STANDARD CLINICAL CATEGORIES AND DEFINITIONS
What are clinical categories and definitions?
A clinical category is the name of category of treatments, for example joint reconstruction or ear, nose and throat.
A clinical definition is the name of the treatments that are covered in that category, like hip replacement or sinus surgery.
Why is the government ensuring all health funds use the same clinical definitions?
In the past, Australian health funds may have used different terms (or definitions) to describe these groups of treatments or services. This was confusing and made it hard to compare policies across different funds.
By 1 April 2020, all Australian health funds will need to use the same clinical definitions, which will help you compare different products and understand what’s covered.
How do I know which treatments and procedures are covered under each definition?
It’s not the easiest read, but you’ll find the definitions and what’s included in Schedule 4 of the Private Health Insurance (Reforms) Amendment Rules 2018.
What if I’ve booked hospital treatment and it’s not in my new cover?
If you booked treatment before 1 April 2019 (and were eligible to claim for the service when you booked) we’ll cover it at your previous level of entitlement provided you have the treatment before 1 November 2019.
I need hospital treatment that’s being removed from my cover, but haven’t booked it yet. What can I do?
We appreciate that losing cover for treatment you need is upsetting and frustrating, especially if you’ve been on your cover for a long time.
We’ll honour claims for treatment you booked before 1 April 2019, provided you're treated by 1 November 2019. For future claims you’ll need to upgrade to a new product that includes the treatment.
As a goodwill gesture, if you upgrade by 1 May 2019 you won’t have to re-serve any waiting periods. That’s an extra month after the changes come into effect on 1 April 2019. There will be waiting periods for treatments or services that weren't on your previous cover.