Membership guide Health insurance by fxw33739


									Membership guide
    Health insurance

             1 April 2009
Welcome to Defence Health                                     1
Your membership card                                          2
Online services                                               3
Membership eligibility                                        4
Managing your membership                                      5
Your child dependants                                         6
Changing your cover                                           7
Temporary suspension of membership                            8
Waiting periods                                               10
Claiming your benefits                                        12
Excesses                                                      15
Compensation and damages                                      15
Premium information                                           16
Federal Government 30% Rebate                                 18
Lifetime Health Cover                                         18
Medicare Levy Surcharge                                       19
Direct Debit Request Service Agreement                        20
Privacy statement                                             21
Defence Health Fund Rules                                     21
Compliments and complaints                                    21
Private Health Insurance Code of Conduct                      22
Index                                                         23

Information in this brochure is current as at 1 April 2009.
Welcome to Defence Health
This Membership Guide contains useful information about using your
membership card, online member services, claiming, managing your
membership and paying premiums.

Keep it with your other Defence Health documentation and refer to it
when necessary.

If you anticipate undergoing any treatment we recommend you contact us
first for a benefit estimate.

And remember, as with all forms of insurance, you should review your
health cover from time to time, to ensure you continue to have the cover
that is best for you.

Your membership card
Your membership card is important. It identifies you as a member of
Defence Health when you go to hospital or make an on-the-spot claim at
an allied health service provider (e.g. dentist, optometrist, etc) displaying
the HICAPS or IBA Health logo.

Your card details your membership number and those that are covered by
your membership. If you add or remove people covered by the membership,
a new card will be issued.

Safeguard your membership card
Your membership card gives your health provider direct access to your
benefits. Here are a few tips for you to safeguard it:
     Treat your card like a credit card
     Keep your card in a safe place like your wallet or purse
     Advise us immediately if your card is lost or stolen
     Never leave your card with a health provider
     Always check the health provider’s receipt carefully before signing.

Additional cards
You can request additional membership cards at any time for anyone listed
on your membership who is over 18 years of age and/or living at another

Replacement cards
If for any reason your membership card cannot be read or has been
misplaced you can order a replacement card. Simply contact our Member
Service Centre by email or phone and a replacement card will be arranged
for you.

Online services
The Defence Health website provides you with the convenience of
managing your membership online at a time that suits you. From the
website you can:
     View your membership details
     View your cover details
     Update your address and contact details
     Change your level of cover
     Add dependants
     View your claims history
     View your remaining limits
     View your payment details
     Set up direct debit for the automatic payment of your premiums
     Set up direct credit for receiving your benefit payments
     Pay your contributions by credit card
     Change your password
     Download your annual Private Health Insurance Statement
     View our range of health insurance options
     Download claim forms
     View a list of hospitals with which Defence Health has agreed prices
     (Agreement hospitals)
     View a list of doctors who may choose to use agreed medical treatment
     prices (Access Gap Cover)
     Locate allied health care providers who accept the Defence Health
     membership card for on-the-spot claiming
     View a list of prostheses for which there will be a no or known gap.

Registering is easy
To register for online services go to and from
the home page select ‘Register’ located in the Member Area at the top
righthand corner. Once you have completed the registration process you
will receive a message advising you of your successful registration.

A letter will then be mailed to you confirming that your Member Area
account has been activated and you are all set up and ready to log in and
manage your membership.

And remember to keep your PIN secure and secret.

Membership eligibility
The following people may be covered by a policy and are referred to as
qualified persons:

                                                             May be         May be
                                                            covered by     the policy
                                                             a policy        holder
 1. Current and former Permanent or Reserve                    a              a
    members of the ADF
 2. Current and former employees of the Department             a              a
    of Defence or other Defence related departments
 3. Current and former employees of:
    a.    Defence related agencies, authorities or             a               a
          companies; and
    b.    Companies contracted to Defence;                     a               a
    where the employee is or was involved in supplying
    goods or services to Defence
 4. Persons insured with Defence Health on                     a              a
    12 October 2007

The following people who are related to a qualified person may also be
covered by a policy:
                                                             May be         May be
                                                            covered by     the policy
                                                             a policy        holder
 1. Partners and former partners                               a              a
 2. Dependent children                                         a
 3. Parents                                                    a              a
 4. Adult children, their partners                             a              a
    and dependent children                                     a
 5. Brothers and sisters, their partners                       a              a
    and dependent children                                     a

A ‘Defence related department’ is an entity which has a reporting obligation to, or is
within the portfolio responsibility of the Minister for Defence or a Minister Assisting
such Minister or a Parliamentary Secretary to either Minister.

A ‘Defence related agency’ is as referred to in the Financial Management and
Accountability Act 1997.

A ‘Defence related authority or company’ is as referred to in the Commonwealth
Authorities and Companies Act 1997.

Managing your membership
Cooling off period
If for any reason you change your mind within the first 30 days of joining
and have not made a claim, simply write to us and we will cancel your
policy and refund any premiums you have paid.

Policy types
Defence Health offers policies which cover the following combinations
of eligible persons:

Permanent ADF policies

ADF Single                              or

ADF Children

ADF Family

ADF Reserve and civilian policies

Single                                  or



Single parent family

Role of the policy holder
The policy holder must be aged 18 or over. They are responsible for
the policy and all correspondence will be addressed to them. Only the
policy holder is able to add or remove others from the policy and obtain
information about claims made on the policy.

Anyone aged 16 or over can remove themselves from the policy but they are
not able to remove others.

Delegated authority
The policy holder may delegate authority to a nominated adult dependant to:
    request policy details and other personal information
    change or update policy details, and
    submit claims.

Partner separation
In the case of separation the partner can remove themselves from the policy
and apply for their own policy.

Your child dependants
Dependants to age 21
Your single children can remain covered under your family policy until
they are aged 21.

Student dependants to age 25
If they are single, and studying full time they can remain covered under
your family policy until age 25. To remain covered under your family policy
their student status must be confirmed at the start of each year.

Young Adult Support Plan
Your single, non-student children aged between 21 and 24 can purchase
and maintain their own Top Extras cover and continue to receive the
benefits of your family hospital cover until their 25th birthday. Provided
they have done so prior to 31 December 2009 they can continue to
enjoy this feature.

Changing your cover
Change of membership details
You are required to advise Defence Health of any change to your
membership details within two months of the change taking place.

In general changes can be managed by you online, or be notified by you
via phone, email, fax or post. Typical changes and accepted methods of
notification include but are not limited to:
                                             Online      Phone           Writing
    Changes of contact details                a            a              a
    Change of name                            a            a              a
    Change of partner                         a            a              a
    Adding a new dependant                    a            a              a
    A dependant child who ceases or defers    a            a              a
    study or reduces study to part-time
    Registering to pay 30% Rebate reduced                                 a*
    Registering to pay your premiums          a                           a*
    automatically through a nominated
    bank account

* Must be applied for by completing the appropriate form, which can be
  downloaded from the website.

Written confirmation of your change will be forwarded to you in 7-10 days.

Upgrading your cover
If you are upgrading your cover you may need to serve waiting periods on
the upgraded cover. Upgrading your cover includes:
      increasing the level of cover
      adding a new cover, and
      reducing or removing an excess.
You will, however, be entitled to the benefits of your previous cover for the
duration of any waiting period.

Downgrading your cover
You may choose to downgrade your cover by:
      reducing the level of cover
      removing a current cover, or
      increasing or adding an excess.
In these circumstances you will not serve additional waiting periods.
However, waiting periods will apply should you subsequently upgrade at a
later date.

Adding or removing a person from your membership
Let us know if you would like to add or remove a person from your
membership. We will ensure that you continue to have the best level of
cover for your needs.

Adding a newborn
If you wish to add a newborn child, you can transfer to a family cover from
the date of your child’s birth. As long as you add your newborn within two
months of their birth, with premiums paid from their birth, cover for the
newborn will be immediate with no waiting periods.

If you already have family cover, you can add your newborn child by
advising us of the baby’s name and date of birth (by the web, phone, email,
fax or post) within two months of their birth. Their cover will be immediate
with no waiting periods.

Transferring from another fund
Where a member of another fund transfers to Defence Health with a break
in cover of two months or less, any waiting periods already served under
their previous cover for comparable benefits will be honoured. If you are
upgrading your cover in the transfer you may need to serve waiting periods
on the upgraded cover.

Where a member of another fund transfers to Defence Health with a break
in cover greater than two months, they will be required to serve all relevant
waiting periods.

Any break in cover will be recorded as Lifetime Health Cover days without
hospital cover.

Discharging from the Permanent ADF
A member who joins within two months of discharge and whose cover
takes effect from the day following discharge will have absolutely no
waiting periods on their own cover.

Temporary suspension of membership
With the agreement of Defence Health you may suspend your cover for any
of the following reasons:
      overseas posting
      ADF Reservists on continuous full-time service (CFTS)
      overseas travel, or
      financial hardship.

You can download a Suspending your health cover fact sheet and
application form from the website or request one by calling the
Member Service Centre.

Medicare Levy Surcharge warning
The Medicare Levy Surcharge is payable by high income earners during
any period of suspended hospital cover. If you earn over the Medicare Levy
Surcharge taxable income threshold you should seek financial/taxation
advice before suspending.

General conditions for suspension
     To suspend your cover you must advise Defence Health prior to
     the occurrence of the relevant reason for suspension. Applications
     for suspension will not be processed retrospectively.
     Premiums must have been paid up to the date of suspension before
     a suspension can be approved.
     Benefits are not payable for treatment received during the period
     of suspension.
     Written confirmation of your suspension will be posted within
     7-10 days.
     To avoid additional waiting periods the membership must be
     reactivated within one month of the relevant reason for suspension
     ceasing to apply, or the maximum period of suspension being reached.
     To avoid Lifetime Health Cover days without hospital cover the
     resumption should be active from the date the reason for suspension
     ceased to apply, or the maximum suspension period was reached.

Overseas postings
When sent overseas on an accompanied posting, your dependants receive
the same level of care from the ADF that you enjoy. You may therefore wish
to suspend your cover whilst on an accompanied posting. Your cover may
be suspended for a minimum of 28 days and a maximum of two years.
If your posting is extended you can apply for an extension of your
suspension period. To suspend your cover you must advise Defence Health
prior to departure. You should also authorise your pay representative
to cease your allotment.

No new waiting periods will apply provided you reinstate your cover at the
equivalent level within one month of returning to Australia. Proof of your
entry date (e.g. boarding pass) will be required.

ADF Reservists on CFTS
If you are on CFTS for more than 28 days, you may suspend your personal
cover or vary your premiums to cover your dependants only for the
duration of the service.

No new waiting periods will apply provided you reinstate your cover at the
equivalent level within one month of ceasing your CFTS. Proof of your
CFTS cessation date will be required.

Overseas travel
If you travel overseas for an extended period or move overseas to work, then
you can arrange to suspend your cover prior to departure for a minimum
of 28 days and a maximum of two years.

No new waiting periods will apply provided you reinstate your cover at the
equivalent level within one month of returning to Australia. Proof of your
entry date (e.g. boarding pass) will be required. If you are travelling for
leisure you should consider taking out travel insurance.

Financial hardship
A member may apply to suspend their membership for a minimum period
of 3 months and a maximum period of 12 months whilst experiencing
financial hardship. Each member is permitted three hardship suspensions
in a lifetime. You must have contributed to a hospital cover with Defence
Health for at least 12 months before a suspension for financial hardship
will be permitted. A member with hospital and extras cover may not
suspend one component without also suspending the other. The financial
hardship must be detailed in the Membership suspension application.

No new waiting periods will apply provided you reinstate your cover at
the equivalent level within one month of the maximum suspension period
being reached.

Waiting periods
What is a waiting period?
A waiting period refers to a stage of health fund membership during which
no benefit is payable for particular services.

Why do waiting periods apply?
If there were no waiting periods, people could take out cover or upgrade
to a higher cover only when they knew or suspected they might need
treatment. Their costs would then have to be paid by the long-term
members of the fund leading to much higher premiums for all fund
members. This would not be fair.

Therefore, when you join a health fund or upgrade your existing cover, you
may have to wait a period of time before you can claim benefits.

When do waiting periods apply?
Waiting periods apply where a person:
     is insured for the first time or has not been insured within the previous
     two or more months
     upgrades to a higher level of cover (includes reducing or removing
     an excess or co-payment)
     transfers from another fund and has not completed our waiting
     periods for equivalent benefits or chooses to upgrade their cover
     when they transfer.

Note: When upgrading your cover you will be entitled to the benefits of
your previous cover for the duration of any waiting periods.

What waiting periods apply at Defence Health?
Waiting periods that apply to Defence Health cover are:
     2 months for rehabilitation, psychiatric and palliative care
     12 months for a pre-existing condition excluding rehabilitation,
     psychiatric and palliative care
     12 months for obstetric (pregnancy) related services
     12 months for laser refractive eye surgery
     12 months for the supply of blood glucose monitors, blood pressure
     monitors, TENS machines, C-PAP machines, nebulisers and spacers,
     mobility aids, foot orthoses, orthopaedic shoes, compression garments,
     non-cosmetic prostheses, splints and braces
     12 months for treatment under major dental categories including
     periodontics, oral surgery, endodontics, crowns and bridgework,
     orthodontics, prosthodontics, and high cost dentistry
     36 months for the supply of hearing aids, and
     2 months for all other treatments.

Cover for an accident is immediate provided it is not recoverable from
another source such as Workers Compensation, third party or other liability

What is a pre-existing condition?
A pre-existing condition is an ailment or illness, where signs or symptoms
existed at any time in the six months prior to you joining or upgrading to a
higher level of cover.

It is not necessary that you or your doctor knew what your condition was
or that the condition had been diagnosed.

A condition can still be classed as pre-existing even if you hadn’t seen your
doctor about it before joining or upgrading. If you knew you weren’t well,
or had signs of an ailment that a doctor would have detected during the six
months prior to joining or upgrading, then the ailment would be classed as

Risk factors, including family history of an ailment, are not signs or
symptoms of a pre-existing ailment. They will not be considered when
deciding whether an ailment is pre-existing.

Who decides if I have a pre-existing condition?
The only person authorised to decide whether you have a pre-existing
condition is a medical or other health practitioner appointed by Defence
Health. The practitioner will consider the opinion of, and evidence
presented by your treating practitioners before making an informed

If you have had your current cover for less than 12 months and need
treatment, you should confirm with Defence Health whether the
pre-existing condition waiting period will apply.

Defence Health may require you and your treating practitioners to
complete a Pre-existing Ailment form in order to obtain facts about your
illness. The practitioner appointed by Defence Health to review your case
will need a number of business days to investigate and make an assessment.

Claiming your benefits
Hospital claims
In most cases when you are discharged from hospital your account will be
settled directly with the hospital. If your hospital stay:
      was subject to any waiting periods, or
      involved the payment of an excess, or
      involved any personal expenses (e.g. telephone calls, newspapers, etc.),
then you will be responsible for the expense and the hospital may require
settlement on discharge.

In-hospital medical claims
You should encourage your doctor to use the Access Gap Cover medical
schedule to help you minimize or even avoid any out-of-pocket expenses.
For maximum convenience we suggest your doctor sends the account
directly to Defence Health. If your doctor is not willing to send the account
directly to Defence Health, we encourage you to send it to us. To be eligible
for the higher Access Gap Cover benefits, the doctor’s account must be
suitably endorsed, show financial consent for any amounts payable by
you and instruct you to send the claim directly to your health fund.
If these details are not present on the account, you will be required to
send the account to Medicare.

Allied health (extras) claims
Using your membership card
Your Defence Health membership card enables your benefit to be paid
directly to participating allied health service providers who display the
HICAPS or IBA Health logo.

After the services have been provided your membership card will be swiped
and your claim processed in seconds. The appropriate benefit for your level
of cover is automatically credited to the health care provider, so you only
need to pay the difference (if any) between the service cost and benefit. It is
fast, convenient and there are no claim forms to fill in.

Direct claims payment service
Access your benefits quickly and easily with our direct claims payment
service. Once we receive and process your claim your benefits will be
immediately deposited into your nominated bank, building society or credit
union account. You will not have to waste time in bank queues or wait for
the cheque to clear.

To register an account for direct claims payment:
     call or email the details of your preferred direct claims payment
     account, or
     register via the online Member Area, or
     download and complete the Direct claims payment application
     form from the website.

By fax
Defcredit and the Australian Defence Credit Union (ADCU) branches are
authorised to fax your completed claim form and receipts directly to us. If
you submit your paid claims before 3:00pm EST, we can credit your benefit
payment directly into your nominated bank, building society or credit
union account on the next working day. If the fax is illegible and we are
unable to contact the sender, your claim will be processed when we receive
the original claim form, receipts and accounts, which will be forwarded to
us on your behalf.

By mail
To claim your benefit by mail, complete a claim form, attach your original
accounts or receipts, and mail them to us.

Obtaining a claim form
Claim forms are available for download from our website or by phoning our
Member Service Centre. Defence Health from time to time will include a
claim form with certain communications to you.

Paid accounts
If you have already paid the health care provider, we can credit your benefit
payment directly into your nominated bank, building society or credit
union account. Alternatively we will send you a cheque.

Unpaid accounts
In most cases, where you submit a claim directly to Defence Health, you
will receive a cheque in the name of the provider to enable you to settle the

Where your provider submits a claim directly to Defence Health, or you
send in an Access Gap Cover endorsed account, we will pay your provider
directly. You will receive a statement confirming the amount paid on your

Claiming conditions
     A claim for benefits must be lodged within two years of the date of the
     service. Benefits will be refused if a claim is lodged after this period.
     For Defence Health to assess your claim all account/receipts must be
     originals (or provider endorsed duplicates) and include the:
          appropriate item number or full description of the service
          or product
          patient’s name
          date of service
          fee charged
          provider’s name, qualifications and practice address, and
          provider number (if applicable).
     Tooth numbers are required on dental accounts where treatment has
     taken place on individual teeth.
     Alternative therapy providers must be recognised by the Australian
     Regional Health Group at the time the service is provided.
     Benefits and limits are assessed having regard to the date on which
     the services were rendered or product supplied except for courses
     of orthodontic treatment and first aid training.
     Limits renew each financial year (1 July to 30 June).
     Services must be provided by approved practitioners in private practice
     or salaried doctors in public hospitals.
     All documents submitted in connection with a claim become
     the property of Defence Health, unless otherwise agreed by the Fund.
     Benefits are not payable for claims for services rendered while
     premiums are in arrears or the membership is suspended.
     Benefits are not payable, or may be payable at a reduced rate, during
     any applicable waiting periods.
     Benefits are not payable for claims for services rendered outside
     Australia or for items purchased or hired from overseas suppliers.
     Benefits are not payable on claims subject to compensation, third
     party or other liability provision.
     Benefits are not payable for treatment rendered by a provider to:
          the provider’s spouse, defacto, partner, dependants, or
          business partner, or
          the spouse, defacto partner or dependants of the provider’s
          business partner.
     Extras benefits are not payable for services rendered in
     a public hospital.

Ambulance treatment claims
Benefits are not payable towards any ambulance transportation costs
that are fully covered by a third party arrangement such as an ambulance
subscription scheme or a State/Territory ambulance transportation scheme.
Benefits may be payable however, for any ambulance treatment costs not
fully covered by such schemes.

Defence Health pays a government-imposed ambulance levy on behalf of all
members with hospital cover residing in NSW/ACT.

If you reside in NSW/ACT, have hospital cover, and receive an ambulance
account you do not need to pay the account. Send the account to Defence
Health, and we will endorse the ambulance account with your membership
number and a Defence Health stamp, and return the account with a letter
advising you to forward it to the ambulance service. Where you have paid the
account we will still endorse the account for you to forward to the ambulance
service – you will be entitled to a refund from the ambulance service.

Multiple services in one day
Where an insured person has two or more consultations for the same type of
service on the same day, benefits will only be payable where:
      there is a time lapse of three hours or more between consultations, and
      the consultations relate to two separate conditions.

Where an insured person has two consultations with the same provider on
the same day, benefits are payable where:
      two different types of services are provided, and
      the provider is qualified to perform both types of service.

Claims auditing
Defence Health randomly selects claims for audit. If your claims are selected
we may contact you or your provider for additional information. We ask
you to assist us in this important process.

Members contributing to a hospital cover with an excess will pay the excess
once per membership, per financial year.

The excess is applied in both public and private hospitals. Importantly,
the excess will not apply to your dependent children under either the Top
Hospital or ADF Top Hospital covers. For those single parents with Top
Hospital (SPF closed) cover the excess will not apply to your dependent
children under 16 years of age.

Where a patient’s hospitalisation extends beyond the end of a financial
year, the excess amount for the new financial year will apply to the first
subsequent admission of the new financial year.

Calculation of the excess amount will apply to hospitalisations in the order
they are processed by Defence Health.

Compensation and damages
Benefits are not payable for expenses incurred in relation to an injury where
the insured person has received, or may be entitled to receive, compensation
in respect of that injury.

Where Defence Health has paid benefits, whether by way of provisional
payments or otherwise and the insured person has received compensation
in respect of the injury, the insured person must repay to Defence Health
the full amount that Defence Health paid in relation to the injury, upon the
determination or settlement of the claim for compensation.

Provisional payment of claims
Defence Health may consider factors such as unemployment or financial
hardship when choosing to make a provisional payment or benefits in
respect of expenses incurred in relation to a compensable injury.

The provisional payment is conditional upon the insured person agreeing to
repay to Defence Health the full amount of the provisional payment. This
debt will be immediately repayable upon the award or settlement of the
compensation claim.

Premium information
Premiums must be in advance
To ensure the efficient processing of claims and hospital eligibility checks,
premiums are required to be paid in advance.

State of residence
Members are required to hold a policy and pay the premium which is
applicable to the State or Territory in which they reside. When members
move between States they must notify Defence Health within two months
to ensure full cover is able to be provided in their new State of residence.
Permanent ADF personnel are encouraged to take advantage of the special
national premiums which are offered on ADF policies.

Paying your premiums
Defence Health offers a range of payment options, including:

Direct debit deductions
This is the most popular and convenient method of payment. Your
premiums are automatically deducted from your bank, credit union
or building society account on the date of your choosing. Payment
frequencies are monthly, quarterly, half yearly and yearly.

Regular credit card payments are deducted on the 15th of your preferred
payment frequency.

Your first deduction after you join or change the level of your cover may
include an adjustment amount.

If you change your direct debit arrangements or wish to change your level
of cover, you must notify us in writing at least 15 days prior to your next

Military allotments and Department of Defence
payroll deductions
Permanent ADF personnel and Department of Defence civilian employees
are able to arrange fortnightly payroll deductions. The membership must be
owned by the ADF member or the Defence civilian employee.

If you change your level of cover you must advise your pay representative
of your new allotment or payroll deduction amount. The change in cover
will become effective from the date your allotment or payroll deduction

Premium guarantee
If you pay your premiums up to 12 months in advance prior to written
notification of an impending rate change, you will not be asked to pay the
increased rate until your next payment date. Any change to benefits during
this period of time will still apply.

You cannot extend your cover beyond 12 months from the date of your
payment and the premium guarantee is dependent on you maintaining the
same level of cover, State of residency and membership classification.

If you make any changes to your level of cover, policy type, your State of
residency or suspend or reactivate your membership during this period,
the new premium will apply from the date of the change or the date you
resume your membership.

Special premiums for the ADF
Permanent ADF premiums
Permanent ADF members are encouraged to take advantage of the special
national premiums which are offered on ADF Single, ADF Children only
and ADF Family policies.

ADF Reserve premiums
Active ADF Reserve members and Standby Reserve members with a
training day commitment will receive a discount on their hospital and
combined base premiums.

Memberships in arrears
A membership is in arrears whenever the date to which premiums have
been paid is earlier than the current date. Benefits are not payable for any
treatment provided during a period of arrears.

It is important to keep us up to date whenever you change your contact
details so we can contact you should your membership fall into arrears.

Maximum period of arrears
When a membership is more than two months in arrears Defence Health
may terminate the membership.

Reinstatement of terminated membership
Where a membership has been terminated Defence Health may
reinstate the policy at the request of the policy holder, with continuity of
entitlements where all arrears premiums are paid.

Federal Government 30% Rebate
The Federal Government 30% Rebate makes private health insurance more
affordable. When you take out hospital or extras insurance or a combined
package, you can receive the rebate as a reduction on your premiums, or a
tax offset claimable on your income tax return or a cash rebate claimable
from a Medicare office.

The amount will depend on your age:
     if everyone covered by your membership is aged under 65 years,
     your rebate will be 30%
     if you or someone covered by your membership is aged between
     65 and 69, your rebate is 35%
     if you or someone covered by your membership is aged 70 years
     or older, your rebate is 40%.

To receive your rebate as a reduced premium simply complete the
downloadable Application to receive the 30% rebate as a reduced premium

Lifetime Health Cover
Lifetime Health Cover is a Federal Government initiative which recognises
the length of time a person has hospital insurance with a registered health
fund. If you take out hospital insurance by 1 July following your 31st
birthday and maintain it, you will pay lower premiums compared to
someone who joins when they are older.

If you take out hospital insurance later in life, then you will pay a 2%
loading on top of the base premium for every year you are aged over 30.

For example, a person who first takes out hospital cover at age 40 will pay
20% more every year than someone who takes out hospital cover at age 30.
The longer you leave it, the higher the loading. The maximum loading is

The loading will be removed after you have maintained hospital cover for a
continuous 10 year period.

Under Lifetime Health Cover, members are able to cease their hospital
cover for a cumulative period of 1,094 days in their lifetime without
affecting their loading. On the 1,095th day and for every 365 ‘days without
hospital cover’ thereafter, your Lifetime Health Cover loading will increase
by 2%. Should you consider ceasing your hospital cover, first discuss your
options with Defence Health.

If you are transferring your hospital cover from another fund your ‘Transfer
Certificate’ will confirm your Lifetime Health Cover loading and days
without hospital cover for our records.

Lifetime Health Cover and the ADF
Special provisions apply to permanent members of the ADF on discharge
in recognition of you having had effective hospital cover during your period
of service.

If you are over 30 and purchase hospital cover on your date of discharge,
your Lifetime Health Cover loading, if any, will be determined by either
the age you were when you enlisted, or your date of enlistment. If you were
under 30 when you enlisted, or you enlisted prior to 1 July 2000, then you
are unlikely to have a Lifetime Health Cover loading.

If you are aged over 30 on your date of discharge and do not purchase
hospital cover, then you will start accumulating ‘days without hospital
cover’. If you are thinking about discharging in the near future, then
call Defence Health to find out how you may be affected by Lifetime
Health Cover.

You may need to think now about whether the Lifetime Health Cover
loading affects your civilian partner.

Medicare Levy Surcharge
The Medicare Levy Surcharge of 1% of taxable income will apply if you
do not have an appropriate level of hospital insurance and your taxable
income is over $70,000* per year as an individual or a combined $140,000*
per year for most couples or families. This income threshold increases by
$1,500* for each additional child after the first. The surcharge is in addition
to your Medicare Levy.

By taking out any hospital insurance with Defence Health, you will be
exempt from paying the Medicare Levy Surcharge.

If you need financial advice please seek the services of your accountant or
financial advisor.

Medicare Levy Surcharge and the ADF
Single, permanent ADF members are exempt from the Medicare Levy
Surcharge. However, permanent ADF members with a civilian spouse/
defacto earning a taxable income will need to consider the impact of the
Medicare Levy Surcharge where the combined taxable income is over
$140,000* per year, with the income threshold increasing by $1,500* for
each additional child after the first. The amount payable by both you and
your spouse/defacto will be 1% of your individual taxable income.

* These Medicare Levy Surcharge income thresholds are effective from
  1 July 2008 and are indexed annually.

Direct Debit Request Service Agreement
The Direct Debit Request (DDR) Service Agreement is relevant if you have
elected to pay your premiums by direct debit. It sets out your rights and
responsibilities, together with where you should go for assistance in respect
of your direct debit arrangement with Defence Health Limited.

Initial term of the arrangement
In terms of the DDR arrangement made between us and signed by you, we
undertake to periodically debit your nominated account in accordance with
your signed authority to direct debit.

Drawing arrangements
If any drawing falls due on a non-business day, it will be debited from your
account on the next business day following the scheduled drawing date. We
will give you at least 14 days notice when we intend to make changes to the
initial terms of the arrangement.

Your rights
Changes to the arrangement
If you want to make changes to the drawing arrangement, please notify us
in writing at least 14 business days prior to your next scheduled drawing
date. These changes may include:
      deferring the drawing
      altering the schedule
      stopping an individual debit
      suspending the DDR
      cancelling the DDR completely.

If you have any enquiries they should be directed to Defence Health
Limited, alternatively you can contact your financial institution. All
personal customer information held by us will remain confidential except
for information that may be provided to our financial institution to initiate
the drawing to your nominated account, or information which may be
disclosed to a third party as required by law.

If you believe that a drawing has been initiated incorrectly, you should raise
the matter with Defence Health Limited. Alternatively you can contact
your financial institution.

Your responsibilities
It is your responsibility to ensure that:
       you check with your financial institution that your nominated account
       details are correct and can accept direct debits (direct debits through
       BECS, the bulk electronic clearing system, are not available on
       all accounts)
       on the drawing date there are sufficient cleared funds in the
       nominated account
       you advise Defence Health if the nominated account is transferred
       or closed.

If your drawing is returned or dishonoured by your financial institution,
Defence Health will deduct an amount equal to your standard contribution
plus the arrears amount on your regular deduction day in the following
month. We will notify you in writing if your drawing is returned or
dishonoured. Any transaction fees payable by us in respect of the above may
be passed on to you. Consecutive returns or dishonours may result in the
direct debit facility being withdrawn.

Privacy statement
Defence Health has a legal obligation to comply with the Commonwealth
Privacy Act 1988 and the National Privacy Principles. The Defence Health
privacy statement informs you about how your personal information will
be collected, held, used and disclosed, how you may gain access to that
information and how you may complain about possible breaches of privacy.

A copy of the full, current statement may be obtained from

We will generally collect and use your information to approve your
transactions/claims, to provide services you have requested and to inform
you of products, benefits and services we think you may be interested in.
We may use or disclose your personal information for another purpose,
but only if we have your prior consent, or we are required to do so to
fulfil our obligations as a private health insurer or for any other reasonably
expected purpose related to the provision of your health benefits. For
example, we may disclose your information to other service providers we
have arrangements with or who provide services to us, or where otherwise
permitted or required by law.

If you do not provide the information requested or do not consent to us
requesting it from third parties, we may be unable to provide health benefit
services to you.

Defence Health Fund Rules
All members are bound by the Fund Rules of Defence Health Limited.
Your cover has been accepted and benefits will be paid in accordance
with these Rules. These Rules change from time to time and can be
downloaded from, or may be requested
by calling 1800 335 425.

Compliments and complaints
Defence Health values your feedback on our products and services which
assists us to monitor our policies, procedures and systems to ensure we are
meeting the needs of our members.

As part of our commitment, we have implemented an issues and complaints
handling system based on Australian and International Standards to deal
with your concerns and suggestions in a timely, efficient and consistent

If we are unable to satisfy your concern you can contact the Private Health
Insurance Ombudsman. The Ombudsman provides free information and
assistance to resolve disputes:
      phone 1800 640 695, or
      write to Level 7, 362 Kent St Sydney NSW 2000

Private Health Insurance Code
of Conduct
Under the Private Health Insurance Code of Conduct, Defence Health
agrees to:
     provide information to you in plain language
     ensure that policy documentation is full and complete
     ensure that all persons providing information on health insurance
     are appropriately trained and able to provide clear explanations
     ensure information exchanged between you and Defence Health
     is protected in accordance with privacy principles
     provide you with easy access to our internal issues and complaints
     handling system and advise you of your rights to take an issue to
     the Private Health Insurance Ombudsman, and
     continue to improve our standards of practice and service.

A copy of the Code of Conduct may be obtained from or by phoning 1800 335 425.

Access Gap Cover                            3, 12, 13
ADF Reserve policies                                5
Agreement hospitals                                 3
Alternative therapy providers                      14
Ambulance treatment claims                     14, 15
Australian Regional Health Group                   14

Changing your cover
      Adding a newborn                              8
      Adding or removing a person                   8
      Downgrading your cover                        7
      Upgrading your cover                          7
Civilian policies                                   5
   Allied health (extras) claims               12, 13
   Claiming conditions                             14
   Direct claims payment service                   12
   Hospital/In-hospital                            12
   Using your membership card                      12
Compensation and damages                       15, 16
Compliments and complaints                     21, 22
Cooling off period                                  5

Days without hospital cover               8, 9, 18, 19
Defence Health Fund Rules                           21
Defence Health website                               3
Defence related agency                               4
Defence related authority or company                 4
Defence related department                           4
Delegated authority                                  6
   Single children to age 21                        6
   Student dependants to age 25                     6
   Young Adult Support Plan                         6
Direct Debit Request Service Agreement         20, 21
Discharging from the Permanent ADF              8, 19

Excesses                                       12, 15

Federal Government 30% Rebate                      18
Feedback, your                                 21, 22

HICAPS (using your membership card)             2, 12

IBA Health (using your membership card)         2, 12

Lifetime Health Cover                     8, 9, 18, 19

Medicare Levy Surcharge                           9, 19
Member Area (online services)                         3
Membership card                                       2
Additional cards                                      2
Claiming with your membership card                2, 12
Replacement cards                                     2
Membership eligibility                                4
Memberships in arrears                               17
Moving between States                                16

Online services                                      3

Partner separation                                   6
Permanent ADF policies                               5
Policy holder                                        6
Policy types                                         5
Pre-existing condition                              11
    ADF Reserve premiums                            17
    Military allotments and payroll deductions      16
    Paying your premiums                            16
    Permanent ADF premiums                          17
    Premium guarantee                               17
Privacy statement                                   21
Private Health Insurance Code of Conduct            22
Private Health Insurance Ombudsman                  22
Provisional payment of claims                       16

Qualified persons                                    4

Reinstatement of terminated membership              17

Suspension of membership
   ADF Reservist on CFTS                             9
   Financial hardship                               10
   General conditions                                9
   Overseas posting                                  9
   Overseas travel                                  10

Transfer certificate                                18
Transfer from another fund                           8

Waiting periods                                  10, 11

Contact us
Defence Health Limited                  Phone
ABN 80 008 629 481                      Enquiries 1800 335 425
AFSL 313890                             Monday to Friday
                                        8:30 am to 5:00 pm EST
                                        1300 665 096
                                        Post                           CODE
                                        PO Box 7518
                                        Melbourne Victoria 8004

                                        Level 2, 344 St Kilda Road
                                        Melbourne Victoria 3004

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