Claiming On Your Health Insurance

Find out if any waiting periods apply, or if it's a pre-existing condition

Before you can claim for hospital services, you must be in your chosen cover for a set period of time, known as a Waiting Period. Waiting Periods are necessary to keep health cover fair. They protect existing customers who contribute to a fund over time for when they might need health cover. If we didn't have waiting periods, people might join a fund to claim for a planned item and then leave, potentially increasing the overall cost of private health cover.

Waiting periods will apply if you have only recently joined a health fund, or taken out hospital cover for the first time. And, benefits can't be paid to you until a waiting period's over.

If you have transferred from another fund, or you're an existing nib customer, and have chosen a higher level of nib hospital cover, the lower benefit will be paid until the waiting period for your new cover has been served.

Transferring from another fund to an equivalent level of nib cover? If no more than 59 days have lapsed since you left your old fund to join nib and you've served the waiting periods with your old fund, then you have what we call 'continuity of cover'. This means the relevant nib waiting periods won't need to be served, and you'll be covered from when you join. It's important to know any services you didn't serve waiting periods for with your old fund will need to be served with nib.

Waiting periods for hospital procedures are:

Note: your cover may exclude some of these procedures.

You should also check if a Restriction or Benefit Limitation Period applies to your cover.

What if I need to go to hospital before the waiting period is up?

If you are within waiting periods, we need to be sure the reason you're going to hospital isn't because of a pre-existing condition. This means there weren't any signs or symptoms within 6 months before you joined or upgraded to your current hospital cover. All health funds check this, to protect existing customers from people who join to make a large hospital claim and then leave the fund.

Contact us as soon as you know you need to go to hospital. There are some forms you and your doctors need to complete and it could take some time to get all the information.

What if I have a pre-existing condition?

If the ailment, illness or condition is considered to be pre-existing, you'll have to wait 12 months before you can use your hospital cover for treatment.

If you have had a lower level of hospital cover before your current nib hospital cover, you'll get benefits at the lower level, provided your cover doesn't have any restricted or excluded services.

If you want to know more about how we check pre-existing conditions and ailments, and what your options are, please contact us on 13 14 63.

What if I have an accident? Am I covered?

If you’re in an accident, you and the attending doctor in hospital must complete an Accident Form (available from nib).

Should you require surgery resulting from your accident that would normally be restricted or excluded on your policy, you must be admitted to hospital within 24 hours of the accident. Additionally, the surgery must be undertaken within your first admission. For any subsequent hospital admissions resulting from the accident, exclusions or restrictions under your cover will apply.

Getting admitted to hospital...

This is important if you want to be treated as a private patient in hospital. You'll need to tell the hospital (or day surgery/facility) that you have private health cover. If you aren't admitted as a private patient (i.e. someone with health cover), nib can't pay your claim.

The hospital will give you a National Private Patient Claim to complete before you're admitted. You must provide informed financial consent to the treatment and costs involved. This is a legal document, and the hospital uses this form to claim your expenses after you've been to hospital. It's important that you fill this out and sign it; otherwise we can't pay the hospital. Don't forget to do this. If you have an excess as part of your hospital cover, you will have to pay the excess to the hospital.

When you get out of hospital...

It's important to understand that nib does not bill you for any part of your hospital stay.

When you go to hospital you can expect at least 2 bills - one from the hospital, and the other from your doctors and/or specialists. The hospital usually sends the bill directly to nib, or you may receive the bill when you leave hospital. Your doctors will send you their bill.

If you do get a hospital bill

You may get a bill from the hospital for many different reasons.

• The hospital hasn't confirmed if you are covered for the procedure
• The hospital doesn't have an agreement with nib
• You are within waiting periods for the procedure
• The procedure is to treat a pre-existing condition
• The procedure is excluded on your cover
• You are an "outpatient" when you go to hospital (or a day facility/surgery). A benefit will only be paid if you're an in-patient, receiving treatment that requires a stay in hospital, admitted for the day or overnight

If you're not sure why you have been billed, please contact us.

What do you do if you get sent any doctors' or specialists' bills?

You'll need to claim from Medicare first. Then, bring the top portion of the Medicare Statement of Benefits and any receipts or invoices to an nib Retail Centre, or complete an nib Claim Form and mail to us.

If you haven't paid the account, Medicare and nib will give you a cheque, made out to your doctor. Whatever remains unpaid from the account (i.e. what Medicare and nib didn't pay), is what you pay to the doctor.

When you won't see a bill

In the instance where you've served the waiting periods for your hospital cover, your procedure is covered, the hospital has an agreement with nib and your doctors use the nib MediGap Scheme, all you'll need to pay is your hospital excess (if applicable).

How do you know if your claim has been paid?

• For peace of mind, call us and ask for a statement.
• If your medical provider or specialist participates in the nib MediGap Scheme, you'll receive an nib MediGap statement that shows how much we paid and confirms you don't need to pay out-of-pocket expenses. You don't need to do anything.

Going Overseas?

Travel insurance that covers a wide range of benefits can be arranged by nib.

All nib health covers provide hospital and/or Extras benefits for services received in Australia only.

Want to know more?

The Private Patient's Hospital Charter, published by the Federal Government, is available to members to outline what they can expect from doctors, hospitals and health funds.