Adjustable taxable income, waiting periods, annual maximums and co-payments; not exactly easy bedtime reading for you is it?
But it can be important nonetheless. That’s why we have put together a glossary of key terms that you might find in our brochures, Fund Rules (PDF 176Kb) and on this website, in relation to the various health covers that we offer.
Many terms have specific meanings, so it is necessary to read this glossary in conjunction with our Fund Rules and Standard Information Statements before joining any Bupa health cover.
We hope that this resource explains any terminology that you are unclear about and helps offer some insurance-language peace of mind.
An accident is an unforeseen event, occurring by chance and caused by an unintentional and external force or object resulting in involuntary hurt or damage to the body, which requires immediate (within 72 hours) medical advice or treatment from a registered practitioner other than the member.
Generally your adjusted taxable income includes your:
taxable incomeAn annual maximum is the maximum amount you can claim in a service category per person and per calendar year (unless otherwise stated). For certain services, annual maximums also apply on the number of times that benefits are payable for the same service (eg initial consultations). These maximums apply from the date of service or purchase. Some services also have lifetime limits or periodic annual maximums (eg orthodontics). Per person annual maximums are not transferable to any other member on your policy.
This refers to the difference between what your doctor charges and the amount Medicare pays for inpatient procedures. If your doctor charges up to the Medicare Benefits Schedule (MBS) fee or is participating in the Bupa Medical Gap Scheme, in most cases you will have no medical gap costs to pay.
For doctors who are not participating in our Medical Gap Scheme and are charging above the MBS fee, we will pay the difference between the Medicare benefit and the MBS fee. Any amount above the MBS fee will be the amount you are required to pay and this is referred to as the 'Medical Gap'.
A calendar year is 1 January to 31 December.
In an emergency, we may not have time to determine if you are affected by the pre-existing condition rule before your admission. Consequently, if you have been a Bupa member for less than 12 months you might have to pay for some or all of the hospital and medical charges if:
To lower the cost of your hospital cover, on selected covers you can choose to include an excess or co-payment. Excesses or co-payments are only payable on overnight and same-day inpatient hospital admissions in any hospital.
If you require treatment for a specific procedure or service that is excluded under your level of cover you will not receive any benefits towards your hospital and medical costs and you may have significant out-of pocket costs.
If a service is not covered by Medicare there will be no benefit payable from your hospital cover so you should always check with us to see if you’re covered before receiving treatment.
To receive benefits for health aids and appliances you'll need to visit one of our recognised providers. You'll also need to meet the eligibility criteria, provide proof of purchase and a clinical referral where required. It is important to note that benefits are not payable when a prescribed treatment is not fully custom made (eg orthotics). Visit our website or contact us to find out more.
Benefits for hire, repair and maintenance of health aids and appliances are not payable in the first 12 months after purchasing an item; within 12 months following a repair; or on items where hire and repair are deemed inappropriate.
Benefits are payable towards some home nursing services that do not need to take place in a hospital and are provided in the home. Please contact us to find out more.
Our Living Well Programs help cover health related programs from approved, recognised providers. You can visit our website for a list of our recognised providers. A Living Well Programs approval form must be completed by your doctor for gym memberships, yoga and Pilates to confirm that the program is medically necessary. Other benefit and recognition criteria apply. Visit our website or contact us to find out more.
You are likely to experience out-of-pocket expenses when you are not fully covered for services and benefits, or when a set benefit applies. You should refer to what is and isn't covered for your relevant level of cover to determine when an out-of-pocket expense may occur. You should also refer to our Fund Rules for any additional information on benefits payable. A copy of our Fund Rules can be found on our website or in our retail centres.
It is important to ensure when being admitted to hospital that Informed Financial Consent is provided to you for a pre-booked admission to allow you to understand any out-of-pocket expenses upfront. If you have received any out-of-pocket expenses and require clarification, please contact us directly.
A pre-existing condition is any condition, ailment or illness that you had signs or symptoms of during the six months before you joined or upgraded to a higher level of cover with us. It is not necessary that you or your doctor knew what your condition was or that the condition had been diagnosed.
A condition can still be classed as pre-existing even if you hadn't seen your doctor about it before joining or upgrading to a higher level of cover.
If you knew you weren't well, or had signs of a condition that a doctor would have detected (if you had seen one) during the six months prior to joining or upgrading, then the condition would be classed as pre-existing.
A doctor appointed by us decides whether your condition is pre-existing, not you or your doctor. The appointed doctor must consider your treating doctors' opinions on the signs and symptoms of your condition, but is not bound to agree with them.
You must pay the premium and the Lifetime Health Cover Loading that applies to you. Premiums differ from state to state due to different state charges. If you move to another state your premium will change too. Therefore you must let us know about any change of address.
To receive the benefits available on your cover, you need to:
Bupa may require you to provide proof of identity and/or age when joining, changing your level of cover or in relation to any other transaction with us.
For restricted services there will be full cover in a shared room with your choice of doctor in a public hospital and restricted/default benefits in a private hospital which would not be adequate to cover all hospital costs and are likely to result in large out-of pocket expenses.
If you're on a cover that provides Special Benefits cover, you could receive benefits for accommodation and meal costs if your partner, immediate family member, carer or next of kin is required to stay at hospital with you or a person on your membership. They will be covered for $60 per night for accommodation in hospital and up to $30 a day for hospital meals. Hospital meals are covered when provided at a hospital cafeteria, kiosk or patient meal menu. A $1,000 per person, per calendar year annual maximum applies to Special Benefits.
You will be covered up to the benefit set out in the Government's Prostheses List for a listed prosthesis which is surgically implanted as part of your hospital treatment. The Prostheses List includes: pacemakers, defibrillators, cardiac stents, joint replacements, intraocular lenses and other devices. If a hospital proposes to charge you a 'gap' for your prosthesis, they need your informed financial consent. Please contact us for further details.
A membership may be suspended when travelling overseas for work or leisure. If you are travelling overseas, you may choose to suspend your membership during this period of time. You can suspend your cover for the following period of time:
On select levels of extras cover, if you're travelling for essential medical or hospital treatment because treatment you need cannot be provided by your own doctor, we will help cover the cost when the total return distance is 300 kilometres or more from your normal place of residence.
We also give a benefit towards your overnight accommodation outside of hospital for you and a caregiver. Check your extras cover to determine if you are covered for these benefits.
A waiting period is the time between when you joined us and when you are covered for a service or treatment. If you receive a service or treatment during this time, you are not eligible to receive a benefit payment from us, regardless of when you submit the claim. Different waiting periods apply for different services.
