future medical expenses should be consistent with the medical reports relating to your claim for compensation. Police Health may not reimburse costs relating to your illness or injury if you accept an offer of compensation which is not reasonably consistent with the anticipated future treatment costs. You should notify Police Health of any claim for compensation relating to illness or accident. With extras services, generally each health insurer will calculate their own set of average fees based on the claims they have paid previously. At Police Health, most 16
18 Medicare claims What does Medicare cover? Certain out-of-hospital medical services are paid by Medicare and are therefore not covered by private health insurance. These include visits to or by your doctor, services such as pathology and radiology when provided as an outpatient, and treatment in a hospital emergency department as the patient is not admitted. Visits by a paediatrician to a newborn also fall into this category if the baby has not been admitted to the hospital as a patient in their own right. In all these cases, claims should be lodged with Medicare for payment. For more information on what Medicare covers visit What is the Medicare Benefits Schedule? This is the level of fees set and recognised by the Commonwealth Department of Health and Ageing for the payment of Medicare benefits for medical services. It is important to remember that while benefits are based on this fee schedule (referred to as Scheduled Fee), medical providers are free to set their fees at any level. How much does Medicare pay? Medicare pays 85% of its Scheduled Fee for medical services provided to people who have not been admitted to hospital and 75% of the Scheduled Fee for services provided to people who have been admitted (in-patient). In the vast majority of cases, Police Health's Access Gap Cover scheme (see page 4) covers the difference between the Scheduled Fee and the doctor's charge for in-patient services*. Where a doctor chooses not to participate in Access Gap Cover and charges above the amount in the Medicare Benefit Schedule, Police Health is only permitted to pay up to the Scheduled Fee. *Note: if you are not registered for Medicare benefits, for instance if you are a non-resident of Australia, you will not receive benefits for Medicare Services. What about out-of-pocket costs In providing its health insurance, Police Health strives to minimise treatment costs to members. While we have succeeded in covering most situations, there are some occasions when members will incur a charge from the service provider: Charges greater than the Scheduled Fee that do not fall within the Access Gap Cover. Charges greater than those recognised for Access Gap Cover. Non in-patient services, including emergency department fees. Visits by a paediatrician to a newborn who has not been admitted to hospital as a patient in their own right. 17
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