Important information - Glossary, terms and conditions of membership

Our commitment to you

Latrobe values your membership and we will endeavour to present all communiqués as plainly as possible to ensure that before you become a member you understand the fund rules and or conditions that apply. We strongly recommend that you take the time to read and retain the important information designed to assist you in making the right purchase for your needs. If you have any concerns or queries about your level of cover that is not quite clear, please contact us for assistance on 1300 362 155.

Plain Language
Latrobe is committed to providing information to our members in plain language to assist you to fully understand your level of cover. We regularly review our policy documents and other information provided to members in order to ensure comprehension.

Significant detrimental changes to policy benefits
Significant detrimental changes to hospital cover including contracting arrangements:

• Members will be given a minimum of 60 days notice;
• These changes will not be applied to pre booked admissions; and
• Any members on a current course of treatment will be reviewed to determine appropriate transitional measures.

Significant detrimental changes to ancillary policy benefits, we undertake to:

• Provide affected members with at least 30 days notice; and
• When applicable, we will put in place transitional measures for roll over type benefits accumulated in a previous year.

Cooling off period
Rest assured that if you change your mind for any reason whatsoever and decide to cancel your policy within 30 days of commencing or upgrading your policy, we will provide a full refund of any premiums that you have paid, providing no claims have been made under the policy.

Glossary, terms and conditions of membership

Accident
An occurrence causing a physical injury or bodily condition, resulting from the application of unintentional external force and requiring immediate treatment. Accident does not include illness; operational procedures; the effects of alcohol, drugs of addiction or non-prescribed drugs; pregnancy; aggravation of an existing physical injury or condition.

Admission (to hospital)
Refers to a period of time in hospital for which accommodation charges are raised. It does not include treatment at an emergency centre of a hospital.

Approved service providers
To be eligible for benefits, services must be covered by your selected policy and provided in Australia by a provider approved by Latrobe for the particular service being claimed. Latrobe reserves the right to withdraw approval of a provider without notice. Before receiving treatment, contact Latrobe to confirm that your provider is approved. The approval and registration of any ancillary, dental, medical or hospital provider for the payment of benefits does not constitute a recommendation by Latrobe, nor do we represent that their services will or may be of benefit to policy holders. Latrobe accepts no responsibility for the outcome of any advice, service, product or treatment given to policy holders by an approved provider.

Calendar year
A calendar year starts on 1 January and ends on 31 December annually.

Certified age at entry (CAE)
Under the Lifetime Health Cover scheme, all adult policy holders are assigned a CAE when first taking private hospital cover. The CAE determines what loading, if any, is applied to the base cost of your private hospital cover. It may or may not be your actual age.

Claim time limit
If claims are not made within 2 years of the date of service, benefits are not payable. We recommend that you submit all claims as soon as practical after the service is provided.

Compensation from other sources
You are not entitled to claim benefits if compensation and/or damages can be claimed from another source. For example: WorkCover, Transport Accident Commission, public liability, travel insurance or private legal action. Latrobe may be able to assist you in the case of financial hardship, for more information please contact us.

Cooling off period
Rest assured that if you change your mind for any reason whatsoever and decide to cancel your policy within 30 days of commencing or upgrading your policy, we will provide a full refund of any premiums that you have paid, providing no claims have been made under the policy.

Default benefits and other limited benefits
Default benefits are set and periodically reviewed by the government. They are the minimum level of benefits health funds must pay for valid claims for treatment provided in a shared ward in public hospitals.

Limited benefits are paid for treatment in non-participating private hospitals, for nursing home type patients and for treatments not covered by Medicare, for example: dental, podiatric and cosmetic surgery.

Always contact Latrobe to confirm the extent of your cover before admission to hospital.

Dental surgery
You are covered for the costs with the appropriate hospital cover, associated with dental surgery in a participating private hospital or a public hospital, but not for the dentist’s fees. You can claim a benefit for the dental fees if you have an appropriate Extras policy. If you are planning dental surgery, you are strongly urged to contact us to confirm the scope of your cover.

Dependents
Means a person dependant upon the principal policy holder including; adult partner (including defacto and same-sex partner), own children, stepchildren, legally adopted children and children of whom the principal policy holder is the legal guardian who do not have a partner.

Dependant child
Means a person who is; aged under 18 years of age who does not have a spouse or partner; or a student dependant.

Student dependants
To qualify under family cover as a student dependant, your child must attend full-time study at a Latrobe recognised educational institution. For continued cover, you must complete and return the Student Dependant Registration form that is sent to you annually. The registration form also recommends alternative health cover solutions, if your child no longer qualifies. From their 25th birthday, your children are required to take out their own policy even if they are still studying full time.

Dependant child non student
Means a person who is aged from 18 up until 25 and does not have a spouse or partner and is no longer a full time student.

Financial policy
Policy fees must always be paid at least 1 payment period in advance. If your policy is in arrears for 60 days, it is automatically cancelled. Accounts and/or reminder notices are sent if you pay at a branch or agency, Australia Post, credit card or B-Pay. Accounts are not sent if you choose weekly or fortnightly payments, if you participate in a payroll deduction plan, or pay by direct debit.

Immediate treatment
Refers to the initial treatment required immediately following an accident. This does not include any subsequent treatment.

Initial consultation
The first consultation with a service provider that is usually to obtain a full medical history or discuss treatment options.

Newborn baby cover
To ensure the newborn is covered at birth, upgrade from a single policy to a family policy is required 2 months prior to the due expected delivery date. Documentation of due expected date of delivery from treating doctor is required. A family policy automatically covers newborn babies subject to normal rules and conditions.

Overseas travel
Your Latrobe policy does not cover claims against the cost of medical, hospital or other health services provided while you are travelling overseas. You are strongly advised to take out travel insurance. Policy holders are eligible for substantial discounts on travel insurance purchased through Latrobe. Persons who are not citizens or permanent residents of Australia may have out of pocket costs associated with their medical bills that are not covered by Medicare.

Participating private hospitals
Latrobe has contracts with participating private hospitals Australia wide. This guarantees the cost of your hospital treatments will be covered in accordance with the information we have provided to you. For a current list of participating private hospitals, visit our website latrobehealth.com.au or call Latrobe.

Pharmacy Benefits
Pharmacy includes prescribed drugs and medicines dispensed by a pharmacist; travel and allergy vaccinations dispensed by a pharmacist or doctor, but not contraceptives and PBS subsidised prescriptions. The benefit is calculated after deducting the current PBS general patient contribution.

Pharmaceutical Benefits Scheme (PBS)
The PBS is a Federal Government Scheme to subsidise the cost of certain drugs. You pay a contribution towards the cost of each new prescription, which the government reviews from time to time. Prescriptions covered by the PBS are not eligible for benefits under any Latrobe Extras cover.

Membership year
A 12-month period commencing on the day you join Latrobe, or change to another Latrobe policy.

Pre-existing conditions
This is any ailment, illness or condition where the signs or symptoms were, in the opinion of a Latrobe appointed medical practitioner, in existence during the 6 months prior to the day you joined or upgraded your cover. Latrobe’s medical practitioner takes into account information provided by your own practitioner who treated the condition, when forming an opinion as to whether or not your condition is pre-existing. No benefits are paid for the treatment of a pre-existing condition during the first 12 months of starting a new cover. Please go to Upgrade of Cover and Waiting Periods for important related information.

Private Patient’s Hospital Charter
The Private Patients’ Hospital Charter is a guide to what it means to be a private patient in a public hospital, a private hospital or day hospital facility. It also provides information about what to do if you have a problem with your medical treatment or your private health insurance. We encourage you to read it carefully and we welcome any questions you may have. Call us for a copy to be sent to you, or visit the Federal Government’s website to read or download a copy. www.health.gov.au

Psychology services
In the case of a service whereby the member who incurred the medical expense has elected to claim the Medicare benefit, no private health insurance benefit will be payable.

Rules
Latrobe’s rules govern all matters to do with your policy and the operation of the fund and the Federal Government reviews these rules to ensure they are fair and comply with all relevant legislation. When you apply for a Latrobe policy, you agree to abide by the rules, which you can view by appointment at any branch office. Latrobe’s rules may change from time to time. You will always receive written advice before any new rule is introduced, if it might reduce your policy conditions or benefits.

Surgically implanted prostheses
All prostheses listed on the Commonwealth Prostheses Listing are covered at the clinically equivalent “no gap prosthesis” item price. Should you or your doctor choose a prosthesis that is not listed as a no-gap item, you will be charged a gap. That is, you will have to pay the difference between the no-gap price for a clinically equivalent device and the price that the supplier has set.

Suspension policy
When planning overseas travel, you can apply to suspend your policy. During suspension, you do not make any contributions and services normally covered are not eligible for claim benefits. Latrobe may consider a suspension period in the event of financial hardship. Conditions for suspension vary according to your circumstances; suspension may not be a suitable option if you qualify to pay the Medicare Levy Surcharge. For more detail about Latrobe's suspension guidelines or an updated policy document, please call 1300 362 155.

Third party and partner authority
On a family or couples policy, you and your partner both have equal authority to make any kind of transaction and to give Latrobe any kind of instruction including cancellation of cover. If this does not meet with your needs, please call us to make suitable arrangements. Due to privacy laws, we must have your written authority if you want another person to have control or access to your policy (for example in the event of absence overseas, illness or incapacity, speech, hearing or language difficulties). Please tick the appropriate box on the application or call Latrobe for a Third Party Authority to be sent to you.

Transferring from another fund
You receive continuity of cover for the entitlements you had with your previous fund when:

1. You transfer within 30 days of expiry with the other fund.
2. You have served the required waiting periods with the other fund. However, if you’ve served part but not all of the waiting periods, you must serve the remaining period with Latrobe before you are eligible to claim.
3. The cover you take with Latrobe is not an upgrade of the cover you had with the other fund.

When you transfer to Latrobe and also upgrade your cover, you are entitled to equivalent benefits paid by the previous fund or Latrobe’s closest approximate policy, until relevant waiting periods are completed.

Please note: Any excess paid at the previous fund is not transferrable and you will be required to pay any excess obligation to Latrobe.

Upgrade of cover
This is any change in cover that entitles you to receive higher benefits. Higher benefits include a higher rebate for a particular service, cover for services not included in your previous level of cover, changing to a hospital cover with a lower, or no, excess.

Waiting periods
You are covered immediately for treatment required as a result of an accident that occurs after you join Latrobe.

For all other treatments or services, you must serve a waiting period. This is a specified time you must wait after joining before you can claim benefits under your hospital or extras cover. These waiting periods apply to new policy holders starting private health cover and to existing policy holders upgrading their cover.

12 months pre-existing conditions, major dental and orthodontic treatment, optical, blood glucose monitors, compressor pumps and nebulisers, hearing aids, C-PAP machines, non-surgically implanted prostheses.
9 months pregnancy related conditions - Expected delivery date must be after the completion of 9 month waiting period. Written confirmation of expected delivey date is required from the treating Obstetrician.
3 months general dental treatment, mouthguards
2 months all other services