Private Health Insurance (Complying Product) Amendment Rules 2012 (No. 2) (Cth)

Case
No judgment structure available for this case.

Private Health Insurance (Complying Product) Amendment Rules 2012 (No.2)

I, Richard Magor, delegate of the Minister for Health,make these Rules under item 3 of the table in section 333-20 of the Private Health Insurance Act 2007.

____________________________________

Richard Magor

Assistant Secretary

Private Health Insurance Branch

Medical Benefits Division

Department of Health and Ageing

22 March 2012

Contents

PART 1PRELIMINARY

SCHEDULE – AMENDMENTS4

Part 1Preliminary

1.Name of Rules

These Rules are the Private Health Insurance (Complying Product) Amendment Rules 2012 (No.2).

2.Commencement

These Rules commence on 1 April 2012.

3.Amendment of the Private Health Insurance (Complying Product) Rules 2010 (No.2)

The Schedule amends the Private Health Insurance (Complying Product) Rules 2010 (No.2).

Schedule – Amendments

[1] Schedule 1- Standard information statements: hospital treatment

Delete Schedule 1 and substitute:

Schedule 1―Standard information statements: hospital treatment

Form of statement

  1. Note:

    The next page of these rules is page 15. It appears without page number, header or footer. This is to allow the form to be shown in its actual size as an A4 page.

Private Health Insurance Standard Information Statement – Hospital Policy

This Statement provides basic information for the purposes of comparison only. For full explanation of this hospital policy please contact the health insurer on <phone number> or visit <website URL>.

Health insurer:

<Health Insurer name>

(This insurer has membership restrictions)

Who is covered:

<Type of cover>

Product name:

<Product name>

Monthly premium:

 $<xx.yy>

(indicative only)

Available for:

Residents of <State/Territory>

Employees/Members of <Company/Organisation name>

Closed to new members

(must be purchased with certain general treatment policies)

Medicare Levy Surcharge:

<NOT> Exempt

Available From:

<dd mmm yyyy>

The price shown is monthly premium with the 30% Rebate deducted. It does not include any Lifetime Health Cover loading or factor in any discounts that may be available or higher level of Rebate that may apply.

What’s covered if i have to go to hospital?

 ü

<Insert appropriate text>

What services are not covered at all?

(Exclusions)

 û

<Insert list of exclusions> OR No exclusions

What services are only covered to a limited extent?

(Restrictions, Benefit Limitation Periods)

You are not fully covered for: OR No restrictions

•

<Insert list of restrictions>

You are not fully covered for the time period listed after the services for:

OR No benefit limitation periods

•

<Insert list of BLP items + limitation periods>

How long are the waiting periods for new and upgrading members?

 •

<Insert list of waiting periods>

Will i have to pay anything if i go to hospital?

(Excesses, Co-payments, Medical/Hospital gaps)

Excess: <insert appropriate phrase>

Extra costs per day (co-payments): <Insert appropriate phrase(s)> OR No co-payments

Doctors’ and hospital bills: <X> out of 10 medical services paid for by this health insurer in <State/Territory> have no out-of-pocket expenses. plus (optionally) This insurer also has arrangements that may mean lower out-of-pocket expenses on doctors’ bills. OR Gap cover benefits are not available under this policy.

You may have to pay additional costs depending on the doctors chosen, the treatment you are having and the hospital you go to.

Before you go to hospital, you should ask your doctor, hospital and health insurer about any out-of-pocket costs that may apply to you.

What other features does this policy have?

[2] Schedule 2- Standard information statements: general treatment

Delete Schedule 2 and substitute:

Schedule 2―Standard information statements: general treatment

Form of statement

  1. Note:

    The next page of these rules is page 17. It appears without page number, header or footer. This is to allow the form to be shown in its actual size as an A4 page.

Private Health Insurance Standard Information Statement – General Treatment Policy

This Statement provides basic information for the purposes of comparison only. For full explanation of this general treatment policy please contacts the health insurer on <phone number> or visit <website URL>.

Health insurer:

<Health Insurer name>

(This insurer has membership restrictions)

Who is covered:

<Type of cover>

Product name:

<Product name>

Monthly premium:

$<xx.yy>(indicative only)

Available for:

Residents of <State/Territory>

Employees/Members of <Company/Organisation name>

Closed to new members

(must be purchased with certain hospital policies)

Medicare Levy Surcharge:

NOT Exempt

Available From:

<dd mmm yyyy>

The monthly premium already has the 30% Rebate deducted and does not include any discounts or higher level of Rebate that may apply.

Preferred service provider arrangements: By using this health insurer’s “preferred providers” you will have lower out-of-pocket costs on <list of services>and have access to more “no gap” services. A list of preferred providers is available from the health insurer. OR Insurer’s own wording

Services

Cover

Waiting period

(months)

Benefit limits

(per 12 months)

Examples of maximum benefits

Dental

Periodic oral examination – $<xx.yy> OR

<xx>% of charge

Scale & clean – $ OR % as above

Fluoride treatment – $ OR %

  1. •

    General dental

  1. •

    Major dental

Surgical tooth extraction – $ OR %

Full crown veneered – $ OR %

  1. •

    Endodontic

Filling of one root canal - $ OR %

  1. •

    Orthodontic

Braces for upper & lower teeth, including removal plus fitting of retainer – $ OR %

Optical(eg prescribed spectacles/ contact lenses)

Single vision lenses & frames – $ OR %

Multi-focal lenses & frames – $ OR %

Non PBS pharmaceuticals

Per eligible prescription item - $ OR %

Physiotherapy

Initial visit – $ OR %

Subsequent visit – $ OR %

Chiropractic

Initial visit – $ OR %

Subsequent visit – $ OR %

Podiatry

Initial visit – $ OR %

Subsequent visit – $ OR %

Psychology

Initial visit – $ OR %

Subsequent visit – $ OR %

Acupuncture

Initial visit – $ OR %

Subsequent visit – $ OR %

Naturopathy

Initial visit – $ OR %

Subsequent visit – $ OR %

Remedial massage

Initial visit – $ OR %

Subsequent visit – $ OR %

Hearing aids

Per hearing aid – $ OR %

Blood glucose monitors

Per monitor – $ OR %

Ambulance

<Insert appropriate phrase>

¬ <Special features of the product>

Other features:

[3] Schedule 3- Standard information statements: combined products

Delete Schedule 3 and substitute:

Schedule 3―Standard information statements: combined products

Form of statement

  1. Note:

    The next two pages of these rules appear without a header. This is to allow the form to be shown in its actual size as an A4 page.

Private Health Insurance Standard Information Statement – Combined Policy

This Statement provides basic information for the purposes of comparison only. For full explanation of this combined hospital and general treatment policy please contact the health insurer on <phone number> or visit <website URL>.

Health insurer:

<Health Insurer name>

(This insurer has membership restrictions)

Who is covered:

<Type of cover>

Product name:

<Product name>

Monthly premium:

$<xx.yy>(indicative only)

Available for:

Residents of <State/Territory>

Employees/Members of <Company/Organisation name>

Closed to new members

Medicare Levy Surcharge:

<NOT> Exempt

Available From:

<dd mmm yyyy>

The price shown is monthly premium with the 30% Rebate deducted. It does not include any Lifetime Health Cover loading or factor in any discounts that may be available or higher level of Rebate that may apply.

Hospital Component

The following applies to the hospital component for the <Product name> policy from <Health Insurer name>.

What’s covered if i have to go to hospital?

 ü

<Insert appropriate text>

What services are not covered at all?

(Exclusions)
  1. û

    <Insert list of exclusions> OR No exclusions

What services are only covered to a limited extent?

(Restrictions, Benefit Limitation Periods)

You are not fully covered for: OR No restrictions

  1. •

    <Insert list of restrictions>

You are not fully covered for the time period listed after the services for:

OR No benefit limitation periods

  1. •

    <Insert list of BLP items + limitation periods>

How long are the waiting periods for new and upgrading members?
  1. •

    <Insert list of waiting periods>

Will i have to pay anything if i go to hospital?

(Excesses, Co-payments, Medical/Hospital gaps)

Excess: <insert appropriate phrase> OR No excess

Extra costs per day (co-payments): <Insert appropriate phrase(s)> OR No co-payments

Doctors’ and hospital bills: <X> out of 10 medical services paid for by this health insurer in <State/Territory> have no out-of-pocket expenses. plus (optionally) This insurer also has arrangements that may mean lower out-of-pocket expenses on doctors’ bills. OR Gap cover benefits are not available under this policy.

You may have to pay additional costs depending on

the doctors chosen

the treatment you are having and

the hospital you go to.

Before you go to hospital, you should ask your doctor, hospital and health insurer about any out-of-pocket costs that may apply to you.

What other features does this hospital policy have?

General Treatment Component

The following applies to the general treatment component for the <Product name> policy from <Health Insurer name>.

Preferred service provider arrangements: By using this health insurer’s “preferred providers” you will have lower out of pocket costs on <list of services> and have access to more “no gap” services. A list of preferred providers is available from the health insurer. OR Insurer’s own wording

Services

Cover

Waiting period

(months)

Benefit limits

(per 12 months)

Examples of maximum benefits

Dental

Periodic oral examination – $<xx.yy> OR

xx% of charge

Scale & clean – $ OR % as above

Fluoride treatment – $ OR %

  1. •

    General dental

  1. •

    Major dental

Surgical tooth extraction – $ OR %

Full crown veneered – $ OR %

  1. •

    Endodontic

Filling of one root canal -- $ OR %

  1. •

    Orthodontic

Braces for upper & lower teeth, including removal plus fitting of retainer – $ OR %

Optical (eg prescribed spectacles/ contact lenses)

Single vision lenses & frames – $ OR %

Multi-focal lenses & frames – $ OR %

Non PBS pharmaceuticals

Per eligible prescription item – $ OR %

Physiotherapy

Initial visit – $ OR %

Subsequent visit – $ OR %

Chiropractic

Initial visit – $ OR %

Subsequent visit – $ OR %

Podiatry

Initial visit – $ OR %

Subsequent visit – $ OR %

Psychology

Initial visit – $ OR %

Subsequent visit – $ OR %

Acupuncture

Initial visit – $ OR %

Subsequent visit – $ OR %

Naturopathy

Initial visit – $ OR %

Subsequent visit – $ OR %

Remedial massage

Initial visit – $ OR %

Subsequent visit – $ OR %

Hearing aids

Per hearing aid – $ OR %

Blood glucose monitors

Per monitor – $ OR %

Ambulance

<Insert appropriate phrase>

¬ <Special features of the product>

Other features:

[4] Schedule 4- Standard information statements: permitted content

Delete Schedule 4 and substitute:

Schedule 4―Standard information statements: permitted content

Part 1―all statements

Field

Description

Permitted content

Date of Issue:

Date on which the content of the SIS is updated.

dd [month in words] yyyy

Health Insurer:

Trading Name or Brand Name of the health insurer in the State the product is being sold.

[Health insurer trading name]

Restricted Membership insurers:

Disclaimer to be printed directly below the health insurer name if the product is offered by a restricted membership insurer.

(This insurer has membership restrictions)

Available for:

Name of the State/Territory in which the product subgroup is available for sale.

All States can only be used where every feature of the product subgroups are identical, including the premium.

One of:

  1. •

    NSW & ACT; OR

  2. •

    Northern Territory ; OR

  3. •

    Queensland ; OR

  4. •

    SouthAustralia ; OR

  5. •

    Tasmania ; OR

  6. •

    Victoria ; OR

  7. •

    WesternAustralia OR

  8. •

    All States

Corporate products:

One of the following statements to be printed directly below the State name if the product is a corporate product.

One of “employees” or “members” may be deleted or both can be used.

Employees/Members of [Company/Organisation name]

OR

Employees/Members of organisations with arrangements with this health insurer

Closed Products:

Statement to be printed directly below the State name (or below the corporate product statement if applicable) if the product is not currently available for purchase.

Closed to new members

Product Name:

Marketing name of the product.

[product name]

Who is covered:

Who is covered under this policy.

One of the following:

  1. •

    One adult; OR

  2. •

    Two adults; OR

  3. •

    Dependants only; OR

  4. •

    One adult & dependant(s); OR

  5. •

    One adult & any dependants: OR

  6. •

    Two adults & dependant(s); OR

  7. •

    Two adults & any dependants; OR

  8. •

    At least 3 adults & any dependants;

Monthly Premium:

 Monthly premium, less the 30% Rebate.

Other discounts are not to be included here.

$[xx.yy amount of premium]

Available from:

 Date from which the product becomes available for purchase.

Field only to appear/be completed if the statement is provided before the product is available.The field is to be placed beneath the monthly premium field.

dd [month in words] yyyy

Medicare Levy Surcharge:

 Indicates whether or not the policy will exempt the holder from the Medicare Levy Surcharge.

The field is to be placed beneath the monthly premium field.

Exempt OR

NOT exempt

<product code>

A unique identifying code for the standard information statement

A product code generated by the PrivateHealth.gov.au system.

Part 2―hospital treatment

Field

Description

Permitted content

[If available with general treatment policy only]:

 The statement is to be placed below the premium on the hospital SIS if the policy cannot be purchased on its own.

Not required for a combined policy.

(must be purchased with a general treatment policy) (where the hospital policy can be purchased with any general treatment policy offered by the insurer)

OR

(must be purchased with certain general treatment policies) (where there is a set range of general treatment policies the hospital policy can be combined with)

What’s covered if I have to go to hospital?

Outline of treatment, accommodation and services covered.

Order of content cannot be changed.

One of the following:

ü Hospital treatment, including accommodation as a private patient in a private or public hospital OR

ü Hospital treatment, including accommodation as a private patient in a public hospital only OR

ü Hospital treatment, including accommodation as a private patient in a shared room in a private or public hospital OR

ü Hospital treatment, including accommodation as a private patient in a shared room in a public hospital only OR

ü Hospital treatment, including accommodation as a private patient in a public hospital and shared room accommodation only in a private hospital OR

ü A limited number of services is covered, see below (for policies that restrict or exclude all items except for a list of up to 10 items)

AND (the following can be added directly in front of the hospital statement if applicable)

[number]% of charge for hospital… (where the product covers a set percentage of hospital bills. Maximum allowed percentage is 90%)

AND

limited to [number] days per year (added to any of the above options if required);

ü Doctors’ bills in hospital (see below)

AND one of (if applicable):

Ambulance:

For state specific policies:

û Not covered OR

ü Covered, conditions may apply, contact insurer for details OR

(Ambulance covered by State Government)

For all-state policies:

û Not covered (state government cover in QLD and TAS) OR

ü Covered (state government cover in QLD and TAS, other states contact insurer for details)

AND (the following can be added directly after the ambulance statement if applicable)

– [number] day waiting period OR

– [number] month waiting period

What services are not covered at all?

A list of excluded services.

Order of content cannot be changed.

Only one joint replacement item can be used.

If additional services are excluded, use other services.

No exclusions OR

Any of the following:

û Cardiac and cardiac related services

û Cataract and eye lens procedures

û Pregnancy and birth related services

û Assisted reproductive services

û Joint replacements i.e. shoulder, knee, hip and elbow including revisions

û Hip and knee replacements

û Hip replacements

û Dialysis for chronic renal failure

û Gastric banding and related services

û Sterilisation

û Non-cosmetic plastic surgery

û Hospital treatment for which Medicare pays no benefit eg most cosmetic surgery

û Other services (see insurer for details)

What services are only covered to a limited extent?

A list of restrictions and benefit limitation periods.

Restrictions are to be listed before benefit limitation periods.

Order of content cannot be changed.

For benefit limitation periods, after each service listed insert the number of months.

Only one joint replacement item can be used.

If additional services are restricted or have benefit limitation periods, use other services. These can be listed under other services without having to prior select a service form the list of available services.

No restrictions or benefit limitation periods. OR

No restrictions/benefit limitation periods

No restrictions OR

If the policy has no restrictions but has benefit limitation periods

No benefit limitation periods OR

If the policy has no benefit limitation periods but has restrictions

You are not fully covered for: AND/OR

Restrictions

You are not fully covered for the time period listed after the services for:

benefit limitation periods

List any of the following for restrictions:

  1. •

    Cardiac and cardiac related services

  2. •

    Cataract and eye lens procedures

  3. •

    Pregnancy and birth related services

  4. •

    Assisted reproductive services

  5. •

    Joint replacements i.e. shoulder, knee, hip and elbow including revisions

  6. •

    Hip and knee replacements

  7. •

    Hip replacements

  8. •

    Dialysis for chronic renal failure

  9. •

    Gastric banding and related services

  10. •

    Sterilisation

  11. •

    Non-cosmetic plastic surgery

  12. •

    Rehabilitation

  13. •

    Psychiatric services

  14. •

    Palliative care

  15. •

    Hospital treatment for which Medicare pays no benefit eg most cosmetic surgery

  16. •

    Other services (see insurer for details)

List any of the following for benefit limitation periods:

  1. •

    Cardiac and cardiac related services – [number] months

  2. •

    Cataract and eye lens procedures – [number] months

  3. •

    Pregnancy and birth related services – [number] months

  4. •

    Assisted reproductive services – [number] months

  5. •

    Joint replacements i.e. shoulder, knee, hip and elbow including revisions – [number] months

  6. •

    Hip and knee replacements – [number] months

  7. •

    Hip replacements – [number] months

  8. •

    Dialysis for chronic renal failure – [number] months

  9. •

    Gastric banding and related services – [number] months

  10. •

    Sterilisation– [number] months

  11. •

    Non-cosmetic plastic surgery – [number] months

  12. •

    Rehabilitation – [number] months

  13. •

    Psychiatric services – [number] months

  14. •

    Palliative care – [number] months

  15. •

    Hospital treatment for which Medicare pays no benefit eg most cosmetic surgery – [number] months

  16. •

    Other services (see insurer for details) – [number] months

How long are the waiting periods for new and upgrading members?

Waiting periods that apply before a member can claim.

Must be provided in the order listed.

The waiting period for obstetrics must be deleted if the product does not cover obstetrics.

  1. •

    [number (maximum 2)] months for palliative care, rehabilitation and psychiatric treatments

  2. •

    [number (maximum 12)] months for treatments relating to other pre-existing ailments

  3. •

    [number (maximum 12)] months for obstetric treatments

  4. •

    [number (maximum 2)] months for all other treatments

Will I have to pay anything if I go to hospital?

This box covers excesses, co-payments and medical/hospital gaps.

Each of these appear in separate sub-boxes

Excess:

Choose appropriate statement and insert dollar figures.

The dollar amount for excess per admission is the excess for an overnight admission (if different from the excess for day surgery).

If no excess:

•

No excess

If there is an excess:

You will have to pay an excess of $[number] per admission. OR

You will have to pay an excess of $[number] per admission.

This is limited to a maximum of $[number] per year. OR

You will have to pay an excess on admission.

This is limited to a maximum of $[number] per year. OR

You will have to pay an excess of $[number] per admission.

This is limited to a maximum of $[number] per person per year. OR

You will have to pay an excess on admission.

This is limited to a maximum of $[number] per person per year. OR

You will have to pay an excess of $[number] per admission.

This is limited to a maximum of $[number] per person and $[number] per policy per year.

You will have to pay an excess on admission.

This is limited to a maximum of $[number] per person and $[number] per policy per year.

AND (if required)

  1. •

    Excess payments do not apply to hospital admissions for accidents, child dependents or day surgery (delete any that do not apply but do not change the order)

Extra Cost per day (co-payments):

Insert dollar amounts for the appropriate co-payment amount.

If no co-payment

•

No co-payments

If there is a co-payment:

Every time you go to hospital you will have to pay:

•

$[number] per day for overnight admissions

OR

•

$[number] per day for a shared room AND

  1. •

    $[number] per day for a private room (must be deleted if the policy does not cover accommodation in a private room)

AND

  1. •

    $[number] for day surgery (no overnight stay) OR

  2. •

    No co-payment for day surgery (no overnight stay)

AND (The following can be added directly after the shared and private room co-payment descriptions if applicable)

– up to $[number] per hospital stay

AND (If applicable)

The maximum co-payment is $[number] per year.

Doctors’ and Hospital Bills

This provides information on the proportion of no gap medical services for the insurer.

The percentage of medical services with no gap is the figure for the state in which the product is available.

The information related to the percentage of medical services with no gap is the information submitted to the Private Health Insurance Administration Council (PHIAC) for the year ending 30 June for “Total Services with No Gap” divided by “Total All Services”.

The information required is that released by PHIAC for the most recent year ending 30 June (i.e. when the June quarter figures are released by PHIAC).If the product is an “All States” product, the national average of medical services with no gap is to be used.

Health insurers who participate in the Australian Health Services Alliance’s gap cover arrangements may use the percentage of services with no gap (by state) for the Alliance as a whole.

 As per the form.

The percentage of medical services with no gap is to be expressed as per the example below:

  1. •

    greater than or equal to 69% and less than or equal to 71% – 7 out of 10

  2. •

    greater than 71% but less than 75% – More than 7 out of 10

  3. •

    greater than or equal to 75% but less than 79% – Almost 8 out of 10

[State] is to be the same as “available to” field

If insurer has known gap arrangements, then insert the following after the first sentence:

This insurer also has arrangements that may mean lower out-of-pocket expenses on doctors’ bills.

If gap cover benefits are not available with this policy, then substitute first two sentences with:

Gap cover benefits are not available under this policy.

A new health insurer that does not have available figures for gap cover benefits must use the following (if the new insurer participates in the Australian Health Services Alliance’s gap cover arrangements, they may use the Alliance ’s figure):

Gap cover benefit figures are not yet available.

What other features does this policy have?

The total text in this box must not exceed 4 lines.

If the hospital policy pays full benefits for 10 or fewer specific services, those services MUST be listed in this box.

This box may also be used to describe (for example):

  1. •

    disease management programs and other programs that support healthy lifestyles

  2. •

    discounts for direct debit, paying in advance etc

  3. •

    loyalty bonus/incentive schemes

  4. •

    waiver(s) of co-payments

  5. •

    any other significant product features

Free text up to 4 lines

INCLUDING (if applicable)

This policy only provides full benefits for [list services].

Part 3―general treatment

Field

Description

Permitted content

[If available with hospital policy only]:

 The statement is to be placed below the premium on the general treatment SIS if the policy cannot be purchased on its own.

Not required for a combined policy.

(must be purchased with a hospital policy) (where the general treatment policy can be purchased with any hospital policy offered by the insurer)

OR

(must be purchased with certain hospital policies) (where there is a set range of hospital policies the general policy can be combined with)

Preferred Service Provider Arrangements:

(box)

Describes special arrangements with particular providers.

Text in this box must not exceed 3 lines, including the line with the heading.

Free text up to 3 lines (including the line with the heading)

OR

By using this health insurer’s “preferred providers” you will have lower out of pocket costs on [ insert services or use many allied health] services and have access to more “no gap” services.A list of “preferred providers” is available from the health insurer.

Insurers that do not have preferred provider arrangements must use this phrase.

This health insurer does not operate a preferred provider scheme.

‘Services’ column:

A list of a number of services covered by general treatment.

 As provided in form.

Additions, deletions, modifications or rearrangements not permitted

‘Covered’ column:

Indicates if the service is covered or not.

A service is considered to be covered if a benefit is paid for at least one of the examples in the “examples of maximum benefits” columns.

All services except Ambulance:

ü (service is covered)

û (service is not covered)

û Not available on this product (for policies that cover only one type of service, such as e.g. dental cover)

¬ (see note below)

Ambulance:

For state specific policies:

ü Covered, conditions may apply, contact insurer for details OR

(Ambulance covered by State Government) OR

û Not covered OR

û Not available on this product (for policies that cover only one type of service, such as e.g. dental cover)

¬ (see note below)

For all-state policies:

ü Covered (state government cover in QLD and TAS, other states contact insurer for details) OR

û Not covered (state government cover in QLD and TAS) OR

û Not available on this product (for policies that cover only one type of service, such as e.g. dental cover)

¬ (see note below)

‘Waiting Period (Months)’ column:

The maximum period of time before a member can claim benefits.

Waiting periods for ambulance can be expressed in days or months.

Choose one of…:

When…

-

the service is not covered

[number]

waiting period in months

None

no waiting period

[x days]

short term waiting period for ambulance cover

‘Benefit Limits (per 12 months)’ column:

Limits on benefits.

If there is a limit on general dental, but not on preventative dental, the “(no limit on preventative dental)” words should be used.

If services with combined limits are in adjacent rows in the table, lines between the boxes can be deleted and the limit and list of combined services only written once.

If a sub limit applies on any of these services, use “Sub-limits apply”.

Combined limits for services in non-adjacent boxes must be written in this field in the first occurrence; thereafter “(Combined limit – see [service])”, inserting the name of the service where the list first occurs.

If benefit limits increase over time for any services, only the lowest payable benefit is to be used.

Any combination of:

  1. •

    $[number] per person

  2. •

    $[number] per service

  3. •

    $[number] per policy

If more than one of the above phrases is used, they are to be linked by the words “up to” eg $X per person up to $Y per service up to $Z per policy.

The following may also be used:

  1. •

    $[number] lifetime limit AND/OR

  2. •

    ([number] appliance(s)/service(s) [delete one] every [number] years (if there is a limit on claims every X years) AND/OR

  3. •

    (combined limit for [list services]) OR

  4. •

    (combined limit – see [service]) AND/OR

  5. •

    Sub-limits apply AND/OR

  6. •

    (no limit on preventative dental) OR

  7. •

    No annual limit OR

  8. •

    - (service is not covered)

For combined limits, choose from services:

  1. •

    general dental

  2. •

    major dental

  3. •

    endodontic

  4. •

    orthodontic

  5. •

    optical

  6. •

    non PBS pharmaceuticals

  7. •

    physiotherapy

  8. •

    chiropractic

  9. •

    podiatry

  10. •

    psychology

  11. •

    acupuncture

  12. •

    naturopathy

  13. •

    remedial massage

  14. •

    hearing aids

  15. •

    blood glucose monitors

  16. •

    ambulance

  17. •

    other services

OR

Lifetime limits for individually grouped services:

$[number] per person (combined limit for [a] general dental, major dental, endodontic & orthodontic)

$[number] lifetime limit for [b]

a)insurers may choose any combination of the following services: general dental, major dental, endodontic & orthodontic

b)insurers may choose any one of the following services: general dental, major dental, endodontic & orthodontic

‘Examples of Maximum Benefits’ column:

Examples of the maximum benefit paid for the listed treatments when an insured person visits a practitioner who is not a ‘preferred service provider’.

Only the examples listed may be used.

A percentage figure can only be used where the insurer does not have a maximum limit on the particular item, other than an annual limit. If an insurer pays a benefit that is a percentage of the charge up to a specified dollar limit (i.e. a limit for that item, separately specified from the annual limit), then the specified dollar limit must be used.

General dental, major dental and endodontic examples must be listed even if the service is not covered.

Other examples should be deleted if not covered.

The maximum benefit paid on the following dental item numbers are to be used for the listed examples:

Periodic oral examination – 012

Scale & clean – 114

Fluoride treatment – 121

Surgical tooth extraction – 322

Full crown veneered – 615

Filling of one root canal – 417

Braces for upper & lower teeth, including removal plus fitting of retainer – 881

If surgical tooth extraction is covered under general dental instead of major dental, this example can be moved to the general dental box.

Orthodontics – if different benefits are offered for treatments provided for orthodontists and general dentists, the maximum benefit for an orthodontist should be used.

Optical – if benefits for frames and lenses are paid separately, add together the maximum benefit for each component.

Initial/subsequent visit examples are for individual sessions.

If there is no maximum benefit for the examples listed, the annual benefit limit figure should be used.

$[xx.yy number]

amount of maximum benefit

[number]% of charge

where there is no maximum benefit limit on the particular item, other than an annual limit.

n/a

For general dental, major dental and endodontic if not covered

-

Other services if not covered – delete example(s)

Ambulance – one of:

For state specific policies:

ü Covered, conditions may apply, contact insurer for details OR

(Ambulance covered by State Government) OR

û Not covered OR

û Not available on this product (for policies that cover only one type of service, such as e.g. dental cover)

¬ (see note below)

For all-state policies:

ü Covered (state government cover in QLD and TAS, other states contact insurer for details) OR

û Not covered (state government cover in QLD and TAS) OR

û Not available on this product (for policies that cover only one type of service, such as e.g. dental cover)

¬ (see note below)

¬ Special Features:

This space must be used to describe special features of the product where ¬ is used.

Free text up to 4 lines.

Other Features: (box)

OPTIONAL – this box may be used to describe (for example):

  1. •

    services covered that are not listed in the first column of the main table

  2. •

    discounts for direct debit, paying in advance etc

  3. •

    preventative health/health management programs

  4. •

    loyalty bonus/incentive schemes

  5. •

    other significant product features

Free text up to 4 lines, including the line with the heading.

Actions
Download as PDF Download as Word Document
Cases Citing This Decision

0

Cases Cited

0

Statutory Material Cited

0