Glossary

Accident
An accident is an event leading to bodily injury caused solely and directly by violent, accidental, external and visible means and resulting solely, directly and independently of any other cause. For the avoidance of doubt it does not include unforeseen Conditions attributable to medical causes.

Accident Benefit
Where included in your level of extras cover, Accident Benefit provides you with benefits up to $2,000 per person ($4,000 per family) per Accident, further limited to $2,000 per person (maximum $4,000 per family) per annum, towards certain medical costs related to an Accident. Benefits are only available for treatment required as a result of an Accident, where the Accident results in urgent hospital attention as soon as practicable after the incident.

Accident Benefit is only available to pay any Co-payment or Excess on your Hospital Cover or, after the payment of any extras benefits, to top up any Limits you have on your extras cover. This benefit is not redeemable as cash. See Compensation from a third party.

Where the Accident results in you requiring a service which is an Excluded Service, Hospital Select Value and Hospital Select Plus, Accident Cover cannot be used to cover the cost of that service or to pay your Excess. For the avoidance of doubt Accident Benefit does not cover unforeseen Conditions attributable to medical causes.

Agreement hospitals
We have agreements with selected private hospitals and day facilities that have been approved for in-patient hospital benefits by the Commonwealth Government.

Alternative therapies cover
We provide benefits for Alexander Technique, Bowen Therapy, Chinese and Western herbalism, Feldenkrais, homoeopathy, remedial massage therapy and traditional Chinese medicine. Set Benefits, limits and conditions such as waiting periods apply and services must be rendered by one of our recognised providers.

Baby Bonus Benefit
Planning to have children? To ensure you and your baby are covered you should choose an appropriate level of cover at least 12 months prior to the birth. Under Hospital Super Plus, Hospital Plus, Hospital Value and Hospital Select Plus covers, you may be eligible for the Baby Bonus Benefits depending on how long you stay in hospital for the birth of your baby. For more information on the Baby Bonus Benefit, please read the policy booklet.

Benefits
The Fund will only pay benefits where:

• the waiting period for that service has been served;
• services have been rendered in Australia by an MBF Recognised Provider;
• a service or treatment is medically necessary and clinically relevant to the person on your policy receiving it;
• a service has actually been rendered to a person on the policy in person, eg no benefit for telephone or Internet consultations or written reports;
• a charge has been raised by a service provider for services or appliances recognised by the Fund for benefit purposes;
• you have already paid the provider (if the charges are unpaid, any applicable benefits will be made payable directly to the provider);
• the treatment or service is covered by your chosen level of cover;
• you have met all the conditions of your level of cover
• no benefit is payable from another source; and
• for extras services for which you have not made a claim against Medicare for the service.

The amount of benefit will be calculated at the date of service/purchase, on the cost of the treatment or appliance to the member, taking into account any allowances or discounts given by the provider. No benefit paid by the Fund can exceed the actual charge of the service or appliance.

Overpayments:

If you are overpaid any benefit by the Fund, or owe the Fund money, The Fund may recover (offset) that money from any payment you have made towards your Contribution Rate or otherwise, provided that the Fund gives you at least one-month's notice.

Hospital Cover does not cover you for all treatments:

See Hospital Treatment Charges, Doctor's Charges and Excluded Service for more information. Please note: you will not receive benefits for additional charges for luxury suites; services provided which are not of a medical nature (eg continued hospital accommodation for reasons other than medical); experimental treatment; cosmetic surgery; treatments not covered under Medicare (unless specifically covered in a hospital agreement); and some very high cost drugs.

Extras Cover benefits
These are normally provided for treatment that is part of a treatment plan recognised by the Fund. Examples of where the Fund will not provide benefits include: certain dental item numbers; where the number of consultations exceed a certain amount, eg a maximum of one consultation per day per provider for therapies; and certain types of products, eg bandages provided by a physiotherapist and hearing aid batteries.

Where an Recognised Provider provides services to an Insured Person who is a member of the provider's immediate family, business partner or associate, or members of the family of the business partner or associate, the Fund will not pay a benefit for those services unless it has approved, in accordance with its Fund and Product Rules, an application from the Insured Person requesting payment of benefits.

For more information, please refer to the the Fund's Dental Guidelines, the Fund's Health Management Aids and Appliances Guidelines, The Fund's Optical Guidelines and the Fund's Physiotherapy Guidelines that can be viewed at any office.

Please also see the terms and conditions - section D - Benefits and section E - Limitation of Benefits.

Changes to the Fund and Product Rules including the Policy Terms
Policyholders agree to be bound by any changes in the Fund and Product Rules including the MBF Alliances Policy Terms. These changes may come into effect on a date prior to the date you are paid up to, however, you are bound by the new rules from their effective date. The Fund may make any variation or cancellation of any of the Fund and Product Rules or of the Policy Terms at its discretion, subject to the relevant regulatory approval.

Where practical, the Fund will give you at least 14 days notice of a contribution rate change and notice of other changes that significantly reduce Benefits will be notified in accordance with the relevant provisions of the Private Health Insurance Code of Conduct. In the instance where those provisions are not clear, the Fund will provide at least 30 days notice.

Notice of a change is effective if given by any of the following means:

i. letter sent to the Policyholder at the most recently advised postal address, fax number or email address;
ii. by inclusion in any publication generally made available to Policyholders;
iii. publication on the website;
iv. any electronic transmission; or
v. any other reasonable means.

Where posted, the notice is deemed received on the day following posting.

Changes to legislation
Changes to legislation may occur from time to time which may also affect your benefit entitlement or Contribution Rate. These changes may affect you immediately from the time the new laws become effective.

Changes to your circumstances
When your situation changes, it is your responsibility to notify the Fund.
This means, for example, a new spouse only be added onto a policy when you notify us to do so. They will then be subject to the usual waiting periods from that date. It is not possible to backdate this notification. Please also refer to the policy terms and conditions.

When you change address or contact details, you must also notify the Fund to ensure you receive important notices and communications.

Compensation from a third party
Please also refer to the policy terms and conditions.

If you have an Accident or are injured (eg in a motor vehicle accident or as a result of your employment) and have a right to receive compensation or damages from a third party, you are not eligible for MBF benefits (including future costs of treatment).

This applies whether or not you pursue the claim and whether or not the Fund has made any payment. If you are in this situation, you may apply for provisional benefits which will be paid if you meet the Fund's requirements, but these must be paid back if you receive compensation.

Complaints
The Fund has procedures for you to easily voice concerns or to provide us with feedback. Simply talk to any of our consultants on 133 234 who can address a wide range of issues on the spot. If necessary, a qualified team leader is always on hand to discuss your concerns and, if you are not happy with their response,they will pass on your concerns to the Escalated Customer Support team. It is always our first aim to resolve our members' concerns right here at the Fund. If you are not satisfied with our response to your concern, you can contact the Private Health Insurance Ombudsman on 1800 640 695. This is an independent, free service to address the concerns of all members of Australian health funds. It is funded by a levy paid by private health insurers.

Co-payment
Hospital Plus offers a Co-payment option as an alternative to the usual three levels of Excess. The Co-payment applies each time you are admitted overnight to an Agreement hospital. It does not apply to any public hospital or non-Agreement hospital admissions. The Co-payment is $50 per night limited to a maximum of $250 per admission, even if you’re in hospital for longer than five nights. Under Hospital Plus the Co-payment applies to adult hospital admissions only; it doesn’t apply to Dependant Children (including Family 25) covered on your policy.

Cosmetic surgery
Benefits are only payable for cosmetic surgery or services where it is required for a medical purpose and Medicare benefits are payable. This also applies to extras services which are cosmetic services, eg tooth bleaching.

Couple policy
A Couple policy includes the primary Policy holder and his or her legally married or de facto spouse (living together on a domestic basis).

Dental
In some more complex cases, a general dental procedure may be considered major dental. Simpler 'major dental' procedures may be considered general dental. For orthodontic benefits, the treatment plan must be approved by the Fund prior to services being provided. Different dental benefits are payable if the service is provided by a dental prosthetist or orthodontist. Please also refer to the Fund's General Treatment Benefit Guidelines.

Dependant children
Dependant children includes any of the Primary Policyholder’s or his or her spouse’s children, step children, foster children, adopted children and children over which you are granted guardianship by a court of law, who aren’t married or in a de facto relationship, up until they turn 21. A student dependant means any of a primary policyholder's or his or her spouse's single children aged 21-24 years inclusive, who are full-time students at a recognised tertiary institution and are fully or partially maintained by you.

Doctors' charges
No benefit is payable if the service relates to treatment excluded under your level of cover (see Excluded Service) or where you are not entitled to a Medicare benefit for the treatment (eg non resident or cosmetic surgery).

The Medicare Benefits Schedule Fee ("MBS") is the amount determined by the Commonwealth Government for the purpose of paying Medicare benefits.

For in-patient hospital treatment, Medicare will pay 75% of the MBS, and the Fund will pay up to 25% of the balance of the MBS. If you are treated by a doctor who charges above the MBS this will create an expense not covered by either Medicare or the Fund unless the Fund has an agreement with the doctor or the Fund's Gap Cover Scheme applies (see Gap Cover Scheme).

Please note that radiology and pathology services are considered to be Doctors' Charges. The Fund does not pay any benefits for services outside of hospitals unless we specify otherwise under your level of cover and we have an agreement with the provider for that treatment or for out-patient treatment.

Please also refer to the terms and conditions.

Emergency ambulance transport
Once you have made your payment and your application has been accepted the Fund will only pay a benefit for ambulance services where the services are provided by a State or Territory Government. Benefits are only available for emergency or casualty transportation where, in the opinion of a medical officer, a member requires immediate treatment in circumstances where there is serious threat to the member's life or health. Benefits are not payable for transportation from a hospital to your home, nursing home or other hospital; for transportation for on-going medical treatment; or where your State Government provides an ambulance benefit (eg Queensland and Tasmania).

Excess
Excess is a per year amount of Benefit a Policyholder agreed to forego in exchange for a lower Contribution Rate.

An Excess is the amount you agree to pay per person each calendar year each time a person covered by your Policy is admitted to hospital. The Excess is paid only once per person per calendar year, to a maximum of twice per Policy for Single Parent Family, Couple or Family Policies.

The Excess payable per person must be fully paid for that calendar year before any Benefits from the Fund are payable for a hospital admission for that person. Any payment made by you for Treatment which would not otherwise attract a Benefit from the Fund i.e. personal items in hospital, will not be taken into account for the purposes of determining if the Excess has been paid in full.

For Singles Policies, once the Excess has been paid in full in a calendar year you will not be required to pay any Excess for any further hospital admissions for that calendar year.

For Single Parent Family, Couple and Family Policies, once the Excess is paid in full in a calendar year for two people covered by the Policy, no further Excess will be payable for any hospital admissions occurring during the same calendar year.
Please note that reducing your Excess is considered to be upgrading your cover.
No Excess is payable for hospital admissions for Dependant Children or Dependant Children registered on your Policy under Family 25 if you hold the Fund's Hospital Value product.

Excluded service
An Excluded Service is one where no benefit is payable for any of the doctors' or hospital's charges associated with that admission.
This applies to those members whose level of cover is Hospital Select Value, under which benefits are not payable for the following services:

• Joint replacement including revisions;
• Cataract and eye lens procedures;
• Cardiac and cardiac related services;
• Renal dialysis for chronic renal failure (for customers who joined or transferred to this level of cover on or after 1 April 2006); and
• pregnancy and Birth-Related Services including assisted reproductive services. (Please note most assisted reproductive services are out-patient treatments and are therefore not covered under any level of  hospital cover).

Or Hospital Select Plus under which benefits are not payable for the following services:

• Joint replacement including revisions;
• Cataract and eye lens procedures; and
• Renal dialysis for chronic renal failure (for customers who joined or transferred to this level of cover on or after 1 April 2006).

Extras Cover
They are called ‘Extras’ because they are services that Medicare doesn’t pay a benefit for. Extras include services such as dental, optical and physiotherapy as well as remedial massage, acupuncture, naturopathy and more. There are four levels of Extras Cover to choose from. You can take out some levels of Extras Cover on their own; one is only available in combination with a level of Hospital Cover.

Family 25
Family 25 is available on Family and Single Parent Family cover for an additional premium and will cover single dependant children aged 21 -24 years inclusive who are not student dependants.

Family policy
A Family policy includes only the primary policyholder and his or her legally married or de facto spouse (living together on a domestic basis) and any of their dependent children or dependant children registered on the policy under Family 25.

Federal Government Rebate
If all people on your policy are eligible for full Medicare benefits, you are entitled to a Federal Government Rebate on your premiums. The Federal Government Rebate on private health insurance is designed to make private health cover as affordable as possible for more Australians by reducing the amount you pay for premiums by at least 30%. The rebate has three levels:

• if you’re aged under 65 years, you’re eligible to receive the 30% rebate
• if either you or a person covered by your policy are aged 65 to 69 years (inclusive), then you’re eligible to receive the 35% rebate; or
• if either you or a person covered by your policy are aged 70 years or over, then you’re eligible to receive the 40% rebate.

There are Savings Provision Entitlements that apply to ensure that people remaining on a policy that has been eligible for the 35% or 40% rebate do not have their rebate amount reduced to 30% when the person aged 65 years or over leaves or cancels the policy.

Many customers prefer to claim the rebate through reduced premiums but you can choose to claim it as part of your annual tax return or as a cash refund from any Medicare office.

For more information on the Federal Government Health Insurance Rebate, click here.

The Fund
The Fund refers to MBF Alliances PTY Ltd ABN 89 075 799 235. SGIO Health Insurance is provided to you by the Insurer MBF Alliances Pty Ltd ABN 89 075 799 236. Insurance Australia Limited ABN 11 000 016 722 trading as SGIO Insurance distributes SGIO Health Insurance.

Health management aids and appliances
Where benefits apply, any health management aids and appliances must be MBF recognised for benefits and be part of a treatment plan recognised by MBF.
Where service limits apply, they apply from the date of purchase. Please also refer to the General Treatment Benefit Guidelines.

Hospital Cover
If you’d like to be covered for treatment when admitted to hospital, there are five levels of Hospital Cover to choose from. You can take out Hospital Cover on its own, but many people also combine it with Extras Cover.

Hospital treatment charges
Hospital treatment charges for eligible in-patient admissions in Agreement hospitals are for accommodation, theatre, labour ward, intensive care, most surgically implanted government approved prostheses (a limited number of government-approved surgically implanted prostheses will attract a gap which customers will be required to pay), most pharmaceuticals that are directly related to the reason for your admission, the PBS patient contribution, physiotherapy and certain other therapies where provided by the hospital. It does not include any out-of-pocket expenses.

Lifetime Health Cover
The Federal Government has introduced Lifetime Health Cover (LHC) to encourage the uptake of private hospital cover. In general, to avoid the LHC loading, you need to take out hospital cover by the 30 June following your 31st birthday. Otherwise, for every year you delay joining hospital cover, your Contribution Rate will increase. In fact, you will pay a 2% higher loading on the base Contribution Rate for every year you are aged over 30, up to a maximum of 70%. By taking out hospital cover as soon as possible, you can stop the loading from increasing. It will be frozen at the rate that matches your age on the 1 July prior to the date you join (known as the Certified Age at Entry or CAE). As long as you maintain your hospital cover, your loading won't increase each year.

• Paul turned 31 on 7 June 2004. He purchased hospital cover for the first time on 20 June 2004. On 1 July 2003, Paul's CAE was 30, so he does not pay a loading on his Contribution Rate.
• Kate turned 39 on 6 March 2004. She purchased hospital cover for the first time on 10 June 2004. On 1 July 2003, Kate's CAE was 38. Her loading will be 16%, which is a 2% loading for each year she is aged over 30 before she purchased hospital cover.

If you do have to pay a Lifetime Health Cover loading, you will have it removed after you have held Hospital Cover continuously for 10 years.

What if your hospital cover lapses?
LHC allows those who have locked in their CAE a limited number of days in their lifetime without hospital cover before the loading will be applied or increased. The number of cumulative days without hospital cover allowed before a LHC loading is applied is 1,094 (less than three years).

Members who have:

• have validly suspended their policy in accordance with the MBF Fund and Product Rules; or
• are overseas (including Norfolk Island) for a continuous period of more than 1 year and who have not returned to Australia for a period of more than 90 days, will not have that time count towards their permitted days without hospital cover.

Are there any exceptions?

Anyone born on or before 1 July 1934 has no LHC loading, except where their partner is born after 1 July 1934.
Other people may have different rules applied for LHC. These include:

• some refugees;
• persons who hold or have held a Veterans' Gold Card after 30/6/99;
• Australian citizens and/or holders of permanent visas who were overseas for the whole of the period between 1/1/00 and 1/7/00 inclusive;
• Australian citizens and holders of permanent visas who were overseas on 1/7/00, or were residents of another country on and after 1/7/00, and have not been back to Australia for a period of more than 90 days;
• Australian citizens and holders of permanent visas who are absent from Australia on the day they turn 31 (provided this is after 1/1/00) and have not since returned to Australia for a period of 90 days or more;
• members of the Australian Defence Force (including their dependants) on continuous full-time service whose health services are provided by the Defence Force;
• a person for whom health services are provided by the Australian Antarctic Division of the Department of Environment and Heritage;
• migrants who became eligible for Medicare benefits after 30/9/99;
• New Zealand citizens who became eligible for Medicare benefits after 30/9/99.

For details regarding Lifetime Health Cover call us on 133 234. Alternatively you can visit the Australian Government Department of Health and Ageing website.

Limits
The Limit is the maximum benefit you can claim in a service category per person and per calendar year (1 January to 31 December) unless otherwise stated. For certain services, Limits also apply on the number of times that benefits are payable for the same service, e.g. initial consultations. All Limits apply from the date of service/purchase. Some services have lifetime limits (as referred to in the Product Rules) or periodic limits (as referred to in the General Treatment Benefit Guidelines), e.g. orthodontics and hearing aids. Benefits paid for those services at any previous level of cover (including with another Australian health fund) will carry forward with you for the purpose of calculating a lifetime limit on your new level of cover. Per person Limits on services are not transferable to any other customers on your policy.

Gap Cover Scheme
The Federal Government sets the amount of doctors' charges for the purposes of paying Medicare benefits. This charge is known as the Commonwealth Medicare Benefits Schedule Fee ('CMBS'). Medicare pays for 75% of the CMBS and 25% is paid by the Fund. If you are treated by a doctor who charges above the CMBS, this will create an expense not covered by either Medicare or the Fund. The Fund does not pay any amount charged by your doctor above the CMBS (unless there is an agreement in place between your doctor and the Fund, or your doctor uses the Fund's Gap Cover Scheme), this difference becomes the 'medical gap' and you will be required to pay this out of your own pocket. However, if your doctor participates in the Fund's Gap Cover Scheme (that is, agrees to accept the Fund's benefit), you will have either:

• no ‘medical gap’ to pay for that doctor’s charge, or
• you will know exactly how much you will have to pay for your treatment by that doctor.

Medicare Levy Surcharge
If you are a high income earner ($73,000 for singles or a combined income of $146,000 for couples and families) you may be liable for an additional 1% Medicare Levy surcharge if you don't have an appropriate level of hospital cover. This surcharge is on top of the current Medicare Levy. You can avoid the extra 1% Medicare levy by taking out any of the Hospital covers on this website with an excess of $500 per person or less. Choosing an Excess of $1,000 per person (to a maximum of twice per Policy) will not help you avoid the additional 1% Medicare levy surcharge.  Choosing an Extras cover on its own won't help you avoid or minimise the Federal Government Lifetime Health Cover premium loading, nor will it enable high income earners to avoid the additional 1% Medicare levy. 

Online Active Health Program
NRMA Health Insurance Customers have access to the Online Active Health Program supplied by Fitness2Live. The service will help you find reliable, up-to-date information on health issues, conduct health checks and take part in ongoing programs to help you stay healthy.

Out-of-pocket expenses
Certain charges are not covered by us when you are admitted to hospital. For example, the Fund does not cover medical fees above the Commonwealth Medicare Benefits Schedule Fee ("CMBS") unless  Gap Cover applies; the patient contribution on the PBS drugs that are not intrinsic to your hospital treatment; additional charges for luxury suites; services by providers which are not covered by a hospital agreement; experimental treatment and some high cost drugs; and some personal and take-home items (e.g. toiletries, newspapers, STD and mobile phone calls). We can advise you of your likely benefits but you should find out from the hospital and your doctor what your out-of-pocket expenses may be.

Out-patient treatment
Out-patient Services' means Treatment for which the Fund does not pay a Benefit unless the Fund has a specific agreement with the hospital for a service or the Fund specifies otherwise under your Level of Cover and we have an agreement with the provider for that treatment. Out-patient treatment includes but is not limited to:

i. procedures that do not clinically require formal admission to a
Hospital, eg procedures performed in a doctor's surgery;
ii. emergency room treatment;
iii. consultation with your specialist before a labour admission;
iv. most fertility treatment; and
v. services where Medicare doesn't pay your doctor's fee at the
in-patient hospital benefit rate, eg a paediatrician check-up of a
non-admitted newborn baby in hospital.

Partner authority
The Policyholder has the option to give their Spouse, as nominated on the application form, permission to have the same authority as the Policyholder in relation to the Policy. This authority enables the partner to make claims on behalf of all people covered by the Policy, to make changes to or enquire about:

• personal details, eg address, phone number;
• Level of Cover;
• payment method;
• adding people to or deleting people from the Policy;
• cancelling the Policy and requesting a refund of contributions; and
• to access the personal information of all people covered by the Policy.

To do so, the Policyholder must tick the box on the application form at the time of joining or complete the relevant Fund form. This information is recorded. The Fund will confirm Partner Authority before quoting details or processing any changes requested by the partner. The Policyholder can revoke the Partner Authority at any time by notifying the Fund in writing. Without Partner Authority, a partner is only permitted to sign for and receive claim Benefits for themselves and enquire about their own personal details and claims history.

Pharmaceutical Benefits Scheme (PBS)
The Pharmaceutical Benefits Scheme (PBS) is the national pharmaceutical scheme funded by the Commonwealth Government where patients make a contribution to the cost of the subsidised drug.

The Fund will not provide Benefits for drugs that are named on any PBS list, even where they are prescribed in a different quantity and whether or not you obtain a PBS Benefit. However, the Fund may, on special application, provide Benefits for PBS Authority or Restricted drugs, but only if prescribed for illnesses that do not meet the PBS Authority or Restricted requirements and therefore are rejected under the PBS before being prescribed.

The Fund will only provide Benefits for drugs listed on the Australian Register of Therapeutic Goods administered by the Therapeutic Goods Association (TGA) (or specially recognised by the Fund) and which by law require a prescription and are prescribed in accordance with applicable TGA guidelines.

Contraceptives and anabolic steroids are not covered unless prescribed for an illness.

The Fund will pay a Benefit for the PBS patient contribution where the drug is intrinsic to Hospital Treatment covered by the Fund.

Policy
Policy means a policy of insurance issued by the Fund which is referable to the Fund and which covers one or more Insured Persons.

Policy terms
Policy Terms means the Policy Terms & Conditions and includes the Fund Rules and Product Rules as registered with the Department of Health & Ageing and amended from time to time. Changes may be made to the Policy Terms as set out at paragraph A.3 of the Policy Terms & Conditions

Policyholder or Contributor
Policyholder or Contributor means the person in whose name the Policy is registered and who is responsible for payment of the Contribution Rates for the Policy. This person has the right to add or remove others from the policy and obtain information about claims made on the policy.

Pre-existing Condition
A Pre-existing Condition means a condition where the signs or symptoms of which, in the opinion of a practitioner appointed by the Fund, existed at any time during the six (6) months preceding the day on which the Insured Person joined the Fund or transferred to a higher Level of Cover.

If an ailment, illness or condition is considered pre-existing, new Policyholders must wait 12 months for any hospital Benefits and customers transferring/upgrading to a higher Hospital Cover must wait 12 months to receive the higher hospital Benefits.

Existing customers with a Policy of at least 12 months duration in total across their old and new cover are entitled to the lower Benefits on their old cover. Some examples of Treatment for conditions that would normally be considered to be pre-existing include sterilisation, vasectomy, surgical extraction of wisdom teeth or where you have consulted your doctor for a particular condition prior to joining or upgrading.

Pregnancy and Birth Related Services
Pregnancy and Birth Related Services means any type of Treatment related to the management of pregnancy, labour and childbirth, including ante and post-natal care and includes, but is not restricted to obstetrics-related services.
A Waiting Period of 12 calendar months applies to all Policyholders, whether Single, Couple, Single Parent Family or Family, for Pregnancy and Birth Related Services. No Benefit is payable if the service relates to Treatment excluded under your Level of Cover. Refer to Hospital Cover for more information.

Private Health Insurance Code of Conduct
Private Health Insurance Code of Conduct refers to the industry Code of which the Fund is a signatory.

The Private Health Insurance Code of Conduct (the Code) is a voluntary industry Code that aims to enhance the standards of practice and service in the private health insurance industry.

As a signatory to the Code, we undertake to do a number of things that will benefit you as a member. These include things such as helping you to better understand what you are covered for and to provide you with information about our process for resolving any concerns that you may have.

The Fund proudly supports the Code and we are committed to continually reviewing our operations to ensure compliance. To find out more visit our Code of Conduct.

Private Patients’ Hospital Charter
The Federal Government has produced a statement called the Private Patients’ Hospital Charter. Copies of the Charter are available to customers and members of the public at any branch or by calling us on 133 234.

Recognised provider
Recognised Provider means any person who is in Private Practice and who: is a Medical Practitioner; or

where professional registration is required, has and maintains the required registration and who meets and continues to meet the Fund documented recognition criteria; or

where there is no registration requirement, meets and continues to meet the Fund documented recognition criteria, whose services or appliances attract a Benefit or payment from the Fund and in relation to the provision of General treatment services who is advised by the Fund that he or she is a recognised provider for the purposes of providing the particular General Treatment services.

Medical Practitioner means a person as defined in section 3 (1) of the Health Insurance Act.

Private Practice means:

i. in relation to an individual provider, where the provider is self-employed and solely responsible for his or her own operating costs, sick leave, and annual leave and whose income is principally derived from the fees charged to patients or clients for services rendered at that practice; and
ii. in relation to a group of providers, where the income of that group is principally derived from fees received from patients or clients attending that group notice; provided that the individual or group provider is not funded or contracted to any public or private entity for the payment of rent to such entity.

Services not covered
There are certain services that are not covered. Out-patient treatment, for example, is generally not covered.

Set benefits
Set Benefit means the benefit which is determined by the Fund and reviewed periodically, taking into account, as it considers appropriate:

1. prices raised to Insured Persons of the Fund in the relevant State for the service or Treatment that attracts a Benefit;
2. prices in other States for the service or Treatment that attracts a Benefit;
3. recommended charges of, and Benefits paid by other Funds;
4. recommended charges of professional associations;
5. survey or other market information; any agreements with providers in respect of the provision of the service or Treatment that attracts a Benefit to Insured Persons;the effect on premiums; and
6. overall cost to the Fund.

Single Parent Family Policy
Single Parent Family Policies include only the Policyholder and any of his or her Dependant Children and Dependant Children registered on the Policy under Family 25. Also see Dependant Child and Family 25.

Suspension of your policy
If you are planning to travel overseas for one calendar month or month, it may be possible for you to suspend your policy. Your application to suspend your Policy must be made before your date of departure and certain other criteria must also be met. There may also be other circumstances in which you can suspend your policy. For more information, please call us on 133 234.

Termination
The Fund may terminate a Policy immediately if:

1. in the reasonable opinion of the Fund the Insured Person has deliberately given false information or has falsely obtained or attempted to obtain a Benefit to which they are not entitled;
2. the provision overleaf, 'Termination of a Policy in Arrears' apply; or
3. subject to legislation, the Fund gives two months' notice in writing and refunds any Contribution Rates paid by the customer for the period after the effective date of termination of the Policy.

A Policyholder can terminate their Policy at any time or remove any Insured Person from their Policy by notice in writing to the Fund.

Termination of a Policy in Arrears
Where a period of arrears exceeds sixty (60) days, MBF Alliances may terminate the affected Policy with immediate effect by written notice to the Policyholder.
Where a Policy has been terminated in accordance with these provisions, MBF Alliances has the discretion to reinstate the Policy at the request of the Policyholder, provided that the Policyholder:

1. pays all Contribution Rates as required by MBF Alliances; and
2. is subject to Waiting Periods as though the Policyholder and all Insured Person's under the Policy are new Insured Persons; and the duration of the Policy prior to the date of termination shall not be included for the purposes of calculating tenure of the Policy with the Fund.

Time limit on claims
No Benefits will be paid if claims are lodged after two years from the date of service, Treatment or purchase. The Fund recommends claims are lodged within 12 months. Please note that claims for the Baby Bonus Benefit are only payable if the claim is received by the Fund within 6 months of the baby's birth.

Transfers from another health fund or policy of the Fund
If you transfer from another Australian registered health fund or are covered by another Policy of the Fund, your Policy will have continuity to the same level of Benefit entitlement for services provided by and common to both Levels of Cover.

This is provided that you have already served the relevant Waiting Periods and transferred within two months of ceasing your Policy with the previous fund or rejoined the Fund within two months of cancelling your previous Policy with the Fund.

Please note that delays might incur Lifetime Health Cover (LHC) penalties.

If you transfer to the Fund or rejoin the Fund more than two months after your previous Policy has ceased, you will have to serve all the Waiting Periods applicable to your new Level of Cover.

If you transfer to a Level of the Fund's Cover that provides Benefits not covered by your previous fund's Policy, you must serve the relevant Waiting Periods for the additional benefits.

Where Limits apply, including lifetime Limits, any Benefits paid by your previous Policy are treated as if the Fund had paid them under the new Policy

Treatment Information
In some cases, either before or after payment of a Benefit, the Fund will ask you to provide information about your Treatment, including confirmation that it relates to a diagnosed medical condition and that it is a course of Treatment recognised by the Fund. You agree to assist the Fund in obtaining this information from your provider including copies of clinical records as requested by the Fund that relate to Fund Benefits and/or your Policy.

Unemployment cover
If you are on Hospital Super Plus and you are involuntarily retrenched or made redundant from full-time employment, we will pay your health insurance premium (at the same level of cover) for up to 12 months as long as you remain unemployed, from the start of the second month after you have notified us. The main conditions are:

• If you have a family membership, then only the main income earner is eligible
• The main income earner must have been continuously employed for at least six months prior to their involuntary retrenchment or redundancy
• You must not be a contractor or in self-employment
• You must have held your level of cover for 12 months before your retrenchment or redundancy
• You will need to provide proof of your unemployment to our reasonable requirements every three months providing you still remain unemployed

Upgrading your policy
If moving from one Level of Cover to a higher level or if moving from a higher to a lower Excess in the same cover, Benefits under the new Level of Cover that were not covered under the original Level of Cover or Excess are payable at the previous Level of Cover or Excess entitlement until you have satisfied the Waiting Periods. Where Limits apply, any Benefits already paid will be taken into account.

Waiting periods
Before you can claim under your cover, you must have been in that level of cover for a certain length of time, known as the waiting period. No benefits are payable for any treatment for a service received while you are serving the waiting period for that service. Waiting periods apply in addition to Benefit Limitation Periods (where applicable).

Waiting periods are based on calendar months.

The following is a summary of waiting periods normally applicable to members who are new to private health insurance or who are upgrading their level of cover. Some of the terms used are defined in these MBF Policy Terms & Conditions. Please note that you should check your level of cover first to ensure that benefits are available, as not all levels of cover provide the benefits listed here:

• pre-existing ailment - 12 months *
• pregnancy and birth-related services - 12 months
• congenital conditions where considered pre-existing - 12 months
• major dental - 12 months
• health management aids and appliances - 12 months (except for fully handcrafted surgical shoes - 5 years)
• optical appliances - 6 months
• MBF Living Well Programs - 6 months
• hearing aids - 3 years
• other conditions - 2 months
• hospital treatment for Accidents which occur after joining and would normally have a 2 month waiting period, will have no waiting period.

* Except for psychiatric palliative or rehabilitation services for which a 2 month Waiting Period applies.

Wellness Programs
Wellness Programs help cover selected health-related programs from approved Recognised Providers such as:

Gym membership fees - the Fund can only pay a Benefit for gym membership where the gym program is provided by an approved Provider as part of a health management program or a chronic disease management program. The claim must be submitted with a special approval form (available from the Fund) that is signed by your GP or a Recognised Provider confirming that the gym Program is a health management program or a chronic disease management program. Each approval form is valid for 12 months from the date the approval is signed. Please note that GP Consultations are not covered by the Fund. Benefits are only payable after a month of gym membership and exclude casual visits, aquatic membership and personal trainers.

Pilates - the Fund will only pay a Benefit for Pilates classes where the Pilates program is provided by a Recognised Provider as part of a health management program or a chronic disease management program. The claim must be submitted with a special approval form (available from the Fund) that is signed by your GP or a Recognised Provider confirming that the Pilates Program is a health management program or a chronic disease management program. Each approval form is valid for 12 months from the date the approval is signed. Please note that GP Consultations are not covered by the Fund. Benefits are payable for casual classes or upon completion of a Program.

Quit smoking programs - a course must be undertaken.

Weight management programs - fees only. No Benefit is payable for food, books or videos.

Yoga courses - Benefits for yoga classes are only payable where the yoga program is provided a Recognised Provider as part of a health management program or a chronic disease management program. The claim must be submitted with a special approval form (available from the Fund) that is signed by your GP or a Recognised provider confirming that the yoga Program is a health management program or a chronic disease management program. Each approval form is valid for 12 months from the date the approval is signed. Please note that GP Consultations are not covered by the Fund. Benefits are only payable for an approved Program or a minimum of an eight-class pass. Benefits are payable on completion of the course and will be paid for yoga classes such as (but not limited to) Hatha, Ashtanga, Ivengar, Bikrams and Ki. Casual courses are excluded.