Health assurance

Read all the fine print before selecting a policy.

Policies have conditions, exclusions and explanations in the fine print attached to brochures and application forms. For example, a policy might exclude heart surgery or hip replacements.

Beware of waiting periods for new or upgrading members.

When you join most health funds, or upgrade to a higher level of cover, only treatment for accidents is covered. There are four main waiting periods:
1.  Two months before new members can make a claim.
2.  12 months for obstetrics and maternity claims.
3.  12 months for pre-existing ailments. Funds firmly apply this rule and even undiagnosed illnesses may not be covered.
4.  Waiting periods for "ancillary" benefits such as dental and optical work and for some specific procedures such as cosmetic surgery and IVF.

Check to see if benefit limitation periods apply. These limitations impose additional waiting periods for paying benfits above a certain amount. For example, a new member might have to wait a year before a lower level of bene ts is paid and subsequently longer before full bene ts are paid.

Contact your fund before receiving treatment or entering hospital. Give the fund your membership number, the name of your doctor, details of the hospital and procedure (including the "item" numbers). Ask your fund if it has an agreement with the hospital you are using. If it doesn't, ask what your "out-of-pocket" expenses will be. Ask about your doctor's fees, as many charge more than the amount you can claim from Medicare and your fund.

Is there a daily bed charge in private hospitals?
Check whether you have to make any contribution, such as a $50-a-day bed charge, if you use a private hospital. Can you afford this? Do you have to pay an excess as well as this charge? If you do, this could mean you get little back from your fund if you use a private hospital and your excess is high.

How much is 80% of your dentist bill?
Health funds say they will refund 60 per cent, 70 per cent or 80 per cent, even 100 per cent of the cost of such extras as dental, eye care and other extras, but this may not be 80 per cent of what you pay, but 80 per cent of the health funds' "recognised charge". You should get a copy of the fund's recognised charge list and compare it to what your dentist charges to see whether you are getting value for money. Other funds will pay back a flat dollar amount for each service.

Keep payments up to date.Your policy will usually be cancelled if you fail to make payments for two consecutive months. People rejoining may have to serve all waiting periods again. Some funds do not send reminder notices if your premiums fall behind.

Take care when transferring between funds. You can usually switch to a different fund, without serving waiting periods, if the switch is to the same level of cover. You will have to serve waiting periods before you qualify for any new or higher bene ts the policy may offer.

Promptly lodge any claims. Most funds won't pay bene ts if you claim two years or more after the service.

Understand how policy limits, excesses and co-payments are calculated. Some policies have limits on claims, especially for ancillary bene ts such as dental services, where you may be able to claim only a certain amount in any 12- month period. Many funds have policies with excesses. You agree to pay the first $100-$1000 of the bill, in exchange for lower premiums. A few funds require members to pay a daily amount towards their hospital bills, called co-payments.

Many funds do not offer overseas cover.
Some funds will not pay for any overseas medical treatment and other funds will only make payments at Australian fee levels. If you suspend your health insurance policy while you are overseas, some funds will impose waiting periods on certain treatments when you return.