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05.Read the fine print

Before signing up with any fund, read its brochure and key features guide thoroughly. If there’s anything you don’t completely understand about your entitlements, write to the insurer and get written answers to your questions before you join.

It may seem like a hassle, but not in comparison to the problems you’ll encounter if your cover doesn’t match your expectations.

Fine print checklist

Here are a few of the questions to ask the fund — when you take out insurance, when you’re reviewing it, and before you go into hospital:

  • Who counts as a member? Family cover generally includes your partner and children under a certain age. The age varies from fund to fund - it could be 16, 21 or even up to 23. Some policies may include full-time students under 25 or other dependants. If this extended cover for family members is offered, does it cost extra?
  • Are there any advantages to longer membership? These may include higher benefits or benefit limits, or lower excesses the longer you’re a member.
  • What waiting periods will apply?
  • If you want to go to a specific private hospital or be covered for treatment by a specific health practitioner will there be out-of-pocket expenses?

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Hospital cover
  • Are any treatments excluded?
  • Are any treatments restricted to public hospitals?
  • Are any treatments initially limited to care as a private patient in a public hospital?
  • Are there any limits to treatment, even with so-called 100% cover? For example, you may only be entitled to a certain number of overnight stays overall, or there may be day limits for specific treatments such as for psychiatric or intensive care.
  • What excess/co-payment applies? Is there an annual maximum per membership? How does your excess or co-payment work?
  • Is the hospital you want to go to an agreement hospital with the fund?
  • Does the fund have an agreement with your doctor to cover the ‘gap’ between the actual charge and the Medicare Schedule fee?
Extras/ancillary cover
  • If extras benefits are listed as a percentage, is it a percentage of any fee charged, or a percentage of a ‘reasonable fee’ set by the fund?
  • What are the annual limits for extras benefits and do these apply per person or per membership?
  • Do providers of extras services need to be registered with the fund? Some funds require practitioners to be registered with the appropriate state board. Others require them to be specifically registered with the fund, which can limit the practitioners you can go to. If there is a specific register, make sure you contact the fund to find out if a practitioner is on it before you get treatment, otherwise you won’t get a benefit.
Ambulance cover
  • Usually included in hospital policies and sometimes offered with extras policies. Ambulance cover can vary greatly between funds. Some only cover emergency transport direct to hospital after an accident (and no further transport if you need to be sent on to another hospital).
  • Others cover all types of ambulance transport. Check the fine print, as your cover may not be as good as you think.
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