Terms and conditions

Latrobe Health Services writes these terms and conditions in plain language, so you understand exactly what applies to your membership, claims, waiting periods and benefits. Take the time to read through what’s below, especially before choosing your hospital and extras cover. Our Member Guide outlines complete information about being a Latrobe Health member.

If anything, here isn’t clear, contact us and we’ll walk you through it. And if you ever change your level of cover, review the change within 7 days of getting confirmation, just to make sure it’s right for you.

What’s covered on this page

• Plain language
• Significant changes to your benefits
• Membership terms and conditions
• Claims terms and conditions
• Hospital claims
• Extras claims
• Waiting periods
• Definitions
• Private Patient’s Hospital Charter

Plain language

We write your policy documents in plain language, because you shouldn’t need a dictionary to understand your cover. We regularly review our documents and other member information to keep them easy to follow.

What happens if we make a significant change to your benefits?

If we make a significant change that reduces your cover, including our contracting arrangements, we will:

• give you at least 60 days’ notice
• not apply the change to admissions you’ve already booked
• review the situation of any member already part-way through a course of treatment, so we can work out fair transitional arrangements.

If we make basic changes to your cover benefits, we will give you at least 30 days’ notice

Membership terms and conditions

What types of membership can I choose?

Latrobe Health Services offers four types of membership:

• Single covers you, and only you.
• Single parent covers you and your dependent children.
• Couple covers you and your partner.
• Family covers you, your partner and your eligible dependants.

Who counts as a dependant comes down to their age and whether they’re studying full time. The dependants table in the definitions section below sets out each category.

Can I keep an adult child on my membership?

Got a dependant aged 21 to 30 who’s finished full-time study? On selected covers you can keep them on your membership as a non-student dependant, for an extra premium. They’ll need to be single and not in a de facto relationship.

It’s worth getting independent tax advice before you add them (your accountant will know).

Not sure which membership fits your household? Give us a call on 1300 362 144 and we’ll work it out with you.

Who has authority over a family or couples’ membership?

On a family or couples’ membership, you and your partner have equal authority. Either of you can make a transaction or give us an instruction, including cancelling the cover. If that doesn’t suit your circumstances, contact us and we’ll work out an arrangement that does.

Can someone else manage my membership for me?

Privacy law means we need your written authority before anyone who isn’t on your membership can access or control it, for example if you’re overseas, unwell, or facing a speech, hearing or language barrier. If you’d like someone else to manage your membership, complete this Third-Party Authority form and return to us.

What if I change my mind after joining?

If you change your mind for any reason within 30 days of starting or changing your cover, we’ll give you a full refund of the premiums you’ve paid, as long as you haven’t made a claim.

What happens if my payments fall behind?

Your membership fees need to be paid at least one payment period in advance. If your membership falls 60 days into arrears, it’s automatically cancelled.

What if I’m not eligible for full Medicare benefits?

If you’re not eligible for full Medicare benefits, contact us to talk through your health cover options.

How do I make sure my newborn is covered from birth?

If you’re on a single or couple membership, upgrade to a single parent or family membership within 6 months of your baby’s birth. If you’re already on a single parent or family membership, simply register your newborn within 12 months of the birth.

Can I suspend my membership while travelling?

If you’re planning to travel overseas, we’ll consider a request to suspend your membership. You need to have held your membership for at least twelve months to be eligible.

You won’t make any membership payments during a suspension, and you can’t claim on any services that would normally be covered. We may also consider suspension in cases of financial hardship.

A few things to know before you apply:

• conditions for suspension vary depending on your circumstances
• suspension may not suit you if you’re liable for the Medicare Levy Surcharge.
• you must apply before your departure date
• your membership needs to be reactivated for at least 6 months before we’ll grant another suspension
• if you upgraded your cover in the twelve months before you travel, you’ll still need to serve out the remaining waiting period before the higher benefit applies.

Contact us for advice on membership suspensions, and we’ll talk you through it.

Claims terms and conditions

Many members claim at the time of service by tapping their physical card, or the QR code available in the Latrobe Health Services App. If you need to make a manual claim, use the claiming function in our App.

How long do I have to submit a claim?

Benefits aren’t payable if a claim isn’t made within two years of the date of service. Submit your claims as soon as you can after the service is provided.

What if I can claim compensation elsewhere?

You can’t claim benefits from us if you’re entitled to compensation or damages from another source, such as WorkCover, the Transport Accident Commission, public liability, travel insurance or private legal action. If this leaves you in financial hardship, contact us and we’ll see what we can do.

Am I covered while travelling overseas?

Your Latrobe Health membership doesn’t cover medical, hospital or other health costs while you’re travelling overseas. We strongly recommend taking out travel insurance.

Hospital claims

Participating private hospitals

We hold contracts with participating private hospitals across Australia, guaranteeing your hospital treatment costs are covered as we’ve outlined to you. View the current list of participating private hospitals.

What do I pay for a surgically implanted prosthesis?

Every prosthesis on the Prescribed List of Medical Devices and Human Tissue Products listing is covered at the no-gap price for the clinically equivalent item. If you or your doctor choose a prosthesis that isn’t on that list, you’ll pay the gap: the difference between the no-gap price for the equivalent device and the price the supplier has set.

Am I covered for dental surgery in hospital?

With the right hospital cover, you’re covered for the costs of dental surgery in a participating private hospital or a public hospital, but not the dentist’s fee. You can claim a benefit for the dentist’s fee if you hold an appropriate extras policy. If you’re planning dental surgery, contact us first to confirm exactly what’s covered.

Extras claims

What’s covered under pharmacy benefits?

Pharmacy benefits cover prescribed drugs and medicines dispensed by a pharmacist, and travel and allergy vaccinations dispensed by a pharmacist or doctor. They don’t cover contraceptives or PBS-subsidised prescriptions. Your benefit is calculated after the current PBS general patient contribution is deducted.

Are psychology services covered under the Chronic Disease Management Scheme?

If you elect to claim the Medicare benefit under the Chronic Disease Management Scheme for a psychology service, no private health insurance benefit is payable on that same service.

Waiting periods

Waiting periods apply if you’ve never held cover before, if you’re transferring from another fund onto a higher level of cover, if a waiting period hasn’t already been served, or if you’re an existing Latrobe Health member upgrading your cover.

Accident Advantage is available on a number of our covers. The waiting period on Accident Advantage is one day and the Member Guide sets out the full conditions.

What counts as a pre-existing condition?

A condition is pre-existing if, in the opinion of a Latrobe Health appointed medical advisor, its signs or symptoms existed at any point in the 6 months before you joined or upgraded your cover.

Our medical advisor forms this opinion using information from the practitioner who treated you. No benefits are paid for treating a pre-existing condition during the first 12 months of a new cover.

What happens if I transfer from another health fund?

You keep continuity of cover for the entitlements you had with your previous insurer when:

1. you transfer within 30 days of your cover expiring with the other insurer
2. you’ve served the required waiting periods with the other insurer (if you’ve served part but not all of a waiting period, you’ll need to serve the rest with us before you’re eligible to claim) and
3. the cover you take out with us isn’t an upgrade on what you had with the other insurer.

If you transfer to Latrobe Health and upgrade your cover at the same time, you’re entitled to whichever is the equivalent benefit: what your previous insurer paid, or our closest matching policy, until the relevant waiting periods are complete.

Any excess or co-payment you paid with your previous insurer doesn’t transfer. You’ll need to pay any excess or co-payment owing to Latrobe Health.

What counts as an upgrade in cover?

An upgrade is any change that entitles you to higher benefits from Latrobe Health than your previous cover. That includes:

• benefits for services your previous cover didn’t include
• a change to hospital cover with a lower excess or co-payment
• services where your new cover pays a higher benefit
• services with a higher annual or personal limit.

If you hold extras cover with us, you may not be able to use your membership card to claim electronically at your provider until you’ve served your full waiting periods or we’ve received a clearance certificate from your past insurer.

Definitions

Accident

“Accident” means an unplanned, unintentional, and unexpected event that occurs by chance, by an external force or object, that results in a physical injury requiring immediate treatment or advice for which Benefits may be payable under our Fund Rules.

Immediate treatment: the initial treatment you need right after an accident. It doesn’t include any treatment after that.

Admission (to hospital)

A period of time in hospital for which accommodation charges are raised.

Approved service providers

To be eligible for benefits:

• the service or product must be provided in Australia
• the provider must be approved by us for that particular service or product.

Approval isn’t automatic across every service a provider offers. We might approve a naturopath for naturopathy, for example, but not for massage or myotherapy. Contact us before treatment to confirm your provider is approved.

We can withdraw approval of a provider without notice. Approving a provider for benefit payments isn’t a recommendation from us, and we don’t represent that their services will benefit you. We’re not responsible for the outcome of any advice, service, product or treatment an approved provider gives you.

Benefit year

Calendar year: 1 January to 31 December each year.

Membership year: a 12-month period starting the day you join Latrobe Health, or switch to another Latrobe Health product.

Certified age at entry (CAE)

Under the Lifetime Health Cover scheme, every adult member is assigned a CAE the first time they take out private hospital cover. Your CAE decides what loading, if any, applies to the base cost of your hospital cover. It may not match your actual age.

Default benefits and other limited benefits

Default benefits are the minimum benefits all health insurers must pay for eligible treatment in a shared ward at a public hospital. These rates are set and regularly reviewed by the government.

If you choose a single room in a public hospital, we’ll pay the Department of Health’s shared ward rate, plus up to $80 per night extra in all states except NSW.

In NSW, all health insurers must pay the published NSW single-room rate, so there should be no out-of-pocket costs for your accommodation (excluding any excess or co-payment). If the hospital charges more than the published rate, you may have out-of-pocket costs.

If this happens, please contact us. It shouldn’t occur, and we’re here to help.

Always contact us before you’re admitted to hospital to confirm exactly what’s covered.

Dependants

Initial consultation

The first consultation with a service provider, usually to get a full medical history or discuss treatment options.

Non-surgical prosthesis

Non-surgically Implanted Prostheses are artificial body parts that replace missing or non-functioning parts of the body without the need for surgical implantation. These devices are typically external and are worn or attached to the body.

Examples include:

• Prosthetic limbs (arms and legs)
• Braces (such as knee and back braces)
• Splints (for fingers, hands, wrists, arms and elbows)
• Prosthetic eyes (ocular prostheses)
• Breast prostheses

Pharmaceutical Benefits Scheme (PBS)

A Federal Government scheme that subsidises the cost of certain drugs. You pay a contribution towards each new prescription, reviewed by the government from time to time. Prescriptions covered by the PBS aren’t eligible for benefits under any Latrobe Health extras cover.

Private Patient’s Hospital Charter

The Private Patient’s Hospital Charter explains what it means to be a private patient in a public hospital, a private hospital or a day hospital facility, and what to do if you have a problem with your medical treatment or your health insurance.

It also outlines what to do if you have concerns about your medical treatment or private health insurance, including how to make a complaint. We encourage you to read it and ask us any questions you have.

Fund Rules

Our Fund Rules govern everything to do with your membership and how Latrobe Health operates. When you apply for membership, you agree to abide by them. The Rules can change from time to time, and we’ll always give you written notice before any new rule that might reduce your membership conditions or benefits. View the Fund Rules.

Need to talk it through? We’re just a call away on 1300 362 144.