Your Member Guide
ntil 2014 15
lid u
Va
Re
g . N o. 5 0 3 7
September 2014
More for
You’ll get
our members
more with HCF
We provide health cover to help you stay healthy
More peace of mind
Thank you for choosing HCF for your
private health insurance. As one of over
1.5 million members, you are with a strong
health fund that delivers more to you.
Want to avoid public hospital waiting lists?
Want a doctor you know and trust?
With HCF, it’s your choice.
More benefits
Contents
More for You programs
4
Health and wellbeing programs
6
More ways to help you and your family
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
Rebates, surcharges and incentives
24
Managing your policy
26
Health and wellbeing frequently asked questions
28
Bonus $10,000 Permanent Disability from Accident Benefit
30
Loyalty benefits
31
How your rights are protected
32
Member Service Charter
33
Want to have your say?
34
How fraud affects you
35
Want to change your payment method?
36
Our privacy statement
38
Related websites
39
Glossary40
Index43
2
As Australia’s largest not-for-profit health fund,
we seek to return the highest benefits back to
our members, not shareholders. And we have the
figures to prove it. We returned 91.6 cents in the
dollar in benefits compared to an average of
86.4 cents for other health funds in the 2013
financial year.
This means you get more value with HCF.
But don’t just take our word for it. Canstar, one
of Australia’s leading independent rating agencies,
has awarded us their top national award for
outstanding value health insurance five years
in a row.
More savings
Depending on your level of hospital cover, you
can reduce your premium by opting for a higher
excess, or pay a bit more to get a lower excess.
An excess is the amount you nominate to pay
if you’re admitted to hospital.
You can also save more if you need to claim
because:
• You won’t pay a hospital excess for dependent
children or treatment as a result of an accident
• You pay only one hospital excess amount
per person per calendar year if an excess
is applicable.
You’ll save even more by choosing a doctor who
participates in our no-gap Medicover arrangements.
Many doctors charge above the Medicare Benefits
Schedule fee which can lead to significant out-ofpocket expenses for in-patient medical services.
Medicover No-Gap Arrangement
HCF can save you even more on in-patient medical
bills if you choose a doctor who chooses to use our
no-gap HCF Medicover arrangement. This may
help to prevent you paying extra out-of-pocket
expenses for in-patient medical services.
More cover
• Y
ou'll get the best no-gap medical coverage of
any health fund in Australia (PHIO report 2013)
• You get a range of fully covered services for
teeth, eyes, muscles, backs and feet under our
More for You programs.
More than health insurance
• Look after your health and wellbeing easily
with our My Health Guardian program
• Eligible members in selected areas can access
our afterhours My Home Doctor service
• Get a 10% discount on travel and pet insurance
• Access affordable Cash Assist cover from
HCF Life
• Expect high-quality, award-winning customer
service. HCF has been recognised by the
Customer Service Institute of Australia for
our continued commitment and dedication
to our customers.
HCF’s loyalty benefits. Your limits get better over time.
You can never have too much of a good thing so the longer you’re with HCF, the more you’ll get back.
The amount you can claim on many of our extras will increase each year, depending on your level
of cover. For more information on loyalty benefits, visit hcf.com.au/loyaltybenefits
More for You programs
More for You
programs
Want more fully covered services?
Want to get back on your feet faster?
Our More for You programs 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 Hearing
This program provides free online tools to help
you better understand your hearing ability.
Depending on your level of cover we’ll remove or
significantly reduce out-of-pocket costs for highquality hearing aids from Blamey Saunders Hears,
our participating hearing aid provider.
More for Teeth
This program gives you a range of fully covered
diagnostic and preventative dental services.
These services are available in Sydney through
HCF Dental Centres and across Australia
(except NT and Tas) through participating
dental providers. It's available with all extras
covers and subject to available limits.
More for Eyes
This program gives you a range of fully covered
glasses and access to free digital retinal
photography through our participating optical
providers across Australia and seven HCF Eyecare
Centres in Sydney. It’s available with selected
extras covers and subject to available limits.
More for Muscles
This program gives you one fully covered initial
consultation a year for a New Episode of Care,
through our participating physiotherapists across
Australia. It’s available with all extras covers and
subject to available limits.
4
More for Backs
This program gives you one fully covered initial
consultation a year for eligible musculoskeletal
conditions for a New Episode of Care, through our
participating chiropractors and osteopaths across
Australia. It’s available with all extras covers and
subject to available limits.
More for Feet
This program gives you one fully covered initial
consultation a year for a New Episode of Care,
through our participating podiatry providers
across Australia. It’s available with selected extras
covers and subject to available limits.
HCF Dental Centres
Our HCF Dental Centres are equipped with
modern technology, staffed by experienced
professionals and offer some fully covered
services to help you save money.
Through our extras products, you can claim
for a range of fully covered dental diagnostic
and preventative dental services. Other dental
services, like more complex fillings, crowns and
bridges, will incur a charge.
HCF Eyecare Centres
At HCF Eyecare Centres, you are given access
to a range of fully covered glasses and lenses.
However, you may incur a cost depending on
the style of frames, lenses or contact lenses
you select.
Health management
programs
You can also save up to 30% off the
recommended retail price by purchasing
sunglasses online at sunglasses.hcfeye.com.au
Looking to improve your health?
On eligible extras products, you can
claim on a range of HCF approved
health programs to help you lead a fit
and healthy life. They include:
As a participating provider in the More for Eyes
program, the Eyecare Centres provide you with
access to free digital retinal photography.
• Weight management programs
• Healthy Weight for Life
• Exercise and gym membership
for a specific health problem
(Doctor's referral required)
• Childbirth education
• Lactation consultant
• Learn to swim
• Stress management and
quit smoking programs
• Faecal occult blood test
More
Hearing
A sixfor
month
waiting period and
conditions apply.
Visit hcf.com.au/healthmanagement
for more details.
HCF Eyecare Centres are independently owned
and operated by Eyecare Holdings Pty Limited
ACN 054 365 196.
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 or reference must
not be construed as an endorsement or
recommendation by HCF of that provider
or their services/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.
HCF Dental and
Eyecare Centre
locations:
Blacktown
Level 6, Westpoint Office Tower,
Westpoint Shopping Centre, Patrick St
Dental: 02 9852 2100
Eyecare: 02 9672 9500
Bondi Junction
Level 8, 1 Newland St
Dental: 02 9386 2222
Eyecare: 02 9386 2333
Brookvale
Warringah Mall Shopping Centre
Cnr Pittwater Rd & Condamine St
Dental: 02 9907 5600
Eyecare: 02 9907 5100
Chatswood
Level 6, 13 Spring St
Dental: 02 8448 0144
Eyecare: 02 8448 0111
Hurstville
12 Butler Rd
Dental: 02 8567 3244
Eyecare: 02 8558 9800
Parramatta
Level 6, 128 Marsden St
Dental: 02 9685 1255
Eyecare: 02 9685 0655
Sydney
HCF House, 403 George St
Dental: Level 3, 02 9290 0555
Eyecare: Level 9, 02 9290 0199
For more information on our
Dental and Eyecare Centres,
please visit hcf.com.au, call 13 13 34
or email [email protected]
5
Health and wellbeing programs
Health and
wellbeing programs
After-hours home
doctor service
My Home Doctor is a convenient non-emergency
after-hours home doctor service for eligible
members in selected areas. The service is provided
at no cost to you if you have hospital cover.
We give you access to easy-to-use health
and wellbeing management tools, home
care and support for a number of specific
health conditions.
Health and wellbeing
My Health Guardian is our unique online health
and wellbeing management program, that lets
you create an easy and effective wellbeing plan.
Whether you want to lose weight, have more
energy or simply feel healthier, this innovative
service helps you take the necessary steps on the
path to a healthy, happy life.
Helpful tools include:
• Wellbeing assessment and action plan – a
simple, guided process to assess your lifestyle
and overall health and put together your plan
• Online resource library – access hundreds of
articles, exercises and recipes
• Your personal health coach – ask any diet,
exercise and lifestyle questions
• Exercise and diet plans – create personalised
plans using the Get Fit and Eat Fit tools.
My Health Guardian is a fully covered service for
members aged 18 years and over with hospital
or extras cover.
6
Well-being Plus 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, 'Well-being Plus'.
Available for iPhone and Android.
Visit hcf.com.au/mobile-apps for information
on how to use the app.
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
Home Telemonitoring Service
HCF has partnered with Telstra and Healthways
to provide an extension to the My Health Guardian
program, a new home telemonitoring service for
eligible members with chronic conditions, like
high blood pressure or diabetes. The service is
available for members already participating in the
telephone-based My Health Guardian component
of the program. It allows regular monitoring of
certain chronic conditions via an easy to use
wireless device so that My Health Guardian nurses
can provide you with more informed tailored care
and advice.
To join the Home Telemonitoring Service or find
out more, contact us or visit hcf.com.au/chronic
Think of the peace of mind, having access to such a
service. Whether it’s having your distressed young
child seen by a doctor in the middle of the night,
or simply helping you get treatment sooner when
you feel sick. Coverage spans most of Sydney,
Melbourne, Geelong, Adelaide and South East
Queensland, and is constantly expanding.
To see if your area is covered, contact us
or visit hcf.com.au/mhd
Access world leading
medical experts
If you or someone on your family membership
had a serious illness, wouldn’t it be reassuring
to know that you could access a world-leading
medical expert to review your case? My Global
Specialist is an innovative medical information
service available to members with Top Plus
Hospital cover with nil excess, and either
Multicover or Super Multicover Extras or Top
Hospital with nil excess, and either Top Extras
or Healthcover Plus Extras.
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.
This service is available through Best Doctors, the
world’s leading resource for specialist medical
advice founded by doctors from the Harvard
Medical School.
Healthy Weight For
Life Programs
HCF believes healthy living starts with awareness
and education. Our Healthy Weight For Life
Programs are designed to promote and teach
skills to achieve and maintain a healthy, happy
lifestyle.
The programs have shown positive results
including major improvements to the health and
weight of participants with type 2 diabetes, heart
conditions and osteoarthritis. Each program has a
three-phase weight loss action plan, teaching you
weight control skills to live healthily for life.
For more information visit hcf.com.au/hwfl
Our new service
More at Home is a community care service
available in Northern and Western Sydney,
providing home support to those who need a
helping hand either on a regular basis or
once off.
More at Home gives you access to a
compassionate professional who will assist you
with domestic and/or personal care. They’ll help
with housework, shopping and meal preparation
or even just getting ready in the morning and
providing transport if needed.
You’ll also receive ongoing nursing care with a
registered nurse if you need it. This paid service is
managed by Manchester Unity, a 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 1300 550 124.
Please visit hcf.com.au/mgs or contact us for
more information.
7
Helping you and your family
More ways to help
you and your family
These products provide living benefits that health
insurance cannot cover. They suit a wide range of
people – from singles and young families to baby
boomers – and are easy to apply for – no medical
checks or lengthy questionnaires are necessary.
Please consider each Product Disclosure
Statement available by calling 13 13 34,
emailing [email protected] or visiting
hcf.com.au/cashassist and your financial
situation, objectives and needs before deciding
on these products as the information provided
does not take these into account.
The Cash Assist options are issued by our
own HCF Life Insurance Company Pty Ltd.
ABN 37 001 831 250, AFSL 236 806.
Retirement and
Aged Care Services
Travel Insurance
10% discount for members
Our HCF 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.
You should consider the Travel Insurance Product
Disclosure Statement before deciding to buy this
insurance. This can be obtained by visiting
hcf.com.au/travel or calling 13 13 34.
HCF Travel Insurance is issued by
QBE Insurance (Australia) Limited
ABN 78 003 191 035, AFSL 239 545 (QBE).
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.
We recommend that you consider the Pet
Insurance Product Disclosure Statement
and Financial Services Guide which is
available by calling 1800 630 681 or visit
hcf.com.au/petinsurance before deciding
to buy or continue to hold this product.
HCF Pet Insurance is issued by The Hollard
Insurance Company Pty Ltd (Hollard),
ABN 78 090 584 473, AFSL 241 436.
Cash Assist options
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
We also offer high quality retirement lifestyle
living and aged care services 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 services
Our aged care facilities offer the best in low care,
high care, extra services and dementia care for
residents requiring more support and security.
We have two aged care facilities in Sydney
– Courtlands Village and Northcourt, both
conveniently located in at North Parramatta.
To find out more visit hcf.com.au/agedcare
9
Who can be covered
Who can be covered under
your HCF Policy
So there’s no confusion when you need to make
a claim, it’s important to understand who can
be covered under your health insurance 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.
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.
10
• 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.
Dependants:
Child, Student & Adult
Student dependant means a person who:
a) Is aged between 22-24 (inclusive); and
b) I s 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 22-24 (inclusive); and
b) I sn’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.
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.
11
Making a claim
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, come into one of our branches, email us at
[email protected] or call 13 13 34. 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 a service before it has
been provided
• 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 policy
must sign the claim form or electronic
claims receipt.
• Your healthcare provider must be recognised
by HCF.
Extras claims
There are five ways to claim extras payments.
On the spot
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. This is called ‘the gap’, as explained
on page 22.
Make a 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 in person
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. We will pay you in cash
or credit to your nominated bank account, and
give you a statement for your records. 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.
All other dependants presenting a claim require a
claim form signed by the Policyholder or Partner
listed on the policy. We will pay these claims 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,
pick one up from any HCF branch, or call Self
Service on 13 14 39 and we’ll post or email 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 2001
3.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.
Claim online
You can claim online for some extras like general
dental, dietetics, occupational therapy, podiatry,
speech pathology, remedial massage, naturopathy
and physiotherapy.
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.
Additional information
on extras claims
Artificial appliances
Some covers have benefits for surgical and
artificial appliances like a CPAP machine or a
blood glucose monitor. The aid or appliance
must always meet HCF’s definition of an artificial
appliance (see page 40 of the Glossary).
In addition, appliances may only be eligible when
recognised 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 recognised 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 13 13 34 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, there
is a limit of one physiotherapy, chiropractic or
osteopathy therapy benefit per day.
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,
stress management and quit smoking programs.
Before you start any program, please check with us
that you’re entitled to claim. 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, by calling
13 13 34 or emailing [email protected].
This form must include your doctor’s or specialist’s
confirmation of your specific health condition
that the program addresses. Your physiotherapist
can complete the form if you are claiming for a
class held by a physiotherapist. Benefits are not
claimable for recreational or competitive sports.
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 accrue the longer you keep
extras cover with HCF (up to a lifetime limit).
13
Making a claim
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 13 13 34 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 13 13 34 so we can help
you determine what you’re covered for, and
help you minimise any gap.
14
Pharmacy
Pharmacy benefits can be claimed for items that
are on HCF’s approved pharmacy list and/or
meet the Clinical Policy of Pharmaceuticals (for
Ancilliary Benefits). Please see the definition of
a pharmaceutical item in the Glossary on page 42.
Before the 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 most 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 13 13 34.
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 call us on 13 13 34.
Additional information
on insulin pump
benefits
Insulin pump benefits
The following information relates to members of
HCF who may need, or already have, an insulin
pump and do not have an Exclusion.
At the time the insulin pump is supplied, you must
have completed any relevant waiting periods
(12 months for new members), 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.
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 new 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.
If you are on Top Plus, Top Hospital, Fit & Free
or Healthmate Ultimate cover continuously over
a 5 year period you will be eligible to claim a
benefit of up to 100% of the highest costing insulin
pump on the Federal Government Prostheses
List (currently up to $9,500) – you will have no
out-of-pocket expense for insulin pumps. If you
have maintained any other level of hospital cover
within the 5 year period, and that cover does not
have an Exclusion for insulin pump treatments,
you will be eligible to claim up to half that amount
(currently up to $4,750).
If you wish to replace your insulin pump in less
than 5 years, a pro-rata benefit may be offered
depending on your individual circumstances,
and provided the pump is not under warranty.
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 Minimal 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.
15
Making a claim
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
13 13 34 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. Plus, on selected 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
i.e. where your doctor requests ambulance
transport because your condition requires medical
monitoring and support in transit.
Ambulance transport is 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, 2 months for non-emergency
ambulance cover and 12 months for pre-existing
ailments or conditions.
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.
16
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.
If you fall outside the state based arrangement
for ambulance services and aren’t otherwise
covered, you can claim under your HCF product
for State Government provided emergency
ambulance services.
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.
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
arrangement 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.
Third party and
compensation claims
Please call HCF on 13 13 34 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.
17
Things you need to know
• G
oods 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:
Things you
need to know
Exclusions
What’s not covered?
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.
There are a number of situations where our health
insurance doesn’t cover you:
Minimal Benefits
If you choose a product with Minimal Benefits
for some procedures (like pregnancy and birthrelated services), you’ll be covered in a public
hospital shared room, but your private hospital
costs won’t be fully covered. This means you could
face significant personal expense if you have any
of these procedures in a private hospital.
For procedures attracting Minimal Benefits in a
private hospital, we would:
• Pay a small amount towards your
accommodation
• Pay for Government approved prosthesis for
covered services
• Not pay operating theatre expenses, or labour
ward charges.
There are also some services where doctor’s
charges aren’t payable (for example, elective
cosmetic surgery and surgery by an accredited
podiatric surgeon).
For these, we will only pay a small amount towards
the total cost of the procedure (and no doctor’s
charges). This only applies to services which don’t
attract a benefit from Medicare.
18
• 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
• 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
• 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 treatments
• 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, prosthesis, 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,
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 13 13 34 to check what you’re
covered for prior to going to hospital or
for treatment.
19
Waiting Periods
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 are 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.
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 dependants unless switching from another
fund or policy where they’ve served equivalent
waiting periods. The two year waiting period applies
to hearing aids even if you are transferring from
another fund. 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
20
Hospital waiting periods
Palliative care
Psychiatric services
Rehabilitation services
Pre-existing ailments or conditions
Pregnancy & birth related services
All other hospital services
2 months
12 months
2 months
Same day hospital treatment excess waiver
(available on selected covers)
All hospital services (where not for
pre-existing ailments)
2 months
Pre-existing ailments or conditions
12 months
Extras waiting periods
Health management programs
Artificial appliances (e.g. CPAP
machine, blood glucose monitors)
Dental bleaching, crowns,
bridges and implants
Dentures
Endodontics
Occlusal therapy
Oral surgery
Orthodontics
Periodontics
Pre-existing ailments & conditions
Prosthodontics
Veneers
Hearing aids
School Accident benefit
All other extras services
6 months
12 months
2 years
2 - 12 months
2 months
Ambulance waiting periods
Emergency ambulance (where not for
pre-existing ailments)
Medically necessary non-emergency
ambulance (where not for
pre-existing ailments)
Pre-existing ailments
1 day
2 months
12 months
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.
21
The gap - what it means to you
The gap, what it is, and
what it means for you
Sometimes there’s a difference between how
much a provider charges you and the benefits
HCF pays for, so there may be an amount you’ll
need to pay. This is known as ‘the gap’.
At HCF, we work hard to establish agreements
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,
you should ask your treating health professional,
HCF and hospital about any additional money (‘the
gap’) you have to pay. Many hospital and medical
services and procedures do not incur a gap. In fact,
numerous privately insured services in hospital are
no-gap services. If any treatments do have a gap,
you should know upfront what the cost will be.
This is called Informed Financial Consent.
Hospital gap
Private hospitals charge for accommodation,
operating theatres and other hospital related
services. HCF has agreements in place with
most private hospitals and day surgeries.
These are known as participating private hospitals.
This means you won’t have to pay additional costs
for covered services (subject to your excess and
the conditions relating to your Hospital cover).
HCF hospital products cover in-patient services
(from when you’re officially admitted to hospital to
when you’re officially discharged), however we do
not cover outpatient services (before or after you
have been officially discharged).
If you’re a private patient in a non-participating
private hospital, you may incur significant
additional expenses. To check if your hospital
is a participating private hospital, please visit
hcf.com.au, drop into one of our branches or
call us on 13 13 34.
22
Medical gap
Extras cover
Medical services 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%.
HCF provides gap-free coverage of a range of
diagnostic and preventative dental services with
participating dental providers through its More for
Teeth program. The More for Eyes program provides
free retinal photography and no-gap glasses
through participating providers, depending on
your level of cover. The More for Muscles,
However, many doctors charge more than the
MBS fee and this is when you may face additional
expenses, known as the ‘Medical gap’. HCF is
working on ways to eliminate this medical gap,
with over 88% of medical services claimed by our
members covered by our no-gap arrangements.
HCF Medicover is a direct billing scheme.
It allows members to receive no-gap treatment
when doctors don’t charge more than the HCF
Medicover Schedule fee, and is delivered in a
hospital or day surgery with an agreement
with HCF.
There are over 29,000 doctors throughout
Australia participating in HCF Medicover.
To see a list of these doctors just visit hcf.com.au.
Always ask your doctor if they participate, prior
to each hospital admission. Some doctors choose
not to participate in HCF Medicover, so to address
this, we have a no-gap arrangement called the
HCF gap cover scheme. This provides full gap
cover for in-hospital medical services where the
provider’s charge is equal to, or less than the HCF
gap cover list of benefits.
Prosthesis
Prostheses are items used in surgery to augment
or replace a part of the body e.g. pacemakers or
joint replacement devices. Government approved,
non-cosmetic prostheses that have been
surgically implanted, are covered by HCF. Ask your
doctor which prosthesis is best for you and if a
no-gap option is available.
Your gap checklist
This checklist provides you with questions
to ask before you receive treatment in a
private hospital, or as a private patient in a
public hospital.
Ask your treating specialist:
• What is your fee?
• What is the item number for the procedure?
• Will you charge according to the HCF
Medicover schedule so I can receive
services at no out-of-pocket expense?
• If I have to pay a gap, how much will it be?
• If I have to pay extra costs, when and to
whom do I pay it?
• What if I can’t afford to pay this 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 be?
• Will I receive just one bill?
• Am I having a surgically implanted device
or prosthesis?
More for Backs and More for Feet programs provide
one gap-free initial consultation per year when
you consult a participating provider for a New
Episode of Care.
All More for You program benefits are subject
to you having an eligible extras product and
available extras limits.
•W
hat’s the product name, supplier name,
group name and billing code?
• What’s the Medicare Benefits schedule?
Ask HCF:
•D
oes my policy cover me for this?
•D
o I need to pay an excess or any additional
charges? If so, how much?
•D
o I need to pay extra for my hospital
accommodation, doctor’s fees or anyone
else involved in my treatment?
Ask your hospital:
•D
oes this hospital have an agreement
with HCF?
•W
ill I have a gap to pay for my
hospital accommodation?
•W
ill I incur out-of-pocket expenses during
my time in hospital?
• I f I have to pay a gap, when is it due?
•W
hat else do I have to pay for out of my own
pocket during my time in hospital?
•W
ill the cost of this be covered by my
health fund?
23
Rebates, surcharges and incentives
Rebates, surcharges
and incentives
Lifetime Health Cover
The Australian Government Rebate no longer
applies to the LHC component of private health
insurance.
Lifetime Health Cover (LHC) is a Government
initiative designed to encourage people to
take out hospital insurance earlier in life and
maintain their cover.
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.
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.
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.
You can use the table on page 25 as a guide to
nominating your rebate tier. When calculating your
income you need to include taxable income, fringe
benefits, reportable superannuation contributions,
net financial investment losses and more.
24
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 advisor or the ATO at ato.gov.au or on
13 28 65.
Medicare 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 a taxable income of $90,001 or
more per year for singles and $180,001 and over
for couples and families 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
up to an additional 1.5% surcharge on your
Medicare levy when your tax return is assessed.
Please refer to the 'Medicare Levy Surcharge'
section of the table opposite to see what your
surcharge may be.
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.
For more information visit hcf.com.au
or call 13 13 34.
2014 Government rebate change
In April this year, the Australian Government
changed how your rebate is calculated.
The private health insurance rebate will be
adjusted on 1 April each year. This change will
apply to all Australian private health funds.
See below table for the list of rebate percentages.
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.
Income thresholds for the 2014/15 income tax year
Income
Type of member
No Tier
Tier 1
Singles
Tier 2
Tier 3
$90,000
$90,001 - 105,000
$105,001 - 140,000
$140,001
Families*
$180,000
$180,001 - 210,000
$210,001 - 280,000
$280,001
< Age 65
29.040%
19.360%
9.680%
0%
Age 65-69
33.880%
24.200%
14.520%
0%
Age 70+
38.720%
29.040%
19.360%
0%
All ages
0.0%
1.25%
1.5%
Rebate
Medicare Levy Surcharge
1.0%
Thresholds effective from 1 July 2014. Rebate amounts listed are effective from 1 April 2014 to 31 March 2015.
*Note: Single parents and couples (including de facto couples) are subject to the family tiers. For families with
children, the thresholds are increased by $1,500 for each child after the first.
25
Managing your policy
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.
Changing your details
If your contact details change, please advise us by:
Website: hcf.com.au/members
Phone: 13 13 34
Email: [email protected]
Mail: HCF, GPO Box 4242,
Sydney NSW 2001
Fax: 1800 045 563
In person: Visit any HCF branch
Your membership card
You’ll receive your membership card by mail
within 5 business days after joining HCF. If you
lose your card, log into the Members’ section
at hcf.com.au/members, drop into an HCF
branch, email [email protected] or call 13 13 34
(13 14 39 for Self Service).
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 13 13 34, email [email protected] 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 page 25)
26
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 get 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. To maintain the cover
provided, please call 13 13 34 to arrange for
the premiums to be paid while your health
cover is suspended.
Only health products can be suspended. You can’t
suspend if you’re on Overseas Visitor cover or on
a Life product.
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.
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 member hasn’t made a payment for two
months or more
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 cooling off period
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.
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 13 13 34.
27
FAQ's
Health and wellbeing
frequently asked questions
Can I join the program?
To join My Health Guardian, with these additional
services for chronic conditions, you need to:
• Have a chronic condition
• Have HCF hospital cover (extras only,
ambulance only or HCF Life only products
aren’t eligible)
• Be 18 years of age and over. While you’re in
the My Health Guardian program, upon your
request, your GP will be kept informed of your
health status.
To participate in the My Health Guardian program
or to get more information, call Healthways on
1800 244 854 toll-free (excludes mobiles).
Or, you can email HCF at [email protected]
How does My Global Specialist work?
• Call My Global Specialist on 1800 797 674
• 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 covered
by this service?
Most medical conditions that have already
been assessed and investigated by your doctor.
When are you not covered by this service?
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.
Are there any costs associated with this service?
No, there is no charge for HCF members eligible to
access My Global Specialist.
certain starter packs and injections like antibiotics,
anti-nausea medication, eye ointment and
medications for light pain relief.
Who are Best Doctors?
Best Doctors was founded by doctors
from the Harvard Medical School in 1989.
This organisation now helps people in over 30
countries around the world achieve better medical
outcomes, including the US, UK and Canada.
Can the doctor write prescriptions?
Yes, the doctor can write a prescription for
antibiotics and urgently needed medication.
The doctor will not write prescriptions for blood
pressure medication, cardiac medication, antianxiety medication, sedatives, the contraceptive
pill or other regular medications.
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.
How does the My Home Doctor service work?
• Call 13 SICK (7425) for medical attention for
yourself or a family member on your policy.
For medical emergencies, please call 000
• The operator will arrange for a doctor to
visit your home as quickly as possible
(most patients are seen within 2-3hrs)
• Another person will accompany the doctor
for security reasons and your peace of mind
• The patient must have a current Medicare
number to use the service. Members on
Overseas Visitor cover may use their HCF
Membership number
• A report will be sent electronically to your
regular doctor the following day.
Can the call centre operator give medical advice?
No, call centre operators aren’t medically trained
and therefore can’t offer medical advice.
Can doctors give medical advice over the phone?
No, the doctor must visit the patient and assess
their condition in person.
Can the doctor dispense pain relief medications?
Yes, the doctor can dispense pain relief
medications at their discretion. Each doctor carries
28
Can the doctor write a script for narcotics?
No, the My Home Doctor service follows a strict
no-narcotics policy. Doctors do not carry narcotic
medications, nor will they write scripts for narcotics.
Can the doctor do stitches?
Yes, the doctor carries both suture packs and glue
for lacerations and injuries. Please be aware that
doctors cannot administer tetanus injections.
Who will have access to information disclosed
during the doctor’s visit?
The medical information provided to the
attending doctor will only be communicated
to your regular doctor.
None of the medical information obtained will be
sent to HCF. We will only be aware that you’ve
used My Home Doctor in order to help determine
the value of the service to our members.
Under what circumstances is the My Home
Doctor service not available?
• Medical emergencies
• Patients threatening suicide or appearing
psychologically unstable
• Intoxicated patients or members under the
influence of drugs (intoxicated minors may
be seen in the presence of sober parents)
• Where there is evidence of threatening or
abusive behaviour
• Patients who have been assaulted and wish
to file a police report
• Female patients requiring an internal
vaginal examination.
For more information on the My Home Doctor
service, please visit hcf.com.au/mhd
29
Accident Benefit
Loyalty benefits
Bonus $10,000
Permanent Disability
from Accident Benefit
If you choose a package with Multicover or
Super Multicover, you’ll be covered for a
benefit of $10,000 if you’re permanently and
totally disabled in an accident that occurred
after your cover commenced.
Cover is provided by a group policy issued by
HCF Life and copies are available on request.
To be able to claim, at the time of the accident
you must:
• Be in paid employment
• Be under the age of 65
• Not have suffered the disablement as a result
of drug or alcohol abuse, professional sport
or deliberate self-injury
• Not be covered for the accident by workers
compensation or third party liability insurance
• Not be receiving a discount under a corporate
group plan.
30
Totally and permanently disabled means the
disablement has lasted for at least 12 months
and will completely prevent you, for the rest of
your life, from engaging in any occupation for
which you’re suited by your education, training or
experience. You don’t pay a premium in respect
of the bonus $10,000 Accident Benefit as this
benefit is provided at no extra cost.
HCF loyalty benefits
The longer you’re with us,
the more you can claim
We’re all about giving back to our members.
So for each year you're an HCF member you
can claim more on extras like optical, dental,
orthodontics, physio, chiro and hearing aids.
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.
For full details, please refer to the Combined
Product Disclosure Statement and Financial
Services Guide available at hcf.com.au/pdf/
hcf_health_insurance_brochure.pdf
31
Code of Conduct
Member Service Charter
How your rights
are protected
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 a copy visit the Private Health insurance
section for consumers at health.gov.au or
call 13 13 34.
Private Health Insurance
Ombudsman
To contact the Ombudsman:
Call: 1800 640 695
Visit: phio.org.au
Write: Private Health Insurance Ombudsman
Suite 2, Level 22, 580 George St
Sydney NSW 2000
32
Should any problem arise concerning your
membership, contact HCF directly so that it can
be resolved as quickly as possible. An internal
dispute resolution officer will be appointed to
independently review your complaint.
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.
Member
Service Charter
As an HCF member, you have every right to expect
excellent service from us. We are committed to
achieving this. HCF is a not for profit 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.
Our commitment to you
We promise to:
Provide attentive, caring and prompt service
• We’ll deal with your query on the spot
• We’ll assign one HCF staff member to follow up
with any outstanding issues
• Our sales staff are trained to help with all
your enquiries
• We’ll respond to your emails and letters
promptly
Keep you up-to-date
• Changes in your policy and premiums are simple
to understand and clearly explained
• We’ll let you know of any changes to your policy
conditions or cover before the change occurs
• You’ll receive clear, relevant information on
claims and your membership
of your personal information or how to complain
about a privacy breach and how this is handled by
HCF is explained in the HCF privacy policy.
For a copy of this policy, visit hcf.com.au, your
local branch or call our member services team
on 13 13 34.
Always be available
HCF has many branches, kiosks and agents in key
locations across Australia, plus our call centre is
open 7 days a week and the HCF website
hcf.com.au
Make claiming and dealing with us easy
We give you a range of ways for you to claim –
online, at our branches, via on-the-spot claims
terminals at many providers, or through the post.
Many of our hospitals and providers will process
your claim for you.
We value your feedback
Contact us by emailing [email protected]
or call 13 13 34. We look forward to hearing
from you.
Value your privacy
Your privacy is important to us. How HCF collects,
uses, discloses (which may include obligations to
overseas recipients in compliance with its privacy
obligations) and keeps and secures personal
information including how to opt out from direct
marketing, how to request access to a correction
33
Have your say
Health insurance Fraud
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.
At the Annual General Meeting in November
2011, Constituent Members voted to change
the Constitution.
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. If you were registered as a Voting
Contributor (under the ‘old’ system), you do not
need to re-register. Voting Policyholders elect the
16 Elected Councillors of the company.
Councillors
There are up to 24 Councillors, made up of 16
Elected Councillors, and 8 Board Councillors
(who are the 8 Directors of the Board). This is
a ratio of 2:1. The 16 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.
34
Becoming an Elected
Councillor or a member
of the Board of Directors
Voting Policyholders may express their interest
in becoming an Elected Councillor, providing
they meet the Elected Councillor Eligibility
Criteria. Policyholders may also express their
interest in serving on HCF’s Board as an Elected
Director, providing they meet the Elected
Director Eligibility Criteria.
Timing
You’ll be advised of elections for the Elected
Councillors before every annual general meeting
of the company. 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 13 13 34.
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 1800 727 721, email us on
[email protected] or
visit us at hcf.com.au/fraud
You may report lost cards on 13 13 34.
35
Changing your payment method
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
• Email [email protected]
• Call us on 13 13 34
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 13 14 39 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?
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.
36
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 nonbusiness 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.
• 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, email 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
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, email [email protected]
or call 13 13 34.
• 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 (through letter
or email) no later than five business days from
receiving your request
• If we have taken the wrong amount from your
account, please contact us on 13 13 34 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 premiums are payable to cover periods
in advance of your nominated debit date
37
Our privacy statement
Related websites
Our
privacy statement
We collect your personal information including
sensitive information such as health information
from you and/or the policyholder who is
responsible for your policy and/or from other third
parties detailed in our Privacy Policy, so we can:
• Comply with applicable laws
• Manage our relationship with you
• Record your treatment
• Provide health or other insurance, related
products and services to you (including through
third parties)
• Manage and pay claims and benefits
• Assess your insurance, health and related
lifestyle needs
• Investigate fraudulent or improper claims and
assess risks
• Research and develop products, services and
benefits that may better serve your needs
• Assess your possible interest in and tell you
about such products and services
• Administer our business and deal with
complaints.
The types of organisations and individuals we
disclose personal information to include:
• Third party organisations who deliver services
on our behalf or to us, some of whom may be
located overseas
• Health service providers to improve their ability
to provide you with health services
• Research companies contracted to us to ask
your opinion on improving our service, benefits
or product offerings
• Other insurers or reinsurers including other
health insurers if you have moved your insurance
to or from HCF
• Government including law enforcement agencies
• Related HCF companies
38
• The named Policyholder who has your authority
• Any other authorised individual.
Related websites
The following websites provide information
to help you assess your health care needs.
hcf.com.au
health.gov.au
If you do not provide the personal information
we request, we may not be able to provide you
with our products or services, including health
insurance.
HCF is dedicated to delivering the best quality
healthcare to our members and providing private
health insurance cover for a full range of health
benefits including private hospital, Australia-wide
Ambulance cover and ancillary services.
Information on Medicare Benefits Schedule
(MBS).
You can ask us at any time to stop direct
marketing to you by emailing [email protected]
or calling 13 13 34.
hcf.com.au/members
For more information about the personal
information we collect and how we handle it,
how to access and correct your information or
to make a complaint and how we will respond
to complaints, please read our Privacy Policy.
To view the HCF Privacy Policy:
• Visit hcf.com.au/privacy
• Visit your local branch.
All new Policyholders should ensure that all
members on the policy are made aware of the
HCF Privacy Policy.
Changes to products and pricing
Please read and retain this brochure for
future reference. It should be read in
conjunction with our Health Insurance
brochure. We reserve the right to make
changes to prices, product specifications
and other conditions relating to our
products. Please contact us prior to
purchasing any products or health services
to make sure that you have the latest
information available.
HCF provides a variety of online services to help
you get the most from your membership.
hcfeye.com.au
HCF Eyecare offers a range of fully covered
glasses as well as savings on disposable contact
lenses and sunglasses to HCF Members.
HCF Eyecare is independently owned and operated
by Eyecare Holdings Pty Limited ACN 054 365 196.
privatehealthcareaustralia.org.au
Private Healthcare Australia, formerly known
as the Australian Health Insurance Association,
is the Australian private health industry’s peak
representative body that represents 21 health
funds throughout Australia and collectively covers
over 95% of the private health insurance industry.
ato.gov.au
This website provides information on the tax
benefits and issues around private health cover.
comlaw.gov.au
healthdirect.gov.au
Up-to-date and quality assessed health
information.
nps.org.au
Be medicine wise. Get the most out of your
medicines and make better informed choices
about them.
phiac.gov.au
The Private Health Insurance Administration
Council (PHIAC) is an independent Statutory
Authority that regulates the private health
insurance industry.
phio.org.au
The Private Health Insurance Ombudsman (PHIO)
provides an independent service to help consumers
with health insurance problems and enquiries.
privatehealth.gov.au
This website provides information on private
health insurance policies available in Australia.
seniors.gov.au
Online source for Australians over 50 years of age.
Private Health Insurance Act 2007.
39
Glossary
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 and unintentional
event, occurring by chance and caused solely and
directly by an external mechanical force resulting in
damage or injury to the body requiring immediate
medical advice or treatment from a registered
practitioner other than the Policyholder.
Ambulance
The ambulance service/transport must be provided
by the State government ambulance service.
The transportation is to the nearest appropriate
Australian hospital able to provide the level of
care required.
1. Ambulance benefits are claimable for:
a) Emergency ambulance services that require
hospital or on the spot treatment. Emergency
means an immediate and serious threat to
person’s health or life; or
b) Medically necessary ambulance transport up
to a maximum of $5,000 in a calendar year.
Medically necessary means where the treating
doctor requests the ambulance because the
medical condition requires that level of support.
This is claimable for eligible products only.
2. Ambulance benefits are not payable:
a) Where you are covered by your State
government;
b) Where you are covered under another funding
arrangement (such as payment of levies or
where it’s included in your electricity bills);
c) Where you are covered by another third party
(such as a state ambulance subscription
or through another insurance policy or the
ambulance charges are the subject of a
compensation claim);
d) For transfers between hospitals where the
hospital is liable (e.g. public hospitals usually
cover the cost of transfer to another public
hospital if it does not have the medical facilities
to treat you);
e) For charges made for a medical retrieval team
escort;
f ) For transport on discharge from hospital to your
home or any other location unless requested
by your treating doctor due to your medical
condition (subject to 1(b)); or
g) For transfers between hospitals and/or nursing
home or other medical facility unless requested
by your treating doctor due to your medical
condition (subject to 1(b)).
40
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 22-24 (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 22-24 (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.
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.
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).
Foot orthotics ‘Orthotics’ are deemed in-shoe
appliances used to aid in the management of
diagnosed conditions of the foot, ankle and lower
limb. They are only claimable if your cover includes
foot orthotics and the 12 month waiting period has
been served. The foot orthotics must be supplied
by a recognised podiatrist, pedorthist, orthotist,
sports physician, physiotherapist, chiropractor
or osteopath. Benefits for custom made orthotics
can only be claimed for devices that have been
fabricated by a podiatrist, or by a pedorthist or
orthotist on behalf of a podiatrist following a
biomechanical examination, gait analysis, negative
cast or 3D digitised impression taken of the feet.
HCF Participating hospital means a hospital
where specific charges have been negotiated for
accommodation and other services.
Health management program means a program
approved by HCF. The program will not qualify
unless it is intended to prevent or ameliorate a
specific health condition or conditions.
Hearing aids are defined as devices that are
intended to treat or compensate for an individual's
hearing loss; they are personalised to the user's
hearing characteristics.
Hospital is any public or private facility declared by
the Minister as a hospital.
Initial Consultation in relation to the More for
Muscles, More for Backs and More for Feet programs
means the first service you receive for a New
Episode of Care.
Inpatient means any Member who is formally
admitted to hospital.
Medical adviser means a Medical Practitioner
appointed by HCF to give technical advice from time
to time on professional matters and includes the
medical director.
Medical Practitioner means a Medical Practitioner
within the meaning of the health insurance act.
Medicare benefit means a benefit payable by
the Department of Human Services (formerly
Medicare Australia).
Member means a person covered by a Policy.
Minimal Benefits If you choose a product which
has Minimal Benefits for some procedures (such as
pregnancy and birth- related services), then you’ll
be covered in a public hospital shared room, but
your private hospital costs won’t be fully covered.
This means you may face significant personal
expenses if you have any of these procedures in
a private hospital.
For procedures attracting Minimal Benefits in
a private hospital, HCF would:
• Pay a small amount towards your accommodation;
• Pay for government approved prosthesis
list items; but
• Not pay operating theatre expenses,
or labour ward charges.
In addition, there are some services where doctor’s
charges are not payable (for example, elective
cosmetic surgery and surgery by an accredited
podiatric surgeon). For these, HCF will only pay
a very small amount towards the total cost of the
procedure (and no doctor’s charges). This only
applies to services which do not attract a benefit
from Medicare.
41
Index
Minister means the Federal Minister for the
relevant Commonwealth Department whose
portfolio includes responsibilities for matters
relating to health.
More for You programs in relation to the More for
Muscles, More for Backs and More for Feet programs.
Claimable under eligible extras covers, these
programs provide one no-gap Initial Consultation
per calendar year for a New Episode of Care with
participating providers. The More for Backs program
requires that the New Episode of Care be for an
eligible musculoskeletal condition for a no-gap
benefit to be claimable. A claim for an ineligible
condition is assessed as a non-program claim.
New Episode of Care in relation to the More for
Muscles, More for Backs and More for Feet programs
means:
a)A new health condition, which is where the symptoms are not related to a condition for
which treatment (of the program treatment
type) has previously been sought; or
b)An acute flare-up of an existing condition where
there has been no treatment (of the program
treatment type) for that condition provided in
the previous three months.
Non-participating hospital is a hospital that is not
an HCF Participating hospital.
Partner means a spouse or de-facto partner.
PBS equivalent co-payment the Pharmaceutical
Benefits Scheme (PBS) makes subsidised
prescription medicines available to Australian
residents and requires a co-payment to be paid
towards each item. HCF requires an equivalent
co-payment for each pharmaceutical item before
a pharmacy claim is paid. The amount of the copayment is adjusted around 1 January each year in
line with the Consumer Price Index (CPI).
Pharmaceutical item means a substance that is
ordinarily claimable under an extras product which
meets the following criteria:
a)Is prescribed by a Medical Practitioner or a dental
practitioner on prescription in accordance with
relevant State legislation; and
b)Is supplied by a pharmacist in Private Practice
or General Practitioner under relevant State
legislation; and
c)Is registered (labelled with an AUST R number)
on the Australian Register of Therapeutic
Goods (ARTG) and is prescribed for treatment
of the approved specific indications for the
pharmaceutical item as detailed in the Register;
and/or
42
d)Meets the Clinical Procedure of HCF on
Pharmaceuticals [for Ancillary Benefits] as
approved by the Medical Director or equivalent;
and
e)Provided that none of the following apply:
i) Is listed or was listed under the Pharmaceutical
Benefits Scheme (PBS) in any brand, formulation,
strength, pack size and regardless of whether
PBS availability is subject to any specified
purpose or patient type; or
ii) Is customarily charged at an amount that is
less than, equal to, or within $3 of the current
PBS co-payment for general patients; or
iii) Is generally prescribed for purposes outside
of illness or disease or for reproductive
medicine including contraception or for the
enhancement of sporting, sexual or employment performance; or
iv) Is excluded under the HCF Clinical Pharmaceutical Procedure [for Ancillary Benefits]; or
v) Is available without a prescription.
Policy means complying health insurance product
or life insurance product, as applicable.
Policyholder means the Member whose name
the policy is held under. They are responsible for
premiums, ongoing maintenance of the policy and
receiving payment of benefits. The Policyholder is
also known as the contributor and is the contact
person on the Policy.
Private Practice means a professional practice
(whether sole, partnership or group) that is selfsupporting. This means that its accommodation,
facilities and services are not provided or
subsidised by another party such as a hospital or
publicly funded facility.
Prosthesis means items listed on the Prosthesis
List. Prostheses are items used in surgery to
augment or replace a part of the body e.g.
pacemakers and joint replacement devices.
Prosthesis List means the list of Prosthesis in the
Private Health Insurance (Prostheses) Rules made
pursuant to the Private Health Insurance Act.
Psychiatric care means hospital treatment
received in a hospital that is licensed to provide
psychiatric treatment, and where the reason for
admission was for the treatment of a psychiatric
condition with a program approved by HCF (e.g.
treatment of drug and alcohol disorders and mood
disorders such as depression).
Same-day treatment means hospital treatment
that does not include part of an overnight stay.
Recognised Provider means a provider of general
treatment in Australia who is in Private Practice,
and for each relevant class or service, satisfies all
recognition criteria, and who is recognised by HCF.
Single private room is a suitable room in a hospital
which is purpose built and holds a single bed.
This room would have facility for no more than
a single admitted patient and would include an
ensuite or a shared ensuite with an adjacent single
private room.
Recognition criteria and requirements include
the following:
a) The provider is registered or holds a licence under
relevant State or Territory legislation to render
services for which recognition is sought
b) The provider is professionally qualified, or a member
of a professional body recognised by HCF
c) Any other criteria that HCF considers reasonable,
such as complying with the Terms and Conditions
for HCF Recognised Providers of General Treatment.
Two year optical limit means once you have been
a member on Super Multicover and Top Plus cover
for 12 months, your optical limit converts to a 2
year limit of $500. Your $500 limit always spans
the current and previous year and entitles you to
claim the full $500 in one year or progressively
over the two year period. If the full limit of $500
is exhausted in one year, there is no benefit the
following year. Sublimit of $250 per year for contact
lenses applies.
Rehabilitation care means hospital treatment
received in a hospital that is licensed to provide
rehabilitation treatment within a program approved
by HCF.
Index
A Accident 40
Ambulance benefits 40
Ambulance claims 16
Artificial appliances 13, 20, 40
C Cancelling cover 27
Changing details 26, 37
Claiming (health insurance expenses) 12, 13
Cooling off period 27
D Dental Centres 4, 5
Dependants 10, 40
Direct debit 36, 37
E Exclusions 18, 41
Extended family cover 10, 41
Eyecare Centres 4, 5
F Fraud 26, 27, 35, 38
Foot orthotics 41
H Health Fund Rules 26
Health management programs 4, 13, 20
Hospital claims 15
Hospital gap 22
I Inpatient 41
Insulin pump 15
My Global Specialist 4, 5, 28
My Health Guardian 3, 4, 18, 28
My Home Doctor 3, 4, 29
O Ombudsman 32, 39
P Participating hospital 22, 41
Pet insurance 3, 9, 44
Pharmaceuticals 14, 15, 19, 42
Policyholder 10, 34, 42
Privacy 32, 38
Private Health Insurance Code of Conduct 32
Psychiatric care 43
Psychology 14, 19
R Rebates 24, 25
Rehabilitation care 43
Retirement and aged care services 9
S Single private room 43
Suspension of cover 25, 26, 27, 36
T Travel and accommodation 14
Travel insurance 9
Two year optical limit 43
W Waiting periods 20
L Lifetime Health Cover (LHC) 25
M Medical gap 18, 19, 22
Medicare Levy Surcharge 25
Membership Card 26
Minimal benefits 15, 18, 41
More for You programs 4, 42
Please contact HCF on 13 13 34 or visit one
of our branches before purchasing any
products to make sure you have the latest
information available.
43
Why choosing HCF for your health cover
is the right move
•
•
•
•
•
•
We’re Australia’s largest not-for-profit health fund
We returned 91.6 cents in the dollar as member benefits
in the 2013 financial year compared with the industry
average of 86.4 cents
You’ll enjoy the best no-gap medical coverage of any
health fund in Australia (PHIO report 2013)
We’ve won Canstar’s top outstanding value award 5 years
in a row, so you’ll get more value
Get Australia’s best customer service – HCF won the
2013 ‘Best of the Best’ award from the Customer Service
Institute of Australia (CSIA)
We reward your loyalty with higher extras benefits the
longer you’re with us
Call 13 13 34
Click hcf.com.au
Visit one of our branches
Email [email protected]
The Hospitals Contribution
Fund of Australia Limited.
ABN 68 000 026 746
Head Office: 403 George Street,
Sydney NSW 2000
4058879 SEP14_VAL0072_MG

Attention HCF Family – Community Groups will be starting

HCF Corporate Brochure

通 信 英語版 火事ですか、救急ですか。 Do you require an ambulance

Download PDF - American Academy of Family Physicians

HEALTH HISTORY FORM - カイルアインターナショナルスクール

IMIPRAMINE What does it do? How should you take it

FULL NAME DATE OF BIRTH HOME ADDRESS TELEPHONE NO

Preventing Infections When Your White Blood Cell Count is Low

ProSolutions SC Blue

1 MEDICATION GUIDE BELSOMRA ® (bell-SOM-rah

Delta NCS System-I (Stimulator + Detector) $33,595

NorWest Client Survey-ColumnPie Displays