When it comes to private health insurance, an accident is an injury that occurs unintentionally or unexpectedly and requires immediate treatment by a doctor at a hospital. An accident can’t be attributed to medical causes.
For example, you’re at home on the roof and fall from a ladder, landing on your arm. A bone is visibly out of place and you’re in immediate pain. Your partner urgently takes you in their car to your closest private hospital’s emergency facility, where as an out-patient you have scans that indicate you’ve broken your wrist in several places and require urgent surgery. You’re admitted into hospital and are now considered an in-patient, and will have surgery on your wrist first thing in the morning.
Accident Cover is there for when a member is hospitalised as the result of an accident and they’re within waiting periods for hospital cover, or hold a level of hospital cover that has an exclusion for the treatment they need. Phoenix Health will waive the waiting period and pay benefits towards the private hospital admission for the treatment of that condition.
For example, you joined hospital cover for the first time six months ago and, as such, are still within your waiting periods. You have an accident and attend an emergency department, where it’s determined that you require surgery at a private hospital. You can apply for Accident Cover benefits to be paid towards the treatment of this condition.
For Accident Cover benefits to be assessed, the member must report to an emergency facility within 24 hours of the injury and a Doctor’s report of this visit must be submitted to Phoenix Health along with any other supporting documentation as requested. All treatment relating to the injury must be initiated within 30 days and completed within 90 days of the accident.
Contact the Phoenix Health Team on 1800 028 817 as soon as you are able, and we can guide you through the Accident Cover claiming process.
Accident Cover cannot be used where:
- the member is admitted into a public hospital for treatment after an accident
- the accident can be related back to a pre-existing medical condition, pregnancy, drug and alcohol use, illegal activities or any condition resulting from a surgical procedure
- the treatment is claimable through compensation and damages or another third-party insurance policy
- the accident occurred outside of Australia.
In the case of an accident, the first step is to make sure everyone is safe, then to call 000 for an ambulance or go to a hospital emergency department within 24 hours of your accident.
We ask that you contact Phoenix Health as soon as you are able to so that we are able to talk you through your options and the Accident Cover process!
At Phoenix Health, on all of our hospital covers, we provide unlimited cover for all medically necessary emergency and non-emergency ambulance treatment and transport across Australia: road, sea and air – because we want you to have peace of mind that you’re covered when you need it.
What is emergency ambulance?
An emergency ambulance service is when an ambulance is called to a medical emergency, unplanned illness or injury, accident or incident, where medical care and transport is believed to be urgently required.
What is non-emergency ambulance?
A non-emergency ambulance service is when an ambulance is called to a medical emergency, unplanned illness or injury, accident or incident, where medical care can be provided at the scene by ambulance officers, or when transport is required, but it is not an emergency.
Does ambulance have a waiting period?
Ambulance cover only has a 1 day waiting period, so you can feel confident knowing we’ve got you covered!
What if I receive an ambulance bill?
In an emergency there may not be time to give your Phoenix Health details, so if you receive a bill and it’s claimable, send it to us as you would any other claim – we’ll process your claim and generally pay the ambulance provider directly.
It’s important to know that where an ambulance service is claimable through another source, including a state ambulance subscription, your claim should be made with them in the first instance.
What does medically necessary mean?
Medically necessary means on-site treatment or transport to the closest hospital or emergency department for treatment of an acute medical condition or accident.
Fees and charges in an emergency department
If you are taken to a public hospital emergency facility and you’re eligible for Medicare benefits, you shouldn’t see any bills from your trip to the emergency department and will generally not experience any out-of-pocket costs.
There may be times when you elect to attend a private hospital emergency facility for treatment – you may be able to request that the ambulance take you there, or you may arrive by private transport. While you may not wait as long to be treated in a private emergency facility, you need to be aware of the out-of-pocket costs you may experience.
Private emergency departments often charge a facility fee which is payable directly to the hospital and is not claimable through private health insurance. In some cases, you may be able to claim a portion through Medicare. Any treatment you receive in the emergency department is an out-patient treatment and, as such, you will only be able to claim a portion through Medicare. If you are then admitted into hospital as an in-patient for further treatment, your Phoenix Health cover will kick in.
Fees and charges if you’re admitted into hospital after an accident
The bills for your hospital accommodation and theatre fees will come directly to us, so you won’t see those. Any other bills should be taken to Medicare first. If you have an excess on your hospital cover, you will still be required to pay this.
If you are unsure about a bill or invoice you have received, just give us a call and we’ll be happy to help.
Ambulance
If an ambulance was called to treat you, your bill for this service may come straight to Phoenix Health; however, there is a chance it may be sent to you. As benefits are available for medically necessary emergency and non-emergency ambulance services under Phoenix Health hospital cover, if you receive a bill and it’s claimable, send it to us as you would any other claim for us to process.
It’s important to know that where an ambulance service is claimable through another source, including a state ambulance subscription, your claim should be made with them in the first instance.
Discharge medications
When you leave hospital after your procedure, you’ll often be given discharge medications to continue your treatment at home. There is no benefit payable on discharge medication under your hospital cover, so you won’t be able to claim these costs as part of your hospital admission.
If you hold Extras cover, you may be able to claim a portion of the cost of your discharge medications. We can check this for you – just give us a call.
Post-op doctor appointments
Once you’ve left hospital, it’s important to know that any follow-up appointments you may have with your specialists are considered an out-patient service and are not claimable through your private health insurance. You may be able to claim a portion of the cost of these appointments through Medicare.
Need assistance before, during or after a hospital admission?
Our Health Support Programs are designed to give eligible members extra support when they need it. From hospital and recovery support to mental health, chronic conditions, pregnancy and early parenting, and joint and mobility support, our programs can help you manage your health and recovery.
Programs are delivered by health professionals, often in conjunction with your treating doctors, and are available to eligible members with Phoenix Health hospital cover.
Explore our Health Support Programs to learn more about the support available and eligibility requirements.
Taking a little extra care of your health right after you’ve had surgery is so important, and while you can’t claim for out-patient specialist visits, there are other ways your health insurance has your back.
Have Extras Cover?
If you hold Phoenix Health Extras Cover, you may be able to claim a benefit towards allied health services that can help with your recovery, like physiotherapy, remedial massage, occupational therapy and chiropractic, as well as Aids to Recovery for items like toilet seat raisers, pregnancy recovery pants, wigs after cancer treatment and bras after a mastectomy. You should refer to your Product Information Sheet for your level of cover or get in touch with a Phoenix Health team member to check your eligibility and find out how to claim.
Our Health Support Programs are designed to help you through your hospital experience and recovery. We want you to feel confident and supported, so you can get back to enjoying life sooner. Explore our Health Support Programs to learn more about the support available.
