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Glossary

Please refer to the Important Information (PDF, 339Kb) and our Fund Rules (PDF 179Kb) for more information and to see how these definitions may apply to you.

Overseas Visitors can find more information http://www.bupa.com.au/visitors-info or in our overseas working visitors rules (PDF, 462 KB) or overseas non-working visitors rules (PDF, 444 KB).

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

A

Accident

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 occurred in Australia, which requires, within 72 hours of the event, medical advice or treatment from a registered practitioner other than the policy holder and, if necessary, any further medical treatment where such admission (including any readmission) or treatment must be within 180 days of the event.

Annual maximum

See 'yearly limit'.

Australian Government Rebate on private health insurance

A means tested rebate that can reduce the cost of health insurance.

Australian Medical Association (AMA)

A group representing and protecting the rights of registered doctors and medical students in Australia.

AMA fee

See the schedule of medical fees published by the Australian Medical Association (AMA).

B

Benefit

The amount you’ll get back when you claim for a recognised service.

Benefit Bonus

A loyalty feature rewarding members for continuous time on Silver, Gold & Platinum Extras. Benefits increase 2% every year, to a maximum of 10%.

Bupa Medical Gap Scheme

An arrangement between Bupa and medical providers giving you certainty of what you will pay. It can help reduce or eliminate your out-of-pocket medical costs. The provider bills us directly and if there is a gap, the provider will ask you for payment./p>

C

Complaint

A complaint as defined by the Australian Complaint Handling Standard ISO AS 10002-2014 is an "expression of dissatisfaction made to or about an organisation, related to its products, services, staff or the handling of a complaint, where a response or resolution is explicitly or implicitly expected or legally required"

Complainant

A person who makes a complaint about any of Bupa’s products or services.

Co-payment

If your cover has a co-payment, this is the amount you agree to pay each day towards the cost of your hospital stay, for up to five days.

Cosmetic Surgery (from 1 July)

A cosmetic treatment is one which is concerned with altering the appearance of a body part or tissue which lies within the bounds of normal variation.

Examples of Cosmetic Surgery:

  • Rhinoplasty (nose reconstruction) without previous trauma or congenital defect
  • Breast enlargement
  • Liposuction

D

Day surgery/facility

A place you are admitted for treatment (eg private hospital) when you’re admitted and discharged on the same day.

E

Emergency

A serious and unexpected situation requiring immediate action.

Excess

An excess is a one-off payment you make each calendar year if you need to go to hospital. You need to pay this before you are admitted to hospital and before we will cover the rest of the hospital costs that your policy includes. You will have agreed on what this amount is when you chose your level of cover and can find it on your product information sheet, available by logging in to myBupa.

An excess is paid once per person and not paid again by the same person, even if you change to a new Bupa cover in that same calendar year, unless you increase your new cover to a cover that has a larger excess than what you paid previously. In that case, you’d only pay the difference between the smaller and higher excess if you were to be admitted to hospital again that year. Other conditions apply.

Exclusions

Things you can’t claim for because they’re not included in your cover.

Extras cover

Also called 'ancillary' cover, it's for non-hospital services that Medicare may not pay a benefit for – eg dental, optical, physio.

F

Family in-hospital benefit

A benefit to help cover meals and accommodation (provided by and in the hospital) for a relative or carer when they need to stay in hospital with you.

Fixed fee

A daily fee a small number of Network hospitals will charge, which you’ll have to pay. It’s different (and in addition) to a co-payment or excess.

Fund Rules

Means the Fund Rules of Bupa Australia Pty Ltd which you agree to upon taking out a health insurance policy with us. They are available at on this website at Bupa fund rules (PDF, 1.8mb)

G

Gap

The amount you need to pay when your treatment costs are higher than Medicare and/or your cover allows.

H

Hospital cover

Covering your costs when you’re admitted to hospital, including benefits for prosthesis and medical services provided during your hospital stay.

I

Informed Financial Consent

The written approval a provider should get from you on any out-of-pocket costs before your treatment.

Inpatient

You’re an inpatient when you’ve been formally admitted to hospital (does not include treatment in a hospital emergency department).

L

Lifetime Health Cover (LHC)

Lifetime Health Cover loading is paid when you don’t take out hospital cover before 1 July following your 31st birthday – it goes up 2% a year, to a maximum of 70%. Any loading that applies will be removed after you’ve held hospital cover continuously for 10 years.

Lifetime limit

The total amount you can claim on a service in your lifetime.

Loyalty maximums

After your first year of membership, we increase how much you can claim for most extras services by a set percentage or amount.

M

Medical cover

Cover for medical services provided by surgeons and specialists during a hospital stay including diagnostics services such as pathology and radiology.

Medical gap bonus

A dollar bonus available on Ultimate Health Cover & Ultimate Corporate Health Cover that we give you each year, accumulating to help pay for any in-hospital medical gaps.

Medicare Benefits Schedule (MBS)

Set benefits for specified medical services that the Government will pay for through Medicare.

Medicare

Australia’s public healthcare system for all citizens and most permanent residents. It provides free or subsidised cover for certain healthcare services.

Medicare Levy Surcharge (MLS)

A surcharge that applies to people earning over a certain income when an appropriate level of hospital cover is not held.

Member Exclusives

A selection of offers and discounts you receive as a Bupa member.

Members First

There are both Members First Hospital providers and Members First Extras providers. Read more.

Members First - Extras

Our network of dental, optical, physiotherapy and chiropractic practitioners who provide most services at a set price to members (sometimes with no out-of-pocket costs). Read more.

Members First – Hospitals & Day Facilities

Private hospitals that Bupa has arrangements with to provide treatment for members with some additional benefits like the private room offer and maternity care package (where applicable).

Members First day facilities are private hospitals that guarantee you will have no hospital or medical out of pocket costs (apart from any co-payment or excess). Read more (PDF, 300Kb).

Minimum benefit

A low benefit payable on some hospital services that is likely to result in you having large out-of-pocket costs.

N

Natural therapies

Alternative treatments that we cover, including acupuncture, naturopathy and remedial massage.

Network hospitals

Private hospitals that Bupa has arrangements with, to make sure in most cases you’re covered for hospital costs. Read more (PDF, 300Kb).

O

Obesity related procedures and surgeries (from 1 April)

Obesity and metabolic related services that you need to be admitted to hospital for. This includes Gastric Banding, Gastric Sleeve, Gastric Bypass, Gastric Balloon, and other weight loss related procedures. Check with your doctor if your planned procedure or surgery is obesity and/or metabolic related.

Out-of-pocket

The difference you have to pay between the Bupa benefit and what is charged by a provider.

Out-patient

Treatment when you're not admitted to hospital (eg emergency room treatment, specialist or GP consults).

P

Packaged cover

Both extras and hospital cover.

Pre-existing conditions

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.

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 doctor's opinion on the signs and symptoms of your condition, but is not bound to agree with them.

Pregnancy and birth related services

How these services are defined and how you’re covered for them varies depending on the type of cover you hold.

Cover for people with Medicare

Hospital cover for pregnancy and birth related services relates to services and treatment provided for the care of women when admitted to hospital during pregnancy, the delivery of your baby and following delivery. Any treatment or services that you are not admitted to hospital for, like consultations with your obstetrician, are not part of hospital cover. To manage conditions such as ectopic pregnancy, termination, and miscarriage you may need gynaecological services, which have a 2 month waiting period.

Fertility services that aim to help you conceive are ‘IVF and Assisted Reproductive Services’, so they are not considered to be pregnancy and birth related services.

Cover for Overseas Visitors

Your cover for pregnancy and birth related services relates to services and treatment provided for the care of women during pregnancy, the delivery of your baby and following delivery.

Any treatment or services that you are not admitted to hospital for, like consultations with your obstetrician, are part of out-patient medical cover.

To manage conditions such as ectopic pregnancy, termination, and miscarriage, you may need gynaecological services, which have a 2 month waiting period.

Fertility services that aim to help you conceive are 'IVF and Assisted Reproductive Services', so they are not considered to be pregnancy and birth related services.

This definition does not apply to Overseas Students.

Private Health Insurance

An insurance product for which a premium is paid to provide hospital cover outside of the public system and /or cover for services not covered by Medicare such as physiotherapy, optometry, general dental and podiatry services.

Private Room

Private Room means, for the purposes of a private room in a public hospital, a room in a hospital which:

(a) is purpose built and suitable for no one other than a single admitted adult patient;
(b) holds one single sized bed; and
(c) has a dedicated ensuite.

Provider

A doctor, hospital, healthcare professional or healthcare facility that provides a service to you (the patient).

R

Reconstructive Surgery

Surgery to restore function or typical appearance by reconstructing defective organs or parts. The reason for the surgery is what's important. It would usually follow a previous medically necessary surgery, a traumatic event that caused a change in the appearance and/or function of a part of the body or a significant congenital problem (something you were born with), that created problems with how your body works. For example, after a mastectomy for breast cancer, there may be a desire to reconstruct the breast back to an acceptable appearance for you, whereas changing the appearance of the breast for most other reasons would be cosmetic in nature and intent.

Other examples of 'Reconstructive Surgery':

  • Repairing a scar resulting from an accident or previous surgery (unless it was cosmetic surgery)
  • Facial reconstructive surgery following severe trauma, cancer surgery or a major congenital problem (from birth)
  • Repairing a body part after a trauma injury

Restricted Cover (from 1 April)

This definition varies depending on the type of cover you hold.

Cover for visitors on non-working visas (except Guardian Plus Cover)

If a treatment is listed on your product sheet as having ‘restricted cover’, we will only pay a certain amount set by the Australian Government for Australian residents, called the ‘minimum benefit’. This means, if you go to a public or a private hospital for these treatments, most of the time, the hospital will charge a lot more than what we pay, so you are likely to have a large amount to pay yourself.

Restricted cover applies for both new health insurance members, or members transferring funds.

Guardian Plus Cover

If a treatment is listed on your product sheet as having restricted cover, we will only pay a certain amount set by the State Government, called the ‘minimum benefit’. This means, if you go to a public or a private hospital for these treatments, most of the time, the hospital will charge a lot more than what we pay, so you are likely to have a large amount to pay yourself.

Restricted cover applies for both new health insurance members or members transferring funds.

Cover for people with Medicare

If a treatment is listed on your product sheet as having ‘restricted cover’, we will only pay a certain amount set by the Australian Government, called the ‘minimum benefit’. If you go to a public hospital for these treatments, in most instances, you’d be covered in a shared room, but you may have an amount to pay yourself. A private hospital may charge even more, so you’d probably have a significant amount to pay yourself.

Cover for Laser Eye Surgery (from 1 July)

For Laser Eye Surgery, restricted cover means that wherever you go for treatment, you would be likely to have a large out of pocket expense, as we will only pay the band 1 minimum benefit that applies to a same day admission in a private hospital.

Restricted Cover Period (from 1 April)

A Restricted Cover Period is a period of time during which you have Restricted Cover for a treatment. The Restricted Cover Period starts at the same time as the Waiting Period. Therefore, you won’t be covered during the Waiting Period, but will have Restricted Cover for the remainder of the Restricted Cover Period.

S

Service

Any treatment given to you by a provider who is recognised by Bupa (this is a provider who has met Bupa’s recognition criteria).

Service limit

The maximum number of times you can use a service and receive benefits from us.

Set benefits

A set amount you’ll get back for treatment from a provider outside of the Members First ancillary network.

Schedule fee

See Medicare Benefits Schedule (MBS) published by Medicare.

T

Top-up bonus

A dollar bonus we give you each year to help pay for any 'extras' gaps.

Y

Yearly limit

The maximum you can claim in a calendar year, depending on your cover. Sometimes referred to as an 'annual maximum'.

W

Waiting periods

A period of time where you won’t receive any benefits from us for treatment received.

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