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Claiming your health insurance benefits

When you are hospitalised, the hospital will usually claim directly from your health fund on your behalf (you may be directly responsible for the payment of an excess or a co-payment).

Extras claims can now be lodged at any Medicare Office under the Medicare Two-way facility, or forwarded with the paid or unpaid account directly to the Health Fund with your claim form and membership details. Many ancillary services are now claimed electronically by your health care provider when you receive treatment.

If you anticipate health care treatment you should contact your fund before treatment commences to confirm your benefit entitlements.

Your benefits

The amount of benefits you receive for hospital or medical treatment will depend on the type of health insurance you purchase, and whether you have chosen to contribute to the costs of your hospital treatment with an excess in exchange for paying a lower premium.

The amount of benefits you will receive also depends on the hospital and doctor you choose and whether they have an agreement with your fund.  When a fund has an agreement with your hospital and when your doctor participates in your health fund's Gap Cover scheme you are less likely to face out-of-pocket costs. If you elect to go to a hospital that does not have an agreement with your fund, you may face significant out-of-pocket costs.

You should ask your doctor well in advance of receiving treatment to give you an estimate of any amount you will have to pay for your doctor's services that is not covered by Medicare and your health fund. You should also ask your hospital and health fund to inform you of any amount you will have to pay for your hospital charges.

You can ask any health fund about the hospitals and doctors with whom they have agreements.

Time limit

You should lodge a claim within two years of the date of the health care service, although some funds may allow claims to be lodged after two years. Check with your fund for confirmation of their rules regarding the lodgement of claims.

Ineligible claims

Benefits are generally not paid:

  • if you will be paid compensation by a third party 

  • for certain extras  services provided by someone not recognised by your fund or if you are not covered for ancillary benefits 

  • if you put false or inaccurate information on your claim form 

  • if you are more than two months behind with your contributions 

  • if you claimed benefits for services provided while your membership in the fund was suspended 

  • if the service provider is directly related to you - that is, if he or she is your spouse, parent, child or sibling; or 

  • if your claim is made two or more years after the date of service.

To help you understand what you can expect from your health fund, doctor and hospital, a Private Patients' Hospital Charter is available. It will assist you with some of the important questions you may need to ask those involved with your health care.  Copies of the Charter are available from health funds, the Department of Health and Ageing and the Private Health Insurance Administration Council (PHIAC).