Terms and Conditions - Health Cover
Effective 23 May 2013
A person may be eligible to become a member of the health fund where full, true and proper disclosure is provided on the application form. Evidence to support any information contained on the application form such as, identity or age, may be required at the discretion of the Fund.
Unless otherwise agreed by Australian Unity a person must be over the age of 15 years or older to hold a membership in his or her own right.
You are not eligible for a membership with Australia Unity, if you are insured under a similar level of cover with another private health insurer.
A single membership covers one person (the member) only. A couple’s membership covers the member and one other adult. A family membership covers the member and their spouse, defacto or partner and dependant children as well as sole parents with one or more eligible dependant children.
A dependant is a child aged up to 23 years old who is unmarried. Upon application dependants can continue to be covered under a family membership up until the age of 25 years, while they remain unmarried or not in a de facto relationship and continue to attend an Australian Unity approved full-time course of study at a school, college or university in Australia.
Unless otherwise offered or agreed by Australian Unity, premiums are payable monthly, or in monthly multiples, in advance. Australian Unity may not accept premium payments that exceed 12 months from the current paid to date of the membership.
5. Membership Arrears
All premiums should be paid in advance. Failure to pay a premium within 60 days of the expiration of the last payment period will result in cancellation of the membership and benefit entitlements.
6. Notice of Premium and benefit changes
Australian Unity’s rate guarantee policy ensures that premiums paid in advance are protected against a rate change until the earlier of; the next due date of premium payment (the member will also be eligible for any increase in benefits).
Notice will be provided in writing to the Fund member by either the post, or email address notified to Australian Unity. Please ensure that your address and other contact details are kept up to date.
7. Hospital cover
Hospitalisation in an Australian Unity Agreement Private Hospital is available at the insured rate for 365 days per year subject to medical certification as to the need for ongoing acute care or, in the case of drug and alcohol or rehabilitation hospital programs, medical certification that progressive gains are being made by the patient as a result of that program.
Payment of benefits for hospitalisation in excess of 35 days will require medical evidence certifying the need for on-going acute care in hospital to be provided to Australian Unity. Surgical procedures listed on the Government Exclusion List may require medical certification before benefits are payable.
Benefits are payable toward the cost of in-hospital PBS pharmaceuticals, but excludes experimental and high cost non-PBS drugs.
Hospital benefits are not payable during a waiting period or where a service is specifically excluded under your chosen cover.
Hospital benefits are not payable for Private hospital emergency room fees. Members are advised to discuss the fees with their surgeon and hospital prior to any treatment.
Excess is an amount of money the Member agrees to pay the Hospital towards the accommodation costs of a Hospital admission in exchange for a lower premium payable under their chosen cover.
Co-payment is a daily amount of money the Member agrees to pay the Hospital for a Hospital stay before benefits are payable under their chosen cover.
Exclusions are selected treatments under a Hospital cover where Hospital and Medical benefits will not be payable by Australian Unity. Refer to your product fact sheet for specific benefit entitlements.
Restricted benefits are hospital benefits, either for a set time frame or for the duration of the cover, that covers you as a private patient in a shared ward of a public hospital. In private hospitals, limited benefits will be payable towards your accommodation and government approved surgical prosthesis. We will not cover private hospital theatre or labour ward fees or costs associated with admission to an intensive or coronary care unit. This benefit is not suitable for cover towards the costs of an admission to Private hospital and significant out of pockets will apply. Contact Australian Unity before undergoing treatment.
Accident means any injury inflicted as a result of unintentional, unexpected actions or events which requires timely treatment by a registered Medical Practitioner but excluding accidental illness, surgical procedures, pregnancy, aggravation of a pre-existing condition, injuries or illnesses induced by alcohol or drug dependence.
Accident Cover. Where a Hospital cover offers this benefit the accident must have occurred after joining that level of cover to be eligible for benefits. The provision
of this benefit is at the discretion of Australian Unity and will be based in the advice of Australian Unity’s appointed medical or para-medical practitioner.
11. Agreement Private Hospitals
Agreement private hospital means a private hospital or day hospital facility that has entered into a hospital purchaser-provider agreement with Australian Unity.
12. Ambulance Benefits
Australian Unity advises members, that where applicable to purchase an Ambulance subscription with your state based provider.
For NSW and ACT members with hospital cover, an Ambulance levy is included in your hospital premium for emergency Ambulance transport.
For Queensland and Tasmania members, you are covered for Ambulance transportation under your State Government scheme.
For VIC, SA, NT and WA members with Hospital cover, who do not hold an ambulance subscription, are eligible for benefits towards Fund recognised emergency ambulance transportation.
The ambulance account must be coded as an emergency transportation by the ambulance service to qualify for benefits. Benefits are not payable when claimable via another source.
13. Extras Cover
Benefits: Treatment or consultations will only be payable on the basis of one consultation per patient, per practitioner, per day.
A consultation is eligible for benefits where it is conducted on a face-to-face basis. It excludes services delivered online or over the telephone unless part of an approved Australian Unity Chronic disease or health management program.
Benefit Replacement Period: means a continuous period of time that must occur between any two purchases of the same type of artificial aid or appliance item before benefits are payable.
14. Recognised Providers
Benefits are only payable for ancillary, dental and nursing services provided by practitioners recognised by Australian Unity and in private practice. Recognition
is subject to change without notice. Recognition by Australian Unity is for benefit payment purposes only and should not be taken or construed in any way as sponsorship, approval of, or any recommendation as to the qualifications and skills of, or services provided by, a practitioner or therapist. Members should check that their practitioner is recognised by Australian Unity before commencing treatment.
15. Waiting periods
Generally, you may claim on services received on and from the commencement of your membership, except where waiting periods apply as outlined in your product fact sheet.
Waiting periods apply when you join, upgrade your cover, reduce your excess or re-join after a break in cover.
When upgrading your cover you may claim benefits at the higher rate for services provided except where a waiting period applies. The benefit will be paid that is equivalent to your previous cover until the waiting period on the new level of cover has been served.
Benefits are only payable on claims made for services rendered within Australia and are limited to the insured rate or the actual amount charged, whichever is less. Conditions and benefits apply at the date of service.
Benefits are not payable for periods during which a membership has premium payments in arrears or is suspended, nor are they payable on claims submitted more than two years after the date of service.
Australian Unity benefits are not payable where a member has a right to claim damages, compensation or benefits from any other source or where such a right to claim later arises. The member is required to reimburse Australian Unity for any benefits paid where damages, compensation or benefits is later received from another source. Please contact our Customer Service team on advice concerning compensation claims.
17. Yearly maximums
All yearly maximums, excesses and benefit limits are calculated from 1st January each calendar year. Yearly maximums are not transferable to any other person under the Membership.
Australian Unity is committed to keeping fund premiums to a minimum, and one way of doing this is to ensure that claims for treatment or services raised by healthcare providers are charged and benefits paid are accurate and correct. Australian Unity may undertake audits of Hospital or Extras claims, and may contact you to assist or seek written consent. Your details will be kept confidential at all times.
19. Transferring from another fund
If a person joins Australian Unity within 30 days of ceasing their previous health cover with another registered Australian private health fund years of membership and benefits paid with the other fund will be taken into account in calculating Australian Unity waiting periods and benefits payable. Please request a Transfer Certificate from the previous fund after joining Australian Unity, or complete, sign and return the Transfer Certificate Request form enclosed in your Australian Unity Welcome Pack.
20. Cooling off Period
We will allow any health member who has not yet made a claim to cancel their membership and receive a full refund of any premiums paid within a period of 30 days from the commencement of their health cover.
21. Refund Policy
After the cooling off period a member wishing to cancel their membership and seek a refund of premiums paid in advance may do so in writing. Any refund will be calculated from the actual date the refund application is received by Australian Unity, or such later date as set out in the notice, and may attract an administration charge not exceeding $50 per membership.
If you are considering cancelling your membership, please discuss this with our Customer Service Team.
Where in the opinion of the Fund there are sufficient grounds to do so, Australian Unity may terminate or suspend a membership at any time by giving written notice to the Member concerned and may refund premiums paid in advance.
Members can apply for a suspension of membership if they are travelling overseas. An application must be received prior to your departure from Australia, and your membership must be financial by at least one month in advance of the requested suspension date.
Benefits will not be payable for any hospital or extras services that occur during the suspension period. Waiting periods cannot be served while a membership is suspended.
Please refer to the Overseas Travel Suspension brochure for details.
23. Becoming a Member
Australian Unity health benefit fund members may be eligible to become a member of Australian Unity Limited ABN 23 087 648 888 after completing two years of continuous membership. Australian Unity health benefit fund members joining through a corporate group membership or members on an overseas product are generally ineligible to become members of Australian Unity Limited.
24. Summary of Terms & Conditions
This brochure contains only a summary of the fund rules. The complete rules of the health benefits fund set out in full the terms and conditions of membership and liability under the fund. These rules are available for inspection at Australian Unity, 114 Albert Road, South Melbourne VIC 3205.