Important information

Important information about your hospital cover

For more detailed information about your level of cover refer to your policy document.

Changing your cover

When changing your level of cover, you may be required to serve waiting periods for any additional items, increased benefits or lower co-payments or excesses that were not on your previous cover.

Where limits apply, any benefits already paid on your previous cover within the current benefit year will be taken into account.

Changing your cover may affect your eligibility or participation in an ahm health management program.

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Claims

Claims are only payable if:

• the service is performed by an ahm recognised provider
• the service date on the receipt is less than two years old
• an original receipt or invoice is submitted to and kept by ahm
• your claim is not payable or subsidised by a third party (such as workers compensation)
• your policy is financial on the date of service.

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Disease management appliances (not available on all policies)

Proof of the diagnosis of your condition and the recommendation for a relevant appliance by a medical practitioner must accompany a claim to receive benefits. The following forms of proof are accepted:

• a doctor’s or specialist’s letter relating to management of the condition
• a doctor’s referral to a specialist for the management of the condition
• prescription for an appliance relevant to the condition
• if you’re currently enrolled in an ahm disease prevention or chronic disease management program relevant to the condition.

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Insulin pump and speech processor replacements

If you hold an eligible policy you'll be able to claim these as an 'outpatient' service which means that the replacement is fitted in a doctor's surgery or rooms rather than in hospital.

On eligible policies, these items are part of your hospital cover and are paid in the same way as other prostheses. This means we'll pay benefits according to the listed minimum price on the Federal Government's Prostheses List. We'll only pay a benefit where your specialist verifies that the replacement is medically necessary and it's not a replacement for a processor or pump that is still within warranty.

In almost all cases, we'll cover the cost of the item in full so you won't need to pay for the item first and then claim a refund from ahm. If your doctor charges more than the listed minimum price on the Prostheses List, we'll only pay the listed minimum price and you will have to pay the difference.

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Midwife assisted home births

As some members choose to have a home birth, Top Hospital, Top Hospital Level 5 and Top Hospital Level 8 and Family Hospital Level 5 will pay a benefit towards midwife assisted deliveries with a registered midwife. The benefit doesn’t apply if there’s a hospitalisation related to the birth.

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Overseas claims

Your hospital policy doesn’t cover you for any medical, hospital or ambulance services received overseas or goods purchased outside of Australia, including online purchases from overseas companies.

If you’re travelling overseas, call us so that we can help you arrange travel insurance at discounted rates. Without adequate travel insurance you could find yourself paying a lot of money if you're hospitalised overseas.

Note: If you’re out of the country for more than 30 days, you can suspend your policy for the time you’re away up to a maximum of 2 years at any one time (see Policy suspension below). However, by doing this, you could be subject to the Medicare Levy Surcharge(MLS).

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Policy in arrears (unfinancial)

Benefits are not payable for services provided during the period in which a policy is in arrears until the premium is fully paid and accepted by ahm.

ahm has the right to refuse to accept premiums if more than two months have elapsed since the financial date of the policy.

ahm fund rules require members to be at least one premium payment in advance.

Note: If a member is more than two months in arrears then the policy will be terminated by notice in writing from ahm to the principal member, effective from the last financial date of the policy.

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Policy suspension

If you're travelling overseas for more than 30 days, you can suspend your policy up to a maximum of 2 years at any one time.

To suspend your policy just send us a written or email request before your holiday with your official itinerary or e-ticket which includes the dates of travel. We’ll get back to you before you leave to confirm the suspended period. We’ll contact you on your return to confirm reinstatement of your policy and reactivating your payments.

Note: You'll still need to serve any waiting periods you may have had before leaving the country and no benefits will be paid for services provided during the suspension period.

Suspending your policy may result in you being charged the Medicare Levy Surcharge (see Medicare Levy Surcharge above). Consult your accountant, tax agent or the Australian Taxation Office for further advice.

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Policy termination

Only the principal member and ahm have the right to terminate a policy. Notice of termination must be given in writing, effective from the date specified in the notice (being a date no earlier than the date of the notice). You’re entitled to a refund of any premiums paid in advance of the date of termination.

Any member or dependant over the age of 16 covered by a policy can terminate their own individual cover by giving notice in writing to ahm, effective from the date specified in the notice (being a date no earlier than the date of the notice) but can't terminate the policy.

Cooling off period - If the principal member terminates their policy within 30 days of joining and hasn’t claimed a benefit during this period, they’re entitled to a full refund.

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Private cover in a public hospital

If you choose to be treated as a private patient in a public hospital we’ll cover the cost of accommodation in a private or shared room for all procedures except restricted services and those not paid by Medicare* (in which case the benefit would be the equivalent of a shared room). If you have a co-payment or excess with your cover, you have to pay it in this situation.

*Treatment as a private patient in a public hospital for excluded services (including services not paid by Medicare) will not receive any benefits under First Step.

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Standard Information Statements

A Standard Information Statement (SIS) is a guide to key benefits and product features of your policy. We send you a copy of your SIS at least once every 12 months when we advise you of changes to your policy and premiums and also whenever there is a detrimental change to a benefit that is listed on the document. You should review the SIS in conjunction with your cover’s policy document to provide a full overview of the benefits available to you.

If you’d like a copy of your SIS, you can download a copy from www.privatehealth.gov.au or call us on 134 246.

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Transferring from another private health insurer

If you’ve transferred from another private health insurer, we’ll acknowledge the waiting periods you’ve already served for comparable benefits.

In accepting a transfer of policy from another private health insurer, we reserve the right to treat any benefits paid by the previous insurer in the current benefit year as already being used under the limits of your new cover.

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Travel & accommodation

We’ll pay a travel and accommodation benefit related to a hospitalisation on eligible policies where either:

• the patient has to travel more than 200 kilometres return in relation to a hospitalisation;
  or
• in life or death situations for a partner or next of kin to accompany the patient;
  or
• for a parent to accompany a child dependant under the age of 18.

This benefit is only payable where both the patient and the supporter are covered under an ahm hospital policy and for travel or accommodation relating to a hospitalisation. The combined benefit per day includes both travel and accommodation. We won’t pay benefits for both the patient and supporter for the same dates.

Accommodation for a patient who travels greater than 200km return in relation to a hospitalisation is only payable for one night before and one night after the admission, unless supported by medical certification of a genuine need for an extended stay.

We'll pay for accommodation for the supporter during the patient's hospital admission only.

Note: Proof of travel and accommodation costs will be required eg. petrol dockets, bus or train tickets, hotel receipts.(Petrol dockets will be accepted when dated up to 3 days prior to hospitalisation and 1 day after discharge from hospital.)

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Waiting periods

When you take out private hospital cover or change your level of cover, you’ll have to wait a set time before you can claim for services and benefits you weren’t previously covered for.

Where benefits are greater on your new level of cover, we’ll pay the benefit at the amount on your previous level of cover until the waiting period is served.

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This is important information about your policy. Please read this in conjunction with your policy document which you can download and save for future reference.