Hospital Cover FAQs
What is a waiting period?
A waiting period is a period of time a member must wait before they are able to claim benefits under their cover. Waiting periods apply where a person:
- is insured for the first time
- has had a break in cover of two or more months immediately prior to joining
- upgrades to a higher level of cover (including reducing or removing an excess)
- transfers from another fund and has not completed an applicable waiting period at that fund for equivalent benefits or chooses to upgrade their cover when they transfer.
What is a pre-existing condition?
A pre-existing condition is an ailment or illness, where signs or symptoms existed at any time in the six months prior to you joining or upgrading to a higher level of cover.
A pre-existing condition is determined by a medical or other health practitioner appointed by Defence Health. The practitioner will consider the opinion and evidence presented by your treating practitioners before making an informed judgement.
If you have had your cover for less than 12 months and need treatment, you should confirm with Defence Health whether the pre-existing condition waiting period will apply.
Defence Health may require you and your treating practitioners to complete a Pre-existing Condition form in order to obtain facts about your illness. The practitioner appointed by Defence Health to review your case will need a number of business days to investigate and make an assessment.
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How often do I have to pay the excess?
The excess you choose is payable by you once per policy per financial year, if and when you make a hospital claim. Importantly, under most policies the excess will not apply to your dependent children.
If you have a single parent family policy that has been closed to future members then the excess will apply to your dependent children aged 16 and over.
Does the excess apply to extras such as optical or physiotherapy?
No, an excess is not applied to extras claims. However, out-of-pocket expenses may apply.
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How do I pay my excess?
Many hospitals will require you to pay any applicable excess prior to your admission. If the hospital does not request you to pay your excess prior to admission, they will send you a bill for this amount at a later date. You do not need to pay the excess to Defence Health.
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What is the 'gap'?
When you go to hospital, the benefits you're entitled to for the medical procedures you receive are based on the Federal Government Commonwealth Medicare Benefits Schedule. However, doctors can charge above this schedule. The 'gap' is the difference between the doctor's charge for the services they provide in hospital and the total benefits you receive from Medicare and Defence Health.
To help avoid or reduce these out-of-pocket medical costs, Defence Health has introduced Access Gap Cover. Participation in Access Gap Cover is at your doctor's discretion and you will need to check with them if they'll be using Access Gap Cover for you. Search for doctors who have registered as willing to particpate in Access Gap Cover.
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What happens if I get taken to hospital in an emergency?
In an emergency situation, you will be taken by ambulance to the nearest accident and emergency section of a public hospital. In this circumstance you have the right to choose to be treated as a public patient at NO charge, by a doctor appointed by the hospital. Your health insurance with Defence Health provides 100% cover for the ambulance treatment provided by a registered ambulance service in Australia.
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My doctor is referring me to a specialist for treatment.
Ask your doctor to refer you to a specialist who will use Access Gap Cover. You will have either no out-of-pocket expenses, or prior to treatment, you will be given an estimate of the costs you will have to meet. You can also search for a doctor who may be willing to apply our Access Gap Cover schedule of fees.
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Are there any questions I should ask my specialist before admission?
Yes. Firstly if you have one of our Top Hospital products you should ask what hospital you will be treated in and ensure, where possible, that you will be attending a hospital with which Defence Health has an agreement regarding charges. You can also review our list of agreement hospitals. If you are covered under our Public Hospital cover you will be significantly out of pocket if you are treated anywhere other than a Public Hospital.
Secondly, you should ask your specialist if they are willing to participate in our gap cover scheme, Access Gap Cover. This also applies to your anaesthetist, pathologist and other medical practitioners who will provide services to you while you are admitted. If they do you will have either no out-of-pocket expenses, or prior to treatment, you will be given an estimate of the costs you will have to meet. You can
search for a doctor who may be willing to apply our Access Gap Cover schedule of fees..
Thirdly, if your surgery requires a prosthesis, ask your specialist which prosthesis will be the best one for you and which no-gap prostheses are available. If the specialist recommends a prosthesis for which a gap is payable, ask what the gap is and why this one is being recommended.
Finally, ask your specialist to explain the costs of the surgery, including the prosthesis and medical out-of-pockets, if any, and any other expenses involved. If there are any gaps for you to pay, ask for a written estimate.
Also refer to our Going to hospital checklist.
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What happens if I choose to be treated in a public hospital?
You can elect to be treated as a public patient in a public hospital, by a doctor appointed by the hospital, at a time determined by the hospital, at no charge.
You can also elect to be treated as a private patient. In this case you are able to choose your doctor from one of the doctors associated with the public hospital. Defence Health will provide benefits towards your accommodation and help cover the doctor's charges. The extent to which these costs are covered will depend on your level of cover, whether you and your doctor choose a "no gap" prosthesis, and whether your doctor uses our Access Gap Cover schedule of fees.
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What happens if I choose to be treated in a private hospital or day hospital facility?
Being a private patient in a private hospital or day hospital facility gives you a choice of doctor and hospital, as well as access to hospital services at a time that may better suit your needs. The extent to which your costs are covered will depend on your level of cover, whether you use an agreement hospital, whether you and your doctor choose a "no gap" prostheses, and whether your doctor uses our Access Gap Cover schedule of fees.
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How do I know if the hospital I am going to is an agreement hospital?
Defence Health has an extensive network of agreement hospitals throughout Australia. It is important that you check this information each time you are going to hospital, as the status of hospitals can change. Don't rely on information you received in relation to a previous hospitalisation. Review our list of agreement hospitals.
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Are there hospitalisations that I'm not covered for?
Yes. Defence Health is unable to pay benefits for hospitalisations where Medicare does not pay the associated doctors' bills (with the exception of Commonwealth registered podiatric surgeons). If you are in doubt about the status of your hospitalisation, your doctor or Medicare will be able to advise you.
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What happens when I am admitted to hospital?
Once you have chosen to be admitted as a private patient, the hospital will first confirm your cover with the fund (or may do so prior to your admission).
If you have an excess on your policy, the hospital will usually require you to pay it on the day of your admission. Make sure you have your credit card or money for the cost.
The hospital will also provide you with Informed Financial Consent. This will detail any additional charges, if any, relating to your treatment that are not covered by your hospital cover.
If you are interested in our Mother Care or Recovery Assist early discharge programs ask the hospital staff to contact our Member Support Program nurses on 1800 653 316.
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How do I pay my hospital bill?
In most cases, the hospital will bill Defence Health directly so you will not see their account. If they do send you the bill, then simply download, complete our claim form and mail the account to Defence Health for settlement.
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