GUIDES & RESOURCES

Understanding The Health Insurance Claim Process

Need to make a claim on your health insurance policy, but aren’t sure how? We’ve got you covered. Read on to learn more about making a health insurance claim, including how to claim, what you can claim for, and how long you have to submit it.
making a health insurance claim

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How to lodge your health insurance claim

There are various methods for lodging a claim through your health insurance policy. The available options for your claim will depend on your health insurance fund, and the type of claim you’re making.

Here are some of the ways you can make a health insurance claim:

On the spot (Extras Cover)

If the healthcare provider has a device called a HICAPS machine, you’ll simply need to swipe your health fund membership card when paying for the service. Your rebate will be automatically deducted from the provider’s fee, so you’ll only be charged the difference between that fee and the amount covered by your insurance for the service.

Online (Extras Cover)

With most funds you can lodge a claim directly through their website (you’ll just need to set up online access first). When you’re ready to make a claim, simply log in and follow the steps to lodge. Depending on your insurer, you may only need to give the healthcare provider’s number, item code and amount. You may also be required to upload your accounts and receipts.

Via an app (Extras Cover)

Many health insurance funds offer a dedicated app which you can use to submit your claim. This works in a similar way to lodging your claim online, as we discussed above.

By post or in person

If preferred, you can usually choose to print out the required claim forms and submit them by mail. You’ll need to include an itemised account, and the original receipts from the healthcare provider. The rebate amount will be refunded into your nominated bank account, usually within a few weeks.

Through a hospital (for hospital cover)

For claims under hospital cover1, your health insurance fund will usually pay the hospital directly. You’ll need to show your health fund membership card and pay any applicable excess on admission, so that the hospital admin staff can check your cover and submit the claim.

You may receive a bill from the hospital for the difference between their fee and the amount covered by your insurance.

Accessing your health insurance claim forms

If you’re submitting your health insurance claim via mail or in person, you’ll need to print out your claim forms. These forms will usually be available in PDF format on your health fund’s website, which you can download and print.

Time limits for making a health insurance claim

It’s best to submit your health insurance claim as soon as possible after you receive treatment2. Not only does this mean there’s less chance of accidentally misplacing receipts or accounts, but it will also result in you receiving your benefit sooner.

It’s important to note that most private health funds won’t pay out if you submit your claim two years or more after receiving the service.

However, if there was a genuine reason why you were unable to make your claim within this timeframe – such as legal action or other unforeseen circumstances – you should contact your health fund to see if they can extend the claim period.

What you can claim on your private health insurance

Private health insurance is generally divided into three categories3: hospital cover, general treatment cover (also called extras cover or ancillary cover) and ambulance cover. Let’s take a look at what can be included by these different types of cover.

Hospital Cover

Hospital cover insures you against all or part of the treatment costs as a private patient in either a public or private hospital1, including doctors’ fees and hospital accommodation. Private Hospital can allow you to:

  • Skip public waiting lists at participating private hospitals
  • Stay in a private room when available in a participating private hospital
  • Choose the doctor or specialist who performs the treatment

What you’re covered for will depend on your level of cover, your insurance provider, and your policy. In general, basic treatment for most in-hospital procedures will be covered up to the Medicare Benefits Schedule fee4, with different policies coming with different exclusions (specific services not covered) and restrictions (services covered to a limited extent)5.

General Treatment

General treatment cover insures you against all or part of the cost of out-of-hospital treatments that generally aren’t funded by Medicare6. The services you’re covered for will depend on your policy and may include treatments like:

• Dental
• Chiropractic
• Podiatry
• Physiotherapy
• Occupational and speech therapy
• Glasses and contact lenses

In most cases, general treatment only provides limited cover for these services, e.g. there may be a limit on the amount you can claim per service, per year or over the lifetime of your policy. It’s also worth noting that some services may not be covered by your policy.

Ambulance Cover

Ambulance cover can be taken out as part of your hospital or general treatment cover, or as a stand-alone cover3. The level of cover can differ depending on the policy you choose and the state you live in. In some cases, ambulance costs are covered by your state government.

Choosing a private health insurance policy

Private health insurance offers the peace of mind that you’re covered for healthcare services when you need them (and may not be able to afford otherwise). What’s more, if you earn over a certain amount, you may have to pay the Medicare Levy Surcharge if you don’t have private hospital cover7.

Searching for a health insurance fund? iSelect makes it easy for you to compare providers and find a policy that’s suitable for you. To find out more about choosing a health insurance fund, contact our friendly team on 13 19 20.

Sources:
1.https://www.privatehealth.gov.au/healthinsurance/howitworks/default.htm#hospital
2. http://www.ombudsman.gov.au/__data/assets/pdf_file/0023/29426/10goldenrules.pdf
3. https://www.privatehealth.gov.au/healthinsurance/whatiscovered/privatehealth.htm
4. https://www.privatehealth.gov.au/healthinsurance/whatiscovered/
5. http://www.ombudsman.gov.au/publications/brochures-and-fact-sheets/phio/policy-exclusions-and-restrictions
6. https://www.humanservices.gov.au/individuals/subjects/medicare-services
7. https://www.ato.gov.au/individuals/medicare-levy/medicare-levy-surcharge/

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