PREPAID Health Insurance

DOWNLOADS GMHBA Full Product Brochure April 2009 
NSW/ACT, QLD, SA, WA, TAS, NT
Victoria

Important Information to Read Before You Buy Online

The Bronze Young Singles Package costs so little because you'd be a private patient in a public hospital with a $500 maximum annual excess and  this cover does NOT pay benefits for:

• eye surgery
• gastric banding
• joint replacement
• renal dialysis
• obstetrics and IVF and related services. 

For new memberships (no previous extras cover) or where 12 months continuous dental cover has not been in existence, all dental benefits will be limited to $200 on the Bronze Young Singles Package during the first 12 months of membership with GMHBA.

Extras Health Insurance - What's covered?

A range of extras services such as dental, physio, chiro and ambulance. These services are not covered by Medicare and you can claim on the spot using your GMHBA membership card at more than 20,000 extras providers throughout Australia. If you’re in any doubt, please call us on 1300 4 GMHBA to find out if your extras provider is recognised by GMHBA.

Bronze Combo Extras Table for Victoria 

Bronze Combo Extras Table for NSW/ACT, QLD, SA, WA, TAS, NT 

Hospital Health Insurance - What's covered?

Public Hospitals
Accommodation costs when you’re admitted to a shared room in a recognised public hospital (subject to bed availability) for services not listed under ‘Exclusions’. Limited benefits may apply to high cost drugs. Drugs purchased outside the hospital are not included.

Private Hospitals
Fixed benefits are payable for accommodation in private hospitals for services not listed under ‘Exclusions’. The benefit depends on the type of treatment, accommodation or surgery received and length of the hospital stay. Additional private hospital costs such as theatre and delivery suite charges are not covered. For services not listed under ‘Exclusions’ benefits for a private room in a public hospital or treatment in a private hospital when using this cover will result in significant out-of-pocket expenses.

Additional benefits
In both public and private hospitals, this cover includes benefits for:
• Medical gap.
• Surgically implanted prostheses – Government prescribed benefits.
• Nursing home type patients - Government prescribed benefits are available towards non acute hospital care.

Exclusions
To make this cover more affordable, no benefits are payable for eye surgery, gastric banding, joint replacement, renal dialysis, obstetrics and IVF and related services.

$500 Maximum Annual Excess
If you’re hospitalised, once you’ve paid the excess you’ll receive the full benefits of Bronze Hospital cover. The excess is payable once every calendar year. If you pay the maximum annual excess in a calendar year there are no more excesses to pay for the remainder of that year regardless of how many times you may be hospitalised. If you don’t have any admissions to hospital you won’t pay the excess.

Health Insurance Waiting Periods

Hospital services (when included on cover)	Waiting period
Accidents - Bodily injuries resulting from accidents which occur after the date of joining GMHBA or upgrading to a higher cover	No waiting period
Obstetrics and maternity	12 months
Pre-existing ailment, illness or condition	12 months
Other hospital services	2 months
Extras services (when included on cover)	Waiting period
All extras benefits except as specified below	2 months
Optical, home and domestic aids, medical aids, and respite care	6 months
Major dental services (Including full & partial dentures, orthodontics, crown & bridgework, gold fillings, inlays & onlays, surgical extractions of a tooth/teeth including wisdom teeth)	12 months
Nebuliser pump	12 months
Blood glucose monitor	12 months
Pressure garments	12 months
Sleep apnoea monitor	12 months
Extremity pump	12 months
Hearing aids	12 months
Orthopaedic appliances (GMHBA approved)	12 months
Prostheses (GMHBA approved non-surgical)	12 months
Tens monitor	12 months
Podiatry surgical procedures and orthotic appliances (foot)	12 months

Pre-existing ailments (Health Insurance PEA Rules)

A pre-existing ailment is one where signs or symptoms of your ailment, illness or condition, in the opinion of a medical practitioner appointed by GMHBA (not your own doctor), existed at any time during the six months preceding the day on which you purchased your hospital insurance or upgraded to a higher level of hospital cover and/or benefit entitlement.

The only person authorised to decide that an ailment is pre-existing is the medical practitioner appointed by GMHBA. However, the fund medical practitioner must consider any information regarding signs and symptoms provided by your treating medical practitioner/s.

The pre-existing ailment rule still applies even if your ailment, illness or condition was not diagnosed prior to joining the hospital cover. The only test is whether or not, in the 6 months prior to joining your current hospital table signs and symptoms:

• were evident to you or,
• would have been evident to a reasonable general practitioner if a general practitioner had been consulted.

Exclusions

Dental Benefit Limitation

For new memberships (no previous extras cover) or where 12 months continuous dental cover has not been in existence, all dental benefits will be limited to $200 per person/single membership and $400 per family membership during the first 12 months of membership with GMHBA.

Further details of waiting periods including pre-existing ailments can be found on pages 73 and 77 of the April 2008 Member Guide.

Hey, this package costs so little because you'd be a private patient in a public hospital with a $500 maximum annual excess and this doesn't pay benefits for: eye surgery, gastric banding, joint replacement, renal dialysis obstetrics and IVF and related services. Got it?

Before you join or transfer your health insurance to GMHBA please read the following important information. If you have any questions about your health insurance please call our trained Customer Service Advisors on 1300 4 GMHBA (46422) or visit a branch. We remind you to contact us for a benefit estimate before commencing any treatment just to confirm the benefit payable and that our premiums may vary for each state/territory. Please retain this member guide with any other GMHBA documents.

Index

Application for membership with GMHBA

You’ll be asked to complete a membership application when you join GMHBA or make changes to your membership. For example, when you change your level of cover or add/remove a person covered by your membership. You can make changes to your membership anytime.

When you complete a membership application it’s important that you provide us with all the information requested to allow us to maintain an accurate record of your membership. It is also important that the information you provide is true and correct.

GMHBA will consider your membership void if you provide false or incorrect information on your membership application and premiums recieved thereon will be refunded. Like most health funds, GMHBA uses the terms ‘fund member’ and ‘dependant’ to define the people covered by a membership. Only the person nominated as the ‘fund member’ can authorise changes to the membership unless the fund member has previously authorised the spouse/partner to make such changes.

Similarly, correspondence issued by GMHBA will be addressed to the fund member and it is the fund member’s responsibility to notify GMHBA of any change of address. The signing of the membership application and the payment of any premium constitutes an acceptance of any conditions laid down in the regulations of the fund in force at that time or as they may be amended from time to time.

GMHBA reserves the right to refuse admission to membership of any level of health insurance except Bronze Hospital cover.

In the event of any policy holder or person named on the policy holder’s membership is convicted in a court of law of assault or similar offence against a staff member related to that staff member’s performance of their duties or is convicted in a court of law of fraud against the fund, the Board may in its discretion, declare the policy holder’s membership void. The status of the policy holder’s membership will be assessed with any outstanding claims being honoured and any monies shall be refunded. Any rights accrued to the policy holder will be forfeited.

Arrears

GMHBA fund members are responsible for ensuring their premiums are up to date. Membership will cease when premiums fall into arrears of more than 2 months after the premium due date. To claim benefits a fund member must be financial at the time of incurring the expense for the service or treatment.

Audits

GMHBA undertakes audit activities in order to protect members’ assets and contain costs. From time to time, in the general interest of members, a GMHBA representative may contact you with a request for assistance to monitor costs - whether relating to benefits paid or charges raised by health care providers. Your co-operation with such requests is critical to our cost containment efforts, and will be treated in a completely confidential manner.

Check your cover

GMHBA offers a wide range of health insurance options each providing a different level of benefits. We recommend that you contact us to confirm your exact benefit entitlement before you go to hospital or get treatment.

Claiming

Claims may be made personally at any GMHBA branch, by post or by the assignment of your benefit entitlement to a hospital or health care provider. In order to assess your claim and calculate your benefit, GMHBA needs the following information:

• A completed claim form when remitted by post or via a provider, and
• The fully itemised health care account/s, and, if you have paid the account/s, the original receipt/s. Photocopies/facsimiles of accounts and/or receipts cannot be accepted.

You’ll also be required to provide additional documentation with claims for the services/items listed below.

• A doctor’s letter of recommendation is required to be lodged with claims for the following items/services: blood glucose monitor, extremity pump, nebuliser pump, appliances, sleep apnoea monitor, pressure garments, GMHBA approved orthopaedic appliances, non-surgical prostheses, oxygen, medical aids, home and domestic nursing aids, defined accommodation (respite), nicotine replacement therapy patches, learn to swim lessons, blood pressure monitors and joint supports.
• An orthodontic treatment plan certificate, completed by the treating orthodontist/dentist is required before orthodontic benefits can commence. You can obtain an orthodontic treatment plan certificate by calling our customer service centre on 1300 4 GMHBA (46422) or from any GMHBA branch. For the purpose of benefit payments, orthodontic treatment is regarded as commencing on the date the appliance is originally fitted. Limits apply every calendar year.

Unpaid accounts (other than hospital accounts)

Claims for unpaid accounts will be paid by direct credit (where available) or cheque. The benefit cheque will be made payable to the health care provider. The cheque should be immediately forwarded to the health care provider, together with your payment for any account balance.

Paid accounts

Benefits for paid accounts will be paid:

• in cash at any GMHBA branch for claims of less than $500, when claimed in person,
• by cheque, made payable to the fund member for largerclaims, and mail claims,
• directly into the members’ financial institution account where these arrangements are in place,
• to GMHBA, where the member requests that the benefit refund is, either in part or full, used to pay GMHBA premiums.

Medical benefits

Claims for medical benefits can only be paid after your claim for medical services has been assessed by Medicare (except in the case of claims made through GMHBA’s medical gap cover - see pages 15-16 for details) and your claim for hospital benefits has been assessed and paid. GMHBA benefits are not payable for services rendered when the patient is not a hospital inpatient.

Agent’s authority

You may authorise another person to collect benefits on your behalf by completing the Agent’s Authority section of the claim form. The fund member and the agent (the person who is being authorised to collect the benefits) must sign the authority. The agent will be requested to sign the claim form again when benefits are paid.

Code of conduct

GMHBA is a fully compliant member of the private health insurance code of conduct. The Australian Health Insurance Association (AHIA) in conjunction with the Health Insurance Restricted Membership Association of Australia (HIRMAA) has developed codes of practice called the Private Health Insurance Practice Codes to reinforce existing regulatory obligations and to establish a minimum standard of business practice applicable to all participants in such codes. The first code to be established is the Private Health Insurance Code of Conduct. Development of the codes commenced in 2003 with a committee formed by AHIA and HIRMAA. That committee had broad representation from funds, so the development has had detailed and expert input from a cross-section of the industry and from stakeholders. The Minister for Health and Ageing and the Treasurer have endorsed the Code. The Code is designed to sit beside the current Government acts and regulations within which the industry operates and underlines the intent of the industry to show its commitment to consumers.

You can download a copy of the Code at www.privatehealth.com.au/codeofconduct.php

Community Rating

GMHBA is a strong supporter of the principles of community rating. As such, GMHBA will not discriminate between members on the basis of their health or any other reason described below. When making decisions in relation to members, GMHBA will disregard the following:

1. The suffering by the member of a chronic disease, illness or any other medical condition.
2. The gender, race, sexual orientation or religious belief of a person.
3. Except in relation to Lifetime Health Cover loadings, the age of a member.
4. Any other characteristic of a person (including but not just matters such as occupation or leisure pursuits) that are likely to result in an increased need for hospital treatment or general treatment.
5. The frequency with which a person needs hospital treatment or general treatment.
6. The amount, or extent, of the benefits to which a member becomes, or has become, entitled during a period.

Connect rewards plus

• GMHBA does not recommend or endorse any health or medical program, therapy or appliance in respect of which connect rewards plus benefits are offered or paid. Some programs, treatments or appliances should not be undertaken or used without medical advice.
• In circumstances where family/couples/single parents memberships change to a single membership, the existing membership may retain the connect rewards accrued.
• Connect rewards plus is a membership reward. Connect rewards plus entitlements cannot be transferred from one membership to another.
• When you have a hospital admission which results in out-ofpocket expenses, we’ll write to you within 60 - 90 days of your hospital discharge to ask if you would like to use your connect rewards plus dollars towards the cost of the inpatient medical gap. In the letter, we’ll include your current connect rewards plus balance. You must have a connect rewards balance and an out-of-pocket medical expense of at least $50 at the time of discharge to qualify for benefits. You can only claim connect reward benefits for inpatient medical gap by producing a copy of the letter and completing the form attached to it. These types of claims cannot be processed in branches on the spot without the member having received a letter from GMHBA first.

Damages or compensation

Where you or your dependants have a right to claim damages or compensation from any other person or body, you are required to pursue that entitlement prior to lodging a claim for benefits with GMHBA. A claim should only be lodged with GMHBA if action at law is unsuccessful. A letter of denial is required. This includes WorkCare, TAC, public liability and third party claims.

Dependants

1. GMHBA membership

Child dependants: are covered up until they turn 21 years of age if they no longer meet the criteria for student dependants. Child dependants that do no meet the criteria (of a student dependant) will be terminated off the membership from the date they turned 21. They have 2 months to organise health insurance from this date however, their new membership will commence from the date they turned 21. They will not be required to serve waiting periods when transferring to an equivalent or lower level of health insurance.

Student dependants: are covered up until they turn 25 years of age. They have 2 months to organise health insurance from this date however, their new membership will commence from the date they turned 25. They will not be required to serve waiting periods when transferring to an equivalent or lower level of health insurance.

Student dependants - mid year school/ apprenticeship & traineeship leavers: who transfer from their parent’s GMHBA membership within 2 months of leaving school or finishing an eligible apprenticeship or traineeship through a registered training group are not required to serve waiting periods when transferring to an equivalent or lower level of cover. A letter from their school or registered training group confirming the date of completion is required.

Student dependants - end of year school/ apprenticeship & traineeship leavers: are covered under their parent’s family or single parent membership until the 31st of March the following year. They will not be required to serve waiting periods when transferring to an equivalent or lower level of health insurance.

Group Training is an employment and training arrangement whereby an organisation employs apprentices and trainees under an Apprenticeship/Traineeship Training Contract and places them with host employers. A registered Group Training Organisation undertakes the employer responsibilities for the quality and continuity of the apprentices’ and trainees’ employment and training. To qualify as a traineeship and be eligible to attract Commonwealth Government incentives, there must be a registered training contract between the trainee and the employer. Please contact us on 1300 4 GMHBA (46422) or visit a branch for more information.

2. Other funds

Student dependants whose parents are fund members of another registered health fund may join GMHBA within 2 months of ceasing to be a dependant, on a level of cover equal to or less than that held by their parents, without serving waiting periods. An acceptable transfer certificate and claims history must be received.

3. Previously uninsured

Previously uninsured dependants may join GMHBA within 2 months of leaving school or on completion of a full-time apprenticeship/ traineeship, and receive immediate Bronze Hospital cover benefits, except for any pre-existing ailment/illness (other than for psychiatric, rehabilitation and palliative care) and maternity cases for which a waiting period of 12 months will apply.

All waiting periods must be served for extras benefits and hospital benefits which are higher than those available from the Bronze Hospital cover.

Child dependant excess

No excess applies for child dependants under 21 on GMHBA’s Gold and Silver family hospital covers listed in the April 2008 member guide.

Dispute resolution process

Our mission to be your trusted partner in the provision of private health insurance goes beyond providing quality affordable products and high levels of customer service.

While we receive many letters of praise about our products and customer service advisors like any organisation we aren’t perfect and on occasions we also receive complaints. We believe that your complaints are of equal or greater importance than praise.

As such we have stringent guidelines in place to ensure we acknowledge you in the most efficient and timely manner.

So, in the unfortunate circumstance that you have a concern or complaint you can contact us through the following channels and can expect an acknowledgement as indicated below:

1. Talk to a GMHBA representative:
   You can talk to a representative by visiting a branch, calling 1300 4 GMHBA (46422) or emailing This e-mail address is being protected from spambots. You need JavaScript enabled to view it . We respond to all our phone calls immediately, and will follow up all e-mail and telephone messages within 24 hours.
2. Write to us:
   We will provide an acknowledgement within 5 working days for written correspondence. Where the matter is complex we will attempt to finalise within a month. However where the difficulty of the matter precludes this, we will inform you of the progress.
3. Write to the Member Services Review Committee (MSRC):
   If after receiving our response if you are still not satisfied you can write to the Member Services Review Committee (MSRC). We have appointed a panel of highly experienced employees including Subject Matter Experts, First Line Leaders, a Senior and Executive Manager who meet regularly to discuss any issues received from members. The aim of the MSRC is to listen to you and provide decisions that are fair and equitable for all our members. You will receive an acknowledgement of your correspondence within 5 working days of the committee’s weekly meeting. You’re welcome to write to the MSRC at PO Box 761 Geelong VIC 3220.
4. Contact our Member Satisfaction Manager:
   If you require further clarification about the decision made at the MSRC please write to the Member Satisfaction Manager at PO Box 761, Geelong VIC 3220. We will acknowledge your correspondence within 5 days of receipt. Where the matter is complex we will attempt to finalise within a month, however where the complexity of the matter precludes this, we will keep you informed of the progress.

If you’re still dissatisfied with the outcome, free independent advice is available from the Private Health Insurance Ombudsman. You can contact the Ombudsman on freecall 1800 640 695 or Level 7, 362 Kent Street, SYDNEY NSW 2000.

Electronic claiming

When you have GMHBA extras cover you can use your GMHBA membership card to claim electronically on the spot when this facility is available at your health care provider. After the service has been provided, your membership card will be swiped through the terminal, your claim details entered and your claim will usually be processed electronically within seconds. Once your claim is authorised by GMHBA, you simply pay any difference between the full fee for the treatment and the amount claimed by GMHBA.

If there is an unexpected rejection of your claim at point of service, your provider should contact GMHBA on 1300 4 GMHBA (46422) to clarify the issue at the time of the service taking place.

Excess

GMHBA’s range of hospital covers often feature an excess to let GMHBA members share some of the cost of hospital admissions in return for lower premiums. An excess is deducted from the benefit paid by GMHBA. For example, if GMHBA’s full benefit for a hospital stay was $5,000 and the member has a $250 excess on their hospital cover, the benefit would reduce by the amount of the excess and an adjusted benefit of $4,750 would be paid.

No excess applies for child dependants under 21 on GMHBA’s Gold and Silver family hospital covers listed in the April 2008 member guide. Excess amounts apply to the overall membership not to each individual covered by the membership.

Exclusions

You cannot claim for the following:

• The supply of contraceptives, fertility and IVF drugs and items available through the Pharmaceutical Benefit Scheme (PBS).
• Natural remedies (Includes Modifast & Optifast).
• Food supplements.
• Pharmacy items, where they are available over the counter and purchased with or without a prescription.
• Supply of liquid filled Temazepam capsules.
• Pharmaceuticals purchased overseas and not listed on the Australian Register of Therapeutic Goods.
• Dental procedures carried out and charged direct to the fund member/dependant by a dental mechanic, other than an advanced dental technician.
• A range of dental procedures when provided on the same day e.g. a filling on a tooth that has been removed.
• Dental procedures where a limit on the number you can have has been exceeded.
• Dental procedures unless tooth identifications (ID) are supplied by the provider.
• Services/treatment for which the member and/or dependant has a right to claim damages or compensation from any other person or body.
• Treatment where the member and/or dependant is eligible for free treatment under any Commonwealth or State Government Act
• Services/treatment rendered more than 2 years prior to the date of claiming.
• Where more than one consultation and/or treatment type per day has been claimed regardless of provider within the group of chiropractor (excluding x-ray), naturopath, homeopath and osteopath.
• Where more than one consultation and/or treatment type per day has been claimed regardless of provider within the group of physiotherapy, myotherapy and if eligible, remedial massage.
• Services/treatment which is not covered by your membership and/or is rendered while the membership is in arrears or is suspended.
• Services/treatment rendered by a practitioner not in privatepractice and/or not recognised by bodies approved by GMHBA.
• Pressure garments purchased for reasons other than treatment of burns, lymphoedema or for postoperative surgery up to 60 days from hospital discharge only.
• GMHBA specified and approved orthopaedic appliances purchased for support purposes only.
• Hiring of equipment (unless otherwise stated).
• Mass immunisation, services rendered in the course of the carrying out of a mass immunisation.
• Dental treatment not rendered face to face (e.g. remotely over the phone).
• Foot orthotics provided by a physiotherapist or chiropractor.
• Additional medical gap benefits where the medical service is rendered by a medical practitioner employed full-time in the public sector.
• Treatment provided to a member of the providers family and/ or to a providers business partner and their family members or any other people not independent from the practice. Family members include: wife/husband, brother/sister, children, parents, grandparents, grandchildren of the provider/business partners’ and their spouse/partner.
• Benefits for lifestyle related services that primarily take the form of sport, recreation or entertainment.
• Fund benefits, payable under a hospital or extras cover shall not exceed the fees and/or charges raised for any treatment and/or services covered for benefits under the relevant cover, after taking into account benefits paid from any other source.
• Benefits for services on treatment received overseas.

Insure? Not sure?

If you need more information about private health insurance please refer to the Private Health Insurance Administration Council (PHIAC) guide “Insure? Not sure?” Which can be downloaded from our website or www.phiac.gov.au/insurenotsure

Liabilities of fund members to GMHBA

A fund member can be liable to GMHBA for unpaid premiums and for overpayments. Overpayments can be made by GMHBA to a fund member, either through an error in completing a claim, or an error in processing a claim. If an overpayment is made, the fund member is liable to repay the amount of the overpayments to GMHBA on demand.

If a fund member is liable to GMHBA for unpaid premiums or overpayments then GMHBA has the right to deduct the amount of that liability from any monies due by GMHBA to the fund member on any account.

Medicare levy surcharge

The Medicare levy surcharge is a surcharge on individuals and families on higher incomes who don’t have eligible private patient hospital cover (eligible cover). The surcharge is 1% of taxable income in addition to the normal 1.5% Medicare Levy. People may have to pay the Medicare levy surcharge if they or any of their dependants do not have eligible cover and they are:

• A single person - without dependent children - with a taxable income (including any reportable fringe benefits of $1,000 or more) greater than $73,000.
• A family - including a couple and single parent - with a combined taxable income (including any reportable fringe benefits of $1,000 or more) greater than $146,000 (increasing by $1,500 per dependent child, after the first child).

Contact your tax adviser or GMHBA for further details about the Medicare levy surcharge.

Membership card

When you join GMHBA, you’ll receive a membership card that identifies you as a member. The card shows your membership number and who is covered. GMHBA’s contact details are listed on the back of the card. Have your membership card on hand when you arrange admission to hospital, visit a participating provider or when you call GMHBA with any questions.

A new card may be issued when you make changes to your membership. Please note that an existing card will become invalid whenever a new membership card is issued. Keep your card safe and please advise GMHBA if your card is lost or stolen.

Membership for non- residents of Australia

GMHBA hospital covers are designed for people who have full Medicare eligibility. These covers will not meet the cost of public hospital treatment, medical treatment or diagnostic services for people who do not have full Medicare eligibility. Temporary residents of Australia who do not have full Medicare eligibility should contact GMHBA on 1300 4 GMHBA (46422) or visit a branch to discuss appropriate health insurance arrangements.

Migrants

Migrants who join GMHBA within 2 months of arriving in Australia shall receive the following concessions:

• No 2 month waiting period for any level of hospital cover.
• No 12 month waiting period for pre-existing ailments/illnesses will apply to Bronze Hospital cover.

All other waiting periods for hospital and extras will apply. Proof of residency must be presented to GMHBA. Lifetime health cover regulations also apply to migrants. Contact GMHBA for details.

Overseas travel

GMHBA does not provide benefits for services or treatment received overseas.

GMHBA advises that you take out travel insurance for the set period of your travel and that it’s suitable to the destinations you’re visiting. You can purchase a range of travel insurance options from this website.

Participating providers

A participating provider is a health care provider, with whom GMHBA has entered into an agreement relating to direct billing and/or fees and benefits. These agreements aim to maximise your cover and minimise your out-of-pocket costs. Details of participating private hospitals can be obtained from any GMHBA branch, by calling 1300 4 GMHBA (46422) or from this website.

a) Participating private hospitals

1. Gold Hospital covers
   Members of GMHBA’s Gold Hospital covers, who are admitted to a participating private hospital and have served all waiting periods are entitled to cover for accommodation, theatre, delivery suite, intensive and coronary care and other agreed hospital charges - less any excess (if applicable). Members should present their GMHBA membership card when attending a participating private hospital. Public hospitals: Gold Hospital cover provides cover for hospital accommodation costs when you are admitted to a private or shared room (subject to bed availability) as a private patient in a recognised public hospital.
2. Silver Hospital Young Couples cover, Silver Hospital Single Parents cover and Silver Hospital Young Singles cover.

These covers have benefit exclusions and restrictions for a range of services:

These excluded services do not attract any benefits.

Limited benefits may apply to cosmetic surgery and high cost drugs. Drugs purchased outside of the hospital are not included.

b) Non-participating hospitals

Fixed benefits are payable for hospitalisation in non-participating private hospitals. Please contact GMHBA on 1300 4 GMHBA (46422) or visit a branch for further details.

Members of Gold Hospital, Silver Hospital Young Couples, Silver Hospital Single Parents and Silver Hospital Young Singles cover who are to be admitted to a non-participating private hospital should contact GMHBA at least 3 business days before admission. GMHBA will then contact the hospital and negotiate fee and benefit arrangements on the members’ behalf with the aim of minimising out-of-pocket costs.

Limited benefits may apply to cosmetic surgery and high cost drugs. Drugs purchased outside of the hospital are not included.

Please Note: Benefits for a private room in a public hospital or for treatment in a private hospital when using Bronze hospital cover will result in significant out-of-pocket expenses. For further information on private patient benefits on Bronze Hospital cover, please call us on 1300 4 GMHBA (46422) or visit a branch.

Participating dentists - dental plus scheme

GMHBA has arranged agreements with many dentists throughout Victoria. These agreements relate to fees and benefits for a number of different preventative and diagnostic dental services. To maximise your cover, dental plus members receive benefits of 70% - 100% of the GMHBA schedule fee for these services, depending on the level of extras cover selected.

GMHBA members also receive substantial benefits for all other services. However these are paid at a fixed amount per service, rather than as a percentage of the GMHBA schedule fee.

You can claim benefits from GMHBA at participating dentists using their electronic claiming systems (if available). Simply show your GMHBA membership card to the dentist for processing and then pay the balance (if any) of the claim. Remember, your membership must be paid up to at least the date of service when electronically claiming.

If your dentist does not participate in the Dental Plus scheme, you’ll still be able to use electronic claiming systems if available however, the dental services benefits will be paid at a fixed amount per service.

Participation by a dentist in the Dental Plus Scheme is not a recommendation or endorsement by GMHBA of the dentist.

Payment in advance

A fund member (or person paying on their behalf) may not make a payment of premiums that would cause the period of cover to exceed 12 months in advance of the contribution due date.

Pre-existing conditions (PEC)

A pre-existing condition is one where signs or symptoms of your ailment, illness or condition, in the opinion of a medical practitioner appointed by GMHBA (not your own doctor), existed at any time during the six months preceding the day on which you purchased your hospital insurance or upgraded to a higher level of hospital cover and/or benefit entitlement.

The only person authorised to decide that a condition is pre-existing is the medical practitioner appointed by GMHBA. However, the fund medical practitioner must consider any information regarding signs and symptoms provided by your treating medical practitioner/s.

The pre-existing condition rule still applies even if your ailment, illness or condition was not diagnosed prior to joining the hospital cover. The only test is whether or not, in the 6 months prior to joining your current hospital table signs and symptoms:

• were evident to you or,
• would have been evident to a reasonable general practitioner if a general practitioner had been consulted.

When to contact GMHBA

If you have less than 12 months membership on your current hospital cover, make sure you contact us before you are admitted to hospital and find out whether the pre-existing ailment waiting period applies to you. We need about 5 working days to make the pre-existing condition assessment, subject to the timely receipt of information from your treating medical practitioner/s. Make sure you allow for this time frame when you agree to a hospital admission date. If you proceed with the admission without confirming benefit entitlements and we subsequently determine your condition to be pre-existing, you’ll have to pay all outstanding hospital charges and medical charges not covered by Medicare.

Emergency admissions

In an emergency, we may not have time to determine if you are affected by the pre-existing condition rule before your admission. Consequently if you have less than 12 months membership on your current hospital cover you might have to pay for some or all of the hospital and medical charges if:

• you are admitted to hospital and you choose to be treatedas a private patient; and
• we later determine that your condition was pre-existing.

Privacy

We value the relationship between GMHBA and our members. An important part of this relationship is our commitment to protecting the personal information entrusted to us by our members.

This commitment is documented in our privacy policy and summarised in our privacy brochure. You can pick up a copy of our privacy brochure from any GMHBA branch, by calling our customer service centre on 1300 4 GMHBA (46422) or from this website.

Proof of age

When you join GMHBA and you are not transferring from another fund, you (and your partner for families) may need to provide one of these acceptable forms of proof of age:

• Current passport or
• Current photo driver’s licence or
• Original birth certificate or
• Statutory declaration (if you have none of the above)

Recommendation or endorsement

GMHBA is a registered health insurance fund and does not offer health or medical services or advice. GMHBA does not recommend or endorse any medical practitioner, dentist, therapist, hospital, health or medical service provider, treatment, therapy or the use of any appliance or prosthetic. GMHBA does not endorse or make any representation whatsoever as to the appropriateness or effectiveness of any service or goods for which a benefit or reward is paid.

Refunds

You may cancel your GMHBA membership from:

• the date you notify GMHBA, in writing of the cancellation (a transfer certificate will be provided to the insured person within 14 days of request) or
• your current premium due date, whichever is the earlier.
• within 60 days of joining and get a full refund of any premiums received provided you have not made a claim.

Replacement rule

A benefit replacement rule applies to a number of items/services covered by GMHBA’s extras covers. The rule requires that after you claim for such an item, you must wait a specified period of time before you can lodge another claim for the same type of item. The replacement rule applies to the following items/services: dentures, all appliances, hearing aids, nebuliser pumps, blood glucose monitors, blood pressure monitors, sleep apnoea monitors, extremity pumps, tens monitor, pressure garments, GMHBA specified orthopaedic appliances and non-surgical prostheses.

Restrictions

Benefits may not be paid or may be paid at a lower level where:

• you have already claimed the maximum allowable benefits during a specified period.
• you have transferred to GMHBA from another fund and have previously claimed for the service/treatment.
• the health care account has been incompletely, incorrectly or inappropriately itemised.
• you have an excess to pay on your chosen level of cover.
• the fund believes that a patient, following a review of the case (on the basis of information provided by the hospital either internally or using an agreed independent source), is not receiving acute care after 35 days continuous hospitalisation, GMHBA benefits will be reduced to Nursing Home Type Patients benefits and will be paid in accordance with the default benefit determined by the Health Department. All Nursing Home Type Patients are required to pay part of the cost of hospital accommodation.
• the service/s is subject to a waiting period or other limit.
• surgery is performed in hospital by a registered podiatrist/podiatric surgeon. Contact GMHBA for details.
• when no CMBS item number is provided by the GP/specialist e.g. cosmetic surgery.
• where professional services are provided to the provider or members of the provider’s family or to a provider’s business partner’s family members or any other people not independent from the practice, only wholesale material costs involved in the provision of the service are subject to benefits.
• Additional medical gap benefits where the medical service is rendered by a medical practitioner employed full-time in the public sector.

Standard Information Statements

A Standard Information Statement (SIS) is available for every product available to new and existing members of the fund. The content of the SIS will be as outlined in the private health insurance (complying product) rules.

An up to date SIS will be forwarded to anyone on request, and at the very least to members once every year (without need to be requested). If more than one adult is insured under a single policy GMHBA will only provide an SIS to one of the adults on the policy.

A newly insured member will be given an up to date copy of the relevant SIS, details about what the policy covers and how benefits are provided and a statement identifying the referable health benefits funds when they join.

State of the health funds report

Every year the Private Health Insurance Ombudsman publishes a State of the Health Funds Report. The aim of this report is to give people extra information to help them make decisions about taking up private health insurance. The report provides general independent comparative information on the performance and service delivery of all health funds. It does not provide detailed information on health fund products. A copy of this report can be downloaded from this website or www.phio.org.au

Suspension

You can suspend your GMHBA membership for periods of overseas travel provided you:

• have at least 12 months continuous unsuspended membership with GMHBA prior to departure, and,
• plan to be overseas for at least 2 months, and,
• have paid premiums to the date of departure, and
• apply for suspension of your membership prior to departure.

You’ll be required to resume your suspended membership within 2 months of returning to Australia and premiums must be paid from the date of re-entry. Your passport, boarding pass or a statutory declaration must be presented to GMHBA as proof of travel.

A 3 year maximum cover suspension period for overseas travel applies. Only the balance of outstanding waiting periods need to be served upon resumption of your membership.

Transferring from another health fund

You can transfer your health insurance from another health fund to GMHBA without serving any new waiting periods for the equivalent cover provided that you:

• have served all waiting periods with your previous fund and,
• transfer to any equivalent or lower level of cover providing you transfer within 30 days of your membership ceasing with your previous fund and,
• provide GMHBA with an acceptable transfer certificate and claims history issued by your previous fund within 7 days of transferring your cover.

GMHBA recommends that your cover starts immediately after your previous cover ends. If your new cover with GMHBA provides higher benefits or benefits for services not covered by your previous fund, you’ll be regarded as a new member for those higher benefits, and/or additional services and will be required to serve the waiting periods - but only for the higher benefits/ additional services.

If you transfer to GMHBA from another fund before completing the waiting periods with your previous fund, you’ll need to serve the balance of the waiting periods with GMHBA (see waiting periods page 54 and below under the heading ‘waiting periods’).

When you transfer to GMHBA your benefit entitlements may be adjusted by benefits already paid by your previous fund. Under lifetime health cover, continuity of a member’s/partner’s certified age at entry (CAE) is possible when transferring from another Australian registered health fund.

Waiting periods

Waiting periods exist to protect members from claims made by those who join the fund or increase their level of cover because they have an ailment or illness that may require treatment.

Waiting periods will apply to:

• New memberships (previously uninsured),
• Additions to a membership (unless the addition/s has already served all waiting periods with GMHBA or another fund) except newborns, adopted and permanent foster children where the family membership has been in existence for at least 2 months, and where the addition/s has already served all waiting periods with GMHBA or another fund,
• Existing GMHBA memberships, and transfers to GMHBA from another fund where the level of cover and/or benefit entitlement is upgraded or increased, plus any hospital or extras service not covered by the previous fund and/or where the waiting periods have not been completed.

For new memberships (no previous extras cover) or where 12 months continuous dental cover has not been in existence, all dental benefits will be limited to $200 per person/single membership and $400 per family membership during the first 12 months of membership with GMHBA.

Limited benefits may apply on hospital covers for cosmetic surgery, depending on the medical justification for the surgery.

Where a member is transferring from another product or from another health fund, waiting periods for hospital (or hospital substitute) treatment that was not covered under the old policy are no longer than:

• 12 months - obstetric or pre-existing condition (other than for psychiatric, rehabilitation or palliative care).
• 2 months - Psychiatric, rehabilitation or palliative care.
• 2 months - Any other benefit for hospital (or hospital substitution) treatment.

For hospital (or hospital substitution) treatment that was covered under the old policy, waiting periods are no longer than the balance of any unexpired waiting period for the benefit that applied to the person under the policy.

Waiting periods – Pre-existing condition (PEC)

A special waiting period applies to new members of hospital tables who have pre-existing conditions. The waiting period also applies to existing members who have recently upgraded their level of hospital cover. If the ailment, illness or condition is considered pre-existing:

• new members must wait 12 months for any hospital benefits (other than psychiatric, rehabilitation and palliative care).
• members transferring/upgrading to a higher hospital cover must wait 12 months to get the higher hospital benefits (other than psychiatric, rehabilitation and palliative care).

Existing members with at least 12 months membership in total across their old and new cover are entitled to the lower benefits on their old cover.