Only the best of care, since 1977 Effective date: 1 April 2015
Welcome to Doctors’ Health Fund Things you need to know
Who can be a member of Doctors’ Health Fund?
It’s so easy to join
Continuity when transferring from another fund
Australian Government private health insurance initiatives Changing your insurance
Financial things you need to know
The Private Health Insurance Code of Conduct How we manage your privacy
How we handle problems and complaints About hospital insurance
Top Cover Prime Choice Smart Starter About extras insurance
Total Extras Essential Extras Direct Debit Service Agreement
CONTENTS
1 2 2 3 3 4 5 5 5 6 6 7 10 12 14 16 18 20 22
Welcome to Doctors’ Health Fund
Doctors’ Health Fund has been providing private health insurance to the medical community since 1977. Our health insurance products provide protection from the impact of healthcare incidents in your life. As a restricted health fund, we strive to ensure our products meet your requirements.
How we are different
• With Top Cover for hospital you will receive benefits up to the AMA list of services and fees and have complete freedom in your choice of doctor.
Your doctor does not have to agree to participate in any medical scheme for you to receive this benefit.
• We don’t have preferred provider arrangements, so our members have their own choice of providers for all extras benefits.
• Use the dentist of your choice and get 100% cover on general dental check up items up to two times a year.
• A high level of optical cover is offered in both of our extras insurance products.
• Choose any hospital insurance product and any extras insurance product from our range to create a combination to suit your needs.
We encourage you to actively consider the level of cover you want and expect from your health insurance. We are happy to answer any questions you may have and discuss the things you should consider when selecting your private health insurance. While price and taxation considerations are important, so is having the cover which will work for you.
For any assistance please contact our Customer Service team on 1800 226 126 or info@doctorshealthfund.com.au
The information in this brochure was correct at the time of publication in May 2014. Any changes to the information in the brochure will be published on our website at doctorshealthfund.com.au
THINGS YOU NEED TO KNOW
A range of topics relevant to choosing and applying for health insurance are on the following pages and further information is available on our website in a section called ‘Understanding Health Cover’.
Information about hospital insurance and the product descriptions starts on page 7.
Information about extras insurance and the product descriptions starts on page 16. We write our product descriptions as clearly as possible and try to provide all the information you need to choose private health insurance which will suit your needs. However, if you have any questions please contact our Customer Service team on 1800 226 126 or info@doctorshealthfund.com.au
Who can be a member of Doctors’ Health Fund?
Eligibility for Membership of Doctors’ Health Fund
To be eligible to be a member of Doctors’ Health Fund you must be or have been:
1. A registered Medical Practitioner*
2. A registered Health Practitioner** in one of the following categories:
• medical
• medical radiation***
• optometry
• dental****
• occupational therapy
• physiotherapy
• psychology
3. A person studying to become a practitioner in the first 2 points above, at an Australian educational institution.
4. An overseas qualified doctor who is registered for the AMC exams.
5. An employee of a Medical Practitioner or a Health Practitioner or an officer or employee of an incorporated practice of a Medical Practitioner or a Health Practitioner.
6. Employed in any role by a federal or state Australian Medical Association (AMA), or an associated or subsidiary organisation of an AMA.
7. Employed in any role by an association whose members are Medical Practitioners or Health Practitioners.
8. An officer or employee (including contractors) of Avant Insurance Limited (ABN 82 003 707 471) or Avant Law Pty Ltd (ACN 136 429 153).
9. The partner, child, grandchild, parent, sibling, former partner, or the partner of an adult child of any person qualified in points 1-8.
Once you have been eligible to be a member of the Fund you retain the right to remain a member, even if you change employment or cease to fulfill the criteria above. Please contact us on 1800 226 126 if you would like help in determining your eligibility.
Definitions:
*’Medical Practitioner’ means a person who is, or was at any time, registered or licensed as a medical practitioner under a law of a State or Territory that provides for the registration or licensing of medical practitioners.
**‘Health Practitioner’ means a person who is, or was at any time, in one of the above categories of health practitioner, as listed in the Health Practitioner Regulation National Law Act 2009 (QLD) (whether or not registered or practising in Queensland or any other Australian State or Territory).
***‘Medical radiation’ means a person working as a medical radiation practitioner, diagnostic radiographer, medical imaging technologist, radiographer, nuclear medicine scientist, nuclear medicine technologist or radiation therapist.
****‘Dental’ means a person working as a dentist, dental therapist, dental hygienist, dental prosthetist or oral health therapist.
It’s so easy to join
After you have read the product descriptions and chosen your health insurance, simply apply online and let us do the work for you. With your authorisation we can organise the following things for you:
• your transfer from another health insurer
• set up automatic payments
• set up faster payment of claims, direct to your account
• register you for the government rebate
Retain a copy of this brochure in your records so you know the details of the hospital and extras health insurance products you have chosen.
Once your membership starts, a 30 day cooling off period commences.
During this time you can choose to cease your membership, or if you have increased your cover you can revert to your previous level of cover, and we will refund the contributions you paid. Of course, if any claims have been paid they will be deducted from the contributions before they are refunded.
Continuity when transferring from another fund
• Any waiting periods that you have served with another fund are recognised by Doctors’ Health Fund, when your new insurance has equal levels of benefits and you join us within two months of leaving your former fund.
If your new cover with Doctors’ Health Fund has greater benefits on any service, you will need to serve the waiting period for that service, as shown on the product descriptions in this brochure.
• Benefits that you have been paid by your previous fund, on any services that have benefit limits, will be reported on the transfer certificate and you will only be able to claim the remaining amount of your benefit limit for those services on your new insurance policy.
• Some accumulated benefits do not carry over from another fund. Benefits that increase due to length of membership, such as orthodontic benefits, will generally carry over.
THINGS YOU NEED TO KNOW
The Doctors’ Health Fund will handle the transfer process for you. Legislation requires your previous health fund to send us your transfer certificate within 14 days of your termination date.
Australian Government private health insurance incentives
To encourage Australians to protect themselves with private health insurance, the Commonwealth Government has introduced the following programs.
Australian Government Rebate on private health insurance The Australian Government has introduced legislation to means test the rebate effective 1 July 2012, based on your income level.
The table below details the different rebate amounts and Medicare Levy Surcharge levels as at 1 April 2015.
Singles ≤$90,000 $90,001-105,000 $105,001-140,000 Families ≤$180,000 $180,001-210,000 $210,001-280,000
Rebate
Under age 65 27.820% 18.547% 9.273%
Age 65-69 32.457% 23.184% 13.910%
Age 70+ 37.094% 27.820% 18.547%
Medicare Levy Surcharge
All ages 0.0% 1.0% 1.25%
*If you’re a family with children, the income threshold for each tier is increased by $1,500 for every child after your first. Family includes couples and single parent families.
For further information as to how this change may affect you, please visit our website at doctorshealthfund.com.au
Lifetime Health Cover
Lifetime Health Cover (LHC) is another Government initiative, which is designed to encourage people to take out and maintain hospital insurance earlier in life. To avoid paying a LHC loading, you need to take out a private health insurance hospital policy by the 1st of July following your 31st birthday.
For each year you delay, you will pay 2% more for your premium, up to a maximum of 70%, as stipulated by the Government LHC guidelines.
If you were born before 1 July 1934, you are exempt from LHC.
Once you have paid a LHC loading on your private health insurance for 10 continuous years, the loading is removed as long as you retain your hospital cover. Some other special circumstances apply, which are described below.
To cover small gaps, such as switching from one insurer to another, you are able to be without private health insurance for periods totaling 1,094 days (i.e.
three years less one day) during your lifetime, without affecting your loading.
As a new migrant to Australia, if you are aged 31 or over, you will not have to
pay a LHC loading if you take out private health insurance within 12 months of being registered for Medicare. After this time you will have to pay 2%
more for each year you are aged over 30 when you take out private health insurance.
What happens to the Australian Government Rebate on private health insurance under Lifetime Health Cover?
From 1 July 2013, if you are eligible for the Australian Government Rebate on private health insurance, this will apply to your base hospital premium only and will not apply to the portion of your hospital premium that has the Lifetime Health Cover loading.
Your LHC base day is the deadline by which you must have taken out private hospital insurance to avoid incurring a LHC loading. For most people this will be 1 July following their 31st birthday, although there are exceptions to this.
If you are a new migrant to Australia, your LHC base day is the later of 1 July following your 31st birthday and the anniversary of when you register for full Medicare benefits.
A Lifetime Health Cover calculator and further information can be found at http://www.privatehealth.gov.au/dynamic/LifetimeHealthCover.aspx
Changing your insurance
You can make changes to your insurance at any time. Either use our online member services to make the updates or fill out an application and membership changes form which is available on the website.
Your username on our online member services portal is your membership number.
Financial things you need to know
• Selecting direct credit for your claim payments reduces the time it takes to pay your claims and for you to receive the payment.
• For contribution premiums, you can pay by direct bank debit, Mastercard or Visa. Selecting a direct debit option is a convenient and flexible way to pay your premiums.
• If your contributions are not up to date claims cannot be paid.
• Once a year the Australian Government considers private health insurers submissions for a price rise on their products. We send a submission and pricing request for approval by the Minister for Health. We notify you of price increases in March.
The Private Health Insurance Code of Conduct
Doctors’ Health Fund has adopted this code of conduct which aims to improve the standards of practice and service in the private health insurance industry. The code sets standards for providing information to customers, staff training and dispute resolution.
The Code of Conduct can be found at
www.privatehealth.com.au/codeofconduct and a link is on our website.
How we manage your privacy
To provide health insurance services to you as a member, Doctors’ Health Fund collects information that includes your personal details, financial information and medical information. We treat personal information with respect and care, to protect it from misuse, loss, unauthorised access, modification or disclosure. Our privacy policy can be found at doctorshealthfund.com.au
How we handle problems and complaints
Doctors’ Health Fund is always happy to receive feedback, and wants to solve problems and resolve complaints. To reduce the likelihood of potential problems arising, we encourage members to familiarise themselves with the health insurance products they have purchased, to make informed decisions for when they need healthcare services. In the Member Zone on the Fund website you will find sections on managing and using your health cover.
Making a complaint
We handle complaints following our Complaints Resolution Policy and Australian Government requirements of private health insurance funds. There are three stages to the process:
1. Contact the Head of Operations by phone, fax, email or post to PO Box Q1749
Queen Victoria Building Sydney NSW 1230
2. If you are not satisfied you can then raise your complaint with The CEO, Doctors’ Health Fund.
3. If we cannot resolve the complaint to your satisfaction you can contact the Private Health Insurance Ombudsman. The Private Health Insurance Ombudsman is a Commonwealth Government agency charged with providing an independent service to help consumers with health insurance problems and enquiries.
The Private Health Insurance Ombudsman Freecall Complaints Hotline: 1800 640 695 Email: info@phio.org.au
Web: www.phio.org.au
Mail: Suite 2, Level 22, 580 George St, Sydney NSW 2000 Telephone: (02) 8235 8777
Facsimile: (02) 8235 8778
THINGS YOU NEED TO KNOW
About hospital insurance
The basics
• Hospital insurance covers you while you are an admitted patient in a hospital or day-only facility.
• Only Medicare recognised treatment is covered by hospital insurance.
• Benefits for a consultation with a doctor prior to being admitted or after you have been discharged from hospital can only be claimed from Medicare.
Hospital insurance - our gap cover is different
We offer two medical services gap cover schemes so you can choose a level of financial protection which suits you for those times when you are an admitted patient.
AMA Gap cover
Our Top Cover for hospital is unique. It offers premium medical gap cover.
This means that on any Medicare eligible service you will receive a benefit up to that listed on the AMA List of services and fees. You will only have out- of-pocket expenses for Medicare recognised services, when your doctor charges above the AMA List of services and fees. As your doctor doesn’t have to agree to participate in this gap scheme you have complete freedom to choose your doctor.
Access gap cover scheme
Our Prime Choice and Smart Starter hospital products, use the Access Gap Cover scheme which can reduce or eliminate your medical services out- of-pocket expenses. This scheme has a record of covering 90% of services with no patient out-of-pocket expense. Ask your doctor if they and any other doctors involved in your treatment will treat you under the gap scheme. The accounts they provide need to be marked as Access Gap Cover scheme accounts. When your doctors choose not to participate in the Access Gap Cover scheme you will be covered to the Medicare schedule fee.
See the example in the table on the next page to compare the different medical benefit outcomes.
Contracted gap cover
Our contractual arrangements with most pathology and radiology providers apply to all our hospital insurance products. The delivery of services by these contracted providers will have no out-of-pocket expense. Claims for services from providers who do not have contracts with the Fund can be handled under the medical services gap cover in the hospital products.
HOSPITAL INSURANCE PRODUCTS
HOSPITAL INSURANCE PRODUCTS
Medical services benefits for a knee reconstruction, item no. 49542
$3,690.00 Top Cover maximum benefit for a knee reconstruction.
Includes Medicare benefit plus the AMA gap benefit.
$2,061.60 Prime Choice & Smart Starter maximum benefit for a knee reconstruction in VIC, the benefit varies by State. Includes Medicare benefit plus the Access gap benefit.
$1,317.80
Medicare Schedule fee payable for a knee reconstruction.
Includes the 75% paid by Medicare and 25% paid by the Fund.
Contracts and cover which protect you
By negotiating contracts with hospitals we are able to establish conditions which help keep the cost of your health insurance down. Using a contracted hospital will provide you with the maximum cover for the hospital service components of your treatment, including accommodation, theatre and pharmaceuticals. We have contracts in place with the majority of Australian private hospitals. Access to the search facility for contract hospitals can be found on our website at doctorshealthfund.com.au
When you need a prosthesis, maximise your cover by checking with your doctor that a government approved prosthesis will be used.
Our ambulance cover protects you in the event of an emergency or medical necessity for this service, anywhere in Australia.
Keeping everyone covered when you’re having a baby
If you are planning to have children check that your hospital cover includes obstetrics. These are the services associated with pregnancy and birth of a baby. Hospital cover has a 12 month waiting period for making claims for all in-patient services related to an obstetrics admission.
After the birth, all you need to do for your baby to be covered is to contact the fund to add them to your membership within two months from the date of their birth. This means moving to a family membership if you are not already on that level of cover. This will ensure your child does not serve any additional waiting periods.
Pre-existing medical conditions
A pre-existing ailment, illness or condition is one where there were signs or symptoms present that a doctor would have detected during the six months before you took your hospital insurance or upgraded your hospital insurance. There is a 12 month waiting period before benefits will be paid
for treatment of pre-existing conditions. The Fund’s medical advisor makes the decision about whether your condition is pre-existing and if the waiting period will apply. The waiting period for treatment that is psychiatric care, rehabilitation or palliative, whether or not for a pre-existing condition, is two months.
Full descriptions of the hospital insurance products are on pages 10-15.
Claiming your benefits for hospital treatment
Hospitals will deal directly with the Fund to claim payment.
Direct billing for medical services claims
The most efficient way to make medical services claims is called direct billing.
You don’t have to go to Medicare. The Fund processes the entire claim for you including the claim to Medicare.
Whether you are covered by Top Cover, Prime Choice or Smart Starter your doctors should always submit the bills for your treatment in hospital directly to Doctors’ Health Fund.
If you are covered by Prime Choice or Smart Starter and your doctors have agreed to treat you under the Access Gap Cover scheme, but they send their bills to you, check they have been marked as Access Gap Cover accounts before submitting them to the Fund with a claim form. Send your claim to:
Mail:
The Doctors’ Health Fund Pty Ltd PO Box Q1749
Queen Victoria Building Sydney NSW 1230
A claim form can be obtained from our website at doctorshealthfund.com.au
Top Cover -
unique cover with AMA gapExcess None
Waiting periods None for accidents
12 months for pre-existing conditions 12 months for obstetrics
2 months for palliative care, rehabilitation and psychiatric treatment
2 months for everything else
Exclusions None
Benefit restrictions Plastic and reconstructive surgery, and other service benefits for hospital and medical costs, are restricted to services eligible for Medicare benefits. When chosen for cosmetic reasons only default hospital accommodation benefits apply and no medical benefits are paid.
Ambulance National cover for emergency and medically necessary ambulance services when:
• an ambulance is called to attend you but you are not subsequently taken to hospital
• it is medically necessary for you to be transported by an ambulance to be admitted to hospital
• you need immediate medical attention at a hospital or other approved facility
• you are an admitted patient and need to be transferred to another hospital Accommodation In a contracted private hospital or day-
only facility, or a public hospital as a private patient, all costs of accommodation are covered. In non-contract hospitals or day-only facilities the lowest contracted benefit is paid and you can expect to have out-of-pocket expenses. Search contracted hospitals on our website at
doctorshealthfund.com.au
Hospital services All costs are covered for theatre and labour ward services while you are an admitted patient in a contract hospital.
HOSPITAL INSURANCE PRODUCTS
AMA gap cover The cost of doctors’ services delivered while an admitted patient is covered by our premium gap cover. Medicare pays 75% of the Medicare Schedule fee and your Fund benefits pay the remainder up to a total equal to the AMA List of services and fees. You pay any amount charged above the AMA List of services and fees.
Most pathology and radiology providers have contracts with us, so while you are an admitted patient most of these services will have no out-of-pocket expense. Medical service claims should always be submitted directly to the Fund by your doctor or you.
Pharmaceuticals In a contracted private hospital or day- only facility, or a public hospital as a private patient all costs of PBS pharmaceuticals related to the condition being treated are covered, and the cost of non-PBS items related to the condition being treated are covered as per the contract with the hospital. In non-contract hospitals or day- only facilities the lowest contracted benefit is paid and you can expect to have out-of- pocket expenses.
Prostheses Covers 100% of the minimum cost specified for government approved prostheses.
Other Up to $100 per day for travel and
accommodation where a doctor certifies the need for a parent, spouse or child to be with a member in hospital more than 200 kms from home. An annual limit of $1,000 applies.
Examples of what you can expect to pay if you go to hospital
• Prostheses cost if charged above the minimum cost
• Personal items such as newspapers and television hire
HOSPITAL INSURANCE PRODUCTS
Prime Choice -
comparable to most other funds’ premium coverExcess Prime choice can be taken with or without an excess.
If you choose to take an excess:
Singles - up to $500 per calendar year.
Couple, single parent and family memberships - up to
$1000 per calendar year.
An excess of up to $500 is paid per admission until the full amount of excess is paid for the year. The total excess amount applies to the entire membership not each person covered by the membership.
Waiting periods None for accidents
12 months for pre-existing conditions 12 months for obstetrics
2 months for palliative care, rehabilitation and psychiatric treatment
2 months for everything else
Exclusions None
Benefit
restrictions Plastic and reconstructive surgery, and other service benefits for hospital and medical costs are restricted to services eligible for Medicare benefits. When chosen for cosmetic reasons only default hospital accommodation benefits apply and no medical benefits are paid.
Ambulance National cover for emergency and medically necessary ambulance services when:
• an ambulance is called to attend you but you are not subsequently taken to hospital
• it is medically necessary for you to be transported by an ambulance to be admitted to hospital
• you need immediate medical attention at a hospital or other approved facility
• you are an admitted patient and need to be transferred to another hospital
Accommodation In a contracted private hospital or day-only facility, or a public hospital as a private patient all costs of accommodation are covered after any excess is paid.
In non-contract hospitals and day-only facilities the lowest contracted benefit is paid and you can expect to have out-of-pocket expenses. Search contracted hospitals on our website at
doctorshealthfund.com.au
Hospital services After the excess is paid all costs are covered for theatre and labour ward services while you are an admitted patient in a contracted hospital for included services.
Access gap cover
scheme The cost of doctors’ services delivered while you are an admitted patient can be covered by the Access Gap Cover scheme which reduces or eliminates your medical services out-of-pocket expenses. When your doctor agrees to participate in the Access Gap Cover scheme the Fund covers the scheme’s scheduled amount for your treatment. The doctor may choose to charge you a payment above the scheme’s scheduled amount. This may be no more than $400 per service or for the birth of a child no more than
$800 for the confinement. Most pathology and radiology providers have contracts with us, so while you are an admitted patient most of these services will have no out-of-pocket expense. Claims using this gap scheme should be submitted directly to the Fund.
Check that your doctors have marked any bills sent to you as Access Gap Cover accounts. To find doctors who participate in this gap scheme use the Doctor Search facility on our website.
Pharmaceuticals In a contracted private hospital or day-only facility, or a public hospital as a private patient all costs of PBS pharmaceuticals related to the condition being treated are covered, and the cost of non-PBS items related to the condition being treated are covered as per the contract with the hospital. In non-contracted hospitals and day-only facilities the lowest contracted benefit is paid and you can expect to have out-of-pocket expenses.
Prostheses Covers 100% of the minimum cost specified for government approved prostheses.
Other Up to $70 per day for travel and accommodation where a doctor certifies the need for a parent, spouse or child to be with a member in hospital more than 200 kms from home. An annual limit of $800 applies.
Examples of what you can expect to pay if you go to hospital
• Your excess
• Prostheses cost if charged above the minimum cost
• Personal items such as newspapers and television hire
• If your doctor does not wish to participate in the Access Gap Scheme, the Fund will only pay benefits up to the Medicare Schedule Fee
HOSPITAL INSURANCE PRODUCTS
Smart Starter -
basic cover, available to singles and couples only Excess Singles - up to $500 per calendar year.Couple memberships - up to $1,000 per calendar year.
An excess of up to $500 is paid per admission until the full amount of excess is paid for the year.
The total excess amount applies to the entire membership not each person covered by the membership.
Waiting periods None for accidents
12 months for pre-existing conditions 2 months for palliative care, rehabilitation and psychiatric treatment
2 months for everything else covered Exclusions No benefits are paid for:
• Pregnancy related services
• Assisted reproductive services
• Sterilisation and reversal of sterilisation
• Hip and knee replacements and revisions
• Cataract and glaucoma treatment
• Gastric banding and obesity surgery
• Plastic surgery and other services which are excluded from Medicare coverage
Benefit
restrictions The below services are limited to delivery as a private patient in a public hospital:
• Cardio-thoracic surgery,
• Psychiatric services are limited to an initial 10 days per annum in a private hospital,
• Dialysis for chronic renal failure
• Rehab services following cardio- thoracic, psychiatric, hip and knee replacement and revisions.
Ambulance National cover for emergency and medically necessary ambulance services when:
• an ambulance is called to attend you but you are not subsequently taken to hospital
• it is medically necessary for you to be transported by an ambulance to be admitted to hospital
• you need immediate medical attention at a hospital or other approved facility
• you are an admitted patient and need to be transferred to another hospital.
Accommodation In a contracted private hospital or day-only facility, or a public hospital as a private patient all costs of accommodation are covered after the excess is paid, for included services
In non-contracted hospitals or day-only facilities the lowest contracted benefit is paid and you can expect to have out-of-pocket expenses. Search contracted hospitals on our website at
doctorshealthfund.com.au
Hospital services After the excess is paid all costs are covered for theatre services while you are an admitted patient in a contract hospital.
Access gap cover
scheme The cost of doctors’ services delivered while you are an admitted patient can be covered by the Access Gap Cover scheme which reduces or eliminates your medical services out-of-pocket expenses. When your doctor agrees to participate in the Access Gap Cover scheme the Fund covers the scheme’s scheduled amount for your treatment. The doctor may choose to charge you a payment above the scheme’s scheduled amount. This may be no more than $400 per service.
Most pathology and radiology providers have contracts with us, so while you are an admitted patient most of these services will have no out-of-pocket expense.
Claims using this gap scheme should be submitted directly to the Fund. Check that your doctors have marked any bills sent to you as Access Gap Cover accounts. To find doctors who participate in this gap scheme use the Doctor Search facility on our website.
Pharmaceuticals In a contracted private hospital or day-only facility, or a public hospital as a private patient, all costs of PBS pharmaceuticals related to the condition being treated are covered, and the cost of non-PBS items related to the condition being treated are covered as per the contract with the hospital. In non-contracted hospitals and day-only facilities the lowest contracted benefit is paid and you can expect to have out-of-pocket expenses.
Prostheses Covers 100% of the minimum cost specified for government approved prostheses.
Other Up to $70 per day for travel and accommodation where a doctor certifies the need for a parent, spouse or child to be with a member in hospital more than 200 kms from home. An annual limit of $500 applies.
Examples of what you can expect to pay if you go to hospital
• Your excess
• Prostheses cost if charged above the minimum cost
• Personal items such as newspapers and television
• If your doctor does not wish to participate in the hire Access Gap Scheme, the Fund will only pay benefits up to the Medicare Schedule fee
EXTRAS INSURANCE PRODUCTS
About extras insurance
• Extras services cover certain healthcare services such as dental, optical and physiotherapy, which are not covered by Medicare.
Our extras insurance difference
Our extras products offer great benefits across a number of areas including:
• Optical cover up to $500 over any two consecutive calendar years.
When making a claim, the previous and current year claims cannot exceed $500. You can logon to online member services to check your optical benefits balance before making a claim.
• The non-PBS pharmaceuticals cover pays 85% of the cost of the prescription after you have paid the current PBS prescription cost. For a non-PBS prescription which costs $150, our cover would pay $96.82.
Full descriptions of the extras insurance products are on pages 18-21.
Service providers and benefit payments
Many services included in extras insurance are delivered by registered practitioners who are governed by systems which register and recognise them as providers. The Fund pays benefits on services delivered by a wide range of these allied health practitioners including dentists, orthodontists, endodontists, periodontists, oral surgeons, prosthodontists, pedodontists, ophthalmologists, optometrists, registered nurses and midwifes, practitioners of orthoptics, occupational therapy, speech therapy, dietetics, podiatry, physiotherapy and psychology. If you are unsure whether your provider is covered, please give us a call.
Remedial massage and Myotherapy
Remedial massage does not operate under a standard system of registration control. For the Fund to pay benefits for remedial massage and myotherapy services the provider must either be a registered physiotherapist or have accreditation in remedial massage therapy or myotherapy with an organisation that adheres to the Department of Health and Ageing governed systems for registration and recognition of them as providers.
Claiming your benefits for extras services
Extras or ancillary service claims can often be made at the provider’s office via the electronic HICAPS system, with no need to submit a claim to the Fund. The provider simply swipes your membership card and you pay any difference between the service charge and the benefit paid – and there’s no paperwork to do. If electronic claiming isn’t available, Doctors’ Health Fund offers a mobile claiming app. You simply take a picture of your receipt and submit through the app, and we will reimburse your expense, according to cover limits, to your nominated account. Alternatively, you can also scan and email your receipt and claim form to info@doctorshealthfund.com.au or submit to:
Mail: The Doctors’ Health Fund Pty Ltd PO Box Q1749, Queen Victoria Building Sydney NSW 1230
Fax: 02 9260 9958
A claim form can be obtained from our website at doctorshealthfund.com.au
Total Extras - premium cover with better benefits
Waiting periods • 12 months for major dental services, aids and appliances
• 24 months for hearing aids
• 2 months for all other services
Limits • Limits per person per calendar year, except where otherwise indicated
ITEM LIMITS BENEFITS PAID
General dental services No annual limits 100% paid for specified examinations and scale and clean, up to two times per year, as long as the fees are within the range of usual, customary and reasonable charges.
Fixed benefits paid for all other items.
Major dental services
– Major dental restorations $1,000
Fixed benefits paid per item
– Endodontic/periodontic $1,000 – Crowns & bridges $1,200 – Dentures and
prosthodontics $1,000
– Orthodontics $600 per year of membership accumulating to a lifetime limit of
$3,000 Optical category limit $500 limit over
any 2 consecutive calendar years.
Claims made in the current and prior year cannot exceed
$500.
EXTRAS INSURANCE PRODUCTS
Total Extras
continuedITEM LIMITS BENEFITS PAID
Non-PBS pharmaceuticals, mammograms, ThinPrep tests, bone density tests
$600
Tests, one each per year
After the current PBS cost, benefits paid are 85% of the remaining cost of a non-PBS script.
$60 per test.
One hearing aid One set of hearing aids every 5 calendar years
$800
Two hearing aids $1,600
Hearing aid repairs $50
Audiology test One visit per year $60 Physiotherapy,
Myotherapy and remedial massage
$700 - Physiotherapy $50 per visit - Group therapy $20 per visit - Hydro therapy $20 per visit - Myotherapy and Remedial Massage $35 per visit
Psychology $600 $100 per visit
Occupational therapy, Speech therapy, Orthoptics, Podiatry, Dietetics, Midwifery services.
$1,000 $35 per visit with calendar year sub limits per therapy type of $600
Home nursing $600 $30 per visit of up to 6
hrs
$60 per visit exceeding 6 hrs
Aids & appliances $1,000
For Fund approved consumable items, benefit paid twice per calendar year.
For Fund approved non-consumable items benefits paid 2 years after the first supply.
75% of the cost of the item where use of the item was ordered by a registered practitioner.
EXTRAS INSURANCE PRODUCTS
Essential Extras - better mid-range cover
Waiting periods • 12 months for major dental services, aids and appliances
• 24 months for hearing aids
• 2 months for all other services
Limits • Limits per person per calendar year, except where otherwise indicated
ITEM LIMITS BENEFITS PAID
General dental services $800 overall limit for General dental and Orthodontics
100% paid for specified examinations and scale and clean, up to two times per year, as long as the fees are within the range of usual, customary and reasonable charges. Fixed benefits paid for all other items.
Major dental services
– Orthodontics Orthodontic services are included in the general dental limit, $250 per year of membership accumulating to a lifetime limit of
$1,250
Major Dental benefits included in the General Dental limit
Optical category limit $500 limit over any 2 consecutive calendar years.
Claims made in the current and prior year cannot exceed
$500
Essential Extras
continuedITEM LIMITS BENEFITS PAID
Non-PBS pharmaceuticals, mammograms, Thin Prep tests, bone density tests
$300
Tests, one each per year
After the current PBS cost, benefits paid are 85% of the remaining cost of a non-PBS script.
$60 per test.
Physiotherapy, Psychology, Occupational therapy, Speech therapy, Orthoptics, Podiatry, Dietetics, Midwifery services, Myotherapy and remedial massage
$900 - Psychology $100 per visit - Physiotherapy $35 per visit - Group therapy $20 per visit All other therapy type as listed $30 per visit Calendar year sub limits per therapy type of $500.
Aids & appliances
including hearing aids $500
For Fund approved consumable items, benefit paid twice per calendar year.
For Fund approved non-consumable items benefits paid 2 years after the first supply.
75% of the cost of the item (except hearing aids) where use of the item was ordered by a registered practitioner.
Single hearing aid $200 Two hearing aids $400 Hearing aid repairs $50
DIRECT DEBIT SERVICE AGREEMENT
Direct Debit Service Agreement
The following is your Direct Debit Service Agreement with The Doctors’
Health Fund Pty Ltd ABN 68 001 417 527.
The agreement is designed to explain what your obligations are when undertaking a Direct Debit arrangement with us. It also details what our obligations are to you as your Direct Debit Provider.
We recommend you keep this agreement in a safe place for future reference.
It forms part of the terms and conditions of your Direct Debit Request (DDR) and should be read in conjunction with your DDR form.
Definitions
Account means the account held at your financial institution from which we are authorised to arrange for funds to be debited.
Agreement means this Direct Debit Request Service Agreement between you and us.
Banking day means a day other than a Saturday or a Sunday or a public holiday listed throughout Australia.
Debit day means the day that payment by you to us is due.
Debit payment means a particular transaction where a debit is made.
Direct Debit Request means the Direct Debit Request between us and you.
Us or we means Doctors’ Health Fund Pty Ltd, (the Debit User) you have authorised by signing a Direct Debit Request.
You means the customer who has signed or authorised by other means the Direct Debit Request.
Your financial institution means the financial institution nominated by you on the DDR at which the account is maintained.
1. Debiting your account
1.1 By signing a Direct Debit Request or by providing us with a valid instruction, you have authorised us to arrange for funds to be debited from your account. You should refer to the Direct Debit Request and this agreement for the terms of the arrangement between us and you.
1.2 We will only arrange for funds to be debited from your account as authorised as in the Direct Debit Request.
1.3 If the debit day falls on a day that is not a banking day, we may direct your financial institution to debit your account on the following banking day. If you are unsure about which day your account has or will be debited you should ask your financial institution.
2. Amendments by us
2.1 We may vary any details of this agreement or a Direct Debit Request at any time by giving you at least fourteen (14) days written notice.
3. Amendments by you
You may change, stop or defer a debit payment, or terminate this agreement by providing us with at least fourteen (14 days) notification by writing to:
The Doctors’ Health Fund Pty Ltd PO Box Q1749
Queen Victoria Building Sydney NSW 1230
by telephoning us on 1800 226 126 during business hours;
or
by arranging it through your own financial institution.
4. Your obligations
4.1 It is your responsibility to ensure that there are sufficient clear funds available in your account to allow a debit payment to be made in accordance with the Direct Debit Request.
4.2 If there are insufficient clear funds in your account to meet a debit payment:
(a) you may be charged a fee and/or interest by your financial institution;
(b) you may also incur fees or charges imposed or incurred by us; and (c) you must arrange for the debit payment to be made by another
method or arrange for sufficient clear funds to be in your account by an agreed time so that we can process the debit payment.
4.3 You should check your account statement to verify that the amounts debited from your account are correct.
4.4 If The Doctors’ Health Fund Pty Ltd is liable to pay goods and services tax (“GST”) on a supply made in connection with this agreement, then you agree to pay The Doctors’ Health Fund Pty Ltd on demand an amount equal to the consideration payable for the supply multiplied by the prevailing GST rate.
5. Dispute
5.1 If you believe that there has been an error in debiting your account, you should notify us directly on 1800 226 126 and confirm that notice in writing with us as soon as possible so that we can resolve your query more quickly. Alternatively you can take it up with your financial institution direct.
5.2 If we conclude, as a result of our investigations, that your account has been incorrectly debited we will respond to your query by arranging for your financial institution to adjust your account (including interest and
charges) accordingly. We will also notify you in writing of the amount by which your account has been adjusted.
5.3 If we conclude, as a result of our investigations, that your account has not been incorrectly debited we will respond to your query by providing you with reasons and any evidence for this finding in writing.
6. Accounts 6.1 You should check:
(a) with your financial institution whether direct debiting is available from your account as direct debiting is not available on all accounts offered by financial institutions;
(b) your account details which you have provided to us are correct by checking them against a recent account statement; and
(c) with your financial institution before completing the Direct Debit Request if you have any queries about how to complete the Direct Debit Request.
7. Confidentiality
7.1 We will keep any information (including your account details) in your Direct Debit Request confidential. We will make reasonable efforts to keep any such information that we have about you secure and to ensure that any of our employees or agents who have access to information about you do not make any unauthorised use, modification, reproduction or disclosure of that information.
7.2 We will only disclose information that we have about you:
(a) to the extent specifically required by law; or
(b) for the purposes of this agreement (including disclosing information in connection with any query or claim).
8. Notice
8.1 If you wish to notify us in writing about anything relating to this agreement, you should write to
The Doctors’ Health Fund Pty Ltd PO Box Q1749
Queen Victoria Building Sydney NSW 1230
8.2 We will notify you by sending a notice in the ordinary post to the address you have given us in the Direct Debit Request.
8.3 Any notice will be deemed to have been received on the third banking day after posting.
Doctors’ Health Fund is a signatory to the Private Health Insurance Code of Conduct.
DIRECT DEBIT SERVICE AGREEMENT
Providing health insurance to the medical community
The Doctors’ Health Fund Pty Ltd A private health insurer
ABN 68 001 417 527 Street Address:
Level 28 HSBC Centre 580 George Street Sydney NSW 2000 Postal Address:
PO Box Q1749 Queen Victoria Building Sydney NSW 1230 Freecall: 1800 226 126 Facsimile: 02 9260 9958
Web: www.doctorshealthfund.com.au Email: info@doctorshealthfund.com.au
