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How Your Private Health Insurance, Medicare and your Sports Personal Accident Insurance work together


While Personal Accident insurance cannot consider any cost for an expenses Medicare can pay a benefit, if you have a Private Health Fund they may be able to assist with covering some or all of the Medicare Gap as they are excluded from the laws that prevent this insurance paying a benefit for Medicare claimable expenses.

It is required within this policy that if you have a Private Health Fund that you must submit the Non-Medicare medical expenses to them first before claiming under this policy.

The below tables show two examples of how a Personal Accident policy can work in conjunction with Medicare and Private Health Insurance. The first table shows an example of an injury claim where the player has a Private Health Fund and the second shows one where the player does not have a Private Health Fund to assist with Non-Medicare medical expenses.

What Personal Accident Insurance Typically Covers

These medical expenses are typically claimable through Personal Accident Insurance. Consult your policy wording to confirm exactly what’s covered by your individual policy.

AMBULANCE TRANSPORT PRIVATE HOSPITAL BED AND THEATRE FEES
PHYSIOTHERAPIST’S FEES
(WITH A DOCTOR’S REFERRAL)
CHIROPRACTOR’S FEES
(WITH A DOCTOR’S REFERRAL)
OSTEOPATH’S FEES
(WIDTH A DOCTOR’S REFERRAL)
DENTIST’S FEES*

* for sound and natural teeth

What Medicare Typically Covers or Partly Covers

These medical expenses are typically covered or partly covered by Medicare. So you can’t claim them through Personal Accident Insurance.

PUBLIC HOSPITAL COSTS SURGEON’S FEES
DOCTOR’S FEES ANAESTHETIST’S FEES
X-RAYS MRI SCANS**

**Most MRI scans can be claimed through Medicare, but not all. If your MRI invoice doesn’t have a Medicare number listed, it’s worth checking if a benefit can be claimed through Personal Accident Insurance.

* for sound and natural teeth

**Most MRI scans can be claimed through Medicare, but not all. If your MRI invoice doesn’t have a Medicare number listed, it’s worth checking if a benefit can be claimed through Personal Accident Insurance.

With Private Health

(Insurance Reimbursement Example)

Expense Fee Medicare Rebate Private Health Rebate Personal Accident Reimbursement Total out of pocket
General Practitioner $70.00 $23.95 N/A N/A Due to Health Act $46.05
Surgeon $3,950.00 $2,962.50 $987.50 N/A Due to Health Act $0
Post-Surgery Consultation $250.00 $72.27 N/A N/A Due to Health Act $177.73
Anaesthetist $850.00 $165.90 $377.25 N/A Due to Health Act $306.85
MRI Scan $295.00 $0 $0 $236.00 $59.00
Hospital Theatre Fee $5,871.00 $0 $5,821.00 $40 (80%) $10.00
Physio $535 (7 visits) $0 $250.00 $228 $57.00
Excess       $0 $0
Total $11,281.00 $3224.62 $7,435.75 $504.00 $656.63

No Private Health

(Insurance Reimbursement Example)

Expense Fee Medicare Rebate Private Health Rebate Personal Accident Reimbursement Total out of pocket
General Practitioner $70.00 $23.95 N/A N/A Due to Health Act $46.05
Surgeon $3,950.00 $2,962.50 N/A N/A Due to Health Act $987.50
Post-Surgery Consultation $250.00 $72.27 N/A N/A Due to Health Act $177.73
Anaesthetist $850.00 $165.90 N/A N/A Due to Health Act $684.10
MRI Scan $295.00 $0 N/A $236.00 $59.00
Hospital Theatre Fee $5,871.00 $0 N/A $4,696.90 (80%) $1,174.20
Physio $535 (7 visits) $0 N/A $67.20 (policy limit reached) $467.80
Excess       $50.00 $50.00
Total $11,281.00 $3224.62 N/A $5,000 $3,646.38

These two examples help explain how this policy can work but are guides only. The reason being, that Private Health Fund cover and Medicare coverage can vary substantially so the examples may not accurately reflect the costs you incur or procedures you require for your injury.

Please consult your Private Health Fund and Medicare to get an accurate understanding of what amounts they are able to cover in your particular situation. 

 

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