Hospital Services

When you're admitted to hospital, the type of benefits we may pay includes:

• accommodation
• operating theatre
• intensive care
• doctor and specialist fees
• government-approved prostheses
• PBS medicines.

The level of benefits we pay will depend on whether you go to a hospital in the HCF private hospital network.

Public hospital admissions for included services
If you receive treatment as a private patient in a public hospital for services included in your level of cover, the benefits payable are at the Gazetted Rate, which is determined by a state or territory health authority. These benefits are higher than Minimum Benefits but if the hospital charges more than the Gazetted Rate, you'll have an out-of-pocket cost.

Participating private hospital admissions for included services
If you receive treatment at a participating private hospital for services included in your level of cover, the benefits payable are specified in the hospital contract with that hospital.

Non-participating private hospital admissions for included services
If you receive treatment at a non-participating private hospital for services included in your level of cover, the benefits payable are only Minimum Benefits. Minimum Benefits are low level benefits. In some instances, the out-of-pocket costs could be significant, and depending on the treatment and length of stay, it could be up to tens or hundreds of thousands of dollars.

No matter which type of hospital you go to, you may need to pay medical out-of-pocket costs for doctors' fees, pathology and X-rays. Call our 24/7 helpline on 13 68 42, then press 2, so we can help guide you to a hospital and doctor in our network.

Emergency department fees

You'll be covered and pay $0 for emergency department fees including administration fees if the visit leads to an admission (and a charge is raised by the hospital).

If you're not admitted, we'll pay up to $200 per visit.

Note: In hospital outpatient clinics (not emergency departments) benefits are only payable for medical fees where the service would be eligible for an MBS benefit if provided to an Australian resident. No other fees or charges are payable for outpatient clinics.

Doctor and specialist services

You're covered for doctors' services for items listed on the Australian Government Medicare Benefits Schedule (MBS) and where the service would be eligible for an MBS benefit if provided to an Australian resident:

• For regular doctor visits, you’ll get back 100% when you see a doctor through our GP Network.
• For specialists and non-network doctors consultations, we'll cover you for 100% of the MBS fee.
• For pathology and radiology, we'll cover you for 100% of the MBS fee for services such as blood tests, scans and X-rays⁺.

If the provider charges above the MBS fee, you will need to pay an out-of-pocket cost.

Medicine

You're covered for medicines listed on the Australian Government approved pharmacy list (PBS):

• Medicines given to you when you leave hospital (after being admitted and discharged) are covered if part of your ongoing treatment. Your ongoing treatment includes medicines provided on a script given to you by a doctor from a medical practice that relate to your reason for admission to hospital or post discharge charge. We’ll cover you for the PBS listed price after you pay an amount equivalent to the current PBS general patient co-payment per medicine.
• Medicines required on a script given to you by a doctor from a medical practice or an emergency department are covered up to $100 per individual medicine, after you pay an amount equivalent to the current PBS general patient co-payment per medicine. There is a yearly limit of $500 per person. 

Ambulance

Emergency transportation to the nearest hospital able to provide the treatment required, from any location except a medical facility, including on-the-spot treatment and emergency transfers between hospitals but only when the original hospital does not have the required clinical facilities.

Extras are services that you claim out-of-hospital such as dental, optical, acupuncture and physiotherapy.

Get 100% back on popular extras
You can get 100% back at extras providers in our network, up to your annual limits. Including:

• 2 dental check-ups a year through our provider network
• a first visit^** to a physio and chiro in our provider network.
• a first visit^** to a podiatrist in our provider network

Plus a range of other services. For other services, there are set benefits which vary according to your cover.

Providers not available in all areas. To find a provider close to you, visit hcf.com.au/health-insurance/overseas-visitors

• Up to $110,000 for medical repatriation
  Repatriation covers the costs (air fares, on-board stretcher, accompanying aero-medical specialists and nursing staff) of returning you to your home country when it's deemed medically necessary by a medical practitioner appointed by HCF due to a medical condition covered under your policy
• Up to $20,000 for return of mortal remains or funeral expenses
  In the unfortunate event of someone on your cover passing away, and if the person passed away due to a medical condition covered under the policy, HCF will pay for the costs of returning their mortal remains to your home country, or the funeral costs if the body is buried or cremated in Australia

Other Things You May Want To Know

Excess

An excess is a non-refundable amount of money you agree to pay when you go to hospital. The excess amount you choose affects the cost of your premium. A higher excess will lower the cost and a lower excess will raise the cost.

For Top Plus you can choose a $0, $500 or $750 excess per person per calendar year when hospitalised. The excess amount will only apply to a maximum of 2 people on family policies per calendar year.

Waiting period

A waiting period is the time you need to wait before a benefit becomes available to you. You'll be covered immediately for all in-hospital and out-of-hospital services included in your cover except for the following where you'll need to wait:

• 2 months for psychiatric related services, rehabilitation or palliative care
• 12 months for pregnancy and birth (obstetrics)
• 12 months for assisted reproductive services
• 12 months for all pre-existing medical conditions^{^} (except for psychiatric related services, rehabilitation or palliative care).
• for PBS medicines required on a script from a doctor at a medical practice or emergency department, a 2 month waiting period applies. 
• for your extras services, different waiting periods apply. For major dental and orthotics, there's a 12 month waiting period. All other services included in your extras have a 2 month waiting period. 

What's not covered?

Hospital

• Out-of-pocket costs if you go to non-participating hospitals or if treated at a public hospital and they charge you more than the Minimum Benefit or Gazetted Rate.
• Hospital costs unless you're admitted to hospital, except emergency department fees.
• Out-of-pocket costs if you become classified as a nursing home type patient.
• Personal convenience, luxury room and take home items.
• The gap on government approved prostheses.
• Any service that's excluded on your policy.
• Hospital treatment when Medicare pays no benefit for Australian residents e.g. elective cosmetic surgery.
• Any excess on your policy

Medical in and out-of-hospital

• Out-of-pocket costs if you go to a non-network doctor or your specialist charges more than the MBS fee.
• Non-PBS medicines including high cost and experimental drugs.
• Co-payments on PBS medicines.
• Out-of-pocket costs when your doctor/s charge more than the MBS fee and when any charges aren't covered by our No Gap arrangement
• Non-emergency ambulance.
• Medical services that are part of any service that's excluded on your policy.
• Out-of-pocket costs for diagnostic services such as X-rays, scans and blood tests if the provider charges more than the MBS fee.
• Medical services for surgical procedures performed by a dentist, podiatrist, podialric surgeon or any other practitioner or service for which Medicare pays no benefit.
• Outpatient medical services provided by an allied health provider (e.g. optometrist, physiotherapist, dentist and psychologist) unless covered under your extras.
• Costs for medical examinations, X-rays, vaccinations or any treatment required for obtaining a visa to enter Australia, change in visa or application for permanent residency or examination for pre-employment purposes.

Other

• Treatment received outside Australia.
• Costs if compensation, damages or benefits are payable by a third party. For example, workers compensation or motor vehicle accident. 
• Out-of-pocket costs for extras goods and services not included in our No Gap network or not covered on your policy. 
• A service that has a waiting period until that time has been served.
• Cost of repatriation that isn't deemed as medically necessary and not due to a medical condition covered under your policy.
• Costs of returning mortal remains to home country, or funeral costs if a member's body is buried or cremated in Australia, if the member passed away due to a medical condition not covered under their policy.

HCF doesn't cover these extras for Top Plus cover:

• Occupational Therapy. 
• Audiology.
• Speech Pathology
• Alexander Technique.
• Hearing Aids, Artificial Aid.
• Health Management Programs. 
• School Accident Benefit. 
• Nutrition Consultations. 
• Naturopathy. 

^{^} A pre-existing condition means an ailment, illness or condition, the signs or symptoms of which in the opinion of a Medical Practitioner appointed by HCF, existed in the period of 6 months ending on the day on which the Policyholder is covered for Hospital Benefits or upgrades to a higher Product or Insured Group. The test applied relies on the presence of signs or symptoms of the illness, ailment or condition; not on a diagnosis.

^* Excludes emergency ambulance transport from a medical facility or a hospital except for emergency inter-hospital transfers where the original admitting hospital doesn't have the required clinical facilities.

⁺ This doesn't include costs for medical examinations, X-rays, vaccinations or any treatment required for obtaining a visa to enter Australia, change in visa or application for permanent residency or examination for pre-employment purposes.

^** A first visit means an initial consultation for an eligible health condition that is new or flare up where no treatment has been provided in the last 3 months.