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Health Insurance Glossary

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  • Covered Australia-wide

Accidental Injury: An injury caused by an unforeseen event, occurring by chance and caused by an external force or object, which results in involuntary injury to the body.

Accommodation (Hospital Accommodation): Accommodation includes a bed/chair in hospital or day facility, all meals and other hospital-provided services including nursing care for the purpose of receiving treatment by a doctor. It does not include treatment by doctors and other health professionals.

Admission: When a person is admitted to hospital by their treating doctor/specialist for the purpose of receiving treatment. This may be a booked admission or through the emergency department. Treatment in the emergency department of a public or private hospital is an outpatient service and therefore not an admission.

Adult: A person who is not a dependant child.

Australian Government Rebate on Private Health Insurance (“Rebate”): Available on all health cover premiums to Australian residents depending on your income, for Medicare Levy Surcharge purposes. The Rebate applies to both Hospital and Extras cover (excluding the Lifetime Health Cover component of Hospital). Members are eligible for a specific Rebate Tier (percentage) based on age and income. Click here for more information.

Authorised Person: Someone who has been granted authority (e.g. Delegation of Authority, Power of Attorney) by a policyholder to access that person’s membership and act on their behalf in some instances.

Benefit: An amount payable by Health Partners to or for a member, in respect of expenses incurred by a member for treatment, in accordance with the terms and conditions of the Health Partners Fund Rules.

Board: The Board of Directors of Health Partners.

Child:

  1. A natural child;
  2. An adopted child;
  3. A foster child;
  4. A stepchild (that is a natural, adopted or foster child of the policyholder’s partner); and
  5. Another child deemed by Health Partners to be in full care and the responsibility of the policyholder.

See also Dependant Child.

Chronic Disease: An illness “that is prolonged in duration, does not often resolve spontaneously, and is rarely cured completely”. Features common to most chronic diseases include:

  1. Complex causality, with multiple factors leading to their onset;
  2. A long development period, for which there may be no symptoms;
  3. A prolonged course of illness, perhaps leading to other health complications; and
  4. Associated functional impairment or disability.

Condition: Any actual or perceived state of health for which treatment is sought. Refer also Treatment.

Consultation: An attendance by a relevant provider on, and in the physical presence of, a patient or as otherwise approved by Health Partners.

Contribution: See Premium.

Contributor: See Policyholder.

Co-payment: The daily amount you agree to pay (in addition to any applicable excess) towards your hospital accommodation. Applicable on some older covers. Click here for more details.

Cover: A defined group of benefits payable under the Policy for expenses incurred by the member.

Day Surgery: Surgery where patients are admitted, treated and discharged on the same day at a private hospital or other medical facility.

Delegation of Authority: Granted by the policyholder, authorises another adult to discuss and manage aspects of the membership. Click here for more information.

Dependant: A person who is:

  1. The policyholder’s partner, or
  2. A dependant child.

Dependant Child/Child Dependant: A person who:

  1. Is a child of the policyholder or the policyholder’s partner;
    1. aged under 21, or
    2. a full-time student over 21 and under 25, or
    3. a non-student over 21 and under 25, and
  2. Does not have a partner (includes spouse or de facto)

Dependant Child Non-student: A person who:

  1. Is aged between 21 and 24 (inclusive); and
  2. Is a dependant child under the Rules of the insurer that insures the person as referred to in subparagraph (a) (ii) of the definition of ‘dependant child’ in the Private Health Insurance Act 2007, whether or not the person is wholly or substantially dependant on an adult insured under the same health insurance policy; and
  3. Does not have a partner; and
  4. Is not receiving full-time education at a registered school, college or university.

Equivalent Cover: A level of cover offered by another fund which Health Partners considers to be equivalent to a level of cover offered by Health Partners.

Excess: An amount that a member agrees to pay towards the cost of hospital treatment, in exchange for lower premiums.

Exclusions: Services which are not included on a cover and therefore no benefits apply. These vary depending on the level of cover; refer to specific cover information for details.

Expenses: Any expenses which qualify for benefits.

Extras Cover: Private health insurance for non-hospital health services that are not covered by Medicare such as dental, optical, physiotherapy and much more. Also known as Ancillary Cover or General Treatment Cover.

Floating Year/Rolling Year: In relation to hospital admissions, a floating year is any period of 12 consecutive months.

Full-time Student: A person who is undertaking a full-time workload for a course at a school, college or university up to the age of 25. Because of possible variation to the definition of “full-time workload”, Health Partners may consider such variations at its discretion.

Fund: The Fund is Health Partners Ltd, a registered private health insurer, governed by the Health Partners Fund Rules in conjunction with the Government Rules.

Gap-free: Where a cover offers a “gap-free” service or treatment, Health Partners will provide a 100% benefit, within annual limits (where applicable).

General Treatment: See Extras Cover

Government Rules: Means the Private Health Insurance Act 2007 and the Private Health Insurance Rules made under that Act.

Health Coaching (formerly “Chronic disease management program”): Means a telephone-based information and support program that is intended to either reduce complications in a person with a diagnosed chronic disease or prevent or delay the onset of chronic disease for a person with identified risk factors for chronic disease.

HICAPS: An electronic claiming service that allows members to claim Extras benefits on-the-spot at recognised providers with HICAPS. This means members only pay the gap at the time of their visit.

Home Nursing: Nursing in a home by a registered nurse who meets the recognition criteria and where the treatment is not hospital treatment.

Hospital Cover: Means a membership which covers some or all hospital treatment.

Hospital Substitute Treatment: Means treatment that substitutes for an episode of hospital treatment, and is general treatment and is any of, or any combination of, nursing, medical, surgical, diagnostic, therapeutic, prosthetic, pharmacological, pathology, or goods and services intended to manage disease, injury or condition as defined in the Private Health Insurance Act 2007. This is covered in our Home Health Partner benefits and is available on all Hospital and Package covers.

Hospital Treatment: Treatment (including the provision of goods and services) that is intended to manage disease, injury or condition, where that treatment is provided by a person who is authorised by a hospital to provide that treatment or, a person under the control of such a person; and is provided at a hospital or in direct control of a hospital, as defined in the Private Health Insurance Act 2007.

Inpatient: A person who is admitted to hospital by their treating doctor for treatment. This does not include treatment in an emergency department as this is an outpatient service.

Informed Financial Consent: The provision of cost information to patients, including notification of likely out-of-pocket expenses (gap), by a service provider, prior to admission to hospital.

Injury: Includes disease.

Lifetime Limit: The maximum amount a member can claim for a certain service in their lifetime. Once this limit has been reached, no further benefits are payable. Some lifetime limits (such as orthodontics) are transferred between funds.

Limit: The maximum amount a member can claim for a service in a given period. All Health Partners limits are quoted per person per calendar year, unless otherwise stated.

Loyalty Benefit: An increase in benefits and/or limits received after a certain period of continuous membership with Health Partners, or on a particular cover specified by Health Partners.

Main Member: See Policyholder.

Major Dental: Significant dental services, such as periodontal treatment, complex fillings, tooth extractions, crowns and bridges.

Medical Gap: The amount a member pays on top of any Medicare benefit and/or Health Partners benefit for medical services when admitted to hospital. The gap will vary depending on the fees charged by the treating doctors and specialists.

Medically Necessary: When treatment is considered necessary by a medical practitioner.

Medicare Benefits Schedule: The Medicare Benefits Schedule (MBS) is a schedule of fees for all services covered by Medicare. For inpatient services, Medicare pays 75% of the MBS and Health Partners pays the remaining 25%. For outpatient services, Medicare pays 85% of the MBS. However, health funds are not allowed to contribute to the remaining 15%.

Medicare Levy Surcharge: The Medicare Levy Surcharge is a Government initiative which involves an additional surcharge of up to 1.5% imposed on people who earn above a certain level of income (on top of the 2% Medicare Levy). It applies only to people who do not have an appropriate level of private hospital cover.

Medical Practitioner: A person who is registered or licensed as a medical practitioner under an Australian law and who satisfies the provider eligibility requirements for the payment of Medicare benefits.

Member: Means each insured person being the policyholder and each of their dependants who are registered in a Membership under the Fund Rules.

Membership: Means a policy of health insurance referable to the Fund.

Membership Category: A category described below containing the number and kind of people described:

  1. Single membership, which comprises only one person;
  2. Couples membership, which comprises only two adults who are the policyholder and their partner/spouse;
  3. Sole parent membership, which comprises only one adult, who is the policyholder and one or more dependant children; and
  4. Family membership, which comprises only two adults, who are the policyholder and their partner/spouse and one or more dependant children.

Non-Emergency Ambulance: Treatment and services that are not classed as “emergency cases” by the ambulance service provider. This can include treatment at the scene with or without transport.

Outpatient: A patient of a hospital who is not an admitted patient (e.g. emergency department services, tests/scans, specialist consultations pre/post admission).

Palliative Care: The care of patients with serious or terminal illness to relieve pain.

Pharmaceutical Benefits Scheme (PBS): An Australian Government scheme that subsidises the cost of some pharmaceuticals.

Partner: In relation to a policyholder means a person who:

  1. Is married to the policyholder;
  2. Is a de facto spouse of the policyholder; or
  3. Irrespective of gender, is in a genuine domestic relationship with the policyholder with them together being a couple.

Partner: In relation to a dependant child means a person who:

  1. Is married to the dependant child;
  2. Is a de facto spouse of the dependant child; or
  3. Irrespective of gender, is in a genuine domestic relationship with the dependant child, with them together being a couple.

Note: If a dependant child has a partner as defined within these Rules, they are not eligible to be covered as a dependant under a Family Membership.

Person: Includes a firm, a body corporate, an unincorporated association or any authority; a reference to a person includes its executors, administrators, successors and permitted assigns.

Policy: A complying health insurance product detailing the terms and conditions of that product.

Policyholder: A person whose name an application for membership of Health Partners has been accepted, who manages and is responsible for all aspects of the membership and the actions of any person they have provided Delegation of Authority to, and who is responsible for payment of premiums associated with that membership.

Pre-existing Condition: An ailment, illness or condition, the signs or symptoms of which, in the opinion of a medical practitioner appointed by Health Partners, existed at any time during the six months preceding the day on which the member became insured under a policy of the Fund or transferred to a higher level of cover as defined by the Government Rules.

Premium: The amount a policyholder is required to pay for a specified period of cover.

Private Hospital: A hospital that is approved as a private hospital under an Australian law or any other hospital recognised by Health Partners as a private hospital.

Private Patient: A person who is admitted to a public or private hospital as an acute care patient and who is not a public patient.

Public Patient: A person who is admitted to a public hospital and who receives treatment as a Medicare patient without charge.

Rebate: See Australian Government Rebate on Private Health Insurance.

Recognised Provider: A recognised provider is one that meets Health Partners’ recognition criteria. Benefits are not payable on services received from providers that are not recognised as being registered with Health Partners.

Recognition Criteria: Means in relation to a person:

  1. The person is registered, or holds a licence, under relevant legislation to render treatment for which recognition is sought;
  2. If the person is a hospital, it is a hospital approved by the Minister under S121-5 of the Private Health Insurance Act 2007;
  3. The person is professionally qualified and a member of a professional body recognised by Health Partners;
  4. The person provides facilities that meet the standards determined or recognised by Health Partners and the Government Rules; and
  5. The person fulfils the other criteria that Health Partners considers reasonable and appropriate from time to time.

Restrictions: Conditions, services or treatments which a policy covers only to a limited extent, and will pay reduced benefits on hospital admissions. It is not sufficient to cover the cost of a private room in a public hospital or any room in a private hospital. If admitted for treatment that is restricted on a policy, large out-of-pocket expenses will apply. More information can be found here.

Resolution Policy: Health Partners policy for resolving disputes with members determined by the Board from time to time.

Standard Information Statement: Means a statement that is provided by Health Partners that provides a summary of a complying health insurance product’s key features and premium as defined in the Government Rules.

Treatment: Means:

  1. In respect of Hospital cover, hospital services and hospital treatment; and
  2. In respect of general treatment, treatment and or services for which benefits are payable under these Rules. To avoid doubt, a “service” excludes any treatment that is not provided by the provider personally or under the direct supervision of the provider.

Waiting Period: The length of time a member will have to wait from the time of joining to be eligible for health fund benefits. Waiting periods apply for benefits for Hospital and Extras services and vary depending on whether a member is new to health insurance, has transferred from another fund or is upgrading their cover.

Young Adult Dependant: See Dependant Child Non-student.

If a word or phrase you are seeking clarification on isn’t listed above, you can also search the terms available at www.privatehealth.gov.au or call us on 1300 113 113.