Hospital Cover provides benefits to help pay towards the cost of treatment you receive whilst admitted into hospital.

When you are admitted into hospital as a private patient you’re covered for things like your medical treatment and hospital accommodation.

Taking out Private Hospital Cover is all about providing you with choice. You have the choice of who treats you, where you are treated, and often when you are treated.

For details specific to each level of cover, see the relevant product information sheet. Please read these in conjunction with the Phoenix Health Member Guide.

Bronze Hospital Bronze Plus
Essentials
Hospital
Bronze Plus
Care
Hospital
Silver
Everyday
Hospital
Silver Plus
Content
Hospital
Silver Plus
Advantage
Hospital
Hospital psychiatric services R R R R R R
Rehabilitation R R R R
Palliative care R R R R R
Bone, joint and muscle
Brain and nervous system
Breast surgery (medically necessary)
Chemotherapy, radiotherapy and immunotherapy for cancer
Diabetes management (excluding insulin pumps)
Digestive system
Ear, nose and throat
Eye (not cataracts)
Gastrointestinal endoscopy
Gynaecology
Hernia and appendix
Joint reconstructions
Kidney and bladder
Male reproductive system
Miscarriage and termination of pregnancy
Pain management
Skin
Tonsils, adenoids and grommets
Heart and vascular system x x
Lung and chest x
Blood x
Back, neck and spine x x x
Plastic and reconstructive surgery (medically necessary) x x
Dental surgery x
Podiatric surgery (provided by a registered podiatric surgeon) x x x
Implantation of hearing devices x x x
Cataracts x x x x
Joint replacements x x x x
Dialysis for chronic kidney failure x x x x x
Pregnancy and birth x x x x x
Assisted reproductive services x x x x x
Weight loss surgery x x x x x x
Insulin pumps x x x x x
Pain management with device x x x x x
Sleep studies x x x x x x

Indicates where a service is covered on the corresponding level of cover

R

Indicates where Restricted benefits apply on the corresponding level of cover

x

Excluded

going to hospital
going to hospital details

Exclusions & Restrictions

What is an exclusion?

When a service is excluded under your hospital cover there will be no benefit payable where the service is the primary reason for admission in a private or public hospital.

What is a restriction?

Restricted cover provides cover in a public hospital as a private patient. If you have restricted services and you are admitted to a private hospital, there will be no benefit payable for any theatre fee charges and a reduced benefit will apply towards your accommodation fees. This means you may be faced with considerable out-of-pocket costs in a private hospital.

What am I covered for, & what am I not covered for?

What does Hospital Cover include?

Hospital Cover provides benefits towards services you receive when you are admitted into hospital as an in-patient for treatment, such as:

  • Day surgery
  • Overnight accommdation
  • Theatre fees
  • Intensive care unit
  • Medicare recognised procedures
  • Private room [where available]
  • Specialist Surgeons, Anaesthetists and Assisting or Attending Doctors fees
  • In – Hospital Pharmacy
  • In – Hospital Pathology
  • In – Hospital medical supplies

You are covered as a private patient in a private hospital, or as a private patient in a public hospital – where you elect to be treated as a private patient. The choice is yours.

Where you elect to be covered as a private patient in a public hospital, you will be eligible for accommodation benefits paid at a shared ward rate. This means should you be given a private room, you may end up with out of pocket expenses.

What treatments are covered under your membership will depend on the level of cover you have selected, so you should always refer to your individual cover information sheet to find out what you are specifically covered for. We recommend contacting us prior to a hospital admission so we can confirm your eligibility for benefits.

Is there anything that my Hospital Cover won’t cover?

Private Hospital Cover can only provide benefits towards services received when you are admitted into hospital, or where the fund has arrangements with providers for services such as Chronic Disease Management and Obstetric programs. There are some services that your hospital cover does not provide benefits for:

  • Treatment received while not admitted into hospital – i.e. outpatient services, GP and Specialists visits,
  • Treatment received in the Emergency Department of a hospital, including emergency department facility fees, and
  • Treatment that does not have a Medicare item number

What is an Excess and Co-Payment?

What is an Excess?

An Excess is an amount you agree to pay towards your treatment if you are hospitalised, usually to reduce the premium of your cover without compromising what you are covered for.
The Excess is payable on admission to hospital once per person, per calendar year, regardless of how many times you may need to go to Hospital and does not apply to dependant children on a policy.

What is a Co-Payment?

A Co-payment is an amount in addition to your nominated Excess, that is payable by you every time you are admitted to hospital for a minimum of one night.
Co-Payments do not apply to day admissions or to dependant children listed on a policy.

Before going to hospital

Access Gap Cover Scheme

Phoenix Health members with private hospital cover can eliminate or reduce out-of-pocket expenses for in-patient hospital treatment where the doctor participates in our Access Gap Cover Scheme. We currently have agreements with over 36,000 doctors who participate in the Access Gap Scheme. It is each doctor’s choice to participate.

Before booking any treatment, you should ask your doctor to explain the costs involved for your hospital admission, any fees or gaps you may be charged, including anaesthetist and assistant surgeons. If there are any gaps for you to pay, ask for a written cost estimate. This is known as Informed Financial Consent.

Doctor & Hospital Search

Looking for a doctor that participates in the Access Gap Cover Scheme? You can quickly search for a doctor or specialist by visiting our search tool.

Going to Hospital?

When you first become aware that you may need to go to hospital, phone us and we can help you prepare by checking your cover, offering advice on what questions to ask your doctor and hospital and even help you fill out any admissions paperwork if you need.

What do I need to ask my Doctor?

Before any treatment, we recommend you ask your doctor these 3 questions;

  1. Will you participate in the Phoenix Health Fund Access Gap Cover scheme?
  2. Will I have any out-of-pocket expenses, and if so, please provide a written estimate of how much?
  3. Will any assisting doctors also use Access Gap Cover and if so, how can I obtain a quote for their services?

Waiting Periods for Hospital Cover

What is a waiting period?

A waiting period is a specific period of time that a member must wait after they have purchased a cover, before they are able to claim against the policy.

Waiting periods for new members to private health insurance

When you are taking out cover for the first time, or you have been without cover for more than 30 days, a waiting period will apply for all services on your chosen level of cover.

Waiting periods for members transferring from another insurer

When you transfer to Phoenix Health from another insurer, and do so within the required time frame, any waiting periods and entitlements you have previously qualified for will transfer with you. Waiting periods will only apply to any upgraded benefits and services; and where you had not fully served your waiting periods with your previous insurer, you will be required to serve the remaining balance of time. While waiting periods are being served, benefits will continue to be paid at the previous level of cover, where available.

Waiting periods for current Phoenix Health members upgrading their cover

For current Phoenix Health members, whenever you upgrade your cover, waiting periods will apply to any increased benefits, limits and services, including to any upgrade in excess and or co-payments. While waiting periods are being served, benefits will continue to be paid at the previous level of cover, where available.

What are the Waiting Periods?

Hospital Cover
Pre-existing conditions

Excluding Hospital Psychiatric services, Rehabilitation and Palliative care

12 months
Pregnancy and birth assisted reproductive services
Hospital Psychiatric services, Rehabilitation and Palliative care

Regardless of whether they are pre-existing or not

2 months
All other conditions requiring a hospital admission, that are not considered pre-existing
Hospital Care programs
Accident cover No waiting period
General Treatment (Extras) Cover
Major Dental, Orthodontics 12 months
Optical 6 months
All other services 2 months
Ambulance Cover
Ambulance 1 Day

Is there a waiting period for Accidents?

Where a member is within waiting periods for hospital cover and hospitalised as a result of an accident, the mandatory waiting period for that condition will be waived and benefits payable for a private hospital admission where the service is not excluded under the level of cover. Excesses are not waived for accidents or where the admission is to a public hospital as a result of an accident. Please contact Phoenix Health for more information about claiming Accidents.

What is a Pre Existing Condition?

A pre-existing condition is any illness or ailment that, in the opinion of a Medical Practitioner, existed at any point in the 6 months prior to taking out cover or upgrading. If you require hospitalisation within the first 12 months of commencing hospital cover or upgrading your level of cover, and have served the general 2 month waiting period, the fund may request a pre-existing form to be completed by your regular GP and Specialist. This information would then be assessed by an independent Medical Practitioner appointed by the fund who will determine if the condition is pre-existing or not and as such whether or not a benefit will be paid or not.

Psychiatric Upgrade Waiver

To improve access to mental health treatment in Australia, the Government have introduced mandatory Psychiatric Hospital upgrade waiver rules. Where a cover has restrictions or exclusions for hospital psychiatric services and you have served your initial 2 month waiting period, you have the option to upgrade to a cover that provides full hospital psychiatric cover, without having to serve any additional waiting periods on the upgrade for that treatment. This psychiatric upgrade waiver is available once per person, per insured lifetime and is transferrable between funds and is detailed on a Transfer Certificate.
The waiver does not apply to any excess that may apply on upgrading cover. All other waiting periods still apply.

Hospital Care Programs

Hatchling Program

Preparing to welcome a child into the world is the beginning of a new stage of life and with this in mind, we have created the Phoenix Health Hatchling Support Program to provide you with ongoing support from the time you learn of your pregnancy through to the first 8 weeks of your baby’s life.