Non-medically necessary procedures

Your private hospital cover is intended to help you pay for medically necessary treatments as an inpatient only. You are not covered for any non-medically necessary procedures. For example, you are not covered for cosmetic surgery. However, you are covered for plastic surgery, reconstructive surgery, or any elective surgery that your doctor and Medicare deem to be medically necessary. Check your product guide for any applicable restrictions or exclusions.

Excluded services

Some covers have excluded services for which we pay no benefit. If your cover has excluded services, these are listed in your product guide.

Restricted services

Some covers have restricted services. If your cover has restricted services, these are listed in your product guide. For restricted services, we will pay the default benefit for hospital accommodation as determined by the Government. 

Emergency departments

You are not covered for visits to public or private hospital emergency departments. Even if you have a Medicare card, you will be required to pay triage fees when you visit a private hospital emergency department.

Consultations 

You’re not covered for consultations with doctors or specialists before your admission or after you are discharged, even if your appointments are at the hospital. Medicare will pay a percentage of the Medicare Benefits Schedule (MBS) fee for these appointments, but due to legislation we are not able to pay any benefits.

Booking or administration fees

You are not covered for booking or administration fees, that surgeons charge patients on top of their quoted medical costs. Health funds can’t cover these fees as they are not for a medical procedure. If you see a fee like that on a statement, ask your doctor to explain the clinical or medical relevance of the charge. If you don’t get a satisfactory answer, you should not pay that fee.

Pre-existing ailments or conditions

You may not be covered for pre-existing ailments  if you're new to TUH or recently upgraded to a higher cover. 

Other costs

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.

*Special consideration for benefits toward high cost medications, exceptional medical procedures or other extraordinary costs related to your health care may be given at the discretion of TUH in accordance with the hospital contract. Requests are considered on a case-by-case basis.