General claiming conditions
The below content details Defence Health's general claiming conditions.
Full details of our rules and conditions are available in our fund rules.
1. A claim for benefits must be lodged within two years of the date of the service.
2. All accounts/receipts must be originals or true copies of the originals on the provider’s letterhead and include the:
(a) appropriate item number or full description of the service or product
(b) patient's name
(c) date of service
(d) fee charged
(e) provider's name, qualifications and practice address, and
(f) provider number (if applicable).
3. Tooth numbers are required on dental accounts where treatment has taken place on individual teeth.
4. Alternative therapy providers must be recognised by the Australian Regional Health Group at the time the service is provided. Remedial Massage providers must also hold at least a Diploma of Remedial Massage to be recognised.
5. Claims are only payable once a service has been provided. Benefits and limits are assessed according to the date on which the service or product was supplied (except for courses of orthodontic treatment).
6. Most extras limits renew on 1 July each year.
7. Services must be provided by approved practitioners in private practice or salaried doctors in public hospitals.
8. All documents submitted in connection with a claim become the property of Defence Health. Accounts for online claims must be retained by the member for two years.
9. Benefits are not payable for services provided while premiums are in arrears or the membership is suspended.
10. Benefits are not payable, or may be paid at a reduced rate, during any applicable waiting periods.
11. Benefits are not payable for services provided outside Australia or for items purchased or hired from overseas suppliers.
12. Benefits are not payable for treatment provided by a family member or business partner; or the family member of a business partner.
13. Extras benefits are not payable for services provided in a public hospital.
14. Benefits are not payable if the service can be claimed through Medicare, DVA, third-party compensation or other insurance.
15. Extras benefits are not payable for pharmaceuticals not related to a medical condition; that can be purchased without a script; or that have been supplied to a hospital inpatient.
16. Benefits for certain health appliances are payable when recommended by a physiotherapist, chiropractor, osteopath, podiatrist, chiropodist, occupational therapist or medical practitioner. Custom-made foot orthotics are only claimable when supplied by an orthotist, podiatrist or chiropodist.
17. If you need to see the same type of health service provider twice in one day, benefits are only payable if the treatment is for two separate conditions. A maximum of two services can be claimed on any one day.
18. If you need to see the same provider twice in one day, benefits are only payable if two separate services have been provided (and the provider is qualified in both). A maximum of two services can be claimed on any one day.
19. If a claim is found to be fraudulent or incorrect, Defence Health may:
a) Suspend all claiming from any source
b) Offset the amount paid against future claims or premiums
c) Reclaim the funds from you.
20. By claiming a benefit, you agree to the general claiming conditions contained in the fund rules.
21. Only certain services may be claimed online up to a daily benefit limit of $500. Benefits within the limit will be paid immediately. When the benefit payable is above the limit the claim will be reviewed prior to payment being released.
22. Online claims may only be made by the policyholder.