membership conditions

A waiting period is the length of time you have to wait before you become eligible for benefits. A two month waiting period applies to all benefits with the following exceptions:

pre-existing conditions	12 months
obstetric related conditions	12 months
health management programs	3 months
optical	6 months
Major dental (including periodontics, endodontics, crowns and bridges, dental implants, dentures and orthodontics)	12 months
health appliances and aids	12 months
orthotic appliances	12 months
occupational therapy	12 months
clinical psychology	12 months
hearing aids	36 months

why do I have to serve waiting periods?

Waiting periods have to be served to protect the premium investment made by existing members from people who may join for only a short time in order to claim a specific benefit. The premium level paid by health fund members is set to meet the costs of all claims made against the fund. If waiting periods did not apply people could join when treatment was required, claim a benefit on expensive treatment and cancel their membership until further treatment was necessary. This hit and run cycle of membership would cause premiums to escalate at an uncontrollable rate. Waiting periods are therefore necessary in fairness to all members.
 

A benefit limitation period is an initial period of time during which only a minimum benefit is paid for some types of hospital treatment.

From 1 April 2010, benefit limitation periods apply to new members to private hospital cover and to members rejoining after a lapse in cover.

They do not apply to existing members changing their hospital cover or to new members transferring from another private health insurer providing their previous cover did not exclude the following services and they are transferring within 30 days of ceasing their previous cover.

A benefit limitation period of two years applies from the date of joining on the following services:

• joint replacements (excluding joint replacement that results from an accident)
• gastric banding
• spinal surgery (excluding spinal surgery that results from an accident)
• psychiatric services
• dialysis for chronic renal failure
• assisted reproductive services

The hospital benefits payable on all hospital products during a designated benefit limitation period will be the minimum benefit as declared by the Minister for Health and Ageing, except when a waiting period is also being served, in which case no benefit applies. The minimum benefit is equivalent to public hospital benefit only. Substantial patient out-of-pockets will apply during a benefit limitation period for treatment in a private hospital.  

A pre-existing condition is an ailment, illness or condition the signs or symptoms of which, in the opinion of a medical practitioner appointed by St.LukesHealth, existed at any time in the period of 6 months ending on the day on which the member became insured under the policy. A 12 month waiting period applies to all pre-existing conditions.
 

Hospital treatment that results from an accident which occurred after joining, is covered immediately on hospital cover, providing there is no right to claim compensation and damages from another source. An accident is an event or occurrence which is unforseen and unintended, which results in physical hurt or damage to the body and requires immediate treatment. An accident does not include an obstetric related condition, or an unforseen ailment, illness or condition brought on by medical causes.
 

No benefit is payable on any hospital cover for treatment relating to cosmetic surgery or other surgical treatment that does not meet the eligibility criteria for the payment of Medicare benefits, or is not listed in the Medicare Benefits Schedule. (with the exception of condition 8 below)
 

A 12 month waiting period applies to obstetric related conditions. After the 12 month waiting period has been served, the mother's hospitalisation will be covered on a single policy and both the mother and baby will be covered on a family policy. However, the baby will not be covered on a single policy if it requires hospitalisation in its own right after birth. To ensure coverage of a new born child, a single policy must be upgraded to a family cover from the child's date of birth, providing the change occurs within 30 days of the child's birth. A newborn child should also be added to a family cover within 30 days of the child's birth to ensure that no waiting periods apply to the child. Premature births or complications arising from a pregnancy where a medical practitioner confirms the baby's expected date of birth is after the 12 month waiting period, will be covered.

Sterilisation, vasectomies and reversals of, are only covered on our hospital covers when they attract a Medicare benefit. Benefit is not payable for procedures not covered by Medicare. Where Medicare benefit is payable, a 12 month waiting period will apply under the pre-existing rule.
 

Surgical procedures performed by a Podiatric Surgeon do not attract Medicare benefit and therefore would normally be excluded from fund benefit. However, St.LukesHealth will pay the Minimum Benefit as declared by the Minister for Health and Ageing on all hospital covers for hospital accommodation relating to surgery performed by a Podiatric Surgeon, providing all waiting periods have been served. Fees raised by the Podiatric Surgeon are not covered.
 

No benefit is payable for services, treatment or appliances rendered or purchased outside of Australia.
 

A single membership covers the individual only. A couples membership covers the member and their partner/spouse. A family membership covers the member, partner/spouse, and dependants. Dependants include children under 23 years of age who are not married or living in a defacto relationship and single full time students under 25 years of age if totally dependent on their parents. Dependants will receive immediate cover for equivalent benefits providing they join their own membership within 30 days of ceasing to qualify as a dependant and providing all waiting periods have been served under their parent's policy.
 

When changing to higher levels of cover, waiting periods and the pre-existing ailment rule will apply for the additional benefit payable on the higher cover. In the interim, your previous level of cover applies provided you have served the waiting periods on your previous level of cover.
 

Members who transfer from another Australian registered health fund within 30 days of ceasing financial membership of the previous fund, may do so without waiting periods providing the benefits are common to both funds, the transfer is to equivalent or lower levels of cover and all waiting periods have been served with the previous fund. Should the transfer be to a higher level of cover or a higher benefit than the previous fund then all waiting periods, including the pre-existing ailment waiting period will apply for the additional benefit.

If a break in hospital cover does occur on transfer, the days without hospital cover will be counted as a period of absence for the purpose of Lifetime Health Cover.  When transferring from another fund, your original age at joining hospital cover with your previous fund will be taken into consideration for the calculation of any premium loading payable under Lifetime Health Cover.
 

Premiums are payable in advance. A discount is allowed to persons who pay half yearly or yearly in advance. This discount does not apply to Packaged Bronze, Packaged 300 and Packaged 500.
 

debiting your account

By signing a Direct Debit Request or by providing St.LukesHealth with a valid instruction, you have authorised St.LukesHealth to arrange for funds to be debited from your account. We will only arrange for funds to be debited from your account as authorised in the Direct Debit Request. If the debit day falls on a weekend or public holiday, we may direct your financial institution to debit your account on the following banking day. Monthly, Quarterly, Half Yearly and yearly direct debit payments are deducted one month in arrears on the 15th of the month, or within 2 business days after the 15th. Weekly and fortnightly direct debit payments are deducted in advance on the Friday of each week or fortnight, or within 2 business days after.

amendments by us

St.LukesHealth may vary any details of this Agreement or a Direct Debit Request at any time by giving you at least 14 days written notice.

amendments by you

You may change or defer a debit payment, or terminate this Agreement by providing us with at least 7 days notification in writing.

your obligations

It is your responsibility to ensure that there are sufficient clear funds available in your account to allow a debit payment to be made in accordance with the Direct Debit Request. If there are insufficient clear funds in your account to meet a debit payment you may be charged a fee and/or interest by your financial institution or you may also incur fees or charges imposed or incurred by us and you must arrange for the debit payment to be made by another method or arrange for sufficient clear funds to be in your account by an agreed time so that we can process the debit payment. You should check your account statement to verify that the amounts debited from your account are correct.

dispute

If you believe that there has been an error in debiting your account, you should notify St.LukesHealth and confirm that notice in writing with us as soon as possible so that we can resolve your query more quickly. Alternatively you can take it up with your financial institution direct. If St.LukesHealth concludes as a result of our investigations that your account has been incorrectly debited we will respond to your query by arranging for your financial institution to adjust your account (including interest and charges) accordingly. We will also notify you in writing of the amount by which your account has been adjusted. If St.LukesHealth concludes as a result of our investigations that your account has not been incorrectly debited we will respond to your query by providing you with reasons and any evidence for this finding in writing.

accounts

You should check with your financial Institution whether direct debiting is available from your account as direct debiting is not available on all accounts offered by financial Institutions. You should also check that your account details which you have provided to us are correct by checking them against a recent account statement and you should check with your financial institution before completing the Direct Debit Request if you have any queries about how to complete the Direct Debit Request.

confidentiality

St.LukesHealth will keep information (including your account details) in your Direct Debit Request confidential. We will make reasonable efforts to keep any such information that we have about you secure and to ensure that any of our employees or agents who have access to information about you do not make any unauthorised use, modification, reproduction or disclosure of that information. St.LukesHealth will only disclose information that we have about you to the extent specifically required by law, or for the purposes of this Agreement (including disclosing information in connection with any query or claim).

notice

If you wish to notify us in writing about anything relating to this Agreement, you should write to us at the Head Office address on the back page of this brochure. St.LukesHealth will notify you by sending a notice in the ordinary post to the address you have given us in the Direct Debit Request. Any notice will be deemed to have been received on the third banking day (other than a Saturday, Sunday or public holiday listed throughout Australia) after posting.
 

If premiums are in arrears, payments will not automatically be accepted. It may be necessary to re-serve waiting periods from the date of payment of the arrears and entitlement to benefit for services rendered while in an unfinancial period may be lost. If premiums fall more than two months in arrears, the policy will be subject to cancellation and all waiting periods may have to be re-served.
 

Benefits are not generally payable for services which took place two years or more prior to the date of lodgement of the claim.
 

Benefits are not payable for any condition for which members or dependants have the right to recover costs from any other source, including third party, workers compensation or persons liable at law.
 

Benefits are only payable when rendered by a practitioner in private practice who has been approved and registered with this fund.

The approval and registration by St.LukesHealth of a Provider, Medical Practitioner, Hospital or Day Hospital Facility (as defined in the Rules and By-Laws of St.LukesHealth) for the payment of benefits does not constitute a representation or recommendation by St.LukesHealth or any of its agents that any particular Provider, Medical Practitioner, Hospital or Day Hospital Facility or any service, product or treatment recommended or provided by that Provider, Medical Practitioner, Hospital or Day Hospital Facility, will or may be of benefit to St.LukesHealth members. St.LukesHealth thus accepts no responsibility for the outcome of any advice, service, product or treatment given to members by a Provider, Medical Practitioner, Hospital or Day Hospital Facility registered with this Fund.
 

Benefits are payable at the insured rate for 365 days for all persons covered in any one year, subject to the following membership conditions.

1.  waiting periods

2.  benefit limitation periods 

3.  pre-existing ailment

5.  cosmetic surgery and surgical procedures not covered by Medicare

6.  obstetric related services

7.  sterilisation / vasectomy or reversal of

8.  podiatric surgery

17. compensation from other sources

20. benefit limited to fee charged

For hospitalisation that extends beyond 35 continuous days, benefits will be reduced unless a medical certificate for ongoing acute care is provided by the patient's doctor and approved by the Fund.
 

Benefits shall be limited to the fee charged or the insured amount whichever is the lesser.

The Medicare Benefit schedule fee is set for the purpose of paying Medicare Benefits. It does not necessarily indicate the amount that the doctor will charge but forms the basis from which the Medicare and 'medical gap' benefit is determined.
 

Under Lifetime Health Cover, if you cease your hospital membership for 3 years or more over your lifetime, an additional premium loading may apply when you rejoin. For more information on periods of absence refer to the lifetime health cover section of this web site or contact St.LukesHealth on 1300 651988.
 

Members may suspend their policy in certain circumstances on application to St.LukesHealth. The fund will consider suspension for periods of extended overseas travel, for periods of unemployment and in special cases of financial hardship. A suspension application will need to be completed. Contact St.LukesHealth on 1300 651988 for more details.

Note: The additional 1% Medicare Levy Surcharge may apply to higher income earners during any period of policy suspension. 
 

St.LukesHealth is committed to respecting your right to privacy and protecting your personal information. We are bound by the National Privacy Principles in the Privacy Act 1988 (Commonwealth) which regulates how we collect and manage your personal information. Our staff are trained to respect your privacy in accordance with our standards, policies and procedures. Our Privacy Policy outlines how we manage your personal information.

It also describes in general terms the type of personal information held, for what purposes, and how that information is collected, stored, used and disclosed. Our Privacy Policy applies to all your dealings with us whether at one of our branches, via our website or with one of our representatives. View our privacy policy for more information.
 

St.LukesHealth supports the Private Health Insurance Code of Conduct. The PHI Code of Conduct is an Industry self regulatory code which aims to promote informed relationships between private health insurers, consumers, agents and brokers. You can download a summary of the code or a full copy of the code by selecting from the links below.

        private health insurance code of conduct summary

        private health insurance code of conduct
 

If you are unable to resolve a complaint with us to your satisfaction, you have the right to address your complaint to the Private Health Insurance Ombudsman (PHIO). These services are free to members.

The Private Health Insurance Ombudsman also provides an annual State of the Health Funds Report to assist consumers in assessing the relative performance and service delivery of each registered health fund. A copy of the report is available from the office of the ombudsman or from the PHIO web site at www.phio.org.au.

The contact details for the Private Health Insurance Ombudsman are:

Level 7, 362 Kent Street,

Sydney NSW 2000

Toll free hotline: 1800 640 695

Tel: (02) 8235 8777

Fax: (02) 8235 8778

Email: info@phio.org.au

Website: www.phio.org.au

You can also view St.LukesHealth complaint resolution procedures by visiting the customer feedback section on this web site.