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Top Plus and Super Multicover Product Summary - HCF

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									   Top Plus and Super Multicover Product Summary
Our top-of-the range cover for those who would rather leave nothing to chance. This level offers comprehensive
Hospital cover across a broad range of services and our highest level of Extras benefits.
This document is a summary only. To check if you are covered for a service before you claim or to understand the
benefit available, call us on 13 13 34 with a description of the goods or services, or the specific medical or dental
item number.

Top Plus Hospital highlights                                                  Super Multicover Extras highlights
                            Benefits                                                                                              Annual
                                                                                                         Benefits
 Removal of tonsils
                                                                                                                                   limits
                                                     4
 Removal of appendix                                                           Diagnostic and preventative dental e.g. scale, Limits for service
                                                     4
                                                                               clean, plaque removal and fluoride treatment         apply
 Hernias                                             4
                                                                               Restorative dental e.g. metallic and adhesive
 Back surgery                                        4                                                                              $550
                                                                               fillings (direct) and in-direct restorations
 Kidney stone and gall-stone removal                 4                         Crowns and bridges                            $800 - $1,200
 Digestive disorders (e.g. stomach ulcers)           4                         Oral Surgery, Endodontics and Periodontics        $500
 Assisted reproductive services (e.g IVF, GIFT)      4                                                                       $440 (lifetime
 Pregnancy and birth related services                                          Orthodontics after 12 months
                                                     4                                                                        limits apply)
 Psychiatric services                                4                         Dietetics                                         $350
 Total and partial hip and knee joint                                          Speech Therapy                                    $500
 replacement                                         4
                                                                               Occupational Therapy                              $600
 Cataract and other lens related surgery             4                         Physiotherapy                                 $600 - $1,200
 Dialysis for chronic renal failure                  4                                                                       $600 - $1,200
 Gastric banding and obesity surgery                                           Chiropractic and osteopathy
                                                     4                                                                     (sublimits apply)
 Rehabilitation services                             4                         Acupuncture, remedial massage, naturopathy,       $600
 Elective cosmetic surgery and podiatric                                       Alexander Technique and homoeopathy         (sublimits apply)
                                                Minimal benefits
 surgery                                                                       Pharmacy (HCF approved e.g. non-PBS)              $700
                                                                                                                               $200 (max $400
More information can be found on page 2.                                       Health Management Programs
                                                                                                                               per membership)

                                                                              More information can be found on page 3.

You get more with HCF.
• We’re not-for-profit, so our members get more
• My Health Guardian online program makes it easier
  for you to look after your health and well-being
• The best no-gap medical coverage of any health fund
  in every state.



Current as at 1 March 2013. Benefits shown are valid until 30 June 2013.
                                                                                                                                                     4




TOP PLUS AND SUPER MULTICOVER PS 0313      This product summary is created from the Health Fund Rules.
                                                                                                                                                   1/
                                         Top Plus Hospital cover
        HCF participating private hospitals and                       Minimal benefits
                   public hospitals                                   If you choose a product which has minimal benefits for some
                                                                      procedures, then you’ll be covered in a public hospital shared room,
 Accommodation, operating theatre                                     but your private hospital costs won’t be fully covered. This means
 and intensive care                                  4
                                                                      you may face significant personal expenses if you have any of these
 Heart surgery                                       4                procedures in a private hospital.
 Government approved prosthesis                      4                In addition, there are some services where doctor’s charges are not
                                                                      payable. For these, HCF will only pay a very small amount towards
 Physiotherapy and Pharmaceuticals                                    the total cost of the procedure (and no doctor’s charges). This only
 in hospital (Directly associated with                                applies to services which do not attract a benefit from Medicare.
 the reason for admission. Excluding                 4                To be certain of what you’re covered for, always check with HCF
 experimental and high cost –                                         before attending any hospital.
 non-PBS drugs)
                                                                      Pregnancy and birth related services
 Assisted reproductive services
 (e.g. IVF, GIFT etc)                                4                To be covered for pregnancy and birth related (obstetrics) services
                                                                      in hospital, make sure your cover includes full benefits for these
 Pregnancy & birth related services                  4                services. If not, you may wish to upgrade to a more comprehensive
 Psychiatric services                                4                cover 12 months before the planned date of birth to minimise your
                                                                      out of pocket expenses. If you’re expecting, make sure you transfer
 Total & partial hip & knee joint                                     to a family membership at least two months prior to the birth of
 replacement surgery                                 4
                                                                      the child to ensure the baby is covered from birth.
 Cataract & other lens related surgery               4                Hospital benefits and 'the gap'
 Dialysis for chronic renal failure                  4                Hospital benefits are payable to persons who are formally admitted
 Digestive disorders (e.g. stomach ulcers)           4                hospital patients at the time of the service. If you are a private
                                                                      patient in a non-participating private hospital, you may face a large
 Gastric banding and obesity surgery                 4                gap, depending on the hospital charges. Prior to treatment, please
 Rehabilitation services                             4                check with your doctor to obtain Medicare item numbers and call
                                                                      HCF to clarify benefits payable.
 Elective cosmetic surgery and podiatric
 surgery by an accredited podiatric           Minimal benefits        Medical Gap: Medicare will cover 75% of the Medicare Benefits
 surgeon                                                              Schedule (MBS) fee for medical charges and HCF will cover the
                                                                      remaining 25%. Some doctors may choose to charge more than the
 Ambulance (State Government services
                                                                      MBS fee and this is when you may face additional expenses, known
 only. QLD and TAS residents are
                                                     4                as the “Medical Gap”.
 covered under their state ambulance
 scheme).                                                             HCF has no-gap arrangements to assist you in eliminating the
                                                                      gap. Always ask your doctor what your charge will be and if they’ll
 Extended family cover available.                    4                participate in HCF’s no-gap arrangement for your procedure. If you
                                                                      still have questions, call HCF on 13 13 34.

  For this product you have no excess for same
  day surgery or hospital admissions in the event
  of an accident or dependant children. Only one
  excess applies per person per calendar year.


Conditions applying to Top Plus hospital cover
Excess Options
Excess options means a nominated amount a Member pays per
calendar year when admitted to hospital. If hospitalised, the total
excess option will apply once per person in a calendar year.
Excess Options available:
NIL or $250 or $450.
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TOP PLUS AND SUPER MULTICOVER PS 0313
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                                                     Super Multicover Extras
                                                                                                              Benefits range                    Limits per person
                 Service category       Description
                                                                                                              from - to                         per calendar year
                                        Examinations – general dentist/specialist dentist                     $32 – $76                         2 services/1 service
                 Diagnostic dental
                                        Single film x-rays – initial/subsequent                               $29/$25                           No limit
                                        Removal of plaque/calculus                                            $36 – $63                         2 services
                 Preventative dental
                                        Application of fluoride                                               $25                               1 service
                 Fillings               Metallic and tooth coloured                                           $80 – $156                        $550
                                        Accrues at $440 per year up to $2,640 maximum lifetime limit for Orthodontist or $1,000 for General Dentist
                 Orthodontics
                                        treatment. Sub-limits apply.
Dental




                                        Surgical extractions                                                  $160 – $260
                 Oral surgery           Extractions                                                           $100 – $130
                                        Occlusal therapy                                                      $35 – $250                        $500
                 Endodontic Services    Treatment of root canals                                              $60 – $170
                 Periodontic Services   Treatment of tissue surrounding the teeth                             $15 – $305
                                        Dentures and components (partial and complete)                        $25 – $800                        $800 every 3 years
                 Dentures
                                        Maintenance and repair                                                $37 – $200                        $200
                                                                                                                                                $800 (increases by $100
                 Crowns and bridges     Preparation and placing of crowns and bridges                         $55 – $635
                                                                                                                                                each year to $1,200)
                                        Spectacle frames                                                      $135
Optical




                 Glasses and contact                                                                                                            $250 (or $500 every
                                        Spectacle lenses – pair                                               $130 – $250
                 lenses                                                                                                                         2 years)*
                                        Contact lenses – pair                                                 $140 – $250
                                        Psychology (after Medicare entitlement is exhausted)                  $80 per visit                     $600
                                        Dietetics                                                             $55/$40                           $350
                                        Podiatry services (cannot be used for in-patient services)            $38/$34                           $400
                                        Audiology                                                             $58/$40                           $350
                                        Speech Therapy                                                        $83/$51                           $500
                                        Occupational Therapy                                                  $72/$50                           $600
                 First/subsequent                                                                             $42 visits 1 – 2/$33 visits
                 visits (unless         Chiropractic                                                                                            $600 - $1,200 combined
                                                                                                              3 – 11/$18 visits 12+             limit# $600 each for
                 otherwise specified)
Therapies




                                                                                                              $45 visits 1 – 2/$35 visits       Chiropractic and
                                        Osteopathy                                                                                              Osteopathy.
                                                                                                              3 – 11/ $18 visits 12+
                                                                                                                                                $300 sublimit for
                                       Exercise Physiology                                                    $40/$33                           Exercise Physiology
                 # Accrues at $120 per
                   year, up to $1,200. Physiotherapy                                                          $53 visits 1 – 2/$38 visits
                                                                                                                                                $600 - $1,200#
                                                                                                              3 – 11/ $18 visits 12+
                                        Acupuncture/Chinese Herbal Medicine consultation (CHM)                $40/$25
                                        Remedial Massage/Myotherapy                                           $40/$25                           $600
                                        Naturopathy/Nutrition consultation                                    $40/$25                           Max. $250 per therapy.
                                        Alexander Technique                                                   $40/$25                           Max $100 for CHM
                                        Homoeopathy                                                           $40/$25
                                                                                                              Up to $100 per trip               $400 for travel (includes
                 Travel &               Minimum 200km+ return trip for medical/hospital
                                                                                                              per membership ($30 per           $200 sublimit for
                 Accomodation           treatment when not available locally
                                                                                                              night for accomodation)           accommodation)
                 HCF approved
Other services




                                        Per script, after equivalent PBS co-payment subtracted                $50                               $700
                 Pharmacy
                 Artificial aids        HCF approved appliances                                               $20 – $500                        $600
                 Hearing aids           Benefits accrue over time and limits renew every five years           Up to $1,800                      $800 – $1,800
                 Health Management
                                        HCF approved – single/couples or family                               $30 – $200                        $200/$400
                 Programs
                 School Accident
                                        Approved ancillary services only                                      Up to $800                        $800
                 Cover

      * After 12 months on Top Plus & Super Multicover you can claim up to $500 over 2 consecutive calendar years (applies to current and previous calendar years).
        Sublimit of $250 applies for contact lenses per year.
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      TOP PLUS AND SUPER MULTICOVER PS 0313
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                                        Things you need to know
                                                Hospital and Extras waiting periods
1 day             Emergency ambulance (where not for pre-existing ailments) and School Accident Cover.
                  Psychiatric, rehabilitation and palliative care. Non emergency ambulance (where not for pre-existing ailments).
2 months
                  All other services (except where longer waiting periods apply).
6 months          HCF Health Management programs and approved HCF Disease Management programs.
                  Pregnancy & birth related services. Pre-existing ailments (excluding psychiatric, rehabilitation and palliative care).
12 months         Crowns, bridges, dentures, endodontics, occlusal therapy, surgical extractions, periodontics, prosthodontics, dental
                  bleaching, veneers and orthodontics.
12-24 months      Artificial Appliances (depending on appliance and product). Hearing aids and repairs.


Exclusions
There are a number of situations where a member is not covered by        • Pharmaceuticals (including PBS pharmaceuticals benefits and
HCF and no Benefits will be payable.                                       other sundry supplies not directly associated with the reason for
                                                                           admission.
HCF Health Insurance does not cover:
                                                                         • Take home items e.g. crutches, toothbrushes and drugs.
• Claims made two years or more after date of service.                   • Personal convenience items e.g. phone calls newspapers, magazines
• When you or your dependants have the right to recover the costs          and beauty salon services.
  from a third party other than us, including an authority, another      • Massage and aromatherapy services.
  insurer (eg. motor vehicle or workers compensation), or under an
                                                                         • Some services provided while in hospital by non-hospital providers.
  employee benefit scheme.
                                                                         • Where a service is excluded from the payment of benefits in a
• Treatment for pre-existing ailments or conditions (within the first
                                                                           hospital, any associated items (e.g. medical gap, prosthesis, pharmacy)
  12 months waiting period).
                                                                           are also excluded.
• Goods and services received during any period where your
                                                                         • The gap on government approved prosthesis item items in non-
  payment is in arrears, your membership is suspended or you are
                                                                           participating private hospitals.
  within waiting periods.
                                                                         • The gap on government approved gap-permitted prostheses items.
• Treatment that we deem inappropriate or not reasonable, after
  receiving independent medical or clinical advice.                      In addition, HCF extras cover does not include:
• Any service where the treatment does not meet the standards in         • On most covers that include Psychology benefits, HCF will only
  the Private Health Insurance (Accreditation) Rules 2008 or as            pay benefits for patients who have been referred by their general
  amended.                                                                 practitioner, onto a Mental Health Plan, through Medicare
• Services that are not delivered face to face, such as online or          Australia and once the Medicare entitlements for the calendar
  telephone consultations, unless you are participating in one of our      year are exhausted. This benefit acts as a safety net after Medicare
  chronic disease management or health improvement programs                Australia and is not payable in any other circumstances.
  such as My Health Guardian.                                            • Goods and services while a hospital patient except for eligible oral
• Goods or services supplied by a provider not recognised by us.           surgery.
• Goods and/or services received overseas or purchased from              • Pharmacy items that are not on our Approved Pharmacy list
  overseas including items sourced over the internet.                      e.g. items listed on the PBS, items prescribed without an illness,
                                                                           items that are available without a prescription, or items that are
In addition, HCF hospital cover does not include:
                                                                           not TGA approved.
• Medical Gap and hospital benefits for excluded items or                • Goods or services that had not been provided at time of claim
  procedures and/or when the claim is not approved for payment             e.g. pre-payment.
  by Medicare Australia.
                                                                         • Fees for completing claim forms and/or reports.
• Private room accommodation for same-day procedures.
                                                                         • Where no specific health condition is being treated or in the
• Experimental treatments.                                                 absence of symptoms, illness or injury.
• Experimental and high cost non-PBS drugs.                              • Routine health checks, screening and mass immunisations.
• Procedures normally performed in a doctor’s surgery or as an           • More than one therapy service performed by the same provider
  outpatient.                                                              in any one day.
• Private hospital emergency room fees.                                  • Co-payments and gaps for government funded health services
• Respite care.                                                            e.g. the co-payment for PBS items
• Nursing home-type patients are limited to benefits set by the          • Where a provider is not in an independent private practice.
  Commonwealth Department of Health and Ageing.                          • More than one of the following therapies received on the same day
• Special nursing i.e. your own private nurse.                             (physiotherapy, chiropractic and osteopathy).
• Luxury room surcharge.                                                 • Claims that do not meet our criteria.
• Donated blood and blood products and donated blood collection
  and storage.
• PBS pharmaceutical benefits in non-participating private hospitals
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TOP PLUS AND SUPER MULTICOVER PS 0313
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