 Full costs at non-participating private hospitals
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If you choose to be treated at a private hospital that is not in our Participating Private Hospital network, you may incur out-of-pocket expenses. To get the most value from your cover, we recommend you use a Participating Hospital.
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During a Waiting Period
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A waiting period starts from the date you join. During a waiting period you are not covered and will not receive any benefits for the types of treatment affected by the waiting period. Once the waiting period is over, you will receive the full benefits listed under your level of cover for that treatment type. All hospital covers have 12 month waiting periods for pre-existing conditions and pregnancy (childbirth), where applicable.
If you transfer to Mutual Community from another health fund on an equivalent level of cover we will honour all the waiting periods you have already served when we receive confirmation of your previous membership and level of cover, but you will need to join within one month of leaving the other fund.
When you upgrade to a higher level of cover, the benefits from your previous level of cover apply during waiting periods.
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Restricted Benefits
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If a service is covered as a Restricted Benefit, this means you will be covered with your choice of doctor for shared room accommodation in a public hospital only. If you go to a private hospital for a specific service which has Restricted Benefits, it is likely to result in large out-of-pocket expenses. Restricted Benefits are an amount set by the Government and are generally not enough to cover accommodation costs in a private hospital.
All hospital covers for Australian residents have Restricted Benefits for cosmetic surgery, sterilisation reversal, surgical podiatry and all services that do not attract a Medicare benefit. Some hospital covers give Restricted Benefits for specific services for the duration of that cover. If Restricted Benefits apply for other treatments under this level of cover, they will be listed below.
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Exclusions
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Some covers exclude specific services. This means you will not be covered for that specified service or treatment whilst on that level of cover. Mutual Community only pays for services that Medicare covers. Medicare does not cover some health screening services and services that are not medically necessary.
For the duration of your cover, you will not receive cover for:
- Any treatment outside of Australia
- Assisted reproductive services (including IVF)
- Cataracts
- Heart and artery
- Hip and knee replacement
- Laser eye correction surgery
- Pregnancy
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Services and situations not covered by health funds
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There are some hospital services that are generally not covered under a health fund's hospital cover:
- If you are not admitted to hospital (including emergency room treatment) you are considered an outpatient and you will not be covered.
- A person who has been in hospital for more than 35 days and is classified as a nursing home type patient (as defined in the Health Insurance Act) may receive limited benefits. In such cases patients are required by law to make a personal contribution towards their care.
- Medical expenses for surgical procedures performed in hospital by a dentist, surgical podiatrist or any other practitioner that is not eligible for the Medicare rebate, such as sterilisation reversal and cosmetic surgery.
- Benefits are not payable for pharmaceuticals supplied on discharge from hospital, unless covered under your extras benefits.
- Mutual Community benefits are not payable where compensation, damages or benefits may be claimed from another source (eg. Workers's Compensation, Compulsory Third Party Insurance, Common Law Damages, Government Programs/Agencies, Travel Insurance, Sports Insurance etc) in relation to a condition, injury or ailment. Mutual Community reserves the right to recover any benefits paid in this regard.
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