Membership Conditions

Important information you need to know

Membership conditions (summary only)


1. Waiting Periods

A waiting period is the length of time you must wait before you become eligible for benefits.
For more information on waiting periods, click here.

2. Pre-existing condition
A pre-existing condition is an ailment, illness or condition the signs or symptoms of which, in the opinion of an independent medical practitioner appointed by St.LukesHealth, existed at any time in the period of six months ending on the day on which the person became insured under the policy. A 12-month waiting period applies to all pre-existing conditions.
 

3. Accidents

Hospital treatment that results from an accident, which occurred after joining, is covered immediately on hospital cover, providing there is no right to claim compensation and damages from another source. An accident is an event or occurrence which is unforeseen and unintended, which results in physical hurt or damage to the body and requires immediate treatment. An accident does not include an obstetric related condition, or an unforeseen ailment, illness or condition brought on by medical causes, or any excluded clinical categories under your selected level of cover.
 

4. Restricted service

Benefits for a restricted service are limited to a shared room benefit in a public hospital should you elect to be treated as a private patient. There is very limited cover in a private hospital meaning you will have significant out-of-pocket costs if you use a private hospital for a restricted service. These costs include accommodation fees and theatre fees charged by the private hospital. You are entitled to Medicare Benefit Schedule rates for any medical services and therefore you may also have an out-of- pocket cost from your doctors. Your prosthesis costs will be in accordance with normal fund rules.
 

5. Excluded services

Benefits for excluded services are not payable therefore there is no cover as a private patient in a public hospital or a private hospital meaning that you will have significant out-of-pocket costs if you opt to be treated as a private patient in a public hospital or  in a private hospital for an excluded service. No benefit is payable towards prosthesis for services that are excluded from a product.
 

6. Cosmetic Surgery and surgical procedures not covered by Medicare

No benefit is payable on any hospital cover for treatment relating to cosmetic surgery or other surgical treatment that does not meet the eligibility criteria for the payment of Medicare benefits, or is not listed in the Medicare Benefits Schedule (with the exceptions of membership conditions 8 and 9).
 

7. Obstetric Related Services

A 12-month waiting period applies to obstetric-related conditions. After the 12-month waiting period has been served, the mother’s hospitalisation will be covered on a single policy and both the mother and baby will be covered on a family policy. To ensure coverage of a newborn child, a single policy must be upgraded to a family cover from the child’s date of birth, providing the change occurs  within 30 days of the child’s birth. A newborn child should also be added to a family cover within 30 days of the child’s birth to ensure that no waiting periods apply to the child. Premature births or complications arising from a pregnancy where a medical practitioner confirms the baby’s expected date of birth is after the 12-month waiting period, will be covered. St.LukesHealth offers private post-natal services to Northern Tasmanian members on selected products. A 12-month waiting period applies to new members and members transferring from another insurer. Members who reside interstate, or in Southern or North-West Tasmania are not eligible for this service, as post-natal services are provided by the private hospitals in these regions, unless they deliver at the Launceston General Hospital.
 

8. Sterilisation/Vasectomy or reversal of

Sterilisation, vasectomies and reversals of, are only covered on our hospital covers when they attract a Medicare benefit. Benefit is not payable for procedures not covered by Medicare. Where Medicare benefit is payable, a 12 month waiting period will apply under the pre-existing rule.
 

9. Podiatric Surgery

St.LukesHealth will pay hospital accommodation benefits on its Gold and Silver products for surgical procedures performed by a registered podiatric surgeon. Surgical procedures performed by a Podiatric Surgeon do not attract Medicare benefit and therefore no medical benefit will be paid towards the charges raised by a Podiatric Surgeon.
 

10. Overseas Treatment

No benefit is payable for services, treatment or appliances rendered or purchased outside of Australia.
 

11. Who is covered?

A single membership covers the individual only.

A couples membership covers the member and their partner/spouse.

A family membership covers the member, partner/ spouse and dependants.

A dependant extension membership covers the member, partner/spouse and dependants including non-student child dependants.

On a family membership, dependants include children under 23 years of age and full and part-time students under 25 years of age who are not married or living in a defacto relationship and if totally dependent on their parents.

On a Dependant Extension membership, dependants include non-student child dependants under 25 years of age who are not married or living in a defacto relationship. Dependants will receive immediate cover for equivalent benefits providing they join their own membership within 60 days of ceasing to qualify as a dependant or non-student child dependant and providing all waiting periods have been served under their parent’s policy.
 

12. Transferring to higher cover

When changing to higher levels of cover, waiting periods and the pre-existing condition rule will apply for the additional benefit payable on the higher cover, except for benefits for psychiatric treatment where a one-off lifetime waiting period exemption may apply.
In the interim, your previous level of cover applies provided you have served the waiting periods on your previous level.
 

13. Transferring from other funds

Members who transfer from another registered health insurer within 60 days of ceasing financial membership of the previous insurer, may do so without waiting periods providing the benefits are common to both insurers, the transfer is to equivalent or lower levels of cover and all waiting periods have been served with the previous insurer. If a break in Hospital cover does occur on transfer, the days without hospital cover will be counted as a period of absence for Lifetime Health Cover. Should the transfer be to a higher level of cover or a higher benefit than the previous insurer then all waiting periods, including the pre-existing condition waiting period will apply for the additional benefit, with the exception of benefits for psychiatric treatment where a one-off lifetime waiting period exemption may apply. When transferring from another insurer, your original age at joining Hospital cover with your previous insurer will be taken into consideration for the calculation of any premium loading payable under Lifetime Health Cover.


14. Payment of contributions

Contributions are payable in advance. A discount is available for those persons who have half-yearly or a year in advance.


15. Direct Debit Request Service Agreement

Debiting your account
By signing a direct debit request or by providing St.LukesHealth with a valid instruction, you have authorised St.LukesHealth to arrange for funds to be debited from your account. We will only arrange for funds to be debited from your account as authorised in the direct debit request. If the debit day falls on a weekend or public holiday, we may direct your financial institution to debit your account on the following banking day. Monthly, quarterly, half yearly and yearly direct debit payments are deducted on the 25th of the month, or within 2 business days after the 25th. Premiums will be deducted for the following calendar month, quarter, half year or year. Weekly and fortnightly direct debit payments are deducted in advance on the Friday of each week or fortnight, or within two business days after.
An adjustment may be taken with your first direct debit payment to bring your payments in line with your chosen direct debit cycle.

Amendments by us
St.LukesHealth may vary any details of this Agreement or a Direct Debit Request at any time by giving you at least 14 days written notice.

Amendments by you
You may change or defer a debit payment, or terminate this Agreement by providing us with at least 7 days’ notification in writing.

Your obligations
It is your responsibility to ensure that there are sufficient clear funds available in your account to allow a debit payment to be made in accordance with the direct debit request. If there are insufficient clear funds in your account to meet a debit payment you may be charged a fee and/or interest by your financial institution or you may also incur fees or charges imposed or incurred by us and you must arrange for the debit payment to be made by another method or arrange for sufficient clear funds to be in your account by an agreed time so that we can process the debit payment. You should check your account statement to verify that the amounts debited from your account are correct.
 
Dispute
If you believe that there has been an error in debiting your account, you should notify St.LukesHealth and confirm that notice in writing with us as soon as possible so that we can resolve your query more quickly. Alternatively you can take it up with your financial institution direct.

If St.LukesHealth concludes as a result of our investigations that your account has been incorrectly debited we will respond to your query by arranging for your financial institution to adjust your account (including interest and charges) accordingly. We will also notify you in writing of the amount by which your account has been adjusted.

If St.LukesHealth concludes as a result of our investigations that your account has not been incorrectly debited we will respond to your query by providing you with reasons and any evidence for this finding in writing.

Accounts
You should check with your financial institution whether direct debiting is available from your account  as direct debiting is not available on all accounts offered by financial institutions. You should also check that your account details which you have provided to us are correct by checking them against a recent account statement and you should check with your financial institution before completing the direct debit request if you have any queries about how to complete the direct debit request.

Confidentiality
St.LukesHealth will keep information (including your account details) in your direct debit request confidential. We will make reasonable efforts to keep any such information that we have about you secure and to ensure that any of our employees or agents who have access to information about you do not make any unauthorised use, modification, reproduction or disclosure of that information.

St.LukesHealth will only disclose information that we have about you to the extent specifically required by law, or for the purposes of this Agreement (including disclosing information in connection with any query or claim).

Notice
If you wish to notify us in writing about anything relating to this Agreement, you should write to us at the head office or email address that can be found here. St.LukesHealth will notify you by sending a notice in the ordinary post to the address you have given us in the direct debit request.

Any notice will be deemed to have been received on the third banking day (other than a Saturday, Sunday or public holiday listed throughout Australia) after posting.


16. Overdue payments

If contributions are in arrears, payments will not automatically be accepted. It may be necessary to re-serve waiting periods from the date of payment of the arrears and entitlement to benefit for services rendered while in an unfinancial period may be lost. If premiums fall more than two months in arrears, the policy will be subject to cancellation and all waiting periods may have to be re-served.


17. Claims lodgement

Benefits are not payable where a claim is lodged more than two (2) years after the date of service.
 

18. Compensation from other sources

Benefits are not payable for any condition for which members or dependants have the right to recover costs from any other source, including third party, worker’s compensation or persons liable at law.


19. Approved providers

Benefits are only payable when rendered by a practitioner in private practice who has been approved and registered with this Fund.

The approval and registration by St.LukesHealth of a Provider, Medical Practitioner, Hospital or Day Hospital Facility (as defined in the Rules and By-Laws of St.LukesHealth) for the payment of benefits does not constitute a representation or recommendation by St.LukesHealth or any of its agents that any particular Provider, Medical Practitioner, Hospital or Day Hospital Facility or any service, product or treatment recommended or provided by that Provider, Medical Practitioner, Hospital or Day Hospital Facility, will or may be of benefit to St.LukesHealth members. St.LukesHealth thus accepts no responsibility for the outcome of any advice, service, product or treatment given to members by a Provider, Medical Practitioner, Hospital or Day Hospital Facility registered with this Fund.


20. Hospital claims

Benefits are payable at the insured rate for 365 days for all persons covered in any one year (subject to conditions 1, 2, 6, 8, 9, 16 and 21). For hospitalisation that extends beyond 35 continuous days, benefits will be reduced unless a medical certificate for ongoing Acute Care is provided by the patient’s doctor and approved by the Fund.


21. Benefit limited to fee charged

Benefits shall be limited to the fee charged or the insured amount whichever is the lesser.
 

22. Medicare Benefits Schedule fee

The Medicare Benefit Schedule fee is set for the purpose of paying Medicare Benefits. It does not necessarily indicate the amount that the doctor will charge but forms the basis from which the Medicare and ‘medical gap’ benefit is determined.


23. Periods of absence from hospital cover

Under Lifetime Health Cover, if you cease your hospital membership for three years or more over your lifetime, an additional premium loading may apply when you rejoin. Refer to our website at stlukes.com.au or contact St.LukesHealth on 1300 651 988 for more information.


24. Policy suspension

Members may suspend their policy in certain circumstances on application to St.LukesHealth. The fund will consider suspension for periods of extended overseas travel, and may consider suspension under special cases. A suspension application will need to be completed. An additional Medicare Levy Surcharge may apply to high income earners during any period of policy suspension. Refer to our website at www.stlukes.com.au.

Click here for further details on the Medicare Levy Surcharge.
 

25. Privacy policy

St.LukesHealth is committed to respecting your right to privacy and protecting your personal information. We are bound by the Australian Privacy Principles in the Privacy Act 1988 (Commonwealth), as amended, which regulates how we collect and manage your personal information. Our staff are trained to respect your privacy in accordance with our standards, policies and procedures. Our Privacy Policy outlines how we manage your personal information. It also describes in general terms the type of personal information held, for what purposes, and how that information is collected, stored, used and disclosed. Our Privacy Policy applies to all your dealings with us whether at one of our customer care centres, via our website or with one of our customer care or business development consultants. To view our privacy statement, click here.


26. Private Health Insurance Code of Conduct

St.LukesHealth supports the Private Health Insurance Code of Conduct.
The PHI Code of Conduct is an Industry self-regulatory code which aims to promote informed relationships between private health insurers, consumers, agents and brokers.
To view a copy of the code visit a St.LukesHealth customer care centre or click here.
 

27. Private Health Insurance Ombudsman

If you are unable to resolve a complaint with us to your satisfaction, you have the right to address your complaint to the Private Health Insurance Ombudsman (PHIO). These services are free to members.

The Private Health Insurance Ombudsman also provides an annual State of the Health Funds Report to assist consumers in assessing the relative performance and service delivery of each registered health fund.
A copy of the report is available from the office of the ombudsman or from the PHIO website at www.ombudsman.gov.au

The contact details for the Private Health Insurance Ombudsman are:
Private Health Insurance Ombudsman GPO Box 442
Canberra ACT 2601
Phone: 1300 362 072 - select option 4 for Private Health Insurance E-mail: phio.info@ombudsman.gov.au
Website: www.ombudsman.gov.au
Online complaints: www.ombudsman.gov.au/making-a-complaint/contact-us
 

Notation

The above is a summary of St.LukesHealth Rules. The complete Rules and By-Laws are available to all members for examination on request at any St.LukesHealth customer care centre. The information contained in this brochure cancels and supersedes all previously published material. The Rules may be amended from time to time. If they are, as a member of St.LukesHealth you agree to be bound by any amendments which are made.

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