Terms and conditions

Terms and conditions

Information about Latrobe membership, claims, waiting periods and benefit defaults and limitations.

Latrobe is committed to presenting information as plainly as possible to ensure our members and potential members understand the terms and conditions that apply to memberships, claims, waiting periods, benefit defaults and limitations. To help you select the most suitable hospital and extras cover for your needs, we strongly recommend that you take the time to read the important information below. If you have any concerns or queries about the clarity and accuracy of the information, please contact us.

 

Topic covered:

 

Plain language

To ensure our members understand their level of cover and the terms and conditions that surround it, Latrobe provides information written in plain language. We regularly review our policy documents and other information provided to members to ensure it is easy to comprehend.

Significant detrimental changes to policy benefits

If we make any 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.

When significant detrimental changes to extras benefits are made, 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.

Terms and conditions of Latrobe memberships

Latrobe offers three types of membership:

  • Single membership, which covers the member only;
  • Family membership which covers the member and their eligible dependants*; and
  • Family Care memberships, which covers the member and their eligible dependants* including non-student dependant children to the age of 25.

*Look under definitions for further information regarding dependants.

Access to membership

 

On a family or couples membership, 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 contact us to make suitable arrangements.

Third party authority

 

Due to privacy laws, we must have your written authority if you want another person who is not on the membership to have control or access to your membership (for example in the event of absence overseas, illness or incapacity, speech, hearing or language difficulties). Please contact us to arrange a Third Party Authority application form to be sent to you.

Cooling off period

 

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

Financial policy

 

Membership fees must always be paid at least one payment period in advance. If your membership is in arrears for 60 days, it is automatically cancelled.

Membership for non-residents of Australia

 

If you are not eligible for full Medicare benefits, please contact us to discuss your health care options.

Newborn baby cover

 

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

Suspension policy

 

Latrobe will consider a request for suspension of your membership if you are planning to travel overseas. To be eligible, you must have held your Latrobe membership for a period of at least twelve months.

During the suspension period you do not make any membership payments, nor can you make a claim for any services that would normally be covered. Latrobe may also consider a suspension period in the event of financial hardship. Please note that:

  • Conditions for suspension vary according to your circumstances.
  • Suspension may not be a suitable option if you qualify to pay the Medicare Levy Surcharge.
  • You must apply for a suspension prior to your departure date.
  • Your membership must be reactivated for a minimum of 6 months prior to a new suspension being granted.
  • If you have upgraded your level of cover at anytime during the twelve months prior to your travel, you will still be required to serve the balance of any waiting periods before the higher level of benefit is paid.

Please contact us for advice and further information regarding membership suspensions.

Terms and conditions of claims

To ensure that your claim is processed as quickly as possible, complete a Latrobe Member Claim Form and submit it to us with the original accounts and receipts (we cannot accept photocopies of accounts or receipts). If all of the documentation is not received, or the claim form has not been completed correctly, the processing of your claim will be delayed.

 

Claim time limit

 

If claims are not made within two years of the date of service, benefits are not payable. We recommend that you submit all claims as soon as practicable 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 ie. 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. Contact us for further information about this.

Overseas travel

 

Your Latrobe membership does not cover claims against the cost of medical, hospital or other health services provided whilst you are travelling overseas. You are strongly advised to take out travel insurance. Members are eligible for substantial discounts on travel insurance purchased online through Latrobe.

Terms and conditions of hospital claims

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. View the current list of participating private hospitals.

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.

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 extent of your cover.

Terms and conditions of extras claims

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.

Psychology services

 

In the case of a service whereby the member who incurred the cost has elected to claim the Medicare benefit (under the Chronic Disease Management Scheme), no private health insurance benefit will be payable.

Terms and conditions of 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 that you must wait after joining before you can claim benefits under your hospital or extras cover. Waiting periods apply to members who have not previously held cover, members transferring from another fund on a higher level of cover, or where waiting periods have not been served, and existing Latrobe members upgrading their level of cover.

12 months waiting period applies to: pre-existing conditions (excluding psychiatric, rehabilitation and palliative care), major dental and orthodontic treatment, optical, blood glucose monitors, blood pressure monitors, compressor pumps and nebulisers, hearing aids, C-PAP machines, TENS machines and non-surgically implanted prostheses. The 12 months waiting period also applies to: pregnancy related conditions. The expected delivery date must be after the completion of a 12 month waiting period. Written confirmation of expected delivery date is required from the treating obstetrician.

3 months waiting period applies to: general dental treatment and mouthguards.

2 month waiting period applies to: all other services, including psychiatric care, rehabilitation and palliative care, where no other waiting period applies.

Pre-existing conditions

 

This refers to any ailment, illness or condition where the signs or symptoms were, in the opinion of a Latrobe appointed medical advisor, in existence at any time in the period of 6 months ending on the day you joined or upgraded your cover.

Latrobe’s medical advisor 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.

Transferring from another insurer

 

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

  1. You transfer within 30 days of expiry with the other insurer.
  2. You have served the required waiting periods with the other insurer. 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 insurer.

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

Latrobe does not have exclusions for any procedures on any of our hospital covers. However, some funds do impose exclusions on their hospital covers. This means that if you require treatment for a service that was excluded under your previous level of cover, you will need to serve waiting periods with Latrobe before any benefits are payable.

Please note: Any excess or co-payment amount paid with your previous insurer is not transferrable and you will be required to pay any excess or co-payment obligation to Latrobe.

Upgrade of cover

 

This is any change in cover that entitles you to receive higher benefits from Latrobe compared with your previous cover.
Higher benefits relate to:

  • Benefits payable for services that were not covered by your previous cover;
  • A change in hospital cover to one with a lower excess or co-payment;
  • Services for which a  higher benefit is payable under your new cover
  • Services for which there is a higher annual/personal limit

Please note: If you have extras cover with Latrobe you may not be able to use your membership card to claim electronically at your provider until full waiting periods have been served.

Psychiatric Benefit Limitation

 

A benefit limitation period of two years applies to all psychiatric care.

A benefit limitation period is an initial period of time during which only a minimum benefit is paid. The benefits payable on all hospital products during a designated benefit limitation period will be the minimum benefit as declared by the Minister for Health and Ageing, except when a waiting period is also being served, in which case no benefit applies.

The psychiatric benefit limitation will be applied for a period of 24 months to new members:

  • who have not held previous hospital cover, or
  • whose hospital cover has lapsed by more than 30 days

Benefit limitations do not apply to existing members changing their level of hospital cover or to new members who transfer to Latrobe within 30 days of ceasing hospital cover with another fund.

Definitions

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.

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

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:

  • The service or product must be provided in Australia.
  • The provider must be approved by Latrobe for the particular service or product being claimed.
  • Providers are not automatically approved for all services or products that they provide. For example, we may approve a naturopath for naturopathy services, but not for massage or myotherapy.

Before receiving treatment, we recommend that you contact us to confirm that your provider is approved.

We reserve the right to withdraw approval of a provider without notice. 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 members.

We accept no responsibility for the outcome of any advice, service, product or treatment given to members by an approved provider.

Benefit year

 

Calendar year: starts on 1 January and ends on 31 December annually.
Membership year: a 12-month period commencing on the day you join Latrobe, or change to another Latrobe product.

Certified age at entry (CAE)

 

Under the Lifetime Health Cover scheme, all adult members are assigned a CAE when first taking out 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.

Default benefits and other limited benefits

 

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

Benefits for accommodation in a single room in a public hospital will be paid in accordance with the rate set by the individual State Health Departments. 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 us before admission to hospital to confirm the extent of your cover.

Dependants

 

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

Dependant child
A person who is aged under 18 years of age who does not have a spouse or partner, or is 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 a Student Dependant Registration form will be mailed to you annually. This form recommends alternative health cover solutions, if your child no longer qualifies. From their 25th birthday, your children are required to take out their own membership even if they are still studying full time.

Dependant child non student
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.

Initial consultation

 

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

Non-surgical prosthesis

 

A replacement body part not surgically implanted; benefits are only payable when ordered by a registered medical practitioner.

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.

Private Patient’s Hospital Charter

 

The Private Patient's 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. Contact us to obtain a copy.

Rules

 

Latrobe’s rules govern all matters to do with your membership and the operation of Latrobe. The Australian Government reviews these rules to ensure they are fair and comply with all relevant legislation. When you apply for a Latrobe membership, 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 membership conditions or benefits.