FAQs for PHI

An excess is an amount of money you agree to pay towards hospital accommodation costs should you, or a family member, be admitted to hospital.

Check your Hospital Fact Sheet to learn more about the excess details for your cover.

Excesses are only ever payable if you are hospitalised. They do not apply to extras. Depending on your level of cover, your excess may be waived in limited circumstances.

Australian Unity hospital covers have a 12-month waiting period for hospital admissions to treat pre-existing conditions. There is also a general 2-month waiting period on all hospital treatments for new members.

This means if you were previously uninsured, you won’t be able to claim on any medical treatment you have in the first 2 months of joining Australian Unity, even if the condition wasn’t pre-existing. After that, you’ll have to wait a further 10 months for treatment of any pre-existing conditions.

You’re considered to have a pre-existing condition if:

• you have an illness, ailment or condition; and

• in the opinion of a medical advisor appointed by Australian Unity, the signs or symptoms existed in the six months leading up to—and/or on the day—you became insured with Australian Unity or upgraded your cover.

This can apply even for conditions you were not aware of.

If you’ve recently joined Australian Unity, and the benefits on your new cover are higher than what you were receiving with your previous fund, you’ll need to wait 12 months for treatment of any pre-existing conditions.

If you’re upgrading your existing cover with Australian Unity, you’ll need to wait 12 months before receiving the higher benefits for any pre-existing conditions. If you’re eligible for benefits under your previous level of cover, and have served the equivalent waiting period, you’ll still be able to receive these while serving the waiting period for higher benefits.

Rules around pre-existing conditions do not apply to: Hospital Psychiatric Services, Rehabilitation and Palliative Care. These all have standard 2-month waiting periods. There is a standard 12-month waiting period on Pregnancy and Birth.

It depends on your level of cover, where you had the procedure and how much your doctor or surgeon charges you.

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 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.

Other medical costs

The amount you pay for the other medical costs related to your procedure—for example, pathology, radiology and doctor/specialist fees while you’re in hospital—will depend on your doctors. Specifically, it will depend on whether your doctors charge the “MBS” fee, or if their costs are higher.

The Medicare Benefits Schedule (MBS) is a list of medical services the Australian Government will pay a benefit towards. Importantly, it includes the amount the government defines as a fair fee for each service. When you're admitted to hospital—whether private or public—Medicare will cover 75% of the MBS fee. Australian Unity will pay the remaining 25% if you're covered for that item. A “gap” can occur if your doctor or specialist charges more than the MBS fee. This comes out of your pocket.

If your cover includes a “Gap Cover benefit”—and your surgeon and other doctors are willing to participate—you may be able to avoid (or reduce) these out-of-pocket costs. Learn more about Gap Cover.

Before you go to hospital, call us on 13 29 39 to find out what you’ll be covered for. We’ll need you to provide the following information:

• Medicare Benefits Schedule (MBS) item numbers involved in the procedure.
• Whether or not your doctor has agreed to participate in the Gap Cover Scheme (if included in your cover) and how much gap (if any) you’ll need to pay.
• Date of your admission.
• Which hospital you’ll be having your procedure at.
• Whether you’ll be admitted to a shared or private room.
• If there are any other expenses that will be raised by your doctor.