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Claiming your benefits

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Benefits you will receive

For information about what benefits you are entitled to, and how to claim, contact your health insurer.

Before you start treatment, you should check whether your health insurer has an agreement in place with your hospital and whether your doctor is participating in the insurer's gap cover arrangements.

You should also ask your doctor(s) and hospital for an estimate of their costs and how much will not be covered by your health insurer. Your health insurer should also be able to assist with calculating likely out-of-pocket costs.

You can ask any health insurer about the hospitals that have agreements with that insurer and doctors who are participating in the insurer's gap cover arrangements. For details see Gap Doctors and Agreement Hospitals.

Time limit

You should lodge any claims within two years of the date of the service although some insurers may allow claims to be lodged after two years. Check with your insurer. The claim form must be signed by you, or by you or your spouse in the case of couple or family memberships.

Prostheses

A prosthesis is an artificial substitute for a missing body part, used for functional or cosmetic reasons or both. Surgically implanted prostheses are sometimes required during a medical procedure, such as a replacement lens for a cataract surgery, artificial hip joint, pacemaker, or heart valve.

For medical procedures covered by the Medicare Benefits Schedule (MBS), your health insurer will fully cover the cost of at least one prosthesis, if required (called a 'no-gap' prosthesis).

In some cases, an alternate prosthesis may be available which costs more than the 'no-gap' version. If you choose to use one of these prostheses, you will have to pay the difference between the 'no-gap' amount and the total amount charged by the supplier for the prostheses. 

If your doctor considers that a gap-permitted prosthesis is the most clinically suitable for a patient, they should provide appropriate clinical and financial information so you can give informed financial consent beforehand.

For each procedure, you should check with your health insurer as to how much it will pay for a particular prosthesis, and whether you will have any 'gap' to pay.

Don't forget that if your private health insurance policy has exclusions then you won't be able to claim for any prostheses provided as part of these services either. For example, if your policy excludes joint replacements, you would not be able to claim for the cost of a replacement hip or knee prostheses.

More information

The Australian Medical Association's 'Doctors involved in your care' lists which doctors and specialists are likely to be involved in common surgical procedures.