How to claim on Health Insurance

Claim on hospital procedures

The hospital procedures (including day surgeries) that you can claim on will vary depending on your level of cover.

Not sure which hospital procedures you can claim on? Log into your account or check your Fact Sheet to view details about your health cover.

Before booking treatment, you should contact us to ask about the benefits you can expect to receive and any out-of-pocket expenses you might incur.

Accommodation and theatre fees

You shouldn’t be charged for accommodation or theatre fees (or prosthesis, if needed) if you’re “Covered” for your procedure at that hospital (your Fact Sheet will tell you which treatments are “Covered” and at which type of hospital); and you’ve completed any applicable waiting periods.

In most cases, the hospital will bill Australian Unity directly. You’ll only receive an invoice if an excess or co-payment applies to your cover (and you haven’t already paid it). If you do happen to receive an invoice for the full amount, please call us on 13 29 39.

If your procedure is “Covered” but is in a “non-agreement” private hospital or a private room of a public hospital, you may incur large out-of-pocket costs. This may include theatre fees, intensive or coronary care costs and accommodation. If your cover provides for “Restricted” benefits, Australian Unity will only pay the basic default benefit[1] for your accommodation and prosthesis (if needed). You will not be covered for any other accommodation and theatre fee costs relating to your procedure, and may incur large out-of-pocket costs. For medical costs, see below.

For any charges not covered by Australian Unity, you will need to contact the hospital and confirm how to pay.

Medical costs

The way you claim the bills from your surgeons and other doctors will vary depending on whether they’re participating in Australian Unity’s Gap Cover scheme.

If your policy includes Gap Cover - and your doctor agrees to participate in the scheme for your procedure—they should deal directly with Medicare and Australian Unity. You should only receive an invoice from them if there are out-of-pocket costs (which can still arise, depending on how much your doctor charges). These costs are not covered by Australian Unity. It’s the responsibility of your treating doctor and hospital to advise you of potential out-of-pocket costs before you’re admitted into hospital. If they don’t provide an estimate of those costs, it is your right to ask for informed financial consent.

Ways to claim (non Gap Cover claims)

If your doctor isn’t participating in Gap Cover, you’ll receive an invoice from them. You can either claim your Australian Unity benefits through Medicare or come to us. Either way, you’ll still need to go to Medicare first.

Option 1: Claim through Medicare

You can submit a Medicare Two-way claim form to Medicare. If payable, Medicare will process its part of the claim and organise payment to you. Medicare will then forward the details to Australian Unity so we can process our part of the claim. We’ll make any payment into your nominated bank or credit union account.

Option 2: Claim through Australian Unity

App or online

1. Submit your paperwork to Medicare. You’ll receive a cheque, or some other form of payment, for your doctor and a statement of Medicare benefits for Australian Unity.
2. Hold onto the payment from Medicare. Then log into your Australian Unity health app, or Online Member Services (online account).
3. Head to ‘Make a claim’ and select ‘Medical services’. Complete the online form. Make sure to include your statement of Medicare benefits and any other documents relevant to your claim.
4. Once we’ve processed your claim, we’ll make a payment into your nominated bank or credit union account.
5. Pass the payment from Australian Unity, and the Medicare payment, onto your doctor. If there’s any amount outstanding, you’ll also need to pay this.

Mail or email

1. Submit your paperwork to Medicare. You’ll receive a cheque, or some other form of payment, for your doctor and a statement of Medicare benefits for Australian Unity.

1. Complete a health cover claim form. Attach your statement of Medicare benefits to the form.
2. Mail or email the completed form and other documents to Australian Unity. You can find the reply-paid postal address and email address on the claim form.
3. Once we’ve processed your claim, we’ll make a payment into your nominated bank or credit union account.
4. If there’s any amount outstanding, you’ll need to pay this.

If your doctor asks you to pay upfront, you can follow the same processes outlined above. Just make sure to show Medicare your proof of payment. Medicare will then pay you directly. Medicare will still issue you a statement of Medicare benefits and you’ll need to include this in your Australian Unity claim.