Conditions of benefits

   Health Cover

The following information is provided as a guide to your cover, however before undergoing any treatment it is important that you call Australian Unity on 13 29 39 8:30am-8:30pm Australian Eastern Standard Time, Monday-Saturday Australia-wide, for complete and up-to-date information regarding your benefit entitlements, as the information in this page is subject to change.


1. Single / Couple / Family Membership

A single membership covers one person (the member) only. A couple membership, covers the member and one other person who is not a dependant child of the member. A family membership covers the member and their spouse / defacto / partner and dependant children as well as sole parents with one or more eligible dependant children.


2. Basic Hospital Cover

Basic Hospital cover (B1) provides benefits to cover the cost of a shared ward in a public hospital only. This table is not suitable for the costs of private hospitalisation. Gap Cover benefits for medical charges above the Government Medicare Schedule are not available under this cover. Please contact us for further information.

3. ‘Accident’

‘Accident’ means any injury inflicted as a result of unintentional, unexpected actions or events which require treatment by a registered medical practitioner but excluding accidental illness, surgical procedures, pregnancy, injuries or illnesses induced by alcohol, drug dependence or aggravation of a pre-existing condition.


4. Dependants

A family membership covers the member, spouse / defacto and their dependant children up to the age of 23 years.

Children continue to be included under the family membership while they remain unmarried and continue to attend an Australian Unity approved full-time course of study up to the age of 25 years. If they join their own membership within three months of ceasing to be included under the family cover, they receive continuity of benefits.


5. Members transferring from other funds

Years of membership and benefits paid with another fund will be taken into account in calculating Australian Unity waiting periods and benefits payable if the member joins an Australian Unity health insurance table within 30 days of ceasing membership with their previous Registered Health Fund.

Please request a Transfer Certificate from the previous fund after joining Australian Unity, or complete and return the Transfer Request section of the enclosed application form.

6. Waiting Periods

After enrolment or transferring to a higher benefit level of cover, benefits will generally be paid immediately with the exception of waiting periods outlined on page 24.

Important Notice

(For pre-existing conditions for psychiatric, rehabilitation and palliative care, benefits will not be payable for the first 2 months of membership.)
For pre-existing conditions, benefits will not be payable for the first 12 months of membership for any illness, ailment or condition, the signs or symptoms of which were known, or which a medical or paramedical practitioner appointed by the company considers, after examining information furnished by the member’s practitioner, and other material relevant to a claim for benefits, were in existence in the member or his/her dependant at any time during the six months ending on the day on which the person became insured.

This is irrespective of whether the member or dependant was aware of the pre-existing illness, ailment or condition, and includes all proposed elective or cosmetic procedures. Australian Unity may request further medical evidence in determining eligibility for benefits.

Benefit limitation periods - The Basic Hospital Cover rate applies to hospital covers for psychiatric and rehabilitation treatments within the first 12 months of membership if previously uninsured

Dental Maximums - Combination tables / Extras tables. Please note that the dental benefit maximums under these tables are different and can affect your dental entitlement when transferring from one table to another. Additional waiting periods can apply when transferring between E2, E3 E5, E7, LPP, LPX, LCL, LCX or a Smart table for crowns, bridges, etc. and for overall dental maximums.

7. Compensation from other sources

Australian Unity benefits are not payable where a member has a right to claim damages, compensation or benefits from any other source. Please contact the Claims Department section for advice concerning compensation claims


8. Extent of Benefits

Benefits are limited to the insured rate or actual amount charged, whichever is less. Conditions and benefits apply as at the date of service. 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.

Hospitalisation in an Australian Unity agreement hospital is available at the insured rate for 365 days per year subject to medical certification as to the need for ongoing acutecare 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.

Benefits for Obstetrics and pregnancy related conditions / treatments will not be payable under Non- Obstetrics Cover (KX/JX) and Smart Start (LB).

Benefits for Obstetrics and pregnancy related conditions under Smart Combination Cover (SK/SJ) will be paid at the Basic rate only. Benefits for Obstetrics and pregnancy related conditions under Hospital Essentials (JE) will attract a per night co-payment of $75 up to a maximum $450 per admission. Benefits for gynaecological treatments / conditions will be covered at the insured rate.

Benefits for purely cosmetic procedures and reversal of sterilisation procedures are payable at a reduced level by Australian Unity and may not attract any rebate from Medicare. Members are advised to discuss the fees with their surgeon and hospital prior to any treatment.


9. Cooling Off Period

We will allow any health member who has not yet made a claim to cancel their policy and receive a full refund of any premiums paid within a period of 30 days from the commencement of their policy.


10. Membership Arrears

All contributions are payable in advance. Failure to pay contributions within two months of the expiration of the member’s last contribution period will result in cessation of both the membership and entitlement to benefits.


11. Claims

Benefits are not payable for periods during which a membership is unfinancial or suspended, nor are they payable on claims submitted more than two years after the date of service.


12. Liability

Australian Unity will not be liable should an application or claim form contain false or inaccurate information or where the member is unfinancial.


13. Yearly Maximums

All yearly maximums, excesses and limits are calculated from 1st January each calendar year.


14. Excess

For singles, the excess is applied once per calendar year if hospitalised. For couples and families, the excess is applied at the single rate up to a maximum of twice per calendar year.

15. Year of Entitlement

A member’s year of entitlement is calculated on the number of calendar years of membership with Australian Unity less any applicable 12 month waiting periods, e.g. major dental.


16. 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.


17. Rate Change

Australian Unity’s rate guarantee policy ensures that contributions paid in advance are protected against the rate change (the member will also be eligible for any increase in benefits). Once contributions are due again, they will be payable at the new rate.

18. Suspension

To assist members, provision exists for members to apply for suspension of membership for up to two years if they are travelling overseas.


19. Becoming a member of Australian Unity Limited

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 are generally ineligible to become members of Australian Unity Limited.


20. Summary of Rules

This page 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 3205.


21. Further Information

If there are any complaints that have not been resolved with Australian Unity, the matter can be referred to the Private Health Insurance Ombudsman who may be contacted on 1800 640 695.

Note: Australian Unity gives no endorsement of any products supplied to members by suppliers listed under ‘Wellplan® Rewards’.

Australian Unity, Wellplan, Wellplan Rewards, LifeChoice, LifeChoice Plus, Smart Start, Smart Combination, The COACH Program® and baby+me are all registered trademarks of Australian Unity Limited.