How is a health insurance claim assessed?
Find out how your claim is assessed and what’s involved
We all turn to good old Google when we're feeling confused or need a quick answer to a lingering question. So, we decided to look at the most ‘Googled’ health insurance questions and answer them in one easy place.
Consider your health insurance search over!
Hospital cover helps to pay the costs of your hospital accommodation, treatments you receive while in hospital, and your doctors’ fees when receiving medical treatment as a private patient. In-hospital services listed on the Medicare Benefits Schedule (MBS) are covered by private hospital insurance policies; however, some policies will exclude certain services to help keep the price low for customers. This is why it’s so important that you have the right level of cover for your personal circumstances. To organise a cover review, call nib on 13 16 42.
When you take out a health insurance policy for the first time, or upgrade your cover, waiting periods will apply before you can claim for some services. Maximum waiting periods for hospital cover are 12 months for pre-existing conditions and pregnancy, two months for psychiatric care, rehabilitation and palliative care (whether pre-existing or not) and two months for all other treatments. Waiting periods also apply for Extras.
If you’ve got private health insurance, it’s important to know what you are and aren’t covered for – that way you know what you can claim.
There are two types of health insurance claims, hospital claims and Extras claims.
Before you head into hospital, ask your doctor to provide a breakdown of your procedure. This breakdown will give you an idea of what services you’ll be receiving throughout your stay in hospital.
After your procedure, the hospital may send your bill directly to nib as your private health insurer to pay. This should be hassle-free for you as we’ll take care of all the paperwork.
If your hospital visit is covered by other forms of insurance, such as worker’s compensation, medical negligence, or public liability, or another party is liable (for example in a car accident), you’ll be eligible to receive benefits directly from your general insurer and not your private health insurer.
Most health funds, including nib, offer a range of Health Management Programs available at no additional charge to eligible customers. These programs are designed to support customers going home from hospital safely, whilst improving physical and mental wellbeing. They also aim to help a patient recover quicker post-hospitalisation.
If you’re making Extras claims – like when you buy a new pair of glasses – it’s often processed automatically at the point of sale when you swipe your membership card, so long as your provider has a HICAPS terminal.
If not, we’ve made it easy to make a claim using the nib app on your iPhone or Android smartphone. Simply open the app, snap a photo of your receipt and hit submit! You can also make a claim online through the nib Online Services page or in person at any nib retail centre.
Once you’ve served any applicable waiting periods, you’ll be able to start claiming Extras. Depending on the level of health cover you choose, you’ll be eligible to receive between 50-75% of the cost back per Extras claim, until you reach your annual limit.
So, if you’re getting a dental check-up that costs $200 and your policy gives you 60% back on Extras, we’ll contribute $120 towards the costs.
The cost of health insurance policies varies across insurers, based on the level of cover you choose. It’s important to remember that in most situations, the more you’re covered for, the higher your premium will be – so cheapest isn’t always best.
At nib, we don’t want you paying more than you should for your private health insurance, so we recommend contacting us for a policy review to ensure you’re not covered for things you don’t need.
Another simple way to save is by looking at how you pay your premium. We offer discounts of up to 4% to customers who set up automatic direct debits from their bank account (discount not available on Ambulance Only cover).
When looking at your private health insurance policy, it’s vital to check what level of excess you’ve got. Often you can lower your premium by choosing a higher excess. On some of our nib hospital covers, you can choose from either a $250 or $500 excess. From 1 April 2019, you'll be able to increase your excess to $750 as part of the private health insurance reforms. To find out more about your excess options, give us a call on 13 16 42.
If you currently hold private health insurance, you could be eligible to receive a rebate from the Australian government. The Australian Government Rebate amount is tiered depending on your individual income (if you’re single), or your family’s income. This rebate can be used to reduce your premiums, or claimed as a tax credit when you lodge your tax return with the Australian Taxation Office (ATO).
If you are single and have a taxable income of $90,000 or more, or are a couple, family or single parent family that has a taxable income of more than $180,000 a year, and do not have hospital cover, you will be required to pay a Medicare Levy Surcharge of between 1% and 1.5% of your total income, depending on your income tier.
If you’re thinking about getting private health insurance with nib, you can get a quote online, or call us on 13 14 26 to discuss your options.
If you have questions about your existing nib policy visit Online Services or call us on 13 14 26.