1 WESTFUND POLICY SUMMARY OSPITAL IDEAL FOR OLDER SINGLES AND COUPLES, OUR PRODUCT PROVIDES TOP OSPITAL COVER (NO EXCLUSIONS OR RESTRICTIONS) AND QUALITY EXTRAS WIT IG BENEFITS ON FUNDAMENTAL SERVICES. PRODUCT NOW CLOSED TO NEW MEMBERS. Please read this Policy Summary carefully and retain it for future reference. For further policy information, definitions and claiming requirements please refer to Westfund s Membership Terms and Conditions, which can be downloaded at www.westfund.com.au/terms/ alternatively, call Westfund on 100 97 88 to request a copy. R 8 ospital Cover ospital Treatment Category Covered Westfund has contracts with numerous private hospitals throughout Australia covering theatre fees and hospital accommodation costs for most procedures. ospital policies do not provide cover for treatment for which Medicare pays no benefit e.g. n-therapeutic Cosmetic Surgery, or if disallowed by the Private ealth Insurance Act 2007. Where no contract exists with a private hospital, benefits are payable at a default rate determined by the Government. In these cases, out-of-pocket expenses may be incurred. We recommend that members check with us prior to admission to hospital to ensure they are covered. ospitals which have contracts with Westfund are listed at: www.westfund.com.au/ health-services/find-a-hospital. Further details can also be obtained by calling us on 100 97 88. As a private patient in a public hospital, you will receive cover for accommodation and your choice of doctor from doctors with a right to practice at that hospital. Westfund will pay benefits for surgically implanted prostheses up to the approved benefits in the Government s Prostheses List and in accordance with the requirements of the Act. Covered Westfund will pay towards your theatre fees, hospital accommodation and prosthetic costs when you are admitted to a contracted hospital. Restricted s which Westfund covers to a limited extent and pays reduced benefits on hospital admissions. The benefit is not sufficient to cover the cost of a private room in a public hospital or any room in a private hospital. If you are admitted to a private hospital for services that are restricted, large out-of-pocket expenses will apply. If the services are eligible under Medicare, you can still receive treatment as a public patient however public hospital waiting lists will apply. Excluded Westfund will not pay benefits towards hospital or medical costs for these services. If you choose to proceed as a private patient for an excluded service, you will have very large outof-pocket expenses. If the services are eligible under Medicare, you can still receive treatment as a public patient however public hospital waiting lists will apply. Rehabilitation ospital psychiatric services Palliative care Brain and nervous system Eye (not cataracts) Ear, nose and throat Tonsils, adenoids and grommets Bone, joint and muscle Joint reconstructions Kidney and bladder Male reproductive system Digestive system ernia and appendix Gastrointestinal endoscopy Gynaecology Miscarriage and termination of pregnancy Chemotherapy, radiotherapy and immunotherapy for cancer Pain management Skin Breast surgery (medically necessary) Diabetes management (excluding insulin pumps) eart and vascular system Lung and chest Blood Back, neck and spine Plastic and reconstructive surgery (medically necessary) Dental surgery Podiatric surgery (provided by an registered podiatric surgeon) Implantation of hearing devices Cataracts Joint replacements Dialysis for chronic kidney failure Pregnancy and birth Assisted reproductive services Weight loss surgery Insulin pumps Pain management with device Sleep studies
2 WESTFUND POLICY SUMMARY OSPITAL Medical Cover Westfund pays benefits for the fees charged by a doctor, surgeon, other specialist services, including pathology and radiology, while you are in hospital. Medicare pays 75% of the Commonwealth Medical Benefits Schedule (CMBS) fee and Westfund pays the additional 25% up to the CMBS fee. Where the fees charged exceed the CMBS fee, Westfund will pay an additional benefit to reduce or eliminate out-of-pocket expenses where the doctor or specialist participates in our Access Gap Scheme. Our Access Gap Scheme allows patients with hospital cover to eliminate or reduce out-ofpocket expenses for medical gap payments for inpatient hospital treatments. Westfund does not pay an amount charged by your doctor above the CMBS fees unless your doctor agrees to participate in the Access Gap Scheme. If a doctor does not use the Access Gap Scheme, patients will be responsible for any additional charges. Doctors are independent of Westfund and each doctor can choose on a case by case basis whether to participate in the Access Gap Scheme. Please visit our website www.westfund.com.au/ health-services/find-a-doctor or give us a call on 100 97 88 for further information on Access Gap Scheme. We encourage Members to contact us before their scheduled appointment to any referred medical specialist. benefits are paid for non-therapeutic cosmetic surgery. Ambulance Emergency Ambulance Transport Excess Nil or $500 Excess Options per adult per calendar Nil Excess for Accidents Nil Excess for Same-day Procedures s Accident-related ospital psychiatric services, Rehabilitation and Palliative care Pregnancy and birth Treatment of a pre-existing condition A pre-existing condition is an illness or condition for which in the opinion of a medical practitioner appointed by Westfund, signs or symptoms existed during the six months before the day you joined Westfund or upgraded to a higher level of cover All other hospitalisations (not listed above) 1 day 100% annual limit Emergency Ambulance transport is ambulance transportation of an unplanned and non-routine nature for the purpose of providing immediate medical attention to a person in the opinion of the treating medical officer. An ambulance service where subsequent transport to a hospital is not required is covered under non-emergency patient transport. n-emergency Patient Transport 100% $5000 per member n-emergency patient transport is ambulance transportation including on the spot treatment where a time critical ambulance response is not essential however clinical monitoring is required for the purpose of providing Medical attention to a person in the opinion of the treating medical officer. 1 day 1 1 Benefit eligible for Westfund recognised ambulance service providers in Australia. Westfund covers the cost of transport by either covering the cost of state government levies or covering the ambulance account
WESTFUND POLICY SUMMARY OSPITAL General Dental Diagnostic & Preventive ontics Endodontics Fillings Extractions/Oral Surgery General Dentist 1 Specialist Dentist Set item benefits depending on item number $1600 per member combined with Major Dental Some items attract higher benefits where completed by Specialist Dentist Major Dental Crowns Bridges Implants Veneers 1 Set item benefits depending on item number $1600 per member combined with General Dental Dentures Optical (prescription only) Frames Single Vision Lenses Bifocal Lenses Multifocal Lenses Contact Lenses 100% $250 per member benefit towards tinting, coating or add-ons. Benefits also apply for Irlen lenses Physiotherapy, Exercise Physiology, Chiropractic and Osteopathic Physiotherapy Group/ Class Individual $10 $42 Exercise Physiology $10 $0 Chiropractic N/A $0 Chiropractic X-ray N/A $55 Osteopathic N/A $0 $600 per member Two chiropractic x-rays per member per calendar
4 WESTFUND POLICY SUMMARY OSPITAL Complementary Therapies Group/ Class Individual Remedial Massage & Myotherapy Acupuncture & Chinese erbalism N/A $25 N/A $25 Dietetics & Nutrition $10 $0 ome Nursing (up to 6 hrs/over 6 hrs) N/A $12/$48 Vision (Eye) Therapy N/A $25 $400 per member Occupational Therapy 1 $10 $40 for surgical Podiatry treatment $4 Surgical Treatment by a N/A 100% Podiatrist Clinical Psychology $50 $50 Speech Therapy (initial/subsequent) $6 $48/$6 Prevention & ealth Management ealth Management Fitness Centre Aquatic Programs Weight Loss Programs Virtual Gastric Banding Diabetes Education Vitamins Omega Probiotics Ear and Eye Preventative ealth Checks -Audiology Test, Corneal Topography, Optical Coherence Tomography, Retinal Photography 2 Months 100 % $100 $80 $160 Fitness, Weight Loss, Virtual Gastric Banding and Aquatic Programs require a Medicare Recognised Practitioner to complete a ealth Management Claim Form to confirm the Program is medically necessary. Forms are available for download at www. westfund.com.au/helpful-resources/formsand-downloads/ The health check must be provided by a Medicare Registered Practitioner and cannot be Medicare claimable. ypnotherapy for Quit Smoking 100 % $250 Lifetime Chronic Disease Association Fees 100 % $0 $500 per member Includes - Asthma Foundation, Diabetes Australia, Arthritis Australia, Coeliac Association, Crohn s and Colitis Australia, Parkinson s Australia, Multiple Sclerosis (MS) Australia, Alzheimer s Australia, National Association of people with IV Australia (NAPWA), Lupus Association of Australia, MedicAlert Foundation, Stoma Associations (Ostomy, Colostomy) (per service) Preventative ealth Tests -Bone Density Test, Bowel Testing Kit, Calcium Score, Mammogram, Mole Scan, Thin Prep Pap Test 2 Months $0 The test must be recommended by a Medicare Registered Practitioner and cannot be Medicare claimable Prescriptions,Injections & Vaccinations $50 per prescription for the amount that exceeds the PBS co-payment Doctor letter required in some instances (see Membership Terms and Conditions)
5 WESTFUND POLICY SUMMARY OSPITAL n Surgically Implanted Prostheses ealth Aid or Appliance Blood Glucose Monitor s Item $100 Blood Pressure Monitor $150 Braces Compression Garments $120 Burn Suits $800 INR Monitor $200 Mammary Prostheses and Brassieres $225 Nebuliser $110 Custom Made Orthopaedic Boot Custom Made/ Preformed Orthotics $200 $200 Peak Flow Meter $5 Wigs 1 $150 Artificial Limbs $200 CPAP (sleep apnoea) Machine EPAP Treatment Oral Appliance for diagnosed snoring CPAP Masks, Accessories and TENS Accessories Low Vision Aids Mobility Aids Oxygen and Accessories Oximeter $500 $100 $100 $500 Repairs to Devices $100 TENS Machine $150 earing Aids & Frequency Modulated Systems 6 months $1400 Claimable per member Every two s Every three s Every three s Every three s Letter of Recommendation Every 1 Every 1 unless relevant hospitalisation is recorded with Westfund Every 1 Every 1 unless relevant hospitalisation is recorded with Westfund Every 1 Every 1 Every 1 unless initial purchase of the device is recorded with Westfund Benefit available for hire and purchase fees Letter of recommendation not required if n Surgically Implanted Prostheses claimed through ICAPS by a Medicare Registered Practitioner Repairs to devices are only available to appliances listed in this table
6 WESTFUND POLICY SUMMARY OSPITAL Member Advantages - Member Advantages provide additional benefits to our members and require individual forms to claim. Forms are available for download at: www.westfund.com.au/helpful-resources/forms-and-downloads/ Accident Benefit 1 day $100 per night per hospitalisation Optical Bonus Sunglasses Accommodation and Travel Benefit Advanced Surgery Benefit Forced Retrenchment/ Protected Industrial Action 1 24 months 6 months $60 per member to use towards outof-pocket costs, accrues to $120 if no optical claims made at any provider in consecutive s $50 per member per calendar A limit of $400 per policy per calendar applies to the Accommodation and Travel Benefit. A benefit of $100 per night is available for Accommodation expenses. A Travel Benefit is available for travel expenses for return trips exceeding 150 kilometres for inpatient or outpatient specialist medical services $200 per night following the procedure, up to $2,400 per hospitalisation Waiver of premiums up to six months Must be hospitalised as the result of an accident Available only at Westfund Eye Care Centres. Bonus can be used towards prescription glasses and contacts only Available only at Westfund Care Centres For advanced surgery admissions due to heart disease, stroke or cancer Must be due to Forced Retrenchment or Protected Industrial Action Finding a registered provider Westfund has established a Provider of Choice Network to ensure members have no or known out-of-pocket expenses for selected General Treatment services. To see if a Provider of Choice is in your area use our search facility at: www.westfund.com.au/choice Finding a registered General Treatment provider Our search facility in the Member Online Area of our website can help you find registered providers; simply go to: www.westfund.com.au, login to the Member Online Area and go to Find Providers. Alternatively, you can find registered providers at www.ahpra.gov.au. Other important information Westfund s Privacy Policy is available at: www.westfund.com.au/privacy To register a complaint please visit: www.westfund.com.au/contact-us/feedback/ Westfund ealth Insurance is a signatory to the Private ealth Insurance Code of Conduct. You can get a copy of the code at: www.westfund.com.au/contact-us/feedback/