Benefits and cover conditions

Like any insurance policy, there are certain conditions that apply to your cover. For health insurance, these are mostly around the benefits paid out on services. Benefits are the payments rebated back to policy holders for hospital and extras services delivered by registered providers. This section outlines things you need to know about receiving benefits and extra things you should know about your cover.
 

Waiting Periods 

Waiting periods are exactly what their name suggests; the length of time a policy holder needs to wait before being able to make claims on services.

They apply when you join any health fund for the very first time, or when you upgrade to a higher level of cover.

Waiting periods are designed to keep health cover fair for everyone, by protecting the fund and Members against people who join intentionally to make big claims, and then cancel their membership.

If you're transferring from another fund and take out an equivalent level of cover, or if you've previously been covered by your parents' membership, we recognise that you've already served the waiting periods, so you can claim straight away. If you upgrade to a higher level of cover when you switch, you'll only need to serve the waiting period on the increased benefits. And best of all, it's really easy to switch.

Our table below outlines the waiting periods that apply to hospital and extras:

Waiting PeriodItem/Service
2 months

Hospital

  • For all hospital treatments or services where there are no pre-existing conditions (excluding accidental injury ^)
  • Approved psychiatric treatment
  • Approved rehabilitation treatment
  • Palliative care

Extras

  • 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
  • Remedial Massage Therapy/Bowen Therapy/Myotherapy
  • Osteopathy
  • Naturopathy
  • Dietician
  • Occupational Therapy
  • Orthoptic Therapy
  • Physiotherapy
  • Exercise Physiology
  • Podiatry
  • Psychology
  • Speech Therapy
  • Healthy Living Benefits
  • Foot Orthoses and Orthopaedic Shoes
  • Pharmaceuticals
  • School Accidents
12 months

Hospital

  • Pre-existing Conditions
  • Obstetrics-related services
  • Mechanical aids and appliances
  • Surgery for assisted fertility programs such as IVF or GIFT, sterilization or vasectomy, elective surgery
  • Mammograms and bone density tests
  • Hearing aids

Extras

  • 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.
  • Child birth education

^ 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 school or sporting accidents) that occurred after joining.

Changes to your circumstances

If you're expecting a change in your circumstances in the future, such as starting a family, it's important to review your policy to make sure you are covered. For example, if you have a single policy, you'll need to upgrade to a Single Parent/Family policy no less than two months from the date of the baby's birth. Please refer to our Membership Guide under the heading "Adding a newborn baby" for more information on cover for your baby.

Similarly, if you think you'll need a particular type of surgery, it's important to check that it's covered by the Health Fund and your policy, and that you'll have served the appropriate waiting period before you undergo the procedure.

 

Receiving Benefits

Benefits are the payments rebated back to policy holders for hospital and extras services delivered by registered providers.

How benefits are paid

There are a couple of different payment options available for receiving benefits.

On the spot

If your medical practitioner offers HICAPS, your benefit amount is immediately deducted from the cost of your treatment, so you’ll only have to pay any difference.

Direct credit

Your benefit can be paid directly into your nominated financial institution account. All you need to do is provide us with your account details on your application or claim form (including account name, BSB and account number), and we’ll pay the benefits directly to your account, usually within 48 hours of the claim being processed.

Queensland Country Health Fund will pay benefits on services 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.

 

Benefit Limitation Period

A Benefit Limitation Period (BLP) is an initial period of time during which only a minimum is paid by us for certain treatments or procedures under any of our Top Hospital Cover products. If a BLP applies to a treatment or procedure, we will still pay something back for these services but it's restricted to the minimum default benefit as determined by the Minister for Health and Ageing.

These default benefits are generally not adequate to cover private hospital costs, but fully cover shared ward costs in a public hospital. This would result in large out of pocket expenses if undertaking treatment in a private facility during the applicable BLP for the following services:

  • A BLP of two years (24 months) applies to bariatric surgery (weight loss surgery) including but not limited to gastric banding, gastric sleeving/diversion and gastric bypass surgery, including replacement, repair of adjustments
  • A BLP of two years (24 months) applies to hip or knee joint replacements
  • BLP of two years (24 months) applies to in-hospital psychiatric treatment for all policies commencing on or after 1 December 2015.

Will benefit limitation periods affect me?

I'm transferring from another health fund

A BLP will not apply to new members transferring from another private health insurer or to existing members changing their level of hospital cover, providing you transfer within 63 days of ceasing your previous cover. If you have not served the full waiting periods under your previous health insurance, you will need to serve the balance of those waiting periods before you'll be able to claim entitlement to any benefits in a private or public hospital.

I'm new to private health insurance, or I've been without it for a while.

A BLP will apply on the above hospital treatments or procedures for new members joining Top Hospital Cover for the first time, or to members re-joining after a lapse in private hospital cover longer than 63 days. In these instances, you will need to serve the hospital waiting periods, after which the BLP will apply to the remaining period, up to the first 24 months of membership.

After the BLP has elapsed, you will be entitled to full benefits for these treatments in a private or public hospital.

 

Benefit limits

To make cover affordable, limits apply to Extras cover. Limits are in place to set the number of times you can claim on a particular service, or combination of services, and to set monetary limits on total claims within any one membership year.

Benefits claimed for services are deducted from your chosen cover's benefit limits, based on the date you received the service or treatment you're claiming for. The majority of limits are per person (unless stated otherwise) and unused benefits can't be transferred to other Members on your policy.

Benefit replacement periods

Under our private hospital cover, we provide excellent benefits on mechanical aids, artificial appliances and hearing aids. A benefit replacement period applies to certain mechanical aids and also to hearing aids, which means that once you’ve been paid a benefit, you must wait a certain period of time from the purchase of the item before you’re entitled to a benefit for replacing it. The table below outlines the benefit replacement periods that apply per Member.

Benefit Replacement PeriodType
3 yearsMechanical aids and appliances
Blood glucose monitors - (Glucometer)
Blood pressure monitor
C-pap machine and humidifier and initial mask and tubing
Tens machine – (not circulation booster)

Benefit replacement benefits - hearing aids

Benefit Replacement PeriodType
3 yearsHearing aids

 

Healthy living

As well as helping you to get well we want to help you to stay well. Therefore we have introduced benefits to encourage you

to live a healthy lifestyle. The Healthy Living Benefit is covered under all extras policies and we will pay up to $150* per person per membership year to assist you to:

  • Participate in your choice of weight management programs
  • Participate in quit smoking programs
  • Participate in other approved health management programs** including:
    • Gym Membership
    • Personal Training programs
  • Have your skin checked for skin cancers through mole mapping
  • Consultation fees for Diabetes Educator
  • Consultation fees for Metabolic dieticians and nutritionists when providing assistance with weight management
  • Bowel Screening tests and Bone Density tests (no doctors referral will be required)
  • PSA Test (one per year). We will cover a second yearly test not covered by Medicare.

* Benefit payable under Premium Extras. Please refer to the relevant Product Brochure to ascertain the benefit payable under your level of extras cover.

** To comply with private health insurance legislation you must have been referred by your health care professional to participate in a health management program to address, improve or prevent a specific health or medical condition. A Health Management Program Benefit Approval Form must accompany a claim for these benefits.

 

Mechanical Aids and Appliances

To support you in maintaining your health, we provide an excellent benefit of up to 85% of the cost of approved mechanical appliances and artificial aids. A limit of $2,000 per person, per membership year applies, and benefit replacement periods are applicable on certain mechanical aids. Covered products include: blood pressure monitors, glucometers, tens machines, crutches, walking frames, wigs etc.

Benefits are not available on second hand equipment or on consumables. A benefit is payable for short term hiring (up to 3 months) of some mechanical aids and the purchase of some machines and monitors is limited to once every three years.

* Excluding repairs and consumables (mask and tubing) for CPAP machines which are paid at 85% of cost up to $250 once every 12 months, within the $2,000 per person per membership year limit for mechanical aids and appliances.

Tens machine (not circulation booster): Sub limit of 85% of cost up to $250 per person per membership year.

Benefit replacement periods

Under our private hospital cover, we provide excellent benefits on mechanical aids and artificial appliances. A benefit replacement period applies to certain mechanical aids, which means that once you’ve been paid a benefit for a particular aid, you must wait a certain period of time from the purchase of the item before you’re entitled to a benefit for replacing it. The table below outlines the benefit replacement periods that apply per Member.

Benefit Replacement PeriodType
3 yearsMechanical Aids
Blood glucose monitors (Glucometer)
Blood pressure monitor
C-pap machine and humidifier and initial mask and tubing
Tens machine (not circulation booster)

 

Out-of-pocket expenses

Out-of-pocket expenses are the additional costs once all Medicare and private health insurance benefits have been expended. Usually, out-of-pocket expenses apply when you’re not fully covered for a particular treatment or service, or when a set benefit limit applies. Discovering you’ll be out of pocket can be a tough pill to swallow, especially after being discharged from hospital, or once your treatment is complete.

It’s your right to know if there are any out-of-pocket expenses that you might incur as part of your treatment, to avoid any surprises later. Knowing the cost of your medical treatment upfront is called Informed Financial Consent, and the Government has introduced a checklist, providing you with the questions you need to ask before going into hospital.

We recommend contacting us before going into hospital so that we can discuss what your policy provides cover for, and if any out-of-pocket expenses will apply. We’ll also supply you with a copy of the checklist. By talking to us before going into hospital, you’ll have the total picture and can avoid any unwanted surprises later.

 

Hearing Aids

Under our private hospital cover we provide excellent benefits towards hearing aids. Benefit limit is provided every 3 years with the limit amount applied based on your length of membership with Queensland Country Health Fund: Up to 10 years $1,000, 10-15 years $1,500 and 15 years+ $2,000. Benefits  per person are calculated at 85% of the cost of hearing aids up to the appropriate limit of benefits. 

Hearing aid benefit replacement periods

A benefit replacement period applies to hearing aids, which means once you’ve been paid a benefit for your hearing aids, you must wait a certain period of time from the purchase of the item before you’re entitled to a benefit for replacing it. The table below outlines the benefit replacement periods that apply per Member.

Benefit Replacement PeriodType

3 years

Any hearing aid cannot be replaced within 3 years from its original purchase date.

Hearing aids

 

Pre-existing conditions

A pre-existing ailment, illness or condition is one where signs or symptoms of the condition were present at any time during the six months prior to applying for Membership of Queensland Country Health Fund or an upgrade of cover, determined by a Queensland Country appointed medical practitioner. You may have a pre-existing condition, ailment or illness without even being aware of it.

If it’s determined that a pre-existing condition was present, you will need to serve a 12 month waiting period before claiming benefits for treatment. It isn’t necessary for the signs or symptoms to have been diagnosed by a doctor at the time of joining or upgrading your cover.

The 12 month waiting period for pre-existing ailments can be applied to all hospital (or hospital substitute) treatments for which we pay benefits. There are a couple of exceptions; a two month waiting period applies to the following services:

  • Approved psychiatric treatment
  • Approved rehabilitation treatment
  • Palliative care

A 12 month waiting period applies to obstetrics (pregnancy) related services.

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 waiting period for the treatment of a pre-existing ailment can also apply to Extras services.

 

Cooling off period

We hope you won't, but if you change your mind about taking out cover with Queensland Country Health Fund and haven’t made any claims, we’ll allow you to cancel your policy and receive a full refund of any premiums paid within 30 days of the commencement of the policy.