Loading

Key Terms

Access Gap cover scheme

We have contractual arrangements with a number of doctors to reduce or eliminate out-of pocket costs when our members are treated as a private patient in hospital. This is known as our 'Access Gap' cover scheme. Under the scheme we have agreed to pay participating doctors a defined amount above the Medicare Benefits Schedule fee if the doctor agrees to cap their fee to this higher amount. In this way, Members are able to minimise ('Known Gap') or completely eliminate ('No Gap') out-of-pocket expenses.

Most doctors participate in the scheme but their participation is on a case by case basis so be sure to ask if your doctor participates and if so, whether or not your treatment be charged under the scheme.

For a listing of doctors who use Access Gap please click here or call us on 1300 806 808.

Accident

Accident means an unforeseen and unintentional event, occurring by chance and caused solely and directly by an external mechanical force or object resulting in involuntary injury to the body requiring urgent medical treatment. For a benefit to be payable, the following criteria must apply:

(a) you are;

     (i) admitted to a hospital; or

     (ii) transferred to another hospital as part of a continuing admission; and

(b) that admission was via that hospital’s accident and emergency department; and

(c) the hospital treatment was not for the treatment of an illness, condition, ailment, sickness or injury that was either known or should reasonably have been known to you at any time; and

(d) the damage or injury resulted in an admission within 24 hours; and

(e) the hospital treatment was for the immediate and urgent treatment for the damage or injury; and

(f) the accident did not occur in the course of your employment or professional duties.

Agreement private hospital and day facilities
The Fund has negotiated benefit arrangements with the majority of private hospitals and day facility hospitals throughout Australia, eliminating or minimising out-of-pocket expenses for members according to their level of cover.

Product excesses and/or co-payments still apply. For a detailed list of agreement hospitals please click here or contact us on 1300 806 808.

Benefit replacement period
The period of time you will need to wait after claiming an item before you can receive further benefits to replace the item.

Applies to the following items:
  • Hearing aids – 36 months 
  • Dentures – 36 months
Benefit Limitation Period (BLP)

A Benefit Limitation Period is where you are only entitled to Minimum Benefits for a particular condition or treatment for the first 12 months of cover.

Cancellation of membership

Members can cancel their membership in writing at any time. Cancellation of membership cannot be backdated, however, new members have a 30 day cooling off period where all premiums paid in advance of their joining date can be refunded. This is provided claims have not been paid during this period. In this instance, the cancellation will occur after the date of the last claim paid.

Cooling off period
Members can cancel their membership in writing at any time. Cancellation of membership cannot be backdated, however, new and upgrading members have a 30 day cooling off period where all premiums paid in advance of their joining date can be refunded. This is provided claims have not been paid during this period. In this instance, the cancellation will occur after the date of the last claim paid.
Co-payment

Some products include a co-payment. It is the amount you pay towards your hospital stay in order to facilitate a lower premium. Co-payments apply to each night of an overnight stay. So for example if you were in hospital for 3 nights and you are on a product with a $100 co-pay you would be required to make a total co-payment of $300 i.e. $100 x 3 days. Some product also apply a co-payment for day admissions.

Drugs in hospital

Drugs prescribed on discharge and drugs not approved by the TGA [and the Pharmaceutical Benefit Scheme (PBS)] are not covered by the Fund, all other inpatient approved drugs associated with the treatment for a condition are covered.

Dependants

Dependant means a person who is one of the following:

(a)   a Dependant Child; or

(b)   a Student Dependant; or

(c)   an Adult Dependant.

Child means in relation to the Policyholder:

(a) a child;
(b) an adopted child;
(c) a foster child;
(d) a step-child; or
(e) a child to whom the Policyholder is appointed as legal guardian and as approved by Us from time to time.

Dependant Child means a person who is:

(a) a Child of the Policyholder;
(b) aged under 21; and
(c) not married or living in a de facto relationship.

Student Dependant means:

(a) a Child of the Policyholder;
(b) who is a Dependant of the Policyholder;
(c) aged over 20 years and up to the age of 25 years;
(d) not married or living in a de facto relationship; and
(e) who is enrolled and attending an approved apprenticeship or full-time student at a school, college or university.

Adult Dependant is:

(a) a person who is a Dependant of the Policyholder;
(b) up to the age of 25 years;
(c) not married or living in a defacto relationship; and
(d) who is not a full time student.

Emergency ambulance
What’s Covered
Ambulance treatment and transport in emergency situations

Benefits are not payable:

a) When an ambulance is called to attend to a patient but they are NOT transported to a Hospital (Call Out Fee)
b) When ambulance costs are fully covered by a Third Party, e.g. Traffic Accident Schemes, workers compensation, public liability or Ambulance Subscription schemes
c) When patients are transferred between public hospitals as an admitted patient
d) For ambulance transfers (patient transport) once patients have been discharged from hospital.
e) Transport for regular treatment (patient transport) e.g. chemotherapy
f) Transport from the admitting hospital to another hospital for treatment

Excess

An excess is the amount you pay towards your hospital stay. Check the policy fact sheet to determine the excess level that applies to your product.

Excluded services
The Fund does not provide cover for services that have an ‘x’ marked against them in the policy fact sheet or listed as excluded in the Fund Rules.

The Fund does not pay benefits for hospital treatment on any of these conditions when you elect to be treated as a private patient.
Family adult membership

Comprises of one adult contributor with a partner and/or spouse with children up to the age of 25 who do not qualify for benefits under the category of ‘Dependant Children’.

Extended Family Cover

Extended Family Cover allows Adult Dependants to be covered on their parent’s family cover for a modest additional premium.

Minimum Benefits (MB)
The Federal Government minimum benefit (also known as the Default Benefit) is the benefit that The Fund will pay for restricted services in a private hospital or day procedure centre. This benefit is a payment towards the accommodation cost only and does not cover any other hospital charges including operating theatre/labour ward. Members should be aware that treatment for a restricted service in a private hospital or day procedure centre may leave substantial out of pocket costs
Podiatric surgery
Where the surgeon is recognised as a specialist by Medicare for in-patient podiatric surgery and where the Member has hospital cover, benefits for the surgeon’s fees are payable if not excluded on your chosen product (refer to the policy fact sheet for your product).

Contact the fund in relation to podiatric surgery prior to treatment.
Pre-existing condition
A pre-existing ailment or pre-existing condition is any ailment, illness, or condition where, in the opinion of a medical adviser appointed by Us (not your own doctor), the signs or symptoms of that illness, ailment or condition existed at any time in the period of 6 months ending on the day on which the member became insured under the policy. The pre-existing condition waiting period applies to new members and members upgrading their policy to any higher level benefits under the new policy.

The pre-existing ailment rule applies to all hospital and extras tables.

Benefits are not payable during the first 12 months of membership for treatment of a pre-existing ailment (excluding psychiatric, rehabilitation and palliative care which have a 2 month waiting period)

When a cover is upgraded, benefits at the higher level of cover will not be paid at the insured level within the first 12 months of membership for treatment of a pre-existing ailment. However, benefits are payable at the previous insured level of cover during this 12 month period, providing that appropriate waiting periods have been served.
Pregnancy and birth related services
Pregnancy and birth-related services include, but are not limited to, antenatal and postnatal care and management of labour and delivery.
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 the fund.

The Federal Government publishes a prostheses schedule that sets out the benefits health funds must pay towards these items. Additional out-of-pocket (i.e. gap payment) prostheses expenses may be incurred that are not covered.

Members are advised to confirm if there are any out of pocket expenses with their treating doctor and/or the private/public hospital prior to admission. To limit your out of pocket expenses, ask your doctor which prosthesis is best for you and if there is a No Gap option available.
Restricted Services
Some of our hospital cover policies provide limited or reduced benefits on hospital admissions. They may not be sufficient to cover the cost of a private room in a public hospital or any room in a private hospital. This may be because of the level of cover which you have purchased or because the hospital/doctor does not have a contract with us. If you are admitted to a hospital for treatment that is restricted by your policy, then large out of pocket expenses may apply. If you have a cover with restricted services or benefits and are planning to use a private hospital please call Us to confirm your eligibility and level of cover for the service.

Access gap is also not available on restricted services.
Waiting period
When joining, or upgrading your level of cover, waiting periods must be served before any benefits are payable. If you are transferring from another health fund, you will not have to re-serve waiting periods if you transfer to a policy that is at the same or a lower level of benefit. However, if your new plan includes new or higher benefits that are not part of your old policy, you will have to wait for those benefits.

Need some help?

If you still have questions, call us on 1300 806 808.

Transport Health Pty Ltd ABN 39 099 028 127 is a registered Health Benefits organisation.