Effective 1 July 2015

Mid Hospital ($500 excess)

& Premium Extras
Great value hospital cover for people who want private hospital cover for most
services, but are happy to have some restricted services to help keep the cost
down. It also gives you our very best extras cover - with top benefits and limits
for a huge range of services.

Mid Hospital
($500 excess)

+
Premium Extras

+
Ambulance cover

1800 808 690

info@peoplecare.com.au
peoplecare.com.au
Please read this document carefully and keep it for future reference.
For the most up-to-date info, visit peoplecare.com.au.
0615v1.0

Mid Hospital cover

($500 excess)

Exclusions
If you need treatment for any procedure listed as an
exclusion, you wont receive any benefits from us and
you may have significant out-of-pocket expenses. Make
sure youve looked at the exclusions on this product,
and always check with us to see if youre covered
before receiving treatment.

Heres what youre covered for:

Hospital service

Covered

Ambulance (see page 4)

Hospital accommodation (a private or public

Same-day patient fees

Intensive care

In-hospital pharmacy (pharmacy items that you

Theatre fees for services included in your

cover^

hospital bed in a shared or private room)

are given while youre admitted to hospital)

Palliative care

Restricted

Psychiatric services

Restricted

Rehabilitation

Restricted

Pregnancy & birth related services

Restricted

Assisted reproductive services (like IVF)

Restricted

Major eye surgery (like cataracts & lens)

Restricted

Cardio-thoracic & related services (e.g.

heart & chest)

Restricted

Dialysis for chronic renal failure

Restricted

Sterilisation

Plastic & reconstructive surgery

Hip & knee replacements & related

services

Restricted

Other joint replacements & related

services (shoulder, wrist, ankle, elbow)

Spinal procedures & related services

Gastric banding & obesity related services

Other Medicare eligible services

Cosmetic surgery

Services not covered by Medicare

Excess
This is the amount youve chosen to pay up-front if
youre admitted to hospital. The good news is its halved
if youre admitted to a public hospital or day surgery.
Even better, theres no excess for dependants under 21.
The excess is payable per adult per financial year. Once
paid, you wont have to pay an excess for any other
hospital admissions in that financial year (yay!).

Whats not covered (Hospital)

There are a few things that arent covered by your
hospital cover. They are:
Treatment & services received within your waiting
periods (see page 4)
Treatments & services that Medicare doesnt cover
(like cosmetic surgery)
Treatment & services received outside Australia
Treatment & services covered by compensation or
another type of insurance (like third party or sports
club insurance)
Treatment & services received more than 2 years ago
Outpatient treatment & services (unless theres a
special agreement between us and the hospital)
Some high cost drugs
Prostheses that arent approved by the
Commonwealth Government. (A prosthesis is an
artificial substitute for a body part)
Ambulance subscriptions or state-based ambulance
levies
Ambulance services paid for by the Government,
compensation or another type of insurance
Ambulance services that arent medically necessary
Pharmacy - most pharmacy items that youre given
while youre in hospital are covered by your hospital
bill. The hospital may charge you extra for pharmacy
items that you take home with you and this isnt
covered by your hospital cover.

You are not covered for theatre fees on excluded or restricted services.

Please get in touch with us if youre planning a hospital

admission so we can talk you through your cover and
any out-of-pocket costs you might have.

Please keep in mind that this isnt the full list of services covered. If youre
planning a trip to hospital, its always a good idea to call us and check what
youre covered for before being admitted.

Whats a restricted service?

These are services that are fully covered in a public
hospital only. There are 11 types of restricted services
on our Mid Hospital Cover (shown above), and if youre
admitted to a private hospital for any of these services
youll have large out-of-pocket costs.

Premium Extras cover

Heres what youre covered for:
Service

Benefit

Annual limit

Ambulance

Ambulance

100%

No limit

Chiropractic &
osteopathic

Chiropractic
Osteopathic

initial: $50
standard: $40

$600 per person

$1,200 per family

Whats not covered (Extras)

There are a few things that arent
covered by your extras cover. They are:

Treatment & services received within

your waiting periods (see page 4)
Natural therapy
Treatments & services that Medicare
Complementary Remedial massage
initial: $50
$400 per person
doesnt cover (like cosmetic surgery)
therapies
standard: $40
$800 per family
Acupuncture
Treatment & services received
Dietetics
outside Australia
General dental
Treatment & services covered by
(preventative, x-rays, basic
80%
No limit
restorations, basic surgery &
compensation or another type of
extractions)
insurance (like third party or sports
Major dental
club insurance)
Dental
(periodontics, endodontics,
80%
$1,500 per person Treatment & services received more
crowns & bridges, implants &
dentures)
than 2 years ago
$1,000
per
person
Pharmaceutical Benefits Scheme
Orthodontics
80%
$3,000 lifetime limit
(PBS) prescriptions, contraceptives or
Equipment
over-the-counter medicines
(CPAP machine, blood
pressure monitor, etc.)
Naturopathic & herbal medicines
80%
Health
services
First aid kits & courses
Health aids &
$700 per person
(Allergy treatments, home
wellness
$1,400 per family
nursing, pre/post-natal
Non-prescription glasses, contacts &
classes, etc.)
sunglasses
80% up to $200
Orthotics
Treatment & services received from
every 2 years
providers that arent registered or
Preventative health
Health
recognised by Peoplecare
$250
per
person
(Health screenings, travel
management
80%
expenses, improvement
$500
per
family
Treatment & services received from
programs
process, etc.)
a family member, relative, business
$1,500 every 5
partner or yourself
Hearing aids
Hearing & audiology
80%
years

Treatment & services you werent

Glasses & contact
100%
$300
per
person
charged for
lenses
Optical
$600 per eye
Services for sport, recreation or
Laser eye surgery
80%
every 2 years
entertainment
$500
per
person
Ambulance subscriptions or statePharmacy
Prescriptions
80% up to $80
$1,000 per family
based levies
Physiotherapy
Ambulance services paid for by
initial: $59
Occupational therapy
standard: $49
the Government, compensation or
Physiotherapy & Orthoptics (eye therapy)
$600 per person
other therapies
$1200 per family
another type of insurance
Exercise physiology
80%
Ambulance services that arent
Hydrotherapy
medically necessary
initial: $50
$500 per person
Podiatry
Podiatry (chiropody)
standard: $40
$1000 per family
Receipts issued by a third party, like
group buying website or group deals
initial: $110
$500 per person
Psychology
Psych/group therapy
standard: $90
$1000 per family
If youre using a gift voucher, we
cant pay the difference between
$500 per person
Speech therapy Speech therapy
80%
the cost of the service and the value
$1,000 per family
of the voucher. For example, if you
Please keep in mind that this isnt the full list of services covered. Its always best to give us a
use a $60 voucher to pay for a $40
buzz before having any treatment to check exactly what youre covered for.
service, you can only claim back the
Its always best to give us a buzz before receiving any treatment or
$40 as the official fee for that service
service to check exactly what benefits youll be able to claim.
Benefits higher than the amount you
paid for the service. For example,
if you receive treatment thats
discounted from $65 to $30, we only
pay a benefit towards the fee you
paid (e.g. $30)

Ambulance cover
Love a
free ride

Did you know that an ambulance ride could cost your

thousands? Weve got your back with our Australiawide, 100% ambulance cover.

Whats covered:

Whats not covered:

100% of the cost of medically necessary ambulance

treatment and transport within Australia no matter
how far you need to travel
Air, land and sea ambulance
No annual limits
No waiting periods

Ambulance subscriptions or state-based ambulance

levies
Ambulance services paid for by the government,
compensation or another type of insurance
Ambulance services that arent medically necessary

Waiting periods
Nobody likes waiting, but all health funds have waiting periods on some services to keep things fair for all
members. The following waiting periods apply before these services are covered on your membership:
Hospital services

Extras services

Waiting period

Ambulance
Services covered by another
fund (when transferring directly
to a similar level of cover)

Ambulance
Hospitalisation related to an
accident
Services covered by another
fund (when transferring directly
to a similar level of cover)

No waiting period

Joining the fund

Upgrading your cover
Health programs (see page xx)

2 months

Rehabilitation, psychiatric
services and palliative care
Pregnancy & birth related
services
Pre-existing conditions (see
below)

12 months

Extras services

Waiting period

No waiting period

Joining the fund

Upgrading your cover
Rehabilitation, psychiatric
services and palliative care
General dental, pharmacy,
physio, chiro, podiatry and
natural therapies

2 months

Optical and health

management programs

6 months

High cost dentistry including

crowns, bridgework, implants,
orthodontics, endodontics,
periodontics and dentures

12 months

Laser eye surgery & hearing aids

24 months

Dont worry, if youre transferring from another fund well make sure we recognise any waiting periods youve
already served!

Whats a pre-existing condition?

Pre-existing conditions have a special, government-regulated waiting period of 12 months. They only apply to
hospital cover. A pre-existing condition is any ailment, illness or condition that you had signs or symptoms of (in the
opinion of a medical practitioner appointed by the health insurer) that existed during the 6 months before you
joined or upgraded hospital cover. Its not actually necessary that you or your doctor knew what your condition
was, or that the condition had been diagnosed. A condition can still be classed as pre-existing even if you hadnt
seen your doctor about it before joining or upgrading hospital cover.

Health Programs
We all love feeling good, so Peoplecare offer a range of free
health programs with our hospital covers to help you stay in the
best possible health and out of hospital.
My Health Online gives you access to a range of health and wellbeing
tools. You can store e-health info about yourself (and share it with your
doctor), keep a calendar of healthcare appointments, access a health
library and more.
Health Risk Assessment asks for your health info across a range of areas
and gives you a personalised health report. If your assessment shows any
health risks, youll be given the option to enrol in one of our free programs.
Hospital @ Home makes it easy to get out of hospital earlier and receive
personal care in your home. If the services you need can be provided at
home, you might be able to avoid a hospital stay altogether.
Strive for Health has been developed to help members with chronic
conditions to manage their health with the help of expert phone or faceto-face support at home.
Rehab @ Home helps you recover in the comfort of your own home with
short term therapy for joint replacements, fractures, spinal conditions,
stroke, respiratory conditions, cardiac conditions and mobility problems.
We offer physio, occupational therapy and more.
Think one of these programs could be for you? Get more info at
peoplecare.com.au/myhealthprograms or get in touch on 1800 808 690.

Things to know about

Your Extras cover

Access Gap

Annual limits are based on the financial year (1 July

30 June), and are per person (unless it says otherwise)
Health management program benefits are available
for approved services that manage or treat a specific
health condition. Things like blood pressure testing,
cholesterol checks, mammograms and hearing
tests can be claimed. To find out if a service youve
received can be claimed for, please get in touch
Please keep in mind that we arent able to pay
benefits towards goods and services that are used
for sport, recreation or entertainment (like gym
memberships or sports shoes)
Pharmacy benefits can be claimed for prescription
medication that costs more than the current
Pharmaceutical Benefit Scheme (PBS) amount. This
amount changes on 1 January every year and is
$37.70 as at 1 January 2015
Complementary therapy benefits can only be paid for
services received by providers registered with either
Medicare or the Australian Regional Health Group
(ARHG)

To try and reduce your out-of-pocket costs as much

as possible, we have Access Gap arrangements with
over 30,000 doctors across Australia. This means you will
have either no gap (where we pay the full cost of your
treatment) or a known gap (where youll know your outof-pocket costs before you have treatment).
Before you go to hospital, ask your doctor if theyll take
part in Access Gap - if they do theyll even send their
bills straight to us, making life easier for you.

Hospital agreements
We have agreements with most private hospitals in
Australia. If youre admitted to one of the few private
hospitals that we dont have an agreement with, we
may not cover the full cost of your hospitalisation.
You can search our agreement hospital list at
peoplecare.com.au, and we recommend that you
give us a buzz if youre planning a hospital admission to
discuss exactly what youll be covered for.

Making a hospital or medical claim

If you change your mind

Hospitals will send your claim straight to us and well

let you know what weve paid once its all sorted. You
dont have to do anything - too easy!

Changed your mind about your cover? No worries! Just

let us know within 30 days of joining or upgrading your
cover and youll get a full refund of any premiums paid
(as long as you havent made any claims in that time, of
course).

Doctors will usually send their medical claims straight

to us as well, but sometimes they dont. If they dont,
youll need to submit a claim to Medicare first (using a
Medicare claim form and Medicare 2-Way claim form),
and theyll send your claim to us once theyve done
their bit. Again, well let you know what weve paid
once its all sorted.

Your Privacy
Were 100% committed to the Privacy Act and
Australian Privacy Principles, which means we only
collect the information we need to give you access
to health services. We wont collect any personal
information unless weve asked first, and we protect the
information we do have with everything weve got.

Making an extras claim

Claiming couldnt be easier! The choice is yours:

Want more info? You can read our full Privacy Policy at
peoplecare.com.au/privacy.

HICAPS just swipe your membership card at

participating providers and well pay your benefits
straight to the provider. Youll only have to pay the
difference between what they charge and our
benefit, and you wont have to submit a claim form
From your phone with our quick & easy Mobile
Claiming app. Download it now from peoplecare.
com.au/mobile
Online claim for the following services using our
Online Member Services at peoplecare.com.au/oms:
Dental

Podiatry

Chiro

Optical

Osteo

Occupational therapy

Love your thoughts

At Peoplecare, its all about you. We love happy
members, and if youre not happy we want to hear
about it so we can make things even better.
If you have any problems with your cover, give us a buzz
on 1800 808 690. Most of the time we can sort things
out on the spot, but you can always ask to speak to a
manager or our CEO if youd prefer. If youd rather write
to us, you can email info@peoplecare.com.au or write
to Locked Bag 33, Wollongong NSW 2500.

Physio

If youre still not happy after contacting us, you can

contact the Private Health Insurance Ombudsman
(PHIO). PHIO is free, independent and protects the rights
of private health fund members. You can call PHIO on
1800 640 695, email info@phio.org.au or visit them at
Level 22, 580 George Street, Sydney NSW 2000. For more
information, visit their website phio.org.au.

Email scan and email your completed claim form

and the receipts for your service to
info@peoplecare.com.au.
Post send a completed claim form and the receipts
for your service to Locked Bag 33, Wollongong NSW
2500

To get a copy of our full complaints policy, go to

peoplecare.com.au or contact us and well send you a
copy.

Online Member Services

Love having access to your membership 24/7? Then our
Online Member Services is for you.
Here is what you can do in Online Member Services
wherever and whenever you like:
View & update your membership details
Check how much of your Extras limits youve used
View your claims history
Make a membership payment by credit card
Find a registered healthcare provider
View & print your annual Tax Statement to get a headstart on your tax
And more! Registering is quick and easy, so sign up
today at peoplecare.com.au/oms.

For the most up-to-date info, visit peoplecare.com.au.

Please read this document carefully and keep it for future reference.

1800 808 690

info@peoplecare.com.au
peoplecare.com.au

Lysaght Peoplecare Limited. A registered private health insurer. ABN 95 087 648 753