• Unmarried children between the age of 21-25 and are not full-time students and
not eligible for cover under the family membership as detailed under the definition of "dependant children".

• Single and not living in a defacto relationship

An adopted or foster child must be added to your membership within two months of joining the family unit in order to avoid additional waiting periods. Documentation supporting guardianship must be provided at time of request.

Adding a Dependant

Expectant mothers on Single memberships must change to a Family membership or Single Parent Family membership two months prior to the expected date of birth to ensure cover for newborns.

Ambulance Benefit

Ambulance benefits are payable for recognised emergency ambulance transport. Ambulance transport is covered in full except in the following circumstances, which are not considered emergencies:

• Transport from the hospital to your residence (home or a nursing home)
• Transport from the admitting hospital to another hospital for treatment
• Transport for regular treatment (eg chemotherapy)
• Treatment by ambulance officers, which does not result in transport to a hospital

Benefit Year

Benefits are payable on a membership year based on the member's joining date.

Cancellation of Membership/Cooling Off Period

Under Fund rules members can cancel their membership in writing at anytime. Cancellation of membership cannot be backdated, however, new members have a 30 day cooling-off period where all premiums paid in advance of their joining date can be refunded. This is provided claims have not been paid during this period. In this instance the cancellation will occur after the date of the last claim paid.

Contracted Hospitals

Transport Health has contracts with around 400 private hospitals throughout Australia to minimise or eliminate out-of- pocket expenses; benefits are paid according to your level of cover.

Contracted Specialist Medical Practitioners

Under the Transport Health initiative, ‘Access Gap’, doctors who charge more than the Schedule Fee can participate in a program that minimises or eliminates patient out-of-pocket medical expenses while in hospital. This in no way compromises or interferes with patient care as participation is voluntary and doctors can opt in or out at any time.

Visit our website or contact our office for further information about Access Gap.

Co-Payments and Excesses

A Co-payment is an amount payable by the member and applicable to each hospital admission during a membership year. Intermediate Hospital (H2) has a daily co-payment of $100 per night, capped at $500 per person, per admission. This is also capped annually at $500 for a single and $1000 per family membership.

The Healthy Choice Hospital (H4) has a daily co-payment of $100 for overnight accommodation capped at $500 per admission. This is not capped annually. There is also a daily co-payment of $100 for day stays / day procedures excluding in-patient dental treatment. The daily co-payment is not capped annually.

The Excess is an amount payable by the member and applicable only once in the membership year. The excess, as in Top Hospital Excess cover (H3X), is $250 per person, on the first overnight admission, per Membership Year. A single membership has a maximum excess of $250 annually.

A family membership must meet a per person excess of $250 up to a maximum of $500, for overnight admissions, in the Membership Year.

Dependent Children

Persons are considered dependants of the contributor in the following instances:
• Unmarried children up to the age of 21
• Unmarried children between the ages of 21 and 25, who are full-time students in an approved apprenticeship / study course

Disclaimer

Transport Health encourages its contracted providers to offer high-quality products and services. The relationship Transport Health has with these providers does not construe an endorsement as to fitness for purpose and is not a recommendation or warranty of the services. Transport Health does not assume any responsibility for the product or service provided and Members should rely on their own enquiries and seek assurances directly from the provider.

Excess

The excess is an amount payable by the member and applicable only once in the membership year. The excess, as in Top Hospital Excess cover is $250 per person, on the first overnight admission, per membership year. A single membership has a maximum excess of $250 annually. A family membership must meet a per person excess of $250 up to a maximum of $500, for overnight admissions, in the membership year.

Young Singles Cover has a $250 excess payable on overnight and/or day stays per admission. This excess is not capped annually.

Excluded Services

Excluded services, as detailed in Healthy Choice Hospital(H4), are not covered. Transport Health does not pay benefits for hospital treatment of any of these conditions when you elect to be treated as a private patient. You are, however, covered by the public system under your Medicare entitlement only when treated as a public patient by hospital appointed doctors in a public hospital.

Extras Cover Sub-limit Period

New Members who were previously uninsured will be subject to a sub-limit on Extras benefits during the first 6 months of membership. This applies to both Top Extras (E1) and Healthy Choice Extras (E4). benefits payable during the first 6 months of membership and after serving the specified waiting periods, cannot exceed 50% of the full annual benefit limit entitlement. If further treatment is required in the subsequent 6 months, members are entitled to the balance of the annual limit. The overall benefit payable over 12 months is equal to the normal quoted annual limit but this amount cannot be claimed totally within the first 6 months. Sub-limits do not apply to members who are transferring from other funds, providing they have held equivalent membership and served the required waiting periods. In general, sub-limits apply to those who were previously uninsured. After 12 months of membership (or the stated waiting period for the service - whichever is the greater), members are entitled to unrestricted benefits as stipulated in our brochure.

Health Services Benefit – Early Hospital Release and Preventative Treatment

This benefit applies only for certified early release from hospital (or when the treatment is in lieu of hospital admission) and is provided in exchange of hospital accommodation benefts.

A doctor’s certificate is required to qualify for this benefit which covers treatment such as home nursing and home help when required as part of a medically certified early release or preventative program.

The benefit is 80% of the cost of each service up to a total annual limit of $500 per person. This benefit is not applicable to Same Day hospital treatment.

How Benefits are Assessed

Benefits are payable only for services rendered by providers with appropriate qualifications and recognised by Transport Health.

Benefits cannot exceed the fee charged. In some instances benefits are not payable:

• For services or treatment where you may have an entitlement to receive compensation and/or damages.
• When claims are made 2 or more years after receiving treatment.
• For treatment received when Membership is unfinancial or suspended.
• For services provided by a family member.

Internal Issues Resolution

Transport Health continuously looks at ways to improve services to members. We comply with the Private Health Insurance Industry Code of Conduct. We have established an internal dispute resolution process to ensure disputes are managed effectively and efficiently, while ensuring privacy and professionalism at all times. If you have an issue of concern, please contact one of our Service Consultants who will endeavour to resolve the issue promptly through our internal disputes resolution process.

Health Insurance issues that cannot be resolved through the usual processes can be addressed to the Private Health Insurance Ombudsman.

The Ombudsman’s Office can be contacted on 1800 640 695 and via the website www.phio.org.au.

Membership

A Single Membership provides cover for an individual.

A Single Parent Family Membership provides cover for an adult contributor and dependent children. See earlier definition of dependent children.

Family/Couples Memberships comprise an adult contributor with a partner and/or dependent children. See earlier definition of dependent children.

Only residents of Australia are eligible to join the Fund.

Membership Year

This is the 12 month period from the date of joining the Fund. For example, if a member joins on 12 March, the Membership Year spans from 12 March in that year to 11 March in the subsequent year.

CPAP Machine

Benefits can only be claimed from either hospital or extras table but not from both.

Newborns

When a newborn baby is in hospital with the mother a separate accommodation charge is not usually raised for the child during the hospital stay. However, Single Parent Family or Family cover is required to cover accommodation costs for:

• Newborns admitted to hospital and/or intensive care
• The second and later children of a multiple birth

Non-Contracted Hospitals

Members admitted to a hospital that does not have a contract with Transport Health need to contact the Fund to discuss benefits payable.

Overseas Suspension

Members may suspend their cover whilst travelling overseas. The minimum period of suspension is 30 days and the maximum period is 12 months.

Members who pay their contributions through payroll will need to ensure that their membership is financial at the date of departure

Pre-Existing Ailment

A Pre-Existing Ailment (PEA) is any ailment, illness or condition, the signs or symptoms of which were in existence during the 6 months preceding the day you purchased your cover. This also applies if you are amending your cover to include higher benefits.

Whether or not you are aware of a pre-existing condition, a neutral medical practitioner may be consulted to assess your claim.

The Pre-Existing Ailment Rule applies to all Hospital and Extras Tables.

Benefits are not payable during the first 12 months of membership for treatment of a pre-existing ailment. When a cover is upgraded, benefits at the higher level of cover will not be paid at the insured level within the first 12 months of membership for treatment of a pre-existing ailment. However, benefits are payable at the previous insured level of cover during this 12 month period, providing appropriate waiting periods have been served.

Pregnancy Related Services

Pregnancy related services include, but are not limited to, antenatal and postnatal care and management of labour and delivery.

Privacy Policy

Members’ personal information will be used only for approved purposes, such as processing claims or providing health related offers and information to you. Transport Health complies with privacy legislation and will not disclose membership details to unauthorised persons.

Transferring from Another Fund

Provided you join Transport Health within 2 months of your financial date-paid-to with the other fund, and you have served all your waiting periods, you are immediately entitled to equivalent benefits when you transfer your membership to Transport Health. If transferring to a higher level of cover, appropriate waiting periods will need to be served before you become eligible for the higher benefits. However, you will be entitled to equivalent benefits to those covered by your previous insurer during the waiting period.

Podiatric Surgery

Where the Surgeon is approved for in-patient podiatric surgery, benefits are payable under Extras Cover and subject to the annual limits as specified. Hospital accommodation and theatre fees are only covered under Hospital Tables where there is an approved Medicare Benefit Schedule (MBS) item number.

Waiting Periods

When joining the Fund, or if upgrading your level of cover, waiting periods must be served before benefits are payable.

No waiting periods apply for:
Emergency Ambulance Transport
Accidents requiring either hospital or ancillary treatment
(Excluding services detailed below)

2 Months
All services, except as specified below

6 Months
Optical

12 Months
Elective Procedures
Pre-Existing ailments (see earlier definition)
Pregnancy related conditions (except IVF - see earlier definition)
Psychiatric BLP (H2 & H4)
Rehabilitation BLP (H2 & H4)
Cardiac Treatment BLP (H2 & H4)
Elective Procedures
Appliances
Bridges, Crowns, Dentures and Implants
Orthodontic Treatment
Orthotics

24 Months
Hearing Aids
Reproductive treatment, such as IVF

36 Months
Laser Eye Surgery

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