Hospital Cover FAQs

What is a waiting period?

A waiting period is a period of time a member must wait before their cover commences. Waiting periods apply to:

• new members and members rejoining Defence Health, and 
• members who upgrade their level of cover and the waiting periods have not been served under their previous cover. However, during the applicable waiting periods, these members will be entitled to benefits at their previous level of cover

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What if I'm still serving waiting periods?

When you take out private hospital cover or upgrade your existing cover, you'll have to wait a set time before you can claim the new or upgraded benefits.

• 2 months - Hospital treatment (where there's no pre-existing ailments, illnesses or conditions)
• 12 months - Obstetrics, pregnancy and birth related conditions in a public or private hospital
• 12 months - Pre-existing ailments, illnesses or conditions

Cover for accidental injury is immediate provided it is not recoverable from another source – Workers Compensation, third party or other liability provision.

If you've had your current cover less than 12 months and you need treatment, you should confirm with Defence Health whether the pre-existing condition waiting period will apply. Defence Health may need a number of business days to make an assessment and may require you to obtain facts about your illness from all your treating practitioners. A practitioner appointed by Defence Health will then consider the opinion of, and evidence presented by, your own practitioners before making an informed judgement. If the practitioner appointed by Defence Health advises that the hospitalisation does not relate to a pre-existing condition, then normal benefits are payable. If the advice is that the hospitalisation does relate to a pre-existing condition then no benefits are paid or benefits are paid at the level of hospital cover held prior to any upgrade.

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What is a pre-existing ailment (PEA)?

A PEA is an ailment, illness or condition, which existed at any time during the six months before you purchased your new cover, or transferred to a cover with higher benefits. There is a 12-month waiting period for all hospital, medical and extras services that involve treatment of a PEA, except general dental services.

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How often do I have to pay the excess?

An excess on your overnight accommodation and theatre fees is payableonce per membership per financial year. Importantly, the excess is not applied against same day procedures.

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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 the 'gap', 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 participated in Access Gap Cover in the past. back to top

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. You are fully covered for the ambulance services.

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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 participate in Defence Health's gap cover scheme, Access Gap Cover. You can also search for a doctor.

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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. It is important you obtain this assurance as doctors are allowed to exercise their own discretion in choosing when they will bill under this system.

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 why this one is being recommended.

Finally, ask your specialist to explain the costs of the surgery, including the prosthesis and medical gap payment, if any, and any other expenses involved. If there are any gaps for you to pay, ask for a written cost estimate. This will tell you if there are any out of pocket expenses you will be responsible for.

Also refer to our Going to hospital checklist. back to top

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, with the doctor of your choice. In this case we 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" prostheses, and whether your doctor uses our Access Gap Cover schedule of fees. back to top

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 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 programs ask the hospital staff to contact our Member Support Program nurses on 1800 653 316. back to top

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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How do I pay my doctor's bills?

It is easiest for you if your doctor agrees to use Access Gap Cover and sends your bill directly to Defence Health. In this instance you can be confident that your benefits will be maximised. There may be an amount payable by you but your doctor is required to advise you of this prior to treatment.

If your doctor is not willing to send the account directly to Defence Health, we encourage you to send it to us. However, the account must be suitably endorsed, show financial consent for any amounts payable by you and instruct you to send the claim directly to us. If these details aren't present on the account you will be required to send the account to Medicare. In this case Defence Health will cover the difference between the Medicare Benefits Schedule (MBS) fee and the Medicare rebate. Any amount above the MBS fee will be your responsibility.

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What types of doctors will be involved in my procedure?

If you are planning an admission to either a public or private hospital as a private patient, it is important to be informed about the likely costs. Your surgeon may have explained their fees to you but there may also be other doctors involved. For example, there may be an anaesthetist and/or an assistant surgeon involved, and all associated doctors such as these will raise fees in addition to your surgeon.

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