Hospital treatment for accidents and emergencies have their own set of rules, which may vary from those of your regular health cover.
Under your regular health cover, you are covered for in-patient hospital treatment for the features under your health insurance policy, and most often this takes the form of elective surgery.
For example, if your health insurance policy includes cover for cataract surgery, and you are informed by your doctor that you require removal of your cataracts, then that surgery is covered by your health fund.
In the case of accidents and emergencies however, special rules apply.
An accident is defined as:
An unintentional or unplanned event resulting in bodily injury that requires immediate medical treatment from a registered practitioner. Excludes accidental illness, pregnancy or aggravation of a pre-existing condition.
Generally, waiting periods don't apply to accidents, so if you're involved in an accident immediately after joining a health fund, you should have health cover straight away.
Also, depending on your health fund, you may also be covered for features that are normally excluded or restricted on your health insurance policy. That means any treatment required as the direct result of an accident may be covered, regardless of whether that treatment is included in your health insurance policy or not.
For example, you may have chosen to exclude knee reconstruction from your health insurance policy to keep the premium costs lower, but if you're in an accident that requires complete knee reconstruction, your health fund may still pay for the cost of the surgery because it was the result of an accident.
The exception to the rule is road accidents, which are generally not covered by your health fund, as they are covered by compulsory third party insurance schemes. In fact, any incident where compensation is claimable from another party is generally not covered by your health fund.
We've compiled some information on accident cover for our participating health funds:
Australian Unity covers all procedures considered medically necessary as the result of an accident.
GMHBA covers only those procedures included in your policy, even in the case of accidents.
HCF covers only those procedures included in your policy, even in the case of accidents. If you require a procedure not listed in your policy, HCF will pay a minimum benefit for treatment at a public hospital.
nib covers all procedures considered medically necessary as the result of an accident for customers with Basic Saver, Basic Plus, Mid Plus, Family Plus, Family Basic Saver, or Young at Heart Mid.
Peoplecare covers only those procedures included in your policy, even in the case of accidents.
Conditions include: formal admission to hospital as an inpatient within 24 hours of the accident's occurrence, and treatment must be undertaken during the first admission to hospital. For any subsequent admissions resulting from the accident, exclusions or restrictions under your cover will apply.
As a general rule, health funds do not cover costs for emergency treatment because the patient is not formally admitted to hospital.
If you go to an emergency department of a public hospital, you should be treated free of charge as a public patient, even if you have private health insurance. You are still eligible to receive public health care under Medicare.
If you go an emergency department of a private hospital, you may incur out-of-pocket costs. Treatment by general practitioners are fully covered by Medicare, but if you are treated by a specialist doctor, Medicare will pay 85% of the Medicare Benefit Schedule only. There may also be a gap between the Medicare Benefit Schedule and the amount charged for any tests required in the emergency department (blood tests, x-rays, etc).
If the private hospital charges a facility fee for attendance at their emergency department, your health fund may provide benefits to cover this cost, depending on your level of cover.
Around one in four presentations to emergency departments ends with the patient being admitted. Once you are formally admitted to hospital, then you can claim medical costs from your health fund, up to the level of your cover and according to the conditions of your cover.
Please note: the information provided here is a guide only and should not be used as a substitute for advice provided by a medical professional or your health fund. We highly recommend you consult your health fund for any specific health insurance-related queries.
