Glossary

Health insurance terms and definitions


means an unforeseen event, occurring by chance and caused by an unintentional and external force or object resulting in involuntary hurt or damage to the Insured Person’s body that has occurred in Australia. It must result in the need for medical advice or treatment from a registered Medical Practitioner (other than anyone on the same Policy) within 72 hours of the event, and if needed, any further treatment within 180 days of the event.

Accidents must not have occurred within 1 day of membership commencement. When an accident has occurred within 1 day of membership commencing the accident rule does not apply and waiting periods apply. This definition is separate to the definition within Accident Cover.


care means hospital treatment where the primary clinical purpose or treatment goal is to, manage labour (obstetric), cure illness or provide
definitive treatment of injury, perform surgery, relieve symptoms of illness or injury (excluding palliative care), reduce the severity of an illness or injury, protect against exacerbation and/or complication of an illness and/or injury which could threaten life or normal function, or to perform diagnostic or therapeutic procedures.


means a person who is not a child dependant.


means a resource with economic value that Health Partners owns or controls.


means 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 these Rules.


means the Board of Directors of Health Partners.


means:

a. a natural child;

b. an adopted child;

c. a foster child;

d. a step-child (that is a natural, adopted or foster child of the policyholder’s partner); and

e. another child deemed by Health Partners to be in full care and the responsibility of the policyholder.

See also Dependent Child and Dependent Child Non-Student.


is one which is no longer available for sale, but which continues to cover existing members still on it. Current members on these levels of cover may retain their cover whilst the membership remains continuous and unchanged. If they leave the cover at any time after its closure, either by choice, change of circumstances or by becoming unfinancial (membership payments have not remained up to date), they cannot re-join it.


In compliance with the Government Rules, means the principle of community rating prevents private health insurers from discriminating between people on the basis of their health or for any other reason described in the Government Rules.


means an insurance policy that meets:

a. Community rating requirements;
b. Coverage requirements;
c. If the policy covers hospital treatment, benefit requirements;
d. Waiting period requirements;
e. Portability requirements;
f. Quality Assurance requirements; and
g. Any other requirements as set out in the Private Health Insurance (Complying Product) Rules.


means an illness “that is prolonged in duration, does not often resolve spontaneously, and is rarely cured completely”.

Features common to most chronic diseases include:

a. complex causality, with multiple factors leading to their onset;
b. a long development period, for which there may be no symptoms;
c. a prolonged course of illness, perhaps leading to other health complications; and
d. associated functional impairment or disability.


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


means the amount a policyholder is required to pay for a specified period of cover.


means a group of members approved under these Fund Rules.


means the amount a member agrees to pay each time a service is provided.


means for you and your partner.


(also referred to as policy) means a defined group of benefits payable under these Rules for expenses incurred by the member.


means a person who is:

a. the policyholder’s partner, or
b. a dependent child.


means a person who is not a Partner and:

a. is aged under 21; or
b. is aged under 25 and receiving a fulltime education at a school, college or university recognised by us; and
c. does not have a partner.


means a person who is not a Partner and:

a. is aged between 21 and 24 (inclusive);
b. is not receiving full-time education at a school, college or university recognised by us; and.
c. does not have a partner.


means a level of cover offered by another fund which Health Partners considers to be equivalent to a level of cover offered by Health Partners.


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


means treatment (including the provision of goods and services by a recognised provider in person) that is intended to manage or prevent disease, injury or condition, and is not hospital treatment but may or may not include hospital substitute treatment as defined in the Private Health Insurance Act 2007. Also referred to as General Treatment or Ancillary Cover.


means the health benefits fund established by Health Partners and governed by these Rules.


means treatment (including the provision of goods and services by a recognised provider in person) that is intended to manage or prevent disease, injury or condition, and is not hospital treatment but may or may not include hospital substitute treatment as defined in the Private Health Insurance Act 2007. Also referred to as Extras Cover or Ancillary Cover.


means Private Health Insurance Act 2007 and the Private Health Insurance Rules made under that Act, as well as the Health Insurance Act 1973 and the rules made under that Act.


means a scheme under which Health Partners and the employer of a member agree that the employer will deduct from amounts payable to the member at the member’s direction, premiums due to Health Partners and pay the same to Health Partners.


means a 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 and which complies with the Government Rules.


means the network of pharmacies who have entered into an agreement with Health Partners.


means the network of participating physiotherapists who have entered into an agreement with Health Partners.


includes Health Partners Dental, Health Partners Optical, Health Partners participating pharmacies, and physiotherapy providers that are part of the Health Partners physiotherapy scheme.


in compliance with the definition under the Government Rules, means Health Partners’ health insurance business of undertaking liability relating to the hospital treatment and/or general treatment of its members, by way of insurance.


in compliance with the definition under the Government Rules, means Health Partners’ health related businesses of:

a. providing optical and dental services and goods;
b. undertaking liability, by way of insurance, to indemnify people who are ineligible for Medicare for costs associated with providing treatment, goods or services, that are provided to those people in Australia and are provided to manage or prevent diseases, injuries or conditions; and
c. providing a financial service to assist people insured under complying health insurance products to meet the costs associated with treatment, goods or services that are provided to manage or prevent diseases, injuries or conditions.


means nursing in a home by a registered nurse who meets the recognition criteria and where the treatment is not hospital treatment.


means a membership which covers some or all hospital treatment.


means an agreement between Health Partners and a private hospital or private day hospital, where Health Partners must pay and that hospital must accept a schedule of agreed prices in full payment for hospital treatment provided to Health Partners’ members covered for this 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.


means 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.


means 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.


means a contract between Health Partners and medical practitioners that allows us to pay benefits in excess of the Medicare Benefits Schedule fees for those practitioners’ services.


means a payment made to an eligible person under the Australian Government’s Medicare Scheme.


means each insured person being the policyholder and each of their dependants who are registered under these Rules and for the avoidance of doubt.


means one or more members covered under the same policy or policies.


means a category described below containing the number and kinds of people described:

a. single membership, which comprises only one person;
b. couples membership, which comprises only two adults who are the policyholder and their partner;
c. single/sole parent membership, which comprises only one adult, who is the policyholder and one or more dependent children; and
d. family membership, which comprises only two adults, who are the policyholder and their partner and one or more dependent children.


means a calendar month.


is defined in Government Rules and means a patient in hospital who has been provided with accommodation and nursing care for a continuous period exceeding 35 days and is then receiving accommodation and nursing care as an end in itself.


means a patient of a hospital who is not an admitted patient, with the exception of qualifying day procedures and treatments.


means a provider of general treatment whose business is neither a Health Partners health related business nor do they have a contract with Health Partners for the provision of general treatment.


means a person who:

a. is married to the policyholder;
b. is a de facto spouse of the policyholder; or
c. irrespective of gender, is in a genuine domestic relationship with the policyholder with them together being a couple.


means a person who:

a. is married to the dependent child;
b. is a de facto spouse of the dependent child, or
c. irrespective of gender, is in a genuine domestic relationship with the dependent child, with them together being a couple.


means a person receiving or registered to receive treatment.


means the Australian Government’s Pharmaceutical Benefits Scheme


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.


means a complying health insurance product detailing the terms and conditions of that product.


means a person whose name an application for membership of Health Partners has been accepted, and who is responsible for payment of premiums.


means where a member has an ailment, illness or condition that, in the opinion of a medical practitioner appointed by Health Partners, the signs or symptoms of which existed at any time during the six months preceding the day on which the member became insured for treatment relating to that ailment, illness or condition under a policy.


means the amount a policyholder is required to pay for a specified period of cover.


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.


means 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.


means a person who is admitted to a public or private hospital as an acute care patient and who is not a public patient.


means:

a. a person who provides goods or services as, or as part of, hospital treatment or general treatment; or
b. a person who manufactures or supplies goods provided as, or as part of, hospital treatment or general treatment.


means a person who is admitted to a public hospital and who receives treatment as a Medicare patient without charge.


means the following conditions apply to a person who is a provider of treatment that we will pay benefits for:

a. the person is registered, or holds a licence, under any relevant State or Territory legislation to render treatment for which recognition is sought;
b. the person is professionally qualified or a member of a professional body recognised by Health Partners;
c. the person maintains comprehensive and accurate patient records that are made at the time of treatment, or as soon as practicable after, that clearly identify the patient and the treatment provided, and are written in English and understandable by a third party;
d. the person provides facilities that meet the standards determined or recognised by Health Partners and the Government Rules; and
e. the person fulfils the other criteria that Health Partners considers reasonable and appropriate from time to time.


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


has the same meaning as a Private Health Insurance Incentive Beneficiary (PHIIB) as defined in the Government Rules.


means for yourself only (including responsible adult).


means health or medical treatment to manage, prevent or alleviate a condition, disease or injury by the provision of either or both of a good or service.


means a specific period after a new cover has commenced during which benefits are not payable or benefits are only payable as per the entitlements of a previous cover or policy for treatment received.


means Health Partners.


means the member and/or policyholder.


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