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Understanding your policy

What does health insurance cover?

There are two broad categories of health insurance cover:

  • Hospital
  • Extras
Hospital cover provides benefits for services in hospital including accommodation and inpatient medical services including doctors and specialists.

Extras cover selected therapies and health related services provided outside of hospital. Some examples of the most commonly claimed Extras services include dental, optical, physiotherapy and chiropractic procedures. Ambulance is also covered under most of our Hospital and Extras policies.

There are a wide variety of options available to enable you to choose the level of cover that best suits your needs.

Click here to see our full range of health insurance products.

What hospital costs does health insurance cover?

Hospital cover pays benefits towards the costs associated with treatment in hospital. It allows you to choose your own doctor and be treated in an Australian private hospital. You can also choose to be treated as a private patient in an Australian public hospital.

The level of hospital cover you choose determines the types of procedures you're covered for. Where a service is covered you can claim for the following in-hospital expenses:

  • Surgery and day surgery
  • Overnight accommodation
  • Operating theatre and critical care fees
  • Intensive care
  • Doctors’ surgical fees and in-hospital consultations
  • Government approved prosthetic devices
  • Allied health services (e.g. physiotherapy)
  • Prescription medication required for specific treatment when in hospital
  • Investigative procedures
  • Nursing care
  • Patient meals
  • Emergency ambulance

An Excess and out-of-pocket expenses may apply to these services.

You should always check what you're covered for before going to hospital. Call us on 1300 806 808.

Click here to see our full range of Hospital products. 

What does Extras health insurance cover?

Extras health insurance covers selected services provided outside of hospital. Some examples of the most common Extras services covered include dental, optical, physiotherapy and chiropractic procedures. Emergency ambulance is also covered under most of our Extras policies. 

There are a wide variety of options available so you can choose the level of cover that best suits your needs. Click here to see our full range of Extras products.

Do I need ambulance cover?

Medicare doesn’t cover you for ambulance services - but we can.

If you’re on any of our policies (excluding Dental Only) we’ll have you covered for Emergency Ambulance.

Each state has its own arrangements on how their Ambulance services are operated and who covers the costs.

DEPARTMENT OF VETERANS AFFAIRS GOLD CARD HOLDERS

Department of Veterans Affairs Gold Card holders are covered for state ambulance services in every State by the Department.

NSW, ACT

If you contribute to Hospital cover we will pay a state levy on your behalf and you are fully covered for ambulance transport. If you contribute to an Extras only cover you have limited cover for emergency only transportation. There may be free coverage for health care concession card and pensioner concession card holders.

TAS

Ambulance Tasmania provides a free service to Tasmanian residents.

QLD

All Queensland residents receive free ambulance cover, both in Queensland and elsewhere across Australia. No Fund benefit is payable if you are entitled to full cover for ambulance services under your State Government scheme.

VIC, SA, NT & WA

Under Our Hospital and/or Extras covers you are covered for emergency Ambulance transportation only.

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What do we need to do if we are planning to have a baby?

If you are thinking about having a baby, you will need to pre-plan and ensure that you are on the appropriate level of cover. Our Top Hospital Cover will provide benefits for obstetrics and pregnancy-related services . However, there is a 12 month waiting period so get a quote now!

When you are pregnant, it is important to transfer to a family policy at least 2 months prior to the expected due date. This is to ensure your baby is covered, particularly if your baby is early.

What cover do I need if I need to get my wisdom teeth out?

If you are getting your wisdom teeth out in hospital, you’ll use your Hospital cover to help cover the costs.

If you are having the extraction done in the chair by a Dental Surgeon, your Extras cover may apply. Please note that annual limits apply and payment will depend on your level of cover.

Please note that a 12 month waiting period applies for wisdom teeth removal.

What is an exclusion?

Exclusions are treatments or procedures that your policy does not cover.

We have a range of products from premium cover with few exclusions through to budget level covers that have more exclusions to make them more affordable. Click here to view the services included in our range of products to find a cover that suits your needs.

It is recommended that you carefully read the list of exclusions when selecting your cover. Any service that has an ‘x’ marked against it in the policy fact sheet will not be covered. There are also other circumstances when we will not pay a benefit. See the Membership Terms & Conditions for more details.

We also recommend that you review your policy and the exclusions each year to ensure that your policy continues to meet your needs.

If you would like to discuss whether a service you are concerned about is covered or would like advice regarding what the best level of cover is for you, please call us on 1300 806 808.

What are restricted services?

Some Transport Health products have restricted services. Where a service is restricted we pay the Federal Government Minimum Benefit (also known as the Default Benefit) 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. Please check the Policy Fact Sheet to determine if there are restricted services for your product. Access Gap is also not available on restricted services.

What is an excess?
An excess is the nominated amount that you agree to pay if you, or someone listed on your policy is admitted to hospital. The excess will apply once per person per calendar year with an annual policy maximum of twice per calendar year for couple, family and single parent policies.  

Depending on your policy, you may be able to elect to take a higher excess option in order to lower your premium.

What is a co-payment?

Co-payments are an amount payable by the member and applicable to each hospital admission during a calendar year.

  • Top Hospital with Co-payment has a daily co-payment of $100 per night, capped at $500 per person, per calendar year. This is also capped annually at $500 per person to a maximum of $1000 per couple / family per calendar year. Co-payments do not apply to same day accommodation on Top Hospital.

  • Healthy Choice Hospital has a daily co-payment of $100 for overnight accommodation capped at $500 per person with a family maximum of $1000 in any calendar year. There is also a daily co-payment of $150 for day stays / day procedures excluding in-patient dental treatment.

What is an Extras Provider and do we have Preferred Providers?
Extras providers are health professionals such as dentists, physiotherapists, optometrists and chiropractors. They provide you with the services that are claimable under your Extras cover. If you want to use their services and would like to check that the cost of those services are covered by your policy, you should check that you have selected the appropriate level of cover for the services required, the benefits paid per treatment and the applicable policy and service limits.

We only pay benefits to recognised health professionals. We cannot pay benefits for services provided by any health professional not recognised by us.

We have a network of Preferred Providers that offer preferential rates or benefits for our Members. Click here to search our network of Preferred Providers or call us on 1300 806 808 for more details on our Preferred Providers and the services which they offer.

What are waiting periods?
A waiting period refers to the period of time before benefits are paid.

They apply to:
  • New members who are not transferring from another Australian private health insurer with an equivalent or higher cover.
  • Existing Members who upgrade to a higher level of cover or who reduce the excess payable. In this case, you need to serve the necessary waiting period for the higher benefit entitlement.
  • Members who transfer from another fund who have not already completed the required waiting period for equivalent benefits.
  • New Dependants, unless they transfer from another fund where they have completed the required waiting period for equivalent benefits.
  • Hearing aid benefits for members transferring from another health fund, irrespective of the previous cover held.
  • Treatment of a pre-existing ailment.
  • Members who cancel their policy for a period of time and then re-join the Fund without having cover with another insurer during the gap period
The following waiting periods will apply to these services:

Emergency ambulance transportation

No waiting period

Accidents requiring either hospital or ancillary treatment (excluding services detailed below)

No waiting period

All services, except as specified below

2 months

Psychiatric, Rehabilitation and Palliative Care, even for a pre-existing condition

2 months

Optical

6 months

Elective procedures

12 months

Appliances

Orthodontic treatment

Foot Orthotics

Major dental, i.e. bridges, crowns, dentures, implants and surgical extractions. 

Pre-existing ailments (see definition)

Pregnancy related conditions

Reproductive treatment, such as IVF/GIFT

All services that refer to Benefit Limitation Periods for the insured level of cover

Hearing aids

24 months

Replacement of Dentures

36 months

What is the 'Gap'?

The Government has a list of fees for services (such as surgical procedures) known as the Medicare Benefits Schedule (MBS). Medicare pays 75% of the MBS, and we pay the remaining 25% as a benefit towards your doctors' bills, provided the procedure is not excluded on your cover. Some doctors and specialists charge more than the MBS. If this occurs, you will be required to pay the 'gap', which is the difference between the MBS and what the doctors charge.

What is 'Access Gap'?

The Access Gap Cover Scheme is designed to cover the ‘Gap’. There may be “No Gap” or a “Known Gap”.

We have access to one of the largest networks of doctors and hospitals in the country through the Gap Cover Scheme. The Gap Cover Scheme aims to reduce or eliminate any gap you may be charged for doctor or specialist fees in relation to your hospital admission. Doctors and specialists who have agreed to our No Gap Scheme have agreed to bill us directly. Where there is a “Known Gap”, the out-of-pocket expenses are disclosed to you. While the doctors and specialists have agreed to participate in the No Gap Scheme, it is at their discretion as to whether they do so on a patient by patient basis. It’s important that you check to see if your doctor or specialist participates in the No Gap Scheme and if so that you ask them if you will be treated under the program and if there will be a ‘gap’.

If you need to go to hospital, please call us on 1300 806 808 and we can help you with everything you need to know about the Gap Cover Scheme and how to access participating doctors and specialists.

Click here for a full list of participating doctors

What should I know before going to Hospital?

What is 'No Gap Diagnostic & Preventative Dental'?

“No Gap Diagnostic & Preventative Dental” means that you will not be required to pay any out-of-pocket expenses on a range of diagnostic and preventative dental procedures including check-ups, cleans, x-rays and fluoride treatments when treated at a Primary Dental Centre. This 100% back benefit is offered in all our Extras covers. Check your cover to see if annual limits and waiting periods apply.

The no gap basic dental procedures include:

  • Comprehensive oral examination
  • Periodic oral examination
  • Oral examination – limited
  • Consultation – extended (30 minutes or more)
  • Intraoral periapical or bitewing radiograph – per exposure
  • Intraoral radiograph – occlusal, maxillary, mandibular – per exposure
  • Removal of plaque and/or stain
  • Recontouring and polishing of pre-existing restoration(s)
  • Removal of calculus – first visit
  • Removal of calculus – subsequent visit
  • Topical application of remineralisation and/or cariostatic agents, one treatment
  • Concentrated remineralisation and/or cariostatic agents, application – single tooth
  • Fissure and/or tooth surface sealing – per tooth
  • Desensitising procedure – per visit

To find your closest Primary Dental Centre visit: www.primarydental.com.au/locations

Who does my policy cover?
All our health insurance policies fit into the following 6 categories (Scales).

  1. Single (1 Adult)
  2. Couples (2 Adults in a Relationship)
  3. Family (2 Adults in a Relationship with Child or Student Dependant/s)
  4. Extended Family (2 Adults in a Relationship with an eligible Adult Dependant/s)
  5. Single Parent Family (1 Adult with Child or Student Dependant/s)
  6. Single Parent Extended Family (1 Adult with eligible Adult Dependant/s)
Only eligible persons listed on the policy are covered.

Please ensure that you understand who is covered under your policy. Review your policy at least once a year to identify changes in your circumstances that could affect your health cover needs. If your family situation changes, please let us know so that we can suggest appropriate adjustments to your cover.

What is the ‘No Gap Physio’ benefit?

The ‘No Gap Physio’ benefit allows you to have one ‘no gap’ initial consultation per calendar year when you are treated at any Primary Physio Centre. You will not be required to pay out of pocket expenses for that initial consultation only.   Out of pocket expenses may apply for additional visits. Check your cover to see if annual limits and waiting periods apply.

Click here to find the Primary Physiotherapy Centre closest to you.

What pharmacy costs are covered by my policy?

The Australian government subsidises prescription medications that are listed on the Pharmaceutical Benefits Scheme (PBS). All Australian residents who are eligible for Medicare are entitled to PBS benefits, however, a co-payment is likely to apply.

We will pay a benefit for the medication when:

  • The drug is only available on prescription; and

  • The drug is listed on the Australian Register of Therapeutic Goods (ARTG)

  • The cost of the drug is over the PBS amount; and

  • The drug is provided under a private prescription

Benefits will not be paid for listed contraceptives.

Please check the policy fact sheets for specific benefit and policy limits.

What is a pre-existing ailment and am I covered for it?
A pre-existing ailment or pre-existing condition is defined as 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.

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.