Definitions, terms and conditions

Access Gap Cover

TUH aims to close the gap on out-of-pocket in-hospital medical expenses for our members. Access Gap Cover is available with any level of hospital cover. Participation in this scheme is the personal choice of your medical practitioner, so check this before commencing treatment. Also ask your specialist to confirm that any assisting specialist/s use Access Gap Cover for billing services. 

How Access Gap Cover works

For eligible private inpatient services, Medicare will cover 75% of the Medicare Benefit Schedule (MBS) fee set by the Government for doctor’s charges. TUH will cover the remaining 25%.

If your doctor charges above the MBS fee, this is an out-of-­pocket cost. If your doctor uses the Access Gap Cover scheme you will either:

  • have lower out-of­-pocket costs; or
  • have no out-of-pocket costs.

Prior to treatment you can request an estimate of costs from your doctor. If your doctor participates in the Access Gap scheme, in most cases, you will not receive an account as TUH receives the bill and makes any claims on your behalf from Medicare. For more information on Access Gap Cover and to search for Access Gap Doctors, please click here. 

See also Medical Gap cover.

Accidents  

You are immediately covered for hospital treatment for accidents with no waiting periods to serve, providing you joined TUH prior to the accident and have the appropriate level of cover for that treatment.

If you have been involved in an accident and received compensation or damages from a third party, additional benefits cannot be claimed in relation to this accident.

Any benefits and any associated costs already paid by TUH must be repaid if you receive compensation. See Emergency departments.

Active Health Bonus

The Active Health Bonus is a reward available to members with eligible levels of cover, when one adult member completes our online health assessment, Health-e-Profile. You may use the bonus to pay the out-of-pocket costs for extras treatments (up to the annual limit). 

  • Participation requires the completion of one questionnaire in each consecutive twelve month period.
  • Benefits are only payable for services provided whilst participating in the health assessment.
  • The Active Health Bonus limit is per policy per calendar year.
  • A six month waiting period to receive the bonus applies from your join date.

The following are not claimable under the Active Health Bonus:

  • co-payments for Pharmaceutical Benefit Scheme (PBS) prescriptions; 
  • any difference between the Medicare Benefits Schedule fee and the doctor’s charge for medical expenses;
  • any medical expense our Fund Rules or legislation prevents us from paying; and
  • hospital excesses.

If you decrease/change your level of cover, you may receive a reduced or no Active Health Bonus.

Australian Government Rebate on Private Health Insurance

See Rebate. 

Ambulance transport 

Emergency ambulance transport is covered when it results from an event that is unplanned, non-routine and which requires transport to hospital for immediate medical attention.

You are not covered for transportation from a hospital to: your home, a nursing home, or another hospital (if you have been admitted to the transferring [first] hospital). You are also not covered for transportation from your home, a nursing home or hospital for ongoing medical treatment, e.g. chemotherapy or dialysis. No benefit will be paid in respect of air ambulance services or any ambulance attendance where a member has not been transported to hospital. 

QLD residents

All Queensland residents are covered by Queensland Ambulance Service (QAS) agreements, including interstate travel. Any claims are to be submitted directly to QAS.

NSW and ACT residents

If you live in ACT and NSW an ambulance levy is included in your hospital cover. If you receive an ambulance account, send it to us for payment.

When a dependant resides in NSW or ACT, but the main member's residential address is in another state, ambulance transport is only covered on combined hospital and extras covers. 

TAS residents

All Tasmanian residents are covered by Ambulance Tasmania.

All other states and territories (for members who have combined hospital and extras policies)
You are entitled to full cover for emergency ambulance transportations. If you receive an ambulance account, send it to us for payment.

Benefit

The amount you receive from TUH when you make a claim. See your product brochure for a list of benefits payable under your cover or please call us.

Benefit Limitation Period (BLP)

For some covers a benefit limitation period of the first 12 months of membership applies for members who are new to private health insurance, upgrading a TUH cover and those transferring from other funds, with hospital cover which pay restricted benefits for private hospital accommodation related to psychiatric services. During the BLP, we pay the public hospital default benefits as per the law, which means you may have significant out-of-pocket costs to pay for the treatment. Waiting periods still apply for services with a BLP. For example, after serving the 2 months waiting period, your psychiatric benefit will be limited to a default benefit for the following 10 months. After 12 months you are entitled to the full benefit claimable for the treatment.

Calendar year

A 12 month period commencing 1 January and ending 31 December. 

Claiming

If a benefit is payable to you, it will be paid directly into your nominated bank account.

We offer five easy ways to claim:

  • to claim on your smart device, download the TUH Claiming app, then photograph your receipts and submit your claim;
  • online claiming is available for eligible services through Member Services Online. Please retain your original accounts and receipts for 12 months after your claim has been paid, as they may be subject to audits;
  • to claim via email, download the Claim form here, complete the form, scan with your original accounts/receipts and email both to onlineclaims@tuh.com.au. Please retain your original accounts and receipts for 6 months after your claim has been paid, as they may be subject to audits;
  • to claim in person or by mail, download the Claim form here, complete the form and mail or bring it into our Health Hub with the original accounts or receipts; 
  • via HICAPS/HealthPoint at your participating health care provider - just swipe your membership card and your benefit is applied immediately; and
  • for inpatient Medical Gap Cover treatment the Medicare statement of benefits is required to process your entitlements.

We retain all documents unless you indicate otherwise.

All claims are subject to Private Health Insurance legislation, Fund Rules and policies and procedures.

Cooling off period

You have the right to a 30 day cooling off period if you change your mind about joining TUH or changing your level of cover. There are to be no claims made during the cooling off period. The 30 day period commences from: 

  1. the joining date;
  2. the date the level of cover increases; or
  3. the date the level of cover decreases.  

For 2 and 3, the cover reverts back to the previous level of cover.

Cosmetic surgery 

“Cosmetic surgery” refers to procedures performed for non-medically necessary reasons. We are unable to pay benefits for these procedures or the hospital costs associated with them.

To help us determine if your treatment is medically necessary, we may ask for further information from your treating practitioner before we can confirm your correct benefit entitlements. If in doubt, talk to your doctor and call us before committing to any treatment. See Plastic and reconstructive surgery.

Default benefit

This benefit is determined by the Government and is the minimum amount funds must pay for accommodation costs in hospitals. Default benefits do not provide any benefit for labour ward or theatre fees. The default benefit covers the cost of:

  • shared accommodation as a private patient at a public hospital;
  • a reduced level of accommodation benefits as a private patient at a private hospital;
  • Access Gap/Medical Gap Cover with participating doctors; and
  • surgically implanted prostheses – we will cover the full cost of any Government approved (no gap) prostheses and the minimum benefit for gap permitted prostheses. 

Significant out-of-pocket costs may result if the treatment can only be claimed at the default benefit rates so remember to check whether your cover suits your needs.

Dental

General dental

The general dental treatments you’re covered for depend on the item number for that treatment. Some covers exclude certain procedures. Contact us for a quote on the item number.

Mouthguards are also covered under this category of treatments with a limit of one per person per calendar year.

Dental prosthetists

Benefits are paid for treatment by registered dental prosthetists at 75% of the benefit which would be payable for treatment provided by registered dentists.

Major dental

Major dental includes all dental services relating to dentures, crowns, bridges, inlays, onlays, facings, dental implants, endodontia, periodontia, anti-snore devices and orthodontia. Conditions apply for Active Choice, Young Choice and Mid Range Extras. Major dental is not covered on Basic Extras.

Orthodontics

Benefits are paid for active treatment and annual limits apply. To be eligible you must submit an orthodontic treatment plan from your orthodontist at the commencement of treatment. TUH will then advise the benefits available in writing, taking into account length of membership, previous orthodontic benefits paid by TUH or any previous fund and length of active treatment. For more information please contact us.

Dependant

  • A natural child, stepchild, legally adopted child or child to whom the policy holder is the legal guardian or who is in the policy holder’s legal custody.
  • The policy holder’s adult children, who are not married or in a de facto relationship and who are under 21 years of age.

Extended dependant cover

TUH offers single parents and families with non-student children (including apprentices) the opportunity to purchase extended dependant cover. This allows young adults who are single, not covered as a student dependant and earning less than $50,000 (taxable income) a year, to be covered on their parents’/guardians’ policy until the age of 25. 

Extended dependant cover is available for Ultimate Choice, Easy Choice and Total Care Hospital with $300 excess combined with Comprehensive Extras.

Student dependants

A policy holder’s student dependent child who is:

  • a full time student at a recognised education facility for the whole of the academic year;
  • under age 25;
  • unmarried and not in a de facto relationship; and
  • earning a taxable income under $50,000.

A policy holder must complete and return to TUH a Student Dependant Registration form upon commencement of study.

Students are not covered if they cease or defer study during the year.

Emergency departments

Visits to public or private hospital emergency departments or other hospital treatments where you are not admitted as an inpatient (as determined by law), are not covered by private health insurance.

Excess

An excess is an amount you elect to contribute towards the cost of your hospital treatment (including same day surgery and procedures, such as chemotherapy and dialysis). Agreeing to pay an excess if you need hospitalisation reduces the amount of annual premium you pay.

The hospital excess is not charged for dependants.

Note: Reducing your excess is considered to be upgrading your membership. Due to this we may charge your previous excess within the first 12 months of the upgrade for pre-existing ailments or conditions.

Excluded services

These are services for which no benefit is payable under some levels of cover. Examples of excluded services include: 

  • Obstetrics (pregnancy and birth related treatments;
  • Labour ward;
  • Infertility investigations and assisted reproductive services;
  • Sterility reversals;
  • Hip, knee and joint replacements;
  • Eye surgery, including cataracts; and
  • Dialysis.

Please contact us or refer to your product brochure for exclusions and restrictions that might apply to your level of cover.

Informed financial consent

Before you receive treatment as a private patient in hospital, you are entitled to ask your doctor, your health fund and your hospital about any out-of-­pocket costs you may incur.

Ask your treating doctor or specialist, wherever practical, how much their fee will be and if you will need to pay a gap. For major treatment, this information should preferably be provided in writing. It is your right to ask for this information before you agree to a proposed treatment. In some circumstances, such as emergency admissions, it will not be possible for your doctor to obtain informed financial consent before the service is provided.

You may have more than one doctor involved in your treatment, such as a surgeon and anaesthetist. Your surgeon should be able to advise who else will be treating you and how you can contact the other doctors to seek fee information from them. See Access Gap Cover.

Law/legislation

The main law governing private health insurance is the Private Health Insurance Act 2007 and associated Rules. TUH must also comply with its Fund Rules.

Lifetime Health Cover

Lifetime Health Cover is a Government initiative designed to encourage people to join a private health fund early in life and to maintain membership. If you take out hospital cover after 1 July following your 31st birthday, your base premium will increase by 2% for each year you are over the age of 30 up to a maximum of 70%. This surcharge also applies to your partner if over 30. If you were born on or before 1 July 1934 you will not be affected by the Lifetime Health Cover surcharge.

Any loading you pay is removed once you have paid the higher premium for a continuous period of 10 years.

IMPORTANT: Having extras cover only will not exempt you from paying the Lifetime Health Cover loading.

Limit

Annual limit

The maximum amount payable per calendar year for an extras benefit. The annual limit is renewed on 1 January each year.

Sub limit

A limit which is applied annually (or another specified period of time) on the benefit paid for a particular item or service within an overall category limit.

For example: With our Easy Choice cover, you have an annual overall major dental limit of $2000. Crowns and bridges have a sub-limit of $650 for your first year, so this is the maximum benefit you can claim for this item. Your overall annual limit will then be reduced to $1350 which you can use for other treatments within the major dental category.

Maternity

See Obstetrics (pregnancy and birth related treatment).

Medical Gap Cover

For eligible private inpatient services, Medicare will cover 75% of the Medicare Benefit Schedule (MBS) fee set by the Government for doctor’s charges. TUH will cover the remaining 25%. If your doctor charges above the MBS fee, this is an out-of-pocket cost. 

Medical practitioner

Means a medical practitioner within the meaning of the Health Insurance Act 1973.

Membership eligibility

TUH is a restricted fund. You must meet the eligibility criteria set out below to qualify for membership with TUH:

  • Current or former member of any union.
  • A family member of a person who is eligible to join TUH. This includes parent, partner or former partner, dependent child, adult child (and their partner), grandchild, brother or sister (and their partner and dependent children).

Medicare Benefits Schedule

The benefits you receive from Medicare are based on a schedule of fees for medical services set by the Australian Government. The Medicare Benefits Schedule (MBS) lists a wide range of consultations, procedures and tests, and the schedule fee for each of these items. Benefits are only payable for hospital procedures that are listed in the MBS and/or meet the eligibility criteria for Medicare benefits. You can look up a service or item number via www.mbsonline.gov.au or ask your medical practitioner.

Nursing Home Type Patients

Non-acute certified admissions exceeding 35 days may be defined as Nursing Home Type Patient. Co-payment may apply, please contact us for more information.

Obstetrics (pregnancy and birth related treatment)

While most of our covers include cover for obstetrics, some don’t. Please refer to the relevant product brochure to see if you have the correct level of cover. Please be aware that a 12 month waiting period applies to this.

By law, TUH is unable to pay any expenses relating to visits to your obstetrician, gynaecologist or other doctors (including scans and doctor’s management fees) either before or after you are hospitalised. Medicare will usually pay a benefit on these services.

If you have a single parent or family policy, the baby will be covered from birth. Newborn babies added to an existing policy will be deemed to have already served the waiting periods served by the adult member with the longest period of cover. Members on couples or single cover must transfer to family or single parent membership within three months of the baby's birth and ensure the additional premium is paid from the date of the baby's birth. Remember to contact us to add the baby to let us know when your new baby has been born so he/she can be added to your policy.

Contact us for detailed information about obstetrics (pregnancy and birth related treatment).

Paediatric services provided to your baby in hospital are only claimable if the hospital deems it medically necessary and admits your baby as an inpatient.

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Out-of-pocket costs

Hospital

Possible hospital out-of-pocket costs include:

  • hospital treatment that is not medically necessary or treatment which is not eligible for Medicare benefits;
  • cosmetic surgery;
  • outpatient treatment;
  • charges above the Medicare Benefits Schedule (MBS) fee;
  • some pharmacy items;
  • personal incidentals (e.g. toiletries, newspapers, tv, etc.);
  • experimental procedures/ therapies;
  • high cost medications;*
  • robotic surgery consumables;* 
  • medical devices not included in hospital theatre fee charges as determined by law; and
  • Emergency department.


*Special consideration for benefits toward high cost medications, exceptional medical procedures or other extraordinary costs related to the health care of a TUH member may be given at the discretion of TUH and requests are considered on a case-by-case basis. 

Access/Medical Gap Cover is limited to treatment provided during inpatient hospital admission.

For more information please refer to the Ombudsman’s brochure ‘Doctor’s Bills’ which you can download from www.ombudsman.gov.au. Alternatively you can contact us and we’ll send you a copy.

Extras

An extras out-of-pocket cost is the difference between the amount a service provider charges and the benefit TUH pays. For example, if a physiotherapist charges $70 for a visit and TUH pays a benefit of $32, the out-of-pocket cost would be $38.

Visiting a preferred service provider can reduce the out-of-­pocket costs you are required to pay. For a list of TUH’s preferred dental and optical providers, please click here. 

Overseas products, treatments and services

We do not pay benefits for services provided or products purchased overseas, including internet purchases where the goods are provided from an overseas supplier. This is to ensure you receive the high level of consumer protection and quality of service that is provided under Australian standards and health conditions. 

Overseas travel

Private health insurance does not cover you for medical/ hospital/extras treatment received while travelling overseas. We recommend you obtain travel insurance for all overseas travel.

Payments

Your health insurance premiums are payable in advance. Your membership payments must be up to date to enable you to make claims. Your membership will automatically cease if your payments are more than two months in arrears.

If you are experiencing difficulty in making regular payments, please contact us to discuss payment options.

The following payments methods are available:

  • Direct debit - Payments can be debited fortnightly, monthly, quarterly and half-yearly.
  • Credit card - Payments can be charged monthly, quarterly and half-yearly.
  • Accounts - Accounts are sent monthly, quarterly and half-yearly.

Payment methods include:

Pharmaceutical Benefit Scheme

The Pharmaceutical Benefits Scheme (PBS) is run by the Australian Government to subsidise prescription medicines for Australians who have a Medicare card. If a medicine is subsidised under the PBS, you pay a lower price for the medicine, and the Government pays the rest. For more information, see www.pbs.gov.au. 

If your cover includes pharmaceutical, you are able to claim the amount above the PBS fee up to the benefit amount.

Plastic and reconstructive surgery

Plastic and reconstructive surgery refers to the evaluation and treatment to correct functional impairments caused by trauma and congenital abnormalities. Plastic surgery can be performed to approximate a normal appearance, for example, a breast reconstruction following a mastectomy or skin grafting following burns. Plastic and reconstructive surgery is a restricted service on some levels of cover so please check your level of cover if you believe you may require this benefit. It is also important to note that plastic and reconstructive surgery is not cosmetic surgery.

Cosmetic surgery is performed for non-therapeutic purposes and no benefit is paid by TUH.

Pre-existing ailments or conditions

All hospital claims in the first twelve months of membership for new members, members upgrading to a higher level of hospital cover or transferring from another fund are subject to the pre-existing ailment or condition rule. This rule refers to an ailment, condition or illness, the signs or symptoms of which existed at any time during the six months before a member joined the Fund or upgraded to a higher level of cover, even though a diagnosis may not have been made. 

Our appointed medical adviser will decide if a condition is pre-existing based on medical notes and standard medical practice. If your claim is deemed pre-existing you will receive the benefits relating to your previous lower level of cover or will not be paid if no previous hospital cover was held. Please allow five days for all the information to be received and assessed by the medical adviser. 

A waiting period of 12 months is standard practice within the private health insurance industry to receive benefits for a pre-existing ailment. Two months apply to palliative care, psychiatric services and rehabilitation. More about pre-existing ailments. 

Rate protection

You may pay your membership for up to six months in advance at the rate that applies at the time. This means that you will not have to pay extra if premiums increase during the period for which you have paid. Rate protection will cease if you change your level of cover or suspend membership; any amount paid in advance of the date of the cover change or suspension will be applied at the rate that is current at that time.

Rebate

The Government provides a rebate on private health insurance premiums. The rebate you receive depends on your age (persons over 65 and over receive a higher rebate) and your household income. You must be eligible for Medicare benefits to qualify for the rebate.

You can claim the rebate as a reduction of your premiums, or as a tax rebate when you lodge your annual tax return.

To have the rebate deducted from the premium you pay, just complete the application form for the Australian Government Rebate on Private Health Insurance when you join TUH.

Please visit www.privatehealth.gov.au for more information.

Restricted services

For services listed as restricted (for specific levels of cover) we will pay the default benefit for hospital accommodation as determined by the Government for restricted services. Examples of restricted services include:

  • psychiatric services;
  • rehabilitation;
  • podiatric surgery;
  • gastric banding and obesity surgery; and
  • plastic and reconstructive surgery.

Refer to individual covers for services with restricted benefits. Any excess applicable to your cover will be charged even where a default benefit only is paid.

The default benefit does not cover theatre or labour ward fee benefits.

School accident cover

This cover is available for Ultimate Choice, Easy Choice and Family Extras covers only. It covers your dependent child for accidents occurring while attending, or travelling to or from school or an organised school activity. Benefits are limited to single parent and family cover.

Services covered under the school accident cover include:

  • travel expenses
  • parking expenses
  • physiotherapy (in addition to other physiotherapy benefit entitlements)


Please see the extras cover section of your product brochure for benefits, limits and sub limits. Benefits for other extras services resulting from a school accident will be considered individually.

Excludes:

  • on-street parking fees
  • services that are covered by Medicare
  • services where you can make a claim for compensation
  • services provided more than twelve months after the accident

Spouse/partner authority

A policy holder can request that their spouse/partner (on the same policy) be authorised to operate the policy on the same level as the policy holder (excluding joining/ terminating membership and removing dependants). This can be done by contacting us or by downloading the Spouse/Partner Authority form on our website. The policy holder may withdraw the authority at any time by notifying us, in writing or over the phone. See Transaction authority.

Surgically implanted prostheses

A surgically implanted prosthesis is a piece of equipment that is implanted into the body during a hospital procedure, such as artificial hip, a pacemaker, a cardiac stent, screws and plates. Most Government approved surgically implanted prostheses are covered by your hospital cover. However some will require a patient contribution to be paid if the supplier charges above the listed benefit. If a gap amount applies to your prosthesis your surgeon/hospital will arrange for you to complete an informed financial consent form. 

Suspension of cover

Financial hardship

If you are experiencing financial hardship and have been a financial member of TUH for at least twelve months, we may allow you to suspend your membership for a minimum period of one month to a maximum period of 12 months. Multiple suspensions are allowed, however twelve months must be served between consecutive suspensions. No claims can be made while your membership is suspended or for treatment that occurred while your membership was suspended.

Overseas travel

If you are travelling overseas you may suspend your membership for a minimum period of two calendar months to a maximum period of three years. One month’s premium must be paid in advance of the suspension date. Two suspensions are allowed per calendar year. The second suspension can commence after you have resumed the policy for a period equal to the length of your previous absence or nine months, whichever is shorter. Please contact us to request an Application for Suspension of Membership form, or download the form here. No claims can be made while your membership is suspended.

Application to suspend member­ship must be made prior to the date of overseas departure.

Documentation to verify departure and return dates will be required upon resumption of membership.

Please refer to the conditions that apply to suspension of membership, which are listed on the Application for Suspension of Membership form and the accompanying information sheet.

The remainder of any waiting periods not completed prior to departure will continue when membership is resumed.

Transaction authority

For any persons, other than your spouse/partner, to make transactions on or enquire about your policy a Power of Attorney is required. For enquiries about the policy a Policy Enquiry Authority form must be completed. See Spouse/partner authority. 

Transferring to TUH

Hospital cover

When you transfer to TUH from another fund you will receive continuity of equivalent cover providing you join TUH within two months of leaving your former health fund. If any waiting periods have not been served (at all or in part) with your former fund you will be required to serve the balance of the waiting period before you can claim any benefits from TUH. Where your new cover has higher benefits (including a lower excess or fewer excluded/restricted services) waiting periods will apply.

In case of a lower excess, you'll need to pay the previous higher excess for a hospitalisation in the first two months of cover.

Extras cover

When you transfer to an equivalent level of cover with TUH you will receive the year-one benefits for covers that have annual limits that increase with years of membership and limits with TUH for all services, where applicable, provided all waiting periods have been served with the previous fund.

Credit will be given for waiting periods partially served with your previous fund or on a previous level of cover if you are upgrading. If you transfer to a TUH level of cover that provides services not covered by your previous fund, all relevant waiting periods for these services must be served with TUH.

Any benefits paid by your previous fund will be deducted from the TUH limits within the first twelve months of membership. Continuity of membership will only be taken into account if you join TUH within two months of ceasing membership with your previous health fund.

Travel insurance

Your health insurance does not cover you if you are travelling overseas. As a TUH member you can save up to 30% on travel insurance with QBE Insurance (Australia) Ltd. This offer is only available if you book through our website. Click here for more information.

Waiting periods

For all new memberships, upgrades of cover (where your new cover has higher benefits, lower excess or more services), including transfers from another fund, the following conditions will apply:

  • two months for all hospital and extras services unless specified otherwise; 
  • two months for palliative care, psychiatric services (BLP apply for some covers), rehabilitation and home care programs; 
  • six months for Active Health Bonus, outpatient midwife services, disease management programs and optical (Young Choice, Family Extras, Healthy Options (60%) Extras and Mid Range Extras); 
  • twelve months for pre-­existing ailments or conditions (excluding palliative care, psychiatric services and rehabilitation), obstetrics (pregnancy and birth related treatment); and prostheses; 
  • twelve months for major dental, orthodontia; hearing aids and mechanical/ health appliances; and 
  • two years for refractive laser eye surgery.


There are no waiting periods for accidents that occur after you join TUH. Some services do not apply to all levels of cover. See your product brochure for details on services available on your specific level of cover.

Workers Compensation

Claims for work related injuries must be submitted directly to WorkCover of the Workers Compensation authority in your state. In the event that WorkCover rejects your claim, TUH may make payment relevant to your level of cover. We require fully itemised accounts/receipts with a copy of WorkCover’s letter stating that you are not entitled to WorkCover benefits.