Restrictions, Exclusions And Other Things Private Health Insurance Won't Cover
The level of hospital cover you have determines what procedures you're covered for,
what we'll help chip in for, and what we won't pay for.
We want to be upfront about what we will cover, and what we won't. We figure it's
better to tell you now, rather than later, when you're stuck with a big bill.
Here's a good rule of thumb for hospital stays. If Medicare doesn't cover it, NIB
won't help pay for it. We don't cover all the services and procedures you might
incur if you have to go to hospital.
Restrictions
For restricted procedures, NIB will only pay a benefit called a Public Hospital
Benefit. Public Hospital Benefits will cover you in a shared ward of a public hospital,
and won't go anywhere near the cost for a stay in a private room in Public Hospital
(generally around 50% of the cost) or in a Private Hospital (generally between 5%
and 30% of the cost). NIB will only pay for part of the restricted procedure, and
you'll have to pay the difference. You may need a higher level of hospital cover
if you think you may need to have a restricted procedure done in the future.
Contact NIB to check if any restrictions apply to your cover.
For example, if hip or knee replacements are restricted on your health cover and
you go to private hospital for one of these procedures, your health cover only pays
a small part of your hospital costs. You'll have to pay considerable out of pocket
expenses towards your treatment.
Benefit Limitation Periods
Some NIB covers require a member (who is new to private health cover) to be with
NIB for a period of 24 months before certain hospital services are included as part
of their cover. During the first 24 months of membership (but after the standard
hospital waiting periods have been served), benefits payable for these services
will be limited to Public Hospital Benefits.
Exclusions
Why pay for things you don't need? Some procedures may be excluded from your cover
simply because it helps to keep the cost of your health cover down.
An exclusion means you won't be covered in a public or private hospital and won't
receive a payment from NIB for that procedure. If you're worried you might need
to have a procedure that's listed as excluded, you should think about upgrading
to a higher level of NIB cover.
For instance, if your current health cover excludes hip or knee replacements and
you go to hospital for this procedure, you're not covered for any part of your hospital
and medical costs.
So, don't leave anything to chance -
contact us to check what you're covered for. If you're not covered, we can
upgrade you over the phone. You should be aware that you won't be covered straight
away, as waiting periods will apply to the higher level of cover. Go to
Claiming for information about waiting periods.
Other important information about hospital cover
After 35 days of continuous hospitalisation (readmission within 7 days or less to
the same or another hospital, is also classed as continuous), a certificate from
your doctor is required to confirm the need for continued acute hospital care, in
order to maintain your hospital benefits. If this certificate is not issued, benefits
payable will be reduced to the
Nursing Home Type Patient Benefit.
For psychiatric and rehabilitation patients in a private hospital, cover is limited
to:
- a day only basis, up to 30 days per calendar year
- an overnight basis, up to 65 days per calendar year (day only admissions are included
in this 65 day limit)
Once these limits have been reached, or where readmission for these conditions occurs
within the same calendar year, only Public Hospital Benefits are payable.
Psychiatric conditions and rehabilitation programs are restricted on some NIB health
covers, in which case members are only entitled to Public Hospital Benefits.
|