Private health insurance doesn’t need to be complicated but we understand that sometimes it can be... therefore we have included a number of descriptions and explanations to keep you well informed.

 

1. Singles, Couples & Families

Single: a single policy covers only one person
Couple: a couple policy covers the person who establishes the policy as well as one other adult. The policy can be extended to cover dependant children at no additional cost.
Family: a family policy covers the person who establishes the policy as well as that person’s partner and all dependant children.

2. Dependants

A “Dependant Child” means a legitimate child, an adopted child, a foster child, a stepchild, or an ex-nuptial child of the policy holder who; (i) (a) has not attained the age of 21 years or (b) is a full-time student (at a school, college or university) who is not aged 25 years or over, or (c) is an apprentice who is not aged 25 years or over and does not earn more than $20,000 p.a. and (ii) does not have a partner If a young adult proceeds with their own membership within two months (63 days) of ceasing to be included under a family cover, they receive continuity of benefits and will not have to serve further waiting periods from when the new policy commences (assuming all waiting periods had previously been served under the family membership).

3. Members transferring from other funds

We will take into account the level of cover provided by another fund when calculating waiting periods and benefits payable if the Member joins a Queensland Country insurance policy within 2 months (63 days) of ceasing membership with their previous registered health insurer.

If you change from another fund, we will contact the other fund to determine your past benefits and any applicable waiting periods.

To assist us in transferring your policy, please complete a Clearance Certificate Request and we will arrange this for you.  

4. Waiting Periods

Waiting periods are exactly what their name suggests; a specified period policyholders must wait before being eligible to claim a benefit. They apply when joining any health fund for the very first time or when you upgrade to a higher level of cover.

Waiting periods are necessary in keeping health cover fair by providing protection to existing policyholders for when they may need cover. If waiting periods didn’t exist people may intentionally join to make pre planned claims and then discontinue their membership.

Waiting periods don’t apply when you’re transferring to Queensland Country Health from an equivalent or higher level of cover with another health fund, or if you’ve been previously covered by your parents’ membership and you’re commencing you own. However, if you want to change your existing level of cover for one that is more extensive you will be required to serve waits on the increased benefits only.

If you are thinking of starting a family it’s important to review your policy to ensure you have your desired cover for your changing circumstances. If you have a single policy you will need to upgrade to a family policy no less than two months prior to the actual delivery date to make certain your baby will be covered.

 

 

Waiting Period	Item / Service
2 months	Dental Diagnostic – includes examinations & consultations Preventative – includes cleaning and scaling, fluoride treatment etc. Simple extraction Restorative – composite and amalgam fillings General services – includes mouth guards and Occlusal splints Optical Acupuncture Audiology Chiropractor Massage Therapy Osteopathy Naturopath Dietician Occupational Therapy Orthoptic Therapy Physiotherapy Podiatry Psychology Speech Therapy Healthy Living Benefits
12 months	Pre-existing Conditions Obstetrics-related Services Child birth education and midwifery services Major Dental services Periodontics – specialised gum treatment Surgical Extraction – includes Wisdom tooth extraction Endodontic Services – includes root canal therapy Crowns and Bridges Prosthodontics – Dentures Orthodontics – Braces etc. Mechanical Aids Surgery for assisted fertility programs such as IVF or GIFT, sterilization or vasectomy, elective surgery and surgical extraction of teeth

Two month waiting periods apply for most other items or services. The 2 month Waiting Period is waived for treatment arising from an accident (excluding a school and sporting accident) that occurred after joining.

5. Benefit Replacement Period

A Benefit Replacement Period applies to certain mechanical aids. This means that, once you have been paid a benefit for a particular aid, you must wait for a certain period of time from the date of purchase of the item before you are entitled to a benefit for the replacement of that item. These Benefit Replacement Periods apply per Member.

 

 

Benefit Replacement Period	Mechanical Aid
3 years	Blood glucose monitors - (Glucometer) Blood Pressure Monitor Nebulisers C-pap Machine and Humidifier and initial mask and tubing Tens Machine – (not circulation booster) Hearing Aids

 

6. Compensation Payment

Queensland Country Health Fund does not pay a benefit for services provided to a Member as a result of accident, illness, injury or condition where a Member has a right to claim damages, compensation or benefits from any other source.

7. Benefit Limits

Limits relate to ancillary (Extras) cover and also to the mechanical aids part of the hospital cover. Limits are there to set a limit on the number of times you can claim on a particular service, or to set a dollar limit on claiming on a particular kind of service in a membership year. In most cases limits are reusable each year from the anniversary date of the establishment of your membership. All Limits are calculated from the day you received the service or treatment you're claiming for. Most limits are per person and the limits on services are not transferable to other Members on the policy.

8. Membership Arrears

All contributions are payable in advance. If a Member fails to pay contributions within two months (63 days) of the contribution due date, this may result in cancellation of both the membership and entitlement to benefits.

9. Claims

If a membership is un-financial or suspended, benefits are not payable during this period, nor are they payable on claims submitted more than two years after the date of service.

10. Membership Year

All yearly limits and excesses are calculated from the anniversary date of the establishment of the membership.

11. Recognised Providers

Queensland Country Health Fund will only pay benefits for ancillary, dental and nursing/midwifery services where the services are provided by practitioners recognised by Queensland Country. Recognition is subject to change without notice. There are no benefits payable for overseas hospitalisation or ancillary care.

Recognition of providers is for the purpose of determining the payment of benefits and should not be taken or considered in any way as approval of, or any recommendation as to the qualifications and skills of, or services provided by, a practitioner or therapist. Members should check with Queensland Country that their practitioner is recognised before commencing treatment.

12. Summary of Rules

This page contains only a summary of the fund rules. The complete rules of the health benefits fund set out in full the terms and conditions of membership and liability under the fund. These rules are available for inspection at Queensland Country Health Fund, Level 1, 296 Ross River Road, Aitkenvale QLD 4814.

13. Benefit Conditions

Queensland Country Health Fund will only pay benefits when:

 

• The waiting period for that service has been served
• Services are provided in Australia
• A service or treatment is medically necessary and clinically relevant
• Services are part of a course of treatment recognised by Queensland Country
• The service is provided to a person on the membership
• The service or treatment has been provided by a practitioner or therapist recognised by Queensland Country Health Fund
• The treatment or service is covered under the Member’s level of cover
• No benefits are payable from another source (e.g. compensation payment or Government benefit)
• The conditions of the level of cover have been met

The amount of benefit is calculated on the cost of the treatment or aid to the Member, taking into account any allowances or discounts given by the provider. No benefit paid by Queensland Country Health Fund can exceed the actual charge of the service or appliance.

14. Pre-existing Conditions Rule

A pre-existing ailment, illness or condition is one where, after examining evidence, a medical adviser, or other relevant health care practitioner appointed by Queensland Country Health Fund would consider that signs or symptoms would have been in existence at any time during the six months preceding the application for membership or upgrade of cover. You may have pre-existing condition, ailment or illness without being aware of it. In these cases, there is a 12 month waiting period before you are entitled to claim benefits for treatment. It is not necessary for the signs or symptoms to have been diagnosed by a doctor when a member joined or upgraded their level of cover.

Surgery for assisted fertility programs such as IVF or GIFT, Sterilisation or Vasectomy, elective surgery and surgical extractions attract a 12 month waiting period.

The 12 month Pre-existing Aliment waiting period can be applied to all hospital or hospital substitute treatment for which we pay benefits. However, a two month waiting period applies to the following services:

 

• approved psychiatric treatment
• approved rehabilitation treatment, or
• palliative care.

The 12 month waiting period for the treatment of a Pre-existing Ailment can also apply to ancillary (Extras) services.

15. Portability

Members can transfer from another fund to Queensland Country Health Fund and be eligible for benefits without waits provided they join Queensland Country within two months (63 days) of leaving their former fund, and they have served the equivalent Queensland Country waiting periods with the former fund. From the date Members join they will be eligible for those benefits under their new cover for those services that were payable under their old cover. Benefits will not be paid for treatments that were received before joining Queensland Country.

However, if a Member is transferring to a higher level of cover with Queensland Country they will need to serve the applicable waiting periods on the higher benefits only.

If a Member has not fully served the equivalent Queensland Country waiting periods with their former fund, they will need to serve the balance of these waiting periods with Queensland Country before being eligible for Benefits.

 

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 16. Cooling Off Period

 

Queensland Country Health Fund will allow any Member who has not yet made a claim to cancel their policy and receive a full refund of any premiums paid within a period of 30 days from the commencement of their policy.

 

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