Policy Terms & Conditions

Accident

An Accident is an event leading to bodily injury caused solely and directly by violent, accidental, external and visible means and resulting solely, directly and independently of any other cause.

Accident Cover

Where included in your level of Extras Cover, Accident Cover provides you with benefits up to $2,000 per person ($4,000 per family) per Accident, further limited to $2,000 per person (maximum $4,000 per family) per annum, towards certain costs of an Accident. Benefits are only available for treatment required as a result of an Accident, where the Accident results in urgent hospital attention as soon as practicable after the Accident.

Accident Cover is only available to pay any Co-payment or Excess on your hospital cover from the Fund or after the payment of any extras benefits from the Fund, to top up any Limits you have on your Extras Cover. It cannot be used to pay for any other products or services for which the Fund does not normally pay benefits for (see ‘Benefits’). This benefit is not redeemable for cash. Refer also to ‘Compensation from a third party’.

Where the Accident results in you requiring a service which is an Excluded Service, under either Hospital Select Plus or Hospital Select Value, Accident Cover cannot be used to cover the cost of that service or to pay your Excess.

Benefits

The Fund will only pay benefits where:

• the waiting period for that service has been served
• services have been rendered in Australia by a Recognised Provider of the Fund
• a service or treatment is medically necessary and clinically relevant to the person on the policy receiving it
• any services are part of a course of treatment recognised by the Fund, eg treatment related to a diagnosed medical illness or condition
• a service has actually been rendered to a person on the policy in person, eg no benefit for telephone or Internet consultations or written reports
• a charge has been raised by a service provider for services or appliances recognised by the Fund for benefit purposes
• you have already paid the provider (if the charges are unpaid, any applicable benefits will be made payable directly to the provider)
• the treatment or service is covered by your chosen level of cover
• you have met all the conditions of your level of cover
• no benefit is payable from another source
• for extras services for which you have not made a claim against Medicare for the service.

The amount of benefit will be calculated at the date of service/ purchase and on the cost of the treatment or appliance to you or anyone named on your policy, taking into account any allowances or discounts given by the provider. No benefit paid by the Fund can exceed the actual charge of the service or appliance.

Extras Cover benefits
These are normally provided for treatment that is part of a treatment plan recognised by the Fund. Examples of where the Fund will not provide benefits include: certain dental item numbers; supplements, herbs and lotions provided by alternative therapy providers; and certain types of products, e.g. bandages provided by a physiotherapist and hearing aid batteries. For more information, please refer to the Dental Guidelines, Health Management Aids and Appliances Guidelines, Optical Guidelines and Therapy Guidelines that can be viewed at an SGIC office.

Overpayments
If you are overpaid any benefit by the Fund or owe the Fund money, the Fund may recover (offset) that money from any payment you have made towards your premiums or otherwise, provided that the Fund gives you at least one months notice.

Hospital cover does not cover you for all treatments See ‘Hospital Treatment Charges’ for more information. Please note that, you will not receive benefits for: additional charges for luxury suites; services provided which are not of a medical nature (eg continued hospital accommodation for reasons other than medical); experimental treatment; cosmetic surgery; treatments not covered under Medicare (unless specifically covered in a hospital agreement); and some high cost drugs.

Changes to legislation

Changes to legislation may occur from time to time which may also affect your benefit entitlement or premiums. These changes may affect you immediately from the time the new laws become effective.

Changes to your circumstances

When your situation changes, it is your responsibility to notify the Fund. This means, for example, a new spouse or child may only be added onto a policy when you notify us to do so. They will then be subject to the usual waiting periods from that date. It is not possible to backdate this notification. When you change address or contact details, you must also notify the Fund to ensure you receive important notices and communications.

Compensation from a Third Party

If you have an Accident or are injured (eg in a motor vehicle accident or as a result of your employment) and have a right to receive compensation or damages from a third party, you are not eligible for benefits from the Fund (including future costs of treatment). This applies whether or not you pursue the claim and whether or not the Fund has made any payment. If you are in this situation, you may apply for provisional benefits, which will be paid if you meet the Fund’s requirements, but these must be paid back if you receive compensation.

Complaints

The Fund has procedures for you to easily voice concerns or to provide us with feedback. Simply talk to any member of our team on 133 234, who can address a wide range of issues on-the-spot. If necessary, a qualified team leader is always on hand to discuss your concerns and, if you are not happy with their response, they will pass on your concerns to the Contact Centre Manager. It is always our first aim to resolve our customers’ concerns directly with you. If you are not satisfied with our response to your concern, you can contact the Private Health Insurance Ombudsman on 1800 640 695. This is an independent, free service to address the concerns of all members of Australian health funds. It is funded by a levy paid by private health insurers.

Couple Policy

A Couple Policy includes only the Primary Policy Holder and his or her legally married or de facto spouse (living together on a bona fide domestic basis).

Dental

In some more complex cases, a general dental procedure may be considered major dental. Simpler ‘major dental’ procedures may be considered general dental. For orthodontic benefits, the treatment plan prepared by your Recognised Provider must be submitted to the Fund when making a claim. Different dental benefits are payable if the service is provided by a dental prosthetist or orthodontist. Contact the Fund if you wish to confirm whether your treatment is covered.

Dependant children

A dependant child means:

• any of a Primary Policy Holder’s or his or her spouse’s single children, as notified to the Fund, up to the age of 21 years
• a student dependant.

You may apply each year to have Student Dependant/s registered on your Family or Single Parent Family Policy.

Unless otherwise stated, a child includes adopted, foster, step-children and children over which you are granted guardianship by a court of law. (You will be required to provide evidence that such a child registered on your membership meets this description.)

Direct Debit Request Service Agreement

The Fund will confirm the details of the direct debit arrangements prior to the first drawing and directly debit the account you nominate. The Fund will make deductions on your nominated date of the month. If no date is nominated, deduction will occur on the fifth or the next business day. If the nominated day falls on a weekend or public holiday, deductions will be made on the next business day.

The Fund debits all premiums in advance and will automatically vary the deduction amount if the premium changes or the level of cover changes. The Fund will give not less than 14 days’ written notice should it vary the deduction amount, except when the previous deduction is dishonoured, when the Fund will deduct the previous period’s premium together with the current amount due. For customers who pay premiums at three, six and 12 monthly intervals, should your financial institution dishonour a drawing, the Fund will draw the payment on the nominated day of the following month.

The Fund will notify you if two or more drawings are returned unpaid by your financial institution and provide you with alternative payment options.

The Fund will assist you in the event of a dispute concerning any debit item drawn on the nominated account in compliance with the Industry’s Direct Debit Claims Process. The Fund will endeavour to resolve disputes with your bank or financial institution within industry-agreed time frames.

The Fund will keep all information pertaining to your nominated account at the financial institution private and confidential.

Information can be provided to the Fund’s or your financial institution to resolve a dispute on your behalf.

Customers’ rights and responsibilities

Customers may:

• request the Fund to alter the debit drawing arrangements (frequency, date and level of cover) at any time by contacting the Fund, and
• dispute any debit drawing or terminate the deductions at any time by notifying the Fund not less than seven days before the next scheduled debit drawing.

All enquiries, disputes, requests for payment changes or cancellation should be directed to the Fund.

It is your responsibility that:

• sufficient cleared funds are available in your nominated account on the due date
• the account you nominate permits direct debiting
• 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 notify the Fund if the nominated account is transferred or closed
• you pay your policy premium by an alternative method if the direct debit arrangements are cancelled either by you or the Fund and
• your premiums are up-to-date, whether a notice is received from the Fund or not.

Emergency Ambulance Transport

The Fund will pay a benefit for ambulance transport services only where the services are provided by an organisation recognised by the Fund or a State or Territory run ambulance service. Benefits are only available for emergency or casualty transportation where, in the opinion of a medical officer, a customer requires immediate medical treatment in circumstances where there is a serious threat to the customer’s life or health. Benefits are not payable for general transportation such as from a hospital to your home, nursing home or other hospital; transport for ongoing medical treatment; or where your State Government provides an ambulance benefit (eg Queensland and Tasmania).

Excess

An Excess is the amount you agree to pay per person each calendar year for Hospital Treatment Charges each time a person covered by your policy is admitted to hospital. The Excess is paid only once per person per calendar year, to a maximum of twice per policy for Couple, Single Parent Family or Family Policies. The Excess payable per person must be fully paid for that calendar year before any benefits from the Fund are payable for a hospital admission for that person. Any payment made by you for treatment which would not otherwise attract a benefit from the Fund ie personal items in hospital, will not be taken into account for the purposes of determining if the Excess has been paid in full. For Singles Policies, once the Excess has been paid in full in a calendar year you will not be required to pay any Excess for any further hospital admissions for that calendar year.

For Couple, Single Parent Family and Family Policies, once the Excess is paid in full in a calendar year for two people covered by the policy, no further Excess will be payable for any hospital admissions occurring during the same calendar year. No Excess is payable for hospital admissions for Dependant Children or Dependant Children registered on your policy under Family 25 if you hold the Fund’s Hospital Value product. Please note that reducing your Excess is considered to be upgrading your cover.

Family Policy

A Family Policy includes only the Primary Policy Holder and his or her legally married or de facto spouse (living together on a bona fide domestic basis) and any of their Dependant Children or Dependant Children registered on the policy under Family 25.

The ability to continue to cover your single children who are aged 21–24 years inclusive, who are not Student Dependants, is available on some levels of Family and Single Parent Family cover for an additional premium. Contact the Fund to find out more details.

Fund Rules and Rule Changes

Customers agree to be bound by any changes in the Fund Rules. These changes may come into effect on a date prior to the date you are paid up to, however, you are bound to the new rules from their effective date. The Fund may make any variation, cancellation or annulment of any of the Fund Rules at its discretion, subject to the relevant Ministerial approval.

Where practical, the Fund will give you 14 days notice of a premium change and between 14 days and two months notice of other changes that significantly reduce benefits. Such alteration may include an increase or reduction in premiums or scale of benefits, and includes the right to change policy conditions, amongst other things.

Health Management Aids and Appliances

Where benefits apply, any health management aids and appliances must be recognised for benefits by the Fund and be part of a treatment plan recognised by the Fund. Where service limits apply, they apply from the date of purchase.

Hospital Treatment Charges

Hospital Treatment Charges for eligible in-patient admissions are for accommodation, theatre, labour ward, intensive care, most surgically implanted government approved prostheses (a limited number of government-approved surgically implanted prostheses will attract a gap which customers will be required to pay), most pharmaceuticals that are directly related to the reason for your admission, the PBS patient contribution, physiotherapy and certain other therapies where they are part of the agreement with the hospital. It does not include any out-of-pocket expenses.

Lifetime Health Cover

The Federal Government has introduced Lifetime Health Cover (LHC) to encourage the uptake of private hospital cover. In general, to avoid the LHC loading, you need to take out Hospital Cover by the 30 June following your 31st birthday. Otherwise, for every year you delay joining hospital cover, your premiums will increase. In fact, you will pay a 2% higher loading on the base premium for every year you are aged over 30, up to a maximum of 70%.

By taking out Hospital Cover as soon as possible, you can stop the loading from increasing. It will be frozen at the rate that matches your age on the 1 July prior to the date you join (known as the Certified Age at Entry or CAE). As long as you maintain your Hospital Cover, your loading won’t increase each year. For example;

• Paul turned 31 on 7 June 2005. He purchased Hospital cover for the first time on 20 June 2005. On 1 July 2004, Paul’s CAE was 30, so he does not pay a loading on his premium.
• Kate turned 39 on 6 March 2005. She purchased Hospital cover for the first time on 10 June 2005. On 1 July 2004, Kate’s CAE was 38. Her loading will be 16%, which is a 2% loading for each year she is aged over 30 before she purchased Hospital Cover.

What if your Hospital Cover lapses?

LHC allows those who have locked in their CAE a limited number of days in their lifetime without Hospital Cover before the loading will be applied or increased. The number of cumulative days without Hospital Cover allowed before a LHC loading is applied is 1,094 (less than three years). If a person ceases their Hospital membership for three years or more, calculated over their insured lifetime, they will have to pay an additional 2% loading for each year of absence over and above the first two years of absence when they return to private Hospital Cover. This amount will be added to the loading which originally applied to them (if any) when they first took out Hospital Cover.

Policy holders who:

• have validly suspended their policy in accordance with the Fund Rules or
• are overseas (including Norfolk Island) for a continuous period of more than one year and have not returned to Australia for a period of more than 90 days

will not have that time count towards their permitted days without Hospital Cover.

When will the Loading be removed?

If you have held Hospital cover continuously for 10 years and paid an LHC loading, the loading will be removed. However, if you drop your cover after the loading has been removed and re-join at a later date, you will have the loading re-applied as though it had never been removed. If the period that you are absent from Hospital Cover totals more than 1,094 days (including any accumulated absence days) over your insured lifetime, an additional 2% loading is added for each year you were absent from Hospital Cover. The period of 10 years can be interrupted by permitted days without Hospital Cover; however the permitted days are not counted towards the 10 years.

Are there any exceptions?

Anyone born on or before 1 July 1934 has no LHC loading, except where their partner on the same policy is born after 1 July 1934. Other people may have different rules applied for LHC. These include:

• some refugees
• customers who hold or have held a Veteran’s Gold Card after 30/6/99
• Australian citizens and/or holders of permanent visas who were overseas for the whole of the period between 1/1/00 and 1/7/00 inclusive
• Australian citizens and holders of permanent visas who were overseas on 1/7/00 or were residents of another country on and after 1/7/00 and have not been back to Australia for a period of more than 90 days
• Australian citizens and holders of permanent visas who are absent from Australia on the day they turn 31 (provided this is after 1/1/00) and have not since returned to Australia for a period of 90 days or more
• members of the Australian Defence Force (including their dependants) on continuous, full-time service whose health services are provided by the Defence Force
• a person for whom health services are provided by the Australian Antarctic Division of the Department of Environment and Heritage
• migrants who became eligible for Medicare benefits after 30/9/99, and
• New Zealand citizens who became eligible for Medicare benefits after 30/9/99.

For further details regarding Lifetime Health Cover, please call 133 234.

Alternatively, you can visit the Australian Government Department of Health and Ageing website.

Non-Agreement Hospitals

The Fund cannot guarantee the amount that you will be covered for, for admissions to Non-Agreement Hospitals. Please call us on 133 234 to confirm your likely benefits.

Nursing Home Type Patients (NHTP)

Patients requiring longer-term hospitalisation of more than 35 days may be regarded as Nursing Home Type Patients (NHTP). In the absence of a valid Acute Care Certificate, NHTP will be required to make a personal contribution towards hospital charges, which may be significant. To prove that you are not a NHTP, the Fund will need a valid Acute Care Certificate (the Fund may refer to the Acute Care Advisory Committee for a ruling on its validity). NHTP receive only limited benefits from the Fund. These benefits are significantly lower than what some hospitals charge NHTP. An Excess applies to benefits payable. The Fund does not cover respite care.

Optical

Where benefits apply, they are only payable where the appliance or appliances are designed and manufactured with the sole purpose of correcting a refractive error or to cause image enhancement on the retina of the eye due to change of focal length caused by that appliance.

Partner authority

The Primary Policy Holder has the option to give their partner, as nominated on the application form, authority to have the same authority as the Primary Policy Holder in relation to the policy. This authority enables the partner to make claims on behalf of all people covered by the policy, to make changes to or enquire about:

• personal details, eg address, phone number
• level of cover
• payment method
• adding people to or deleting people from the policy
• cancelling the policy and requesting a refund of contributions, and
• to access the personal information of all people covered by the policy.

The Primary Policy Holder must tick the box on the application form at the time of joining. This information is recorded. The Fund will confirm Partner Authority before quoting details or processing any changes requested by the partner. Without Partner Authority, a partner is only permitted to sign for and receive claim benefits for themselves.

Payments And Your Policy

A person may not contribute to similar services with more than one fund, contribute to more than one level of a similar service with the Fund or contribute to any Fund cover unless they are eligible to be in Australia under Australian law.

Premiums must be paid in advance. An adjustment to your payment and/or ‘date paid to’ may be required following a premium increase, change to your level or scale of cover, change to the Fund’s Rules or change to Legislation (see Fund Rules and Rule changes). You will not be entitled to make a claim for any services provided after the date to which your policy has been paid. If, for any reason, payments fall behind by two months and one day, your policy will be cancelled effective the date you are paid up to. Customers who have had their Policy cancelled due to payment in arrears and who re-join will have to serve the normal waiting periods that apply to all new joins.

You must make payments for the entire ‘date paid to period’ period. Your ‘date paid to period’ period means the period corresponding with the ‘payment frequency’ chosen by you. Your ‘payment frequency’ is the period for which you choose to pay your premiums from the available options for your level of cover. For example, if you pay monthly you must pay for the entire month, and if you pay quarterly you must pay for the entire quarter. If you make a payment that is less than for the entire ‘date paid to period’ period, benefits will not be payable until the entire amount for the ‘date paid to period’ period has been received by the Fund and your Policy will be considered in arrears as though you had made no payment at all for the ‘date paid to period’.

Pharmaceutical Benefits Scheme (PBS)

The Pharmaceutical Benefits Scheme (PBS) is the national pharmaceutical scheme funded by the Commonwealth Government where patients make a contribution to the cost of the subsidised drug. The Fund will not provide benefits for drugs that are named on any PBS list, even where they are prescribed in a different quantity and whether or not you obtain a PBS benefit. However, the Fund may, on special application, provide benefits for PBS Authority or Restricted drugs, but only if prescribed for illnesses that do not meet the PBS Authority or Restricted requirements and therefore are rejected under the PBS before being prescribed. The Fund will only provide benefits for drugs listed on the Australian Register of Therapeutic Goods administered by the TGA (or specially recognised by the Fund) and which by law require a prescription and are so prescribed.

Contraceptives and anabolic steroids are not covered unless prescribed for an illness. The Fund will pay a benefit for the PBS patient contribution where the drug is intrinsic to hospital treatment covered by the Fund.

Podiatric Surgery

Benefits are not payable under any level of the Fund’s Hospital cover for all doctor’s charges for in-patient treatments provided by a podiatrist, including the fees raised by the podiatrist. Hospital Treatment Charges for in-patient treatments provided by an accredited surgeon are covered under most levels of the Fund’s Hospital cover, except Hospital Select Value and Hospital Select Plus. Policy holders with an appropriate level of the Fund’s Extras cover may be entitled to some benefits for the podiatrist’s fees. Please check your level of Extras cover.

Pre-existing Ailment

A pre-existing ailment is one where signs or symptoms of your ailment, illness or condition, in the opinion of a medical practitioner appointed by the Fund (not your own doctor), existed at any time during the six months preceding the day on which you purchased your hospital cover or upgraded to a higher level of hospital cover.

The only person authorised to decide that an ailment is pre-existing is the medical practitioner appointed by the Fund. This medical practitioner must, however, consider any information regarding signs or symptoms provided by your treating medical practitioner(s).

If an ailment, illness or condition is considered pre-existing, new policy holders must wait 12 months for any Hospital benefits and customers transferring/upgrading to a higher Hospital Cover must wait 12 months to receive the higher Hospital benefits. Existing customers with a policy of at least 12 months’ duration in total across their old and new cover are entitled to the lower benefits on their old cover. Some examples of treatments for conditions that would normally be considered to be pre-existing include sterilisation, vasectomy, surgical extraction of wisdom teeth or where you have consulted your doctor for a particular condition prior to joining or upgrading. Please note that the pre-existing ailment waiting period will not apply to any psychiatric, palliative or rehabilitation services you may require. The maximum waiting period applicable for these services under all levels of the Fund’s hospital cover is two months.

Primary Policy Holder

The Primary Policy Holder is the person who has legal responsibility for the policy and for ensuring that premiums are kept up-to-date. This person has the right to add or remove others from the policy and obtain information about claims made on the policy.

Privacy Statement

The Fund collects your personal information (personal information is as defined in the Privacy Act 1998 (Cth) and includes sensitive information, eg health information) so that the Fund can provide you with health insurance and related services, and so that it can continue to operate an efficient and sustainable business. This information is collected and used only in accordance with the National Privacy Principles, other applicable privacy laws, this Privacy Statement and the MBF Group’s Information Handling Policy.

Read our full Privacy Statement for more information.

Private Health Insurance Code of Conduct

The Private Health Insurance Code of Conduct (the Code) is a voluntary industry Code that aims to enhance the standards of practice and service in the private health insurance industry.

As a signatory to the Code, the Fund undertakes to do a number of things that will benefit you as a customer. These include things such as helping you to better understand what you are covered for and to provide you with information about our process for resolving any concerns that you may have. The Fund proudly supports the Code and it is committed to continually reviewing its operations to ensure compliance.

Find out more about the Code of Conduct.

Private Patients’ Hospital Charter

The Federal Government has produced a statement called the Private Patients’ Hospital Charter. Copies of the Charter are available to customers and members of the public at any SGIC office.

Recognised Provider

A Recognised Provider is a person in private practice who is registered under the relevant State or Federal regulation (where applicable) and who also meets the Fund’s documented recognition criteria. Benefits are only payable for services rendered by a Recognised Provider of the Fund, whose services or appliances attract a benefit under your chosen level of cover.

Recognised Tertiary Institution

Includes a TAFE college, university, college of advanced education or business college.

Single Parent Family Policy

Single Parent Family Policies include only the Primary Policy Holder and any of his or her Dependant Children or Dependant Children registered on the policy under Family 25. Also see page 4 of the brochure.

Single Policy

Single Policies include only the Primary Policy Holder.

Suspension Of Your Policy

If you are planning to travel overseas for one calendar month or more, it may be possible for you to suspend your policy. Your application to suspend your policy must be made before your date of departure and certain other criteria must also be met. There may also be other circumstances in which you can suspend your policy. For more information, please call the Fund on 133 234.

Termination

The Fund may terminate a person’s policy immediately if, in the opinion of the Fund, the person has deliberately given false information or has falsely obtained or attempted to obtain a benefit to which they are not entitled under the Fund Rules. In such a case, the Fund reserves the right to prosecute any involved parties. The policy will automatically terminate if your policy payments are two months and one day in arrears. Subject to legislation, the Fund also has the right to terminate your policy without cause by giving two months’ notice in writing and refunding any premium paid by the customer for the period after termination of the policy.

Time Limit On Claims

No benefits will be paid if claims are lodged after two years from the date of service, treatment or purchase. The Fund recommends claims are lodged within 12 months.

Transferring From Another Fund/Policy

If you transfer from another Australian registered health fund or are covered by another policy of the Fund, your policy will have continuity to the same level of benefit entitlement for services provided by and common to both funds/policies of the Fund. This is provided that you have already served the relevant waiting periods and transferred or rejoined within two months of terminating your policy with the previous fund/the Fund. Please note that delays might incur Lifetime Health Cover (LHC) penalties.

If you transfer to the Fund or rejoin the Fund more than two months after you have ceased your policy with the previous fund/the Fund, you will have to serve all the waiting periods applicable to your new level of cover even if you have served some of them in whole or in part with your previous fund/the Fund.

If you transfer to a level of the Fund’s cover that provides benefits not covered by your previous fund or cover, you must serve the relevant waiting periods for the additional benefits.

Where Limits apply, including lifetime limits, any benefits paid by your previous fund are treated as if the Fund had paid them.

Treatment information

In some cases, either before or after payment of a benefit, the Fund will ask you to provide information about your treatment, including confirmation that it relates to a diagnosed medical condition and that it is a course of treatment recognised by the Fund. You agree to assist the Fund in obtaining this information from your provider including copies of clinical records as requested by the Fund that relate to Fund benefits and/or your policy.