1 Your Member Guide Valid until Reg. No Health Insurance Australia July 2015
2 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 Health and wellbeing tools, support and offers 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 Medicover 24 Rebates, surcharges and incentives 25 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 Glossary 38 Index 43 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. 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. Health and wellbeing tools, support and offers HCF knows how important your health and wellbeing is, so we provide a range of quality health programs to you. 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. 2
3 4 100% 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 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 HCF Dental and Eyecare Centre locations: Blacktown Westpoint Shopping Centre, Patrick St Dental: Eyecare: Bondi Junction Level 8, 1 Newland St Dental: Eyecare: Brookvale Westfield Waringah Mall Cnr Pittwater Rd and Condamine St Dental: Eyecare: Chatswood Level 6, 13 Spring St Dental: Eyecare: 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 classes and gym membership for a specific health condition (doctor s referral required) A six month waiting period and conditions apply. See page 13 or visit hcf.com.au/healthmanagement for details. Hurstville 12 Butler Rd Dental: Eyecare: Parramatta Level 6, 128 Marsden St Dental: Eyecare: Sydney HCF House, 403 George St Dental (Level 3): Eyecare (Level 9): For more information on our Dental and Eyecare Centres, please visit hcf.com.au, call or Learn to swim Stress management and quit smoking programs. 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
4 Your membership includes health & wellbeing tools, support and offers Health management programs On eligible extras covers, you can claim on a range of HCF approved Health Management Programs to help you lead a fit and healthy life. Programs include: Weight management Exercise classes and gym membership fees for specific health conditions (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. 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 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. MY HEALTH GUARDIAN 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. Visit hcf.com.au/ mobile-apps for more information on how to download and use the app. Available for iphone and Android. HEALTHY WEIGHT FOR LIFE HCF believes healthy living starts with awareness and and education. Our Healthy Weight For For Life Life programs Programs are are designed to to promote and teach skills to to achieve and maintain a a healthy weight, for for eligible members members with Type with 2 Diabetes, Type 2 Diabetes, Cardiovascular Cardiovascular conditions and conditions Osteoarthritis. and Osteoarthritis. The The programs have shown positive results, including major improvements to to the the health and health wellbeing and wellbeing of participants. of participants Visit hcf.com.au/hwfl for for more more information. 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. To find out which levels of cover include My Global Specialist, or for more information visit hcf.com.au/mgs or contact us. Find Find a Health Health Professional Professional It s now even easier to find a healthcare It s professional now even in easier your to area find with a healthcare our new professional provider search in your facility area on with the our HCF new provider website. search The Find facility a Health on the Professional HCF website. function The now much includes improved the following Find a features: Health Professional function now includes the following features: A modern, maps based interface A The modern, ability maps to search based by interface the provider s The name, ability location to search or profession by the provider s name, The ability location to sort or profession search results by The distance ability from to sort your search location results by distance Smartphone from compatibility your location Smartphone Navigation compatibility Navigation The ability to save, print and The search ability results to save, print and search results To start looking for a healthcare To professional, start looking simply for a healthcare visit hcf.com.au professional, simply visit hcf.com.au Get 10% off 3 and 12 month memberships when you join Fitness First 6 7
5 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. Visit hcf.com.au/travel for more information. Visit hcf.com.au/travel or call to view the Product Disclosure Statement and Financial Services Guide before making decisions about this product. HCF Travel Insurance is issued by QBE Insurance (Australia) Limited ABN , AFSL 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) Visit hcf.com.au/petinsurance for more information. Visit hcf.com.au/petinsurance or call to view the Product Disclosure Statement and Financial Services Guide before making decisions about this product. HCF Pet Insurance is issued by The Hollard Insurance Company Pty Ltd, ABN , AFSL 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 , or visit hcf.com.au/cashassist for details. The Cash Assist covers are issued by our own HCF Life Insurance Company Pty Ltd. ABN , AFSL Retirement and Aged Care Services We also offer high quality retirement lifestyle living and an aged care service 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 service Our aged care facility offers the best in low care, high care, extra services and dementia care for residents requiring more support and security. Our aged care facility Courtlands Village is located in North Parramatta. To find out more, visit hcf.com.au/agedcare 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. 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. More at Home is currently available in metropolitan 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
6 Who can be covered under your HCF Policy The Policyholder 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. Singles 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). Family cover 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). Single Parent Family cover 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). Single Parent Family cover is only available on certain cover options 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 (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 (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
7 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, visit one of our branches or call 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 at your service provider 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. 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 and we ll post or 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 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 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, childbirth education, 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 or ing 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
8 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 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 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. 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 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 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
9 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 non- PBS 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 to find out your entitlements under your current policy. 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). 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. 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 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
10 Things you need to know Exclusions 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. Multiple Procedures and Exclusions If multiple procedures are provided in a single episode of care and one procedure is excluded under your hospital cover then nil benefits apply for the entire episode of care. 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. What s not covered? There are a number of situations where our health insurance doesn t cover you: 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: 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. In addition, our extras cover doesn t include: Psychological 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 to check what you re covered for, prior to going to hospital or for treatment
11 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. Continuity of cover doesn t apply to loyalty limits for services such as hearing aids, dental services (including orthodontic services), physiotherapy, chiropractic, osteopathy and exercise physiology. If you joined during an HCF waiver offer, waiting periods are waived for extras services with waiting periods equal to or less than the waiver. Hospital services are excluded from the waiver offer. Having a baby 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, together with other relevant claim details, to assess whether an ailment is pre-existing. A 12 month waiting period will apply to members with a pre-existing condition or ailment, if they are a new member or an existing member that has upgraded their cover, or a child not previously added to the policy. 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. These waiting periods are applicable where covered under your policy. Hospital waiting periods Palliative care Psychiatric services 2 months Rehabilitation services Pre-existing ailments or conditions 12 months Pregnancy & birth related services All other hospital services 2 months Same day hospital treatment excess waiver (available on selected covers) All hospital services (where not for 2 months pre-existing ailments) 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 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 1 day for pre-existing ailments) Pre-existing ailments 12 months 20 21
12 The gap, what it is, and what it means for you Your gap checklist The gap what it is Sometimes there s a difference between how much a provider charges you and the benefits HCF pays, so there could be an amount you ll need to pay. This is known as the gap. At HCF, we work hard to establish arrangements with health service providers to reduce or eliminate this gap for our members. The gap what you need to know Before you receive treatment as a private patient in a private or public hospital you should ask your treating health professional, the hospital and HCF about any out-of-pocket expenses you ll have to pay ( the gap ). Many hospital and medical services and procedures don t incur a gap, however if your treatment or the hospital admission does have a gap, you should know upfront what the cost to you will be before you are admitted or have the treatment. Being aware of these costs and consenting to them is known as Informed Financial Consent (IFC) please see page 40 for a definition of IFC. Hospital gap Private hospitals charge for accommodation, operating theatres, prostheses and other hospital related services. HCF has agreements with most private hospitals and day surgeries (known as participating private hospitals) across Australia. This means you won t have to pay additional costs (gaps) for services covered under your policy and under our agreement with the participating private hospital (subject to any excess you have on your policy and the conditions relating to your hospital product). HCF hospital products cover in-patient services (from when you re officially admitted to hospital to when you re officially discharged), however they don t cover outpatient services before or after your hospital admission. If you re a private patient in a non-participating private hospital or a private patient in a public hospital only Minimum Benefits will apply and you may incur significant additional expenses. Please see page 40 for a definition of Minimum Benefits. To check if your planned hospital admission will be in a participating private hospital, please visit hcf.com.au, drop into a HCF branch or call us on Medical gap Medical services provided while you are admitted to hospital (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% (for eligible services). However, many doctors charge more than the MBS fee so you may face additional out-of-pocket expenses (known as the medical gap ). HCF has arrangements with a large number of doctors across Australia to help eliminate or reduce medical gaps for our members. HCF Medicover is a direct billing scheme, which allows members to receive medical services with: No-gap (no extra cost to you) or a Known gap (an expense you ll have to pay, capped to maximum of $500 per doctor, per episode) when doctors charge according to the HCF Medicover terms and conditions and when delivered in a private hospital or day surgery with an agreement with HCF. Ask your treating specialist: What type of treatment or procedure will I have? What are the item numbers for the procedure/treatment? How much is your fee? Will you participate in HCF s Medicover arrangement? Will I have to pay a gap? If so, how much will it be? If I have to pay a gap when and to whom do I pay it? What if I can t afford the 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 for the treatment be? Am I having a surgically implanted prosthesis? What s the product name, supplier name, group name and billing code for the prosthesis? Ask your hospital: Do you have an agreement with HCF? Will I have a gap (excess or other cost) to pay for any hospital accommodation? Will all my hospital costs be covered by HCF? Will I incur any other out of pocket expenses during my time in hospital? If I have to pay a gap or any out of pocket expenses, when do I have to pay them? 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? 22 23
13 Medicover How HCF s Medicover Arrangement Works HCF Medicover is our doctor services arrangement. A doctor must choose whether they are a No-Gap or a Known-Gap Provider they can t be both. If your doctor is registered with HCF as a No-Gap Provider and chooses to participate for your procedure, you should have no medical gap to pay for their services. If your doctor is registered with HCF as a Known-Gap Provider, your out-of-pocket (medical gap) should be capped at $500 for all their services related to your admission. Please note: Doctors can choose to participate in HCF s Medicover arrangement on a patient-bypatient basis. If they are a No-Gap Provider and charge a gap (or charge you above the $500 capped gap amount if they are a Known-Gap Provider) only the MBS benefits will apply for their services. If there is a medical gap amount you may have to pay, you should be informed of this and given your Informed Financial Consent (IFC) before the medical services are provided. A list of doctors who are registered for HCF s Medicover arrangements is available at hcf.com.au. Always ask your doctor if they participate in Medicover No-Gap or Known-Gap, before your hospital admission. Remember if you will incur any out of pocket expense (medical gap) the doctor/s should let you know before any treatment. Medicover: What you could pay in No-Gap or Known-Gap situations Medicare Benefits Schedule (MBS) fee is the standard Medicare fee set for your procedure, which is subsidised by the Australian Government. 'MBS only' scenario Doctor only charges the MBS fee You pay $0 'Known Gap' scenario MBS fee + HCF contribution + member pays up to $500 threshold You pay up to $500 per procedure per doctor 'No Gap' scenario MBS fee + HCF contribution You pay $0 'Dr. opts out' scenario MBS fee + unlimited doctors charges paid by member You pay the difference between MBS fee and doctor's charge Prostheses Prostheses are items used in surgery to augment or replace a part of the body (like pacemakers, stents or joint replacement devices). Government approved, non-cosmetic prostheses that have been surgically implanted are covered by your HCF hospital product. If a government approved gap-permitted prosthesis item is used you may have to pay the gap. Ask your doctor which prosthesis is best for you and if a no-gap option is available. See page 41 for a definition of Prostheses. 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. 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 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
14 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: Mail: HCF, GPO Box 4242, Sydney NSW 2001 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, or call Changing to a different level of cover If you want to change your level of cover, just download an application form from hcf.com.au, call , 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. 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). 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 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. 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 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 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 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
15 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 toll-free (excludes mobiles). You can also HCF at or complete our online consent form at hcf.com.au/chronic 28 How does My Global Specialist work? Call My Global Specialist on 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. 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. 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. Who are Best Doctors? Best Doctors was founded by doctors from the Harvard Medical School in 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 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: 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. 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. 29
16 How your rights are protected Customer Service Charter 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 more information visit the Private Health Insurance section for consumers at health.gov.au, or call the Department of Health on 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: Visit: phio.org.au Write: Private Health Insurance Ombudsman Suite 2, Level George St Sydney NSW 2000 As an HCF member, you have every right to expect excellent service from us. We are committed to achieving this. HCF is a not-forprofit 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. 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 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 , and through our website when we receive your at or message through the Members Section of our website, you will immediately receive an acknowledgement via our management system. This tracks your communication with us. We aim to formally acknowledge your 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 So we can help, we ask that you: Be courteous to our staff; Let us know when things change, for example, your contact details; Give us feedback on our service
17 Want to have your say? How fraud affects you 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. 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. Voting Policyholders elect the Elected Councillors of the company. Councillors There are up to 24 Councillors, made up of 16 Elected Councillors, and 8 Board Councillors (who are also Directors of the Board). The 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. Becoming an Elected Councillor Voting Policyholders may express their interest in becoming an Elected Councillor, providing they meet the Elected Councillor Eligibility Criteria. Timing You ll be advised of elections for the Elected Councillors through the members' magazine HCF website. 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 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 , us on or visit us at hcf.com.au/fraud You may report lost cards on
18 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 Call us on 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 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). 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, 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. 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 ), no later than five business days from receiving your request If we have taken the wrong amount from your account, please contact us on 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. 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, call or log in to hcf.com.au/members 34 35
20 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 event, occurring by chance and caused by an external force or object, which results in involuntary injury to the body requiring immediate treatment from a registered practitioner. This definition excludes unforeseen conditions attributable to medical causes. 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; 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 (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 (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 Multiple Procedures and Exclusions means if multiple procedures are provided in a single episode of care and one procedure is excluded under your hospital cover then nil benefits apply for the entire episode of care. 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)
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