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Understanding your health cover

Here you will find information to help you understand how your health cover with us works. You can also access this information online at bupa.com.au/info (PDF, 189Kb) or view our online glossary at bupa.com.au/glossary.

You should also refer to our Fund Rules, PDF 179kb, or for more detail, see the full text, PDF 3Mb), or by calling us, for the full terms and conditions of your cover. The information below applies in addition to our Fund Rules.

Understanding your hospital cover

What is covered?

In hospital

With private hospital cover, you can choose to be treated as a private patient in either a public or a private hospital. To access more information please see our going to hospital guide.

What if I am treated in a Members First or Network Hospital?

With us you are fully covered as a private patient in most hospitals that Bupa has an agreement with, known as Members First and Network hospitals across Australia for any treatment which is recognised by Medicare and is not either restricted or excluded under your cover.

A small number of these hospitals may charge a fixed daily fee. This fee is capped at a maximum number of days for overnight stays. The hospital should inform you of this fee when you make a booking. This fee is in addition to any excess or co-payment you may have as part of your hospital cover.

At Members First Day Hospitals, you have the added benefit of no medical gaps in addition to being covered for hospital costs, provided the treatment is recognised by Medicare and there are no exclusions or restrictions on your level of cover.#

When admitted to hospital, in most cases you will be covered for all in-hospital charges when provided as part of your in-hospital treatment including:

  • accommodation for overnight or same-day stays
  • operating theatre, intensive care and labour ward fees
  • supplied pharmaceuticals approved by the Pharmaceutical Benefits Scheme
  • allied health services including physiotherapy, occupational therapy and dietetics
  • dressings and other consumables
  • pathology and radiology diagnostic tests recognised by Medicare and performed in hospital by Bupa contracted providers
  • surgically implanted prostheses up to the approved benefits in the Government’s Prostheses List
  • private room where available.

We recommend you call us first before making a booking to confirm that your hospital of choice gives you certainty of full cover. We can also discuss any excess or co-payment that may be applicable to your level of cover. You can find out if a hospital has an agreement with us by checking bupa.com.au/find-a-provider.

Can I choose to be treated as a private patient in a public hospital or at a private hospital that Bupa does not have an agreement with?

With us, if you elect to be treated as a private patient in a public hospital or are admitted to a private hospital that Bupa does not have an agreement with, you are covered as set out in the following pages for any treatment recognised by Medicare unless it is excluded or restricted under your cover. In these circumstances, you are likely to incur out-of-pocket expenses for your hospital costs.

What happens if I choose a private hospital that Bupa doesn’t have an agreement with?

If you are admitted to a private hospital that Bupa does not have an agreement with, we will pay shared room minimum benefits and benefits for prostheses up to the benefit in the Government Prostheses List. This will apply for any treatment recognised by Medicare, unless it is excluded or restricted under your cover. These benefits will only partially cover the full cost and you will have significant out-of-pocket expenses.

It is important to note that you will be responsible for the cost of your stay and may be charged directly for your hospital accommodation, doctor’s services (including any diagnostic tests), surgically implanted prostheses (such as artificial hips) and personal expenses such as TV hire and telephone calls. Some of these hospitals bill Bupa directly for the limited benefits we pay. Please also refer to the Medical Costs section of this brochure.

What happens if I choose to be a private patient in a public hospital?

As a private patient in a public hospital you are entitled to choose your doctor, if they are available. Depending on your illness or condition, this may be the same doctor who would have been allocated to you by the hospital as a public patient.

If you elect to be treated as a private patient in a public hospital, we will pay shared room minimum benefits and benefits for prostheses up to the benefit in the Government Prostheses List. This will apply for any treatment recognised by Medicare unless it is excluded or restricted under your cover.

If you choose to stay in a private room for an overnight stay, Bupa will pay a fixed benefit towards the cost of your stay. If this benefit is less than the hospital charge, the hospital should let you know what out of pocket expenses you will have to pay.

It is important to note that in public hospitals, private rooms are generally allocated to people who medically need them.

You will also be responsible for personal expenses such as TV hire and telephone calls and any prostheses charges above the benefit in the Government Prostheses List. Please also refer to the Medical Costs section of this brochure.

To ensure peace of mind, ask your doctor about their fees and whether they participate in our Medical Gap Scheme for your hospital treatment prior to admission. Remember to also ask your doctor about the fees for other practitioners that may be involved in your hospital treatment such as: the anaesthetist and assistant surgeons.

Medical costs

These are the fees charged by a doctor, surgeon, anaesthetist or other specialist for any treatment given when you are in hospital. You are covered for the cost of these medical treatments up to the Medicare Benefit Schedule (MBS) fee. The MBS fee is the amount set by the Federal Government for each medical service covered by Medicare. You must be eligible for Medicare in order to be covered up to the MBS fee.

How benefit is calculated

If you choose to be treated as a private patient in a hospital (public or private), Medicare will cover you for 75% of the MBS fee for associated medical costs and we will cover the remaining 25%.

Medical Gap

If your specialist charges more than the Medicare Benefit Scheme fee there will be a ‘gap’ for you to pay. However, Bupa Medical Gap Scheme can help eliminate or reduce the gap for you if your doctor/s choose to use it. You should talk to your doctor about using the Bupa Medical Scheme.

Through the Bupa Medical Gap scheme we have arrangements that assist with reducing or eliminating out of pocket expenses associated with costs of medical treatments and doctor's fees with hospital treatments.

Medical Costs and your choice of network

If you are treated in a Members First day facility, there are no out-of-pocket expenses for medical treatments (eg your specialist’s fees). Any co-payment or excess related to your level of cover will still apply.

We are also partnered with Genesis Heart Care, a network of cardiologists across VIC, QLD, SA and WA that focus on providing quality, evidence based cardiology services. When you see a cardiologist from Genesis Heart Care you will have certainty of no out-of-pocket expenses for your in-hospital cardiologist treatment. You’ll also be provided with information and advice so you can make informed decisions about your treatment and lifestyle.

What is not covered?

Hospital costs

Situations when you will not be covered include:

  • when you have not been admitted into a hospital and are treated as an outpatient (eg emergency room treatment, outpatient antenatal consultations with an obstetrician)
  • during a waiting period
  • when a service is excluded from your cover
  • when a service is covered as a minimum benefit and you are admitted to a private hospital, you will not be covered above the minimum benefit
  • for the fixed fee charged by a fixed fee hospital or a hospital that has a fixed fee service
  • for psychiatric and rehabilitation day programs, at a hospital Bupa does not have an agreement with
  • hospital treatment provided by a practitioner not authorised by a hospital to provide that treatment
  • hospital treatment for which Medicare pays no benefit, including: medical costs related to surgical podiatry (including the fees charged by the podiatric surgeon); cosmetic surgery where not clinically necessary; respite care; experimental treatment and/or any treatment/procedure not approved by the Medical Services Advisory Committee (MSAC)
  • personal expenses such as: pay TV, internet access, non-local phone calls, newspapers, boarder fees, meals ordered for your visitors, hairdressing and any other personal expenses charged to you unless included in your cover
  • if you are in hospital for more than 35 days and you have been classified as a ‘nursing home type’ patient. (In this situation you may receive limited benefits and be required to make a personal contribution towards the cost of your care)
  • if you choose to use your own allied health provider rather than the hospital’s practitioner for services that form part of your in-hospital treatment (eg chiropractors, dieticians or psychologists)
  • where compensation, damages or benefits may be claimed by another source (eg workers compensation)
  • for any amount charged by a public or non-agreement hospital which is not covered by us or which is above the benefit that we pay
  • for any treatment or service provided outside Australia
  • for some non-PBS, high cost drugs
  • for pharmacy items not opened at the point of leaving the hospital.

What is not covered?

Medical costs

You will not be covered for medical services for surgical procedures performed by a dentist, surgical podiatrist, or any other practitioner or service that is not eligible for a rebate through Medicare.

Inpatient vs outpatient

If you are admitted as a private inpatient, you will be covered for the services listed in your chosen level of hospital cover.

If you receive treatment as an out-patient, the Commonwealth Government sets a fee for each medical service which is described in the Medicare Benefits Schedule (MBS). Medicare pays 85% of the MBS fee for most out-patient services (services outside hospital such as consultations, minor procedures, x-rays, etc). There is an exception for general practitioner consultations, where Medicare pays 100% of the MBS Fee.

The doctor can choose whether to bulk bill or not for the outpatient services:

  • If the doctor chooses to bulk bill, there is no out of pocket expense for the patient. In this case, the doctor accepts the Medicare benefit of 85% or 100% as full payment
  • If the doctor does not bulk bill, the patient is responsible for any charges over the Medicare benefit
  • Families and individuals also have access to the Medicare Safety Net benefit. This benefit is for those that have large out of pocket costs for out-patient services. Once the relevant threshold is met, the Medicare benefit increases. For further information please go to: Medicare Safety Net.

Waiting periods

The following waiting periods apply for hospital cover:

  • laser eye surgery, (only covered on the Ultimate Corporate Health Cover) – 12 months
  • palliative care, psychiatric and rehabilitation services – two months
  • pre-existing conditions, ailments or illnesses and pregnancy (including childbirth) – 12 months
  • all other treatments included in your cover – two months.

When to contact us

If you have been a Bupa member for less than 12 months on your current hospital cover, it is important to contact us before you are admitted to hospital and find out whether the pre-existing condition waiting period applies to you. We need about five working days to make the pre-existing condition assessment, subject to the timely receipt of information from your treating medical practitioner/s. Make sure you allow for this timeframe when you agree to a hospital admission date.

If you proceed with the admission without confirming benefit entitlements and we (the health fund) subsequently determine your condition to be pre-existing, you will be required to pay all hospital charges and medical charges not covered by Medicare.

Planning for a baby

If you are thinking about starting a family we recommend that you contact us to check whether your current level of cover includes pregnancy in advance. This is because a 12-month waiting period applies to pregnancy (including childbirth) and assisted reproductive services.

No waiting periods will apply to the newborn provided they have been added to the appropriate family hospital cover within two months of their birth.

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Understanding your extras cover

What is covered?

With extras cover, you can claim benefits for those services listed on your cover and that are not claimable elsewhere (eg from a third party like Medicare).

For example, Medicare does not provide benefits for:

  • most dental examinations and treatment
  • most physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic services, podiatry or psychology services
  • acupuncture (unless part of a doctor’s consultation) or other natural therapies
  • glasses and contact lenses
  • most health aids and appliances
  • home nursing.

Extras cover allows you to claim benefits for extras services as long as:

  • the treatment is given by a private practice provider who is recognised and registered with us for benefit purposes
  • they meet the criteria set out in our Policy and Fund Rules.

We recommend you contact us before making a booking to confirm how much you can claim and to check that your chosen provider is registered with us.

What is not covered?

Extras benefits will not be payable:

  • during a waiting period
  • where a third party, including Medicare, a Government body, or an insurance company provided a benefit (except for hearing aids and breast prosthesis items)
  • for different services within the same service type from the same provider on the same day. For example, if you went to see an acupuncturist and then received a massage from the same provider on the same day, you cannot claim for both services.
  • when a prescribed treatment for orthotics or surgical shoes is not custom made
  • when a provider is not recognised by us for benefit purposes
  • for any treatment or service rendered outside Australia
  • when you have reached the maximums on your product including annual, lifetime or service limits for the service you are claiming.

Waiting periods

The following waiting periods apply for extras cover:

  • initial waiting period – two months
  • hire, repair and maintenance of health aids and appliances; and Living Well Programs – six months
  • major dental, orthodontics, selected health aids and appliances – 12 months.
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Understanding your ambulance cover

Emergency Ambulance definition

When you take out our hospital cover, extras cover or packaged cover, you will receive cover for recognised emergency ambulance transport and on-the-spot treatment. This is capped at one emergency service each calendar year for a singles membership and two for a couples/families membership.

Please Note: Corporate Hospital Cover levels 1, 2 & 3 and Mining and Resources Health Cover levels 1 & 2 offer uncapped emergency ambulance transportation.

An emergency is when there is reason to believe that the patient’s life may be in danger or the patient should be attended to without undue delay.

Transportation means a journey from the place where immediate medical treatment is sought to the casualty department of a receiving hospital.

Emergency ambulance transportation is defined as air or road transportation by a Recognised Ambulance Provider of an unplanned and of a non-routine nature for the purpose of providing immediate medical attention to a person.

Whether the transportation is deemed an emergency is determined by the paramedic and usually recorded on the account.

Benefits are not payable for:

  • transportation from a hospital to your home
  • transportation from a hospital to a nursing home
  • transportation from a hospital to another hospital where the customer has been admitted to the transferring (first) hospital
  • transportation from the person’s home, a nursing home or hospital for ongoing medical treatment, (eg chemotherapy, dialysis).

Ambulance Cover

We recommend that you take out an ambulance subscription with your recognised State Ambulance Provider if it’s available in your state (VIC, SA, NT and rural postcodes in WA).

We will only provide ambulance benefits, in accordance with your level of cover, when you do not hold a subscription with an ambulance provider and a state ambulance scheme does not provide cover.

NSW and ACT members: If you reside in New South Wales or the Australian Capital Territory and you have hospital cover, you pay an ambulance levy as part of your premium. This entitles you to free emergency ambulance transport under the State Government ambulance transport schemes. When you receive an account for ambulance transport, simply send it to us and we’ll endorse it for you to send back to the appropriate ambulance transport scheme.

QLD and TAS members: If you reside in Queensland or Tasmania, you are covered under your state service scheme.

VIC, SA, WA and NT members: If you reside in Victoria, South Australia, Western Australia or the Northern Territory you will receive cover for recognised emergency ambulance transport and on-the-spot treatment from us. This is as long as you don’t have an ambulance subscription with your state ambulance service or cover through a state-based arrangement.

Most state schemes cover their respective residents within their state of residence only. However, some states have entered into reciprocal agreements that allow you to be covered for ambulance services when you travel outside your state of residence. You should check with your state ambulance provider for when these reciprocal arrangements apply and the level of cover offered.

If you fall outside your state-based arrangement (including any reciprocal agreement) and are not covered for emergency ambulance services, you will be covered by Bupa up to the annual cap, as long as your level of cover contains ambulance cover and the services are provided by a recognised provider.

Recognised Ambulance Providers

Bupa will only pay benefits towards ambulance services when they are provided by any of the following recognised providers:

  • ACT Ambulance Service
  • Ambulance Service of NSW
  • Ambulance Victoria
  • Queensland Ambulance Service
  • South Australia Ambulance Service
  • St John Ambulance Service NT
  • St John Ambulance Service WA
  • Tasmanian Ambulance Service.

Certain types of concession cards issued by Centrelink or the Department of Veterans Affairs (DVA) entitle the cardholders to free ambulance services. These arrangements also vary per state so should be checked directly with Centrelink or the DVA.

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Changing your cover

Switching from another health fund

If you’re changing from another Australian health fund to Bupa, you’ll continue to be covered for all benefit entitlements that you had on your previous cover, as long as these services are offered on your new cover with us. This is referred to as ‘continuity of cover’. To receive continuity of cover, you’ll need to transfer to us within 60 days of leaving your previous fund and ensure that Bupa has received your clearance certificate (which can be requested from your previous fund).

When changing health funds, extras benefits paid by your previous fund will be counted towards your yearly limits in your first year of membership with us. Any benefits paid by your previous fund also count towards lifetime limits. It’s important to note that when you change to Bupa from another fund you may need to wait before you can access your new benefits. In this situation, your benefit entitlements are based on our nearest equivalent cover to what you previously held.

Where your new cover is higher than the cover you held with your previous fund, the lower benefit (including different excess levels) will apply for the waiting period relevant for that service. Please refer to the listed waiting periods included under the Understanding Your Extras Cover and Understanding Your Hospital Cover sections.

If you choose a lower level of cover than you held previously, then the lower benefits on your new cover will apply immediately. This may include a different excess level or minimum benefits. You may also need to serve waiting periods for services or treatments that weren’t covered on your previous cover. In this case you won’t be covered during the waiting period.

Changing your cover with us

If you change your health cover, you may need to wait before you can access your new benefits. Where your new level of cover is higher than what you previously held, the lower level of benefit applies. Please refer to the listed waiting periods included under the Understanding Your Extras Cover and Understanding Your Hospital Cover sections.

During this time you will be covered, however you will receive the lower benefits of the two covers (this includes any applicable excess).

If you choose a lower level of cover than you previously held, then the lower benefits on your new cover will apply immediately and may include different excess levels or minimum benefits. You may also need to serve waiting periods for services or treatments that weren’t covered on your previous cover. In this case you won’t be covered during the waiting period.

If you have any questions about transfers or waiting periods, just contact us.

Ending your membership

We have the right to end a person’s membership as set out in our Fund Rules, including where premiums have not been paid or on notice at the reasonable discretion of Bupa.

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Definitions

For definitions please see the Glossary.

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Other important information

Direct Debit Service Agreement

If you’ve chosen to pay your premiums by direct debit then you’ve accepted the terms of our Direct Debit Service Agreement.

This agreement outlines the responsibilities of Bupa Australia Pty Ltd (“we”, “us”, our”) and you. We will confirm the direct debit arrangements prior to the first drawing (including the premium amount and frequency) and debit your nominated account. Deductions will occur on the nominated day, except for deductions nominated for the 28th, 29th, 30th or 31st, which will occur on the first day of the following month.

If the nominated day falls on a weekend or public holiday, deductions will be made on the closest business day. We will debit all payments in advance and will automatically vary the deduction amount if your premiums or level of cover change. If we vary the deduction amount, we will give you at least 14 days written notice, except when the previous deduction is dishonoured, when we will deduct the previous period’s payment together with the current amount due.

If you pay premiums at three, six, and 12 month intervals, then should your financial institution dishonour a drawing, we will draw the payment on the nominated day of the following month. If two or more drawings are returned unpaid by your financial institution, we will also stop deducting your premiums from your nominated account and will start sending you renewal notices, pending further instructions from you.

We will maintain the privacy and confidentiality of your billing information (unless you have requested or consented that we can disclose it to a third party or the law requires or allows us to do so). We may provide information to our or your financial institution to resolve a dispute on your behalf. You must ensure your nominated account permits direct debiting and that sufficient cleared funds are available in that account on the due date to cover the premiums due. Your financial institution may charge a fee if the payment cannot be met.

You must ensure the authorisation given to draw on the nominated account is identical to the account signing instruction held by the financial institution where the account is based. You must notify us if the nominated account is transferred or closed. You must pay your premium by an alternative method if either you or we cancel the direct debit arrangements. You must ensure your payments are up-to-date, whether a notice is received from us or not.

If paying by credit card, you need to advise us of your new expiry date prior to expiry. You may request that we cancel or alter the debit drawing arrangements by contacting us and providing at least five working days notice of any requested changes. These changes may include deferring the debit, altering the debit dates, stopping an individual debit, suspending the direct debit arrangement or cancelling the direct debit completely.

You can dispute any debit drawing or terminate the deductions at any time by notifying us in writing not less than seven days before the next scheduled debit drawing. If you have any queries about your direct debit agreement, please contact us.

We undertake to respond to queries concerning disputed transactions within five working days of notification.

Privacy and your personal information

Your privacy is important to Bupa. This statement summarises how we handle your personal information. For further information about our information handling practices or our complaints handling process, please refer to our Information Handling Policy (Pdf, 182Kb),or by calling us on 134 135. When you join, you agree to the handling of your personal information as set out here and in our Information Handling Policy (Pdf, 182Kb).

We will only collect personal information that we require to provide, manage and administer our products and services and to operate an efficient and sustainable business.

We are required to collect certain information from you to comply with the Private Health Insurance Act 2007 (Cth). We may also collect information about you from health service providers for the purposes of administering or verifying any claim, and from your employer, broker or agent if you are on a corporate health plan or have joined through a broker or agent. We may disclose your personal Private Health Insurance Code of Conduct. The Private Health Insurance Code of Conduct (the Code) was developed by the private health insurance industry and it aims to enhance the standards of practice and service throughout the industry.

As a signatory to the Code, we undertake to do a number of things that will benefit you as a member. These include:

  • working to enhance our service standards
  • providing information to you in plain language
  • helping you make better informed decisions about our products
  • letting you know how to resolve any concerns that you may have
  • protecting the privacy of your information in line with the privacy legislation and our Information Handling policy.

We’re proud to be a signatory to the Code and we are committed to continually reviewing our operations to ensure compliance. A copy of the Code is available online at bupa.com.au/code-of-conduct information to our related entities, and to third parties including healthcare providers, government and regulatory bodies, other private health insurers, and any persons or entities engaged by us or acting on our behalf. If we send your information outside of Australia, we will require that the recipient of the information complies with privacy laws and contractual obligations to maintain the security of the data.

If you are on a corporate health plan, we may disclose your information to your employer to verify your eligibility to be on that corporate plan. The policy holder is responsible for ensuring that each person on their policy is aware that we handle their personal information as set out here and in our Information Handling Policy. Each person on a policy aged 17 or over may complete a ‘Keeping your personal information confidential’ form to specify who should receive information about their health claims. You are entitled to reasonable access to your personal information within a reasonable timeframe. We reserve the right to charge a fee for collating such information.

If you or any insured person does not consent to the way we handle personal information, or does not provide us with the information we require, we may be unable to provide you with our products and services.

We may use your personal (including health) information to contact you to advise you of health management programs, products and services. When you take out cover with us, you consent to us using your personal information to contact you (by phone, email, SMS or post) about products and services that may be of interest to you. If you do not wish to receive this information, you may opt out by contacting us.

Can we help?

If you have any questions we’re always happy to help. Simply refer to the back cover for our contact details and call us, or pop by your local centre. If you would like more information about our Fund Rules or the Federal Government’s Private Health Insurance Industry Code of Conduct, you can find this information on our website. The Federal Government’s Private Patient’s Hospital Charter is available at privatehealth.gov.au.

Resolution of problems

If you have any concerns or you don’t understand a decision we have made, we’d like to hear from you.

You can contact us by:
Telephone: 1800 802 386
Fax: 1300 662 081
Email: customerrelations@bupa.com.au
Mail: Customer Relations Manager Bupa Australia
PO Box 14639
Melbourne VIC 8001

If you’re still not satisfied with your outcomes from Bupa you may contact the Private Health Insurance Ombudsman on 1800 640 695 or visit them at privatehealth.gov.au

Private Health Insurance Code of Conduct

The Private Health Insurance Code of Conduct (the Code) was developed by the private health insurance industry and it aims to enhance the standards of practice and service throughout the industry.

As a signatory to the Code, we undertake to do a number of things that will benefit you as a member. These include:

  • working to enhance our service standards
  • providing information to you in plain language
  • helping you make better informed decisions about our products
  • letting you know how to resolve any concerns that you may have
  • protecting the privacy of your information in line with the privacy legislation and our Information Handling policy.

We’re proud to be a signatory to the Code and we are committed to continually reviewing our operations to ensure compliance.

A copy of the Code is available at bupa.com.au/code-of-conduct.

Code of Conduct

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