AUSTRALIAN UNITY HEALTH LIMITED FUND RULES

Transcription

1 AUSTRALIAN UNITY HEALTH LIMITED FUND RULES All Registered Health Insurers are required to have Fund Rules under the Private Health Insurance Legislation. These Fund Rules set out the general principles and rules of membership under which the Company conducts its business. IMPORTANT NOTES Before taking out private health insurance with the Company, you and all other persons to be covered on your Membership with the Company must read these Fund Rules. By taking out private health insurance with the Company, you and all the other persons on your Membership become Members of our Fund and agree to our Fund Rules as amended from time to time. We recommend that these Fund Rules be read together with your Product Fact Sheet, member guide, and the terms and conditions. Where terms are capitalised in these Fund Rules, they have the meaning given to them as determined in Section B of these Fund Rules. Australian Unity Health Limited ABN Albert Road, South Melbourne VIC 3205 Call australianunity.com.au

2 Contents A INTRODUCTION... 6 A1 Rules Arrangement... 6 A.1.1 The Fund Rules... 6 A.1.2 Application of the Fund Rules... 6 A.1.3 Order of Precedence... 6 A2 Health Benefits Fund... 6 A.2.1 Establishment and operation of the Fund... 6 A.2.2 Object of the Fund... 6 A.2.3 Entitlement to Benefits... 6 A.2.4 No entitlement to reserves or surplus of Fund... 7 A.2.5 Fund Policies... 7 A3 Obligations to Insurer... 7 A.3.1 Members bound to Fund Rules... 7 A.3.2 Acceptance of Fund Rules... 7 A4 Governing Principles... 7 A5 Use of Funds... 7 A.5.1 Fund assets to be kept distinct and separate... 7 A.5.2 Applying or dealing with assets of the Fund... 8 A6 No Improper Discrimination... 8 A7 Changes to Rules... 9 A.7.1 The Company may amend these Fund Rules... 9 A.7.2 Overriding Waiver... 9 A.7.3 The Company to provide Contributors notice of change... 9 A8 Dispute Resolution... 9 A.8.1 Internal Dispute Resolution process... 9 A.8.2 Private Health Insurance Ombudsman... 9 A9 Notices A.9.1 Service of notices A.9.2 Standard Information Statements A.9.3 Contributor to inform the Company of changes A.9.4 Availability of Fund Rules to Members A10 Winding Up A11 Other B INTERPRETATION AND DEFINITIONS...11 B1 Interpretation B2 Definitions B3 Other C MEMBERSHIP...22 C1 General Conditions of Membership C.1.1 Membership Categories C.1.2 Types of Products C.1.3 Product availability C.1.4 Rights of Contributors C.1.5 Rights of Contributor's Partner and Dependants C.1.6 Delegated Authority

3 C.1.7 Restriction of outside coverage C.1.8 Dual Membership C.1.9 Eligibility for Benefits C2 Eligibility for Membership C.2.1 Eligibility C.2.2 Minimum Age of Contributor C.2.3 State of Residence C3 Dependants C.3.1 Types of Dependants C.3.2 Registration of Dependants and Contributor's Partner C.3.3 Rights of Dependants and the Contributor's Partner C.3.4 Continuity of cover - former Student and Child Dependants C.3.5 Continuity of cover - former Contributor s Partner C4 Membership Applications C.4.1 Application for Membership C.4.2 Obligations of person applying for Membership C.4.3 New-born Child C.4.4 Right to reject application C.4.5 Cooling Off Period C.4.6 Reinstatement of a terminated Membership C5 Duration of Membership C.5.1 Commencement Date C.5.2 Duration of Membership C.5.3 Change of Policy C6 Transfers C.6.1 Transfers - Australian Registered Health Insurers C.6.2 Transfers - Australian Registered Health Insurers when no Waiting Periods apply 28 C.6.3 Transfers - Australian Registered Health Insurers when Waiting Periods apply. 28 C.6.4 Requirement of Transfer Certificate C.6.5 Transfers between Products within the Fund C.6.6 Benefits paid under Old Product to be taken into account C.6.7 Transfers under Suspension C.6.8 Transfers from Overseas Visitor Products C.6.9 Changes in Contributor C7 Cancellation of Membership C.7.1 Cancellation by Contributor C.7.2 Refund of Contributions paid in advance C.7.3 Issue of Transfer Certificates C8 Termination of Membership C.8.1 Termination of Memberships in Arrears C.8.2 Cancellation by the Company C.8.3 Retained rights C.8.4 Special Consideration C9 Temporary Suspension of Membership C.9.1 Application for suspension

4 C.9.2 Overseas suspension of Membership C.9.3 Financial Hardship suspension of Membership C.9.4 Member to provide information C.9.5 Acceptance of application at the Company s discretion C.9.6 Effect of Suspension C.9.7 Resumption of Membership C10 Other D CONTRIBUTIONS...35 D1 Payment of Contributions D.1.1 Determining Contribution rates D.1.2 Period for which Contributions can be made D.1.3 Group deductions D2 Contribution Rate Changes D3 Contribution Discounts D.3.1 Contribution Discounts D.3.2 Discount not to exceed prescribed maximum D.3.3 Contribution Groups D4 Lifetime Health Cover D.4.1 Application of lifetime health cover provisions D years continuous cover D5 Arrears in Contributions D.5.1 Continuation of cover following Arrears D.5.2 Termination of a Membership in Arrears D.5.3 Treatment where Contributions are in Arrears D6 Other E BENEFITS...37 E1 General Conditions E.1.1 Payment of benefits E.1.2 Benefits not to exceed charges E.1.3 When Benefits are not payable E.1.4 Recovery of Benefits E.1.5 Treatment standard requirements E2 Hospital Treatment E.2.1 Hospital Treatment benefits E.2.2 Calculation of Benefits E.2.3 Benefits for Cosmetic and Surgical Podiatry Procedures E.2.4 Purchaser Provider Agreements E.2.5 Non-agreement Hospitals E.2.6 In-hospital pharmacy benefits E.2.7 Accident Cover E.2.8 Medical Gap Cover E.2.9 Miscellaneous matters E3 General Treatment E.3.1 When Benefits are payable E.3.2 Determination of Benefits E.3.3 Emergency Ambulance Transportation E.3.4 Purchaser Provider Agreements - General Treatment

5 E4 Other E.4.1 Chronic Disease Management and hospital substitution programs E.4.2 Preventative Health Benefits F LIMITATION OF BENEFITS...47 F1 Co Payments F2 Excesses F.2.1 Products with Excesses F.2.2 Application of Excesses F3 Waiting Periods F.3.1 Waiting periods to apply F.3.2 Hospital Treatment Waiting Periods F.3.3 General Treatment Waiting Period F.3.4 No Waiting Period applies to Accident related services and Emergency Ambulance 49 F.3.5 No Waiting Period applies to Gold Card Holders F.3.6 Waiver of Waiting Periods F.3.7 Waiting Periods New-borns and Dependants F.3.8 Obstetrics - Confinement F4 Exclusions F5 (Not Used) F6 Restricted Benefits F7 Compensation Damages and Provisional Payment of Claims F.7.1 Where benefits shall not be payable F.7.2 Where Benefits may be available F.7.3 Irrevocable Undertaking F.7.4 Non-compliance with Irrevocable Undertaking F.7.5 Member Obligations F8 Other F.8.1 Lifetime Limits F.8.2 Benefits Not Payable for an Epidemic F 8.3 Limitations of General Treatment Benefits F.8.4 Services Rendered by a Government Body G CLAIMS...53 G1 General G1.1 How claims may be made G1.2 Evidence in support of claim G1.3 Appointment of Medical Practitioner G1.4 Assessment of a claim G1.5 Claim lodgement G1.6 Payment of claims G1.7 Member must nominate account for Benefit crediting purposes G2 Other

6 A INTRODUCTION A1 Rules Arrangement A.1.1 The Fund Rules These Fund Rules consist of: A.1.2 a) the General Conditions; and b) the Schedules. Application of the Fund Rules These Fund Rules apply to all Products and govern the rights and obligations of Members and the Company in relation to the Fund. A.1.3 Order of Precedence In the event of any inconsistency between the General Conditions, any provision in the Schedules and/ or the Constitution, then such inconsistency shall be resolved and prevail in the following order of precedence: a) the Constitution; b) the General Conditions; and c) the Schedules. A copy of the Fund Rules (General Conditions) and Constitution are available at australianunity.com.au/importantdocuments. A copy of the Schedules can be made available by contacting Australian Unity on A2 Health Benefits Fund A.2.1 Establishment and operation of the Fund The Company is a for-profit organisation incorporated under the Corporations Act 2001 (Cth) and has established the Fund in accordance with the Private Health Insurance Legislation. A.2.2 Object of the Fund The object of the Fund is to provide financial assistance to Members towards the cost of Hospital Treatment and / or Hospital-Substitute Treatment and /or General Treatment in accordance with the Private Health Insurance Legislation and these Fund Rules. A.2.3 Entitlement to Benefits A Member will be entitled to Benefits and rights provided under the Member s Membership provided that the Membership is not in Arrears. 6

7 A.2.4 No entitlement to reserves or surplus of Fund Subject to Fund Rule A.10 a Member is not entitled to share in any reserves or surplus of the Fund. A.2.5 Fund Policies Where required, the Company will supplement these Fund Rules with Fund Policies that will not be inconsistent with these Fund Rules. All Members are bound by the Fund Policies. A3 Obligations to Insurer A.3.1 Members bound to Fund Rules Members of the Fund shall be bound by these Fund Rules and Fund Policies, which the Company may amend from time to time in accordance with Fund Rule A7. A.3.2 Acceptance of Fund Rules An application to become a Member shall constitute an acceptance by the Member of all terms and conditions in these Fund Rules. A4 Governing Principles In addition to these Fund Rules, the rights and obligations of Members and the Company will be governed by: a) the Private Health Insurance Legislation including subordinate legislation; b) the Health Insurance Act and the National Health Act 1953 (Cth); c) the Australian Consumer Law; d) any conditions imposed or any directions made by the Minister for Health under the Private Health Insurance Legislation; e) the rules of the Australian Government s Department of Health or its successor, as they apply to Registered Health Insurers; f) the rules of the Australian Prudential Regulation Authority or its successor; and g) the Constitution. A5 Use of Funds A.5.1 Fund assets to be kept distinct and separate The Company must keep the assets of the Fund distinct and separate from assets of its other health benefits funds (if any) and from all other money, assets or investments of the Company. 7

8 A.5.2 Applying or dealing with assets of the Fund The Company must not apply, or deal with, assets of the Fund, whether directly or indirectly, except in accordance with the Private Health Insurance Legislation. The Company must credit the following amounts in respect of the Fund, to the Fund: a) Contributions payable under policies of insurance that are referable to the Fund; b) income from the investment of assets of the Fund; c) money paid to the Company under a judgment of a court relating to any matter concerning the business of the Fund; d) any other money received by the Company in connection with its conduct of the business of the Fund; and e) any other amounts that the Private Health Insurance Legislation specify. Payments from the Fund may not be made for any purpose other than to; a) meet the Membership liabilities in accordance with these Fund Rules; b) meet other liabilities or expenses incurred for the purposes of the business of the Fund; and c) make distributions, investments and for any other purpose allowed under the Private Health Insurance Legislation. A6 No Improper Discrimination When operating the Fund and making decisions in relation to persons applying for Membership or Members, the Company will not have regard to the following matters: a) the suffering by the person from a chronic disease, illness or other medical condition or from a disease, illness or medical condition of a particular kind; or b) the gender, race, sexual orientation or religious belief of a person; or c) the age of a person, except in relation to the calculation of lifetime health cover loading; or d) where a person lives, except in relation to different risk equalisation jurisdictions; or e) any other characteristic of a person (including, but not just, matters such as occupation or leisure pursuits) that is likely to result in an increased need for Hospital Treatment or General Treatment; or f) the frequency with which the person needs Hospital Treatment or General Treatment; or g) the amount or extent of the Benefit to which the person becomes entitled during a period under his or her Membership, except to the extent allowed under the Private Health Insurance Legislation; or h) any other matter set out in the Private Health Insurance Legislation as being improper discrimination. 8

9 A7 Changes to Rules A.7.1 The Company may amend these Fund Rules The Company may delete, add to or amend these Fund Rules at any time in a manner consistent with the Private Health Insurance Legislation and any other law. A.7.2 Overriding Waiver The Company may under specified circumstances waive the application of a Fund Rule, in its discretion, provided that such a waiver does not reduce a Member s entitlement to Benefits. The waiver of a particular Fund Rule in a given circumstance does not suggest that the Company will, or require the Company to, waive the application of that Fund Rule in any other circumstance including where a circumstance similar to the given circumstance arises again. A.7.3 The Company to provide Contributors notice of change The Company will notify Contributors prior to any amendments to these Fund Rules under Fund Rule A.7.1, in the time and manner required by the Private Health Insurance Legislation, the Code and in accordance with the Australian Consumer Law. If the Private Health Insurance Legislation, the Code or the Australian Consumer Law does not prescribe applicable notice requirements, then the Company will provide reasonable notice to Contributors of any amendment to the Fund Rules: a) which makes a change that is or might be detrimental to the interests of a Member on the Membership; b) which increases the Contribution payable (excluding rounding adjustments); or c) that relates to keeping the rights of Members current. Where a Member became entitled to receive a Benefit at a time when a previous Fund Rule applied, the Benefit specified in that earlier Fund Rule will be payable. A8 Dispute Resolution A.8.1 Internal Dispute Resolution process A Member may at any time make a complaint to the Company in connection with the Fund or any matter relating to a Contributor s Membership or Product. Such complaints may be made orally or in writing by the Member. The Company will use reasonable endeavours to respond to the complaint quickly and efficiently and in accordance with its internal dispute resolution process. A.8.2 Private Health Insurance Ombudsman A Member may contact the Private Health Insurance Ombudsman at any time in relation to any issue with the Fund and nothing in these Fund Rules restricts such contact. 9

10 A9 Notices A.9.1 Service of notices Any notice required to be provided by the Company to a Contributor under these Fund Rules (Notice), unless otherwise prescribed by the Private Health Insurance Legislation, will be: A.9.2 a) in writing, explaining in plain English; b) delivered to the address (including any electronic address) last nominated by the Member to the Company; and c) an obligation by the Contributor to inform members within that membership of change and shall notify any adult insured under that Product of the change within a reasonable period. Standard Information Statements In accordance with the Private Health Insurance Legislation the Company will make available up to date Standard Information Statements: A.9.3 a) to all persons on request; b) to the Contributor of every Membership that is commenced with the Company, along with details of what the Membership covers and how Benefits under it will be paid, and a statement identifying that the Membership is referable to the Fund operated by the Company; c) to the Contributor of every Membership when a change to the Fund Rules that is or might be detrimental to the interests of a Member requires an update to the Standard Information Statement for that Member s Product; d) to the Contributor of every Membership at least every 12 months; and e) to the Contributor of every Membership that is transferred from another Product or Registered Health Insurer. Contributor to inform the Company of changes A Contributor must inform the Company as soon as reasonably possible after a change of address of any Member under the Membership. A.9.4 Availability of Fund Rules to Members These Fund Rules (General Conditions) are available on the Company s website at australianunity.com.au/importantdocuments. The Schedules can be made available by contacting Australian Unity on

11 A10 Winding Up Where the Fund ceases to be registered under the Private Health Insurance Legislation: a) the Fund will be wound up according to the requirements of the Private Health Insurance Legislation; and b) any credits or outstanding liabilities of the Fund shall be utilised as determined by the Board of Directors of the Company, in accordance with the Constitution and the Private Health Insurance Legislation. A11 Other By making an application to become a Member of the Fund, the Contributor may be eligible or may become eligible to become a member of Australian Unity Limited ACN ( AUL ) as determined by the AUL Constitution and, by doing so, the Contributor will be subject to the rules as set out in the AUL Constitution. A copy of the AUL Constitution is available on the Company s website at australianunity.com.au/importantdocuments. B INTERPRETATION AND DEFINITIONS B1 Interpretation In these Fund Rules, except where the context otherwise requires: a) the singular includes the plural and vice versa, and a gender includes other genders; b) another grammatical form of a defined word or expression has a corresponding meaning; c) a reference to A$, $A, dollar or $ is to Australian currency; d) a reference to a party includes the party's executors, administrators, successors and permitted assigns and substitutes; e) a reference to a statute, ordinance, code or other law includes regulations and other instruments under it and consolidations, amendments, re-enactments or replacements of any of them; f) a reference to a State includes a reference to a Territory; g) any part of these Fund Rules that may become illegal or unenforceable will be severed and interpreted in order to maintain the integrity of the Fund Rules as a whole; h) unless defined in Fund Rule B2, capitalised terms have the understanding to be reasonably understood by the private health insurance industry or Private Health Insurance Legislation as applicable; i) a reference to a Member receiving Compensation includes: i. Compensation paid to another person at the direction of the Member; and ii. Compensation paid to another Member on the same Membership in connection with a treatment, good or service received by the Member. 11

12 These Fund Rules are to be interpreted as far as possible in a manner that is consistent with the Private Health Insurance Legislation. B2 Definitions Accident means an unplanned and unforeseen event, occurring by chance, and leading to bodily injuries caused solely and directly by an external force or object requiring treatment from a Medical Practitioner (defined here as a medical doctor who is not the member or a relative of the Member) within 7 days of the event, but excludes injuries arising out of: surgical procedures; unforeseen illness; pregnancy; drug use; and aggravation of an underlying condition or injury; Accredited Podiatrist means, for the purpose of Hospital Treatment, an Approved Commonwealth Accredited Podiatrist under the Health Insurance Act; Acute Care means the provision of treatment for an ailment or disability which cannot be provided by a nursing home; Acute Care Certificate means a form required to be completed by a Medical Practitioner for a Hospital stay of over 35 continuous days to verify the type of patient as needing Acute Care; Admitted Patient means a person who meets a certain medical criteria and undergoes a Hospital s formal admission process as either an Overnight Stay patient or a Same Day patient to receive a service under the required Episode of care; Agreement Hospital means a private Hospital that has entered into a Hospital Purchaser Provider Agreement (HPPA) with the Company; Ancillary Schedule means a General Treatment Policy document, used by the Company, detailing claims assessment rules, Product benefits and claim eligibility criteria; Approved in respect of a person, Medical Practitioner, organisation, Hospital, facility, treatment or procedure, means a person, Medical Practitioner, organisation, Hospital, facility, treatment or procedure which has been recognised or Approved by the Company for the purpose only of payment of Benefits and includes a Recognised Provider; Arrears means, in respect of a Membership, where the Contributor fails to pay in full all Contributions due to be paid by him or her on or before the due date; Artificial Aids/Appliances means any health aid or device designed to assist a Member s medical condition as Approved by the Company, excluding Prostheses; 12

13 Banding System means the methodology used to categorise Hospital procedures including for the application of accommodation and theatre charges; Base Rate means the base rate of Contribution in relation to a Product set by the Company that would be payable if: a) the Contribution amount were not increased under Fund Rule D4; and b) there was no discount of the kind allowed under subsection 66-5(2) of the Private Health Insurance Act 2007; Benefit means an amount of money or service that may be provided to a Member, or on behalf of or for the benefit of a Member to a Recognised Provider, Medical Practitioner or Hospital by the Fund, in accordance with the terms of a Product and these Fund Rules; Benefit Replacement Period means a continuous period of time that must occur between any two purchases of the same type of Artificial Aid/Appliance item before Benefits are payable; Calendar Year means the twelve month period commencing 1st January and finishing 31st December of the same year; Child Dependant in respect of a Membership means a dependent child, legally adopted child or stepchild of the Contributor or of the Contributor s Partner who has not attained the age of 23 years and is not married or living in a De Facto Relationship; Chronic Disease Management Program has the same meaning within the Private Health Insurance Legislation; Clinically Relevant means an appropriate course of treatment such as a procedure or service that is performed or rendered by a Medical Practitioner or Recognised Provider that is generally accepted within the relevant profession; Code means the Private Healthcare Australia (PHA) Private Health Insurance Code of Conduct, as amended or replaced from time to time; Combined Hospital and General Treatment Product means a Product referred to in the Schedules that provides Benefits towards all or some services defined as General Treatment and as Hospital Treatment through a single Product; Commencement Date means the effective date of a Member s coverage under a Product as set out in Fund Rule C5.1; Community means a group of people who meet the relevant criteria set out in a Community Arrangement; 13

14 Community Arrangement means an arrangement between the Company and an organisation regarding the provision of Community Products to persons who are members of, or otherwise associated with, the organisation and meet the criteria described in the arrangement; Community Product means a Product set out in Schedules J and I 35 38; Company means Australian Unity Health Limited (ACN ) the registered office of which is Level 14, 114 Albert Road, South Melbourne 3205 in the State of Victoria; Compensation means any of the following: a) a payment of compensation or damages pursuant to a judgment, award or settlement; b) a payment in accordance with a scheme of insurance or compensation provided for by Commonwealth or State law (for example, workers compensation insurance); c) settlement of a claim for damages (with or without admission of liability); d) a payment for negligence; or e) any other payment that, in the opinion of the Company, is a payment in the nature of compensation or damages; Continuous Hospitalisation means where an Admitted Patient has an Overnight Stay, is then discharged and within seven (7) days is admitted to the same or different Hospital for the same or related condition; Constitution means the constitution of the Company; Contribution means the amount payable by an individual Contributor in respect of the Product referable to his or her Membership; Contribution Group means a group of Contributors Approved by the Company for the purpose set out in Fund Rule D.3.3; Contributor means the person in whose name an application for Membership has been accepted and who is responsible for Contribution payments; Contributor's Partner means a legally married spouse of, or a person in a De Facto Relationship with, the Contributor; Co-payment means a daily amount of money the Contributor agrees to pay the Hospital for a Hospital stay for a Member before Benefits are payable under the relevant Hospital Treatment Product or Combined Hospital and General Treatment Product for that Hospital stay; Cosmetic Procedures means any surgery, treatment or other procedures which are not allocated an item within the Medicare Benefits Schedule issued by the Medical Services Advisory Committee; 14

15 Couples Membership has the meaning given to that term in Fund Rule C.1.1; Couples Rate means the rate of Contribution to a Couples Membership as set out in the Schedules; Day Hospital refers to a Hospital that does not provide overnight accommodation; De Facto Relationship means a relationship between two people who are: a) not legally married, but live together as a couple in a marriage type relationship; and b) are otherwise as determined by relevant laws to be living in a de facto relationship; Dependant means a Child Dependant or Student Dependant; Dental Schedule means a General Treatment Policy document, used by the Company, detailing Australian Dental Association's glossary of treatment codes, the associated Benefit payable and claim eligibility criteria; Emergency Ambulance Transportation means ambulance transportation where the ambulance provider codes and invoices the transportation as an emergency. Benefits are not payable for ambulance transportation that is invoiced by the ambulance provider as non-emergency patient transport; Emergency Ambulance Attendance means the arrival of an Ambulance and attendance and treatment by a paramedic of a patient, where the condition is stable enough that transportation to Hospital is not required; Emergency Hospitalisation means hospitalisation (excluding emergency department) which occurs as a result of a person presenting at a Hospital with or under at least one of the following conditions or circumstances: Significant pain; Shock; Significant infection; Acute trauma; Abuse; Committable mental illness; Significant haemorrhage or threat of haemorrhage; Vital sign or mental status change; Brought to Hospital by police; or Brought to Hospital by ambulance; Episode is the period of care between an admission and separation such as discharge, characterised by only one care type; 15

16 Excess is an amount of money the Contributor agrees to pay the Hospital towards the accommodation costs of a Hospital admission before Benefits are payable under the terms of a Hospital Treatment Product or Combined Hospital and General Treatment Product; Excluded Treatment refers to treatment under a Hospital Treatment Product or Combined Hospital and General Treatment Product for which Benefits are not payable; Fact Sheet means an summary of material information applicable to a particular Product issued by the Company to Members, but is not an exhaustive statement of the Product s terms and conditions; Family Membership has the meaning given to that term in Fund Rule C.1.1; Family Rate means the rate of Contribution to a Family Membership as set out in the Schedules; Flexi-Limit means Benefits that can be allocated between included services specified in the relevant Product Schedule up to a limit. Some sub-limits may apply, within that limit, to some categories of included services; Fulltime Study means undertaking: a) a course of education at a secondary school or tertiary institution, a trade apprenticeship or an industry, employer or government training scheme, which is accredited by a State or Federal Government, provided that the course of study results upon completion in the Student Dependant being qualified to seek or maintain gainful employment in the general workforce and that the Dependant is not, or will not remain, dependent upon the Contributor for personal care, domestic or social support after having attended the course of study; and b) at least three quarters of the normal full-time workload of such course or otherwise deemed by the Company as being full time study; Fund means the health benefits fund established and operated by the Company in accordance with the Private Health Insurance Legislation; Fund Policies means a collection of Policy documents relating to the operation of the Fund by the Company which supplements these Fund Rules; Fund Rules means these rules relating to the operation of the Fund by the Company; Gap Benefits refers to the amount of money payable above the Medicare Benefits Schedule payments pursuant to a Medical Purchaser-Provider Agreement (MPPA), Hospital Purchaser- Provider Agreement or Approved scheme; 16

17 Gap Cover means an arrangement where a Medical Practitioner agrees to participate in a scheme with the Company that covers Members in excess of the Medicare Benefits Schedule for: a) all but a specified amount of the full cost of inpatient medical treatments; or b) the full cost of inpatient medical treatments; General Conditions means Fund Rules A to G of these Fund Rules; General Treatment means treatment (including the provision of goods and services) that is intended to manage or prevent a disease, injury or condition that is not Hospital Treatment. General Treatment includes Hospital-Substitute Treatment; Health Insurance Act means the Health Insurance Act 1973 (Cth); Health Insurance Business means the business of providing insurance that relates to Hospital Treatment or General Treatment; Health Management Program has the same meaning ascribed to that term in the Private Health Insurance Legislation; Home Nursing see Hospital Care at Home; Hospital has the same meaning ascribed to that term under the Private Health Insurance Legislation and includes a Day Hospital; Hospital Benefit means any benefit in respect of any Hospital as set out in the relevant Schedule; Hospital Care At Home means a Hospital-Substitute Treatment program and can include an early discharge or substitution from an acute Hospital care program. Members in consultation with their Medical Practitioner may choose to utilise these services to reduce or avoid acute Hospital accommodation or recovery as described in the Schedules; Hospital Purchaser-Provider Agreement (HPPA) means an agreement entered into between the Company and a Hospital and as amended from time to time; Hospital-Substitute Treatment is treatment that substitutes for an Episode of Hospital Treatment and is any of, or any combination of, nursing, medical, surgical, podiatric surgical, diagnostic, therapeutic, prosthetic, pharmacological, pathology or other services or goods intended to manage a disease, injury or condition; Hospital Treatment is treatment (including the provision of goods and services) that: a) is intended to manage a disease, injury or condition; and 17

18 b) is provided to a person: i. by a person who is authorised by a Hospital to provide the treatment; or ii. under the management or control of such a person; and c) either: i. is provided at a Hospital; or ii. is provided, or arranged, with the direct involvement of a Hospital; and includes any other treatment, or treatment included in a class of treatments, specified in the Private Health Insurance Legislation as "hospital treatment"; Hospital Treatment Product means a Product referred to in the Schedules which include Benefits towards services that constitute Hospital Treatment only; Last Day of the Suspension Period means the day on which a suspended Membership shall cease to be suspended for the purposes of calculating Contribution owing; Lifetime Health Cover Age means, in relation to an adult who takes out hospital cover after his or her Lifetime Health Cover Base Day, the adult s age on the 1 July before the day on which the adult took out the hospital cover; Lifetime Health Cover Base Day has the meaning ascribed to it under section of the Private Health Insurance Act 2007 (Cth); Loyalty Limit means a yearly Benefit amount for a service that may increase in a Calendar Year with continuous Membership as set out in the relevant Product Schedule for an eligible General Treatment Product, and is not transferrable between Products; Medical Practitioner means a person as defined in section 3(1) of the Health Insurance Act and as amended from time to time; Medical Purchaser-Provider Agreement (MPPA) means an agreement entered into, between the Company and a Medical Practitioner, as described under section (1) of the Private Health Insurance Act 2007 and as amended from time to time; Medicare Benefits Schedule means the 'Medicare Benefits Schedule Book' published by the Department of Health and includes any updates to the Schedule published from time to time; Member means a Contributor, Contributor's Partner or a Dependant; Membership means the collection of rights and obligations that apply to Members under these Fund Rules arising out of the purchase of a Product; Minimum (default) Benefit means for the purpose of Hospital Treatment the minimum benefits payable by the Company as required in the Private Health Insurance Legislation; 18

19 New Product has the meaning given to that term in Fund Rule C.6.1; Non-Agreement Hospital means a Hospital either public or private that does not have a Hospital Purchaser-Provider Agreement with the Company; Non-Surgical Prosthesis in respect of General Treatment benefits means any external appliance or device Approved by the Company that is associated with the physical replacement of some part of the human body such as a limb, eye or wig; Nursing Home Type Patient (NHTP) has the same meaning as in subsection 3(1) of the Health Insurance Act; Old Product has the meaning given to that term in Fund Rule C.6.1; Overnight Stay means a period of time in a Hospital that spans both daylight hours and midnight; Overseas Visitor Product means a Product that offers hospital and medical insurance to people who are not citizens of Australia and, or are not eligible to full Medicare entitlements; Palliative Care in respect of Hospital Treatment means Hospital care provided to a patient where the patient s condition has progressed beyond the stage where curative treatment is effective and attainable or, where the patient chooses not to pursue curative treatment. Palliative care provides relief of suffering and enhancement of quality of life. Interventions such as radiotherapy, chemotherapy, and surgery are considered part of the palliative care if they are undertaken specifically to provide symptomatic relief; Permitted Days refers to time where a person does not incur any lifetime health cover penalty due to not being covered by a Policy that covers Hospital Treatment; Pharmaceutical means any medicine listed in the Pharmaceutical Benefits Schedule that is dispensed to the Member; Pharmaceutical Benefits Schedule or PBS means the "Schedule of Pharmaceutical Benefits" published by the Department of Health; Policy means an insurance policy that covers Hospital Treatment or General Treatment or both (whether or not it also covers any other treatment or provides a Benefit for anything else); Pre-existing Condition (PEC) means any illness, ailment, or condition of a Member, the signs or symptoms of which were known or which a Medical Practitioner appointed by the Company considers after examining information furnished by the Member's practitioner, and other material relevant to a claim for Benefits, were in existence at any time during the six month 19

20 period ending on the day on which the person became insured, irrespective of whether the Member was aware of the pre-existing illness, ailment, or condition; Private Health Insurance Legislation means the Private Health Insurance Act 2007 (Cth), Private Health Insurance (Prudential Supervision) Act 2015 (Cth) and their regulations, rules and other instruments under them and consolidations, amendments, re-enactments or replacements of any of them, and other related laws; Private Practice means a professional practice (whether sole, partnership or group) that operates on an independent and self-supporting basis. This means that its accommodation, facilities and/or services are not provided or subsidised by another party such as a public Hospital or publicly funded facility; Private Room means in relation to a Hospital patient a room in which a person occupies the sole bed in the room but does not include a room normally fitted and furnished for multiple occupancy but occupied by one person; Product means a collection of insurance policies issued by the Company: a) that cover the same treatments; and b) that provide Benefits that are worked out in the same manner; and c) whose other terms and conditions are the same as each other; Proper Officer means a senior manager of the Fund authorised to make operational decisions on behalf of the Company and in line with these Fund Rules who is appointed by the Company from time to time and includes any delegate appointed by the Proper Officer to act on his or her behalf under these Fund Rules; Prosthesis means a Surgical Prosthesis or a Non-Surgical Prosthesis; Recognised Provider means a provider of General Treatment (whether the provider is an individual or an organisation) who: a) is Approved and registered by the Company as a provider of relevant treatment, goods or services; b) holds all necessary registrations, licences or approvals under relevant State legislation to render the relevant treatment, goods or services including in relation to the premises from which the treatment, goods or services are to be, or are being, provided; and c) complies with all other requirements of the Private Health Insurance (Accreditation) Rules; Registered Health Insurer means an organisation that is permitted to provide, or is registered as a provider of, private health insurance in Australia under the Private Health Insurance Legislation; 20

21 Restricted Benefit means the Minimum (default) Benefit that applies to a service or treatment under a Hospital product either: a) for a specified time period as determined by the Fund; or b) continuously for the life of the Product; Same Day means a period of time in a Hospital that is not an Overnight Stay (i.e., that does not span midnight); Schedules mean Fund Rules I to M of these Fund Rules; Single Parent Membership has the meaning given to that term in Fund Rule C.1.1; Singles Membership has the meaning given to that term in Fund Rule C.1.1; Single Rate means the rate of Contribution to a Singles Membership as set out in the Schedules; Special Consideration means the process specified in Fund Rule C8.4; Standard Information Statement means a brief summary of the key features of a Product that contains the information, and is in the form, set out in the Private Health Insurance (Complying Product) Rules; Student Dependant in respect of a Membership, is a child, legally adopted child or stepchild of the Contributor or of the Contributor s Partner, who is aged between 23 and 25 years of age, and is not married or living in a De Facto Relationship and who is dependent on the Contributor or the Contributor's Partner and is pursuing Fulltime Study; Surgical Prosthesis in respect of Hospital Treatment Benefits is any implanted item that is listed on the Australian Government s Prosthesis schedule, as Approved by the Minister under the Private Health Insurance Legislation by which the minimum payable Benefit is determined; Transfer Certificate means a certificate issued by a Registered Health Insurer detailing full health insurance cover details and claims histories of a person transferring from the fund operated by that insurer and meeting the required criteria as detailed in the Private Health Insurance Legislation; Transfer means the process in which a person joins a Product from another Product of the Fund or joins a Product offered by the Fund from another Registered Health Insurer; Waiting Period means a period during which a Member must hold continuous Membership under a particular Product before the Member has an entitlement to receive a Benefit at the level payable on that Product; 21

22 Weight Loss Goal is the amount of weight loss that the Member has agreed with the program consultant that they will endeavour to lose as a result of a Company Approved weight loss program that forms part of a Benefit under Health Management Programs; Year of Entitlement means the number of Calendar Years of Membership with the Fund, less any applicable 12 month qualifying period. B3 Other This Rule is left intentionally blank. C MEMBERSHIP C1 General Conditions of Membership C.1.1 Membership Categories The Company may offer four Membership categories of the Fund: a) Single Membership Being a Membership that consists of the Contributor only; b) Couples Membership Being a Membership that consists only of the Contributor and the Contributor s Partner; c) Single Parent Membership being a Membership that consists of the Contributor and one or more Dependants only; and d) Family Membership being a Membership that consists of the Contributor, the Contributor s Partner and one or more Dependants only. In the event that the Company does not offer a Single Parent Membership or a Couples Membership in relation to a Product, the person may apply to join a Single Membership or Family Membership. C.1.2 Types of Products A person may be admitted to the Fund as a Member following the purchase of one of these Products and otherwise complying with the applicable Fund Rules: a) a Hospital Treatment Product; b) a General Treatment Product; c) any combination of a Hospital Treatment Product and General Treatment Product allowed to be purchased concurrently in the Schedules; or d) a Combined Hospital and General Treatment Product. C.1.3 Product availability The Company may from time to time offer a Product that is only available to purchase: a) by only one or more selected Membership categories as outlined in Fund Rule C.1; b) in the case of a General Treatment Product, where a particular Hospital Treatment Product must be purchased along with the General Treatment Product; c) in the case of a Community Product, on its own or with another Community Product. 22

23 C.1.4 Rights of Contributors In relation to a Membership, provided the Contributor complies with eligibility criteria in Fund Rule C2, the Contributor may: a) submit claims on behalf of the Contributor, Contributor's Partner and Dependants on the Membership; b) request from the Company a statement of claims made by the Contributor, Contributor's Partner and/or any Dependants under the Membership, (unless the Contributor's Partner and Dependants have requested the Company to not disclose their personal claims history to the Contributor); c) request that their claims history and or any other personal information including address not be disclosed to any person, including the Contributor's Partner or Dependants under the Membership; d) change the contact/notice details on the Membership; e) change the payment method and frequency; f) register or de-register Dependants on the Membership; g) change the Product(s) referable to the Membership; h) apply to receive the Federal Government Rebate and nominate a tier in relation to the Membership; i) cease being the Contributor on the Membership by nominating the Contributor s Partner as the Contributor; j) cancel and, subject to these Fund Rules, suspend or re-instate the Membership; and k) request Contribution records of the Membership. C.1.5 Rights of Contributor's Partner and Dependants In relation to a Membership, the Contributor's Partner (if named on the Membership) or a Student Dependant may: a) pay Contributions by all methods; b) request that their claims history not be disclosed to any person, including the Contributor; c) de-register themselves from the Membership (permanently not by suspension) without the approval of the Contributor; d) make enquiries in relation to their Product specifications; and e) submit claims under the Membership. In relation to a Membership, a Child Dependant that is 16 years and over may: a) pay Contributions; b) request that their claims history not be disclosed to any person, including the Contributor; c) make enquiries in relation to their Product specifications; and d) submit claims under the Membership. 23

24 A Child Dependant who is under the age of 16 years cannot make any administrative decisions, including in relation to claims, with respect to the Membership or his or her registration under the Membership. C.1.6 Delegated Authority The Company may permit a Contributor to authorise either orally or in writing, a nominated representative to access or make changes to the Membership on behalf of the Contributor, until further notice is given. This authority will not provide the nominated representative with the authority to nominate further delegated authorities, change the level of cover or terminate the Membership on behalf of the Contributor. C.1.7 Restriction of outside coverage Unless otherwise expressly permitted by the Private Health Insurance Legislation, a person shall not be admitted as a Contributor, Contributor's Partner or Dependant or continue as a Contributor, Contributor's Partner or Dependant, to a Hospital Treatment Product or Combined Hospital and General Treatment Product if he or she is covered for Hospital Treatment under a private health insurance Policy provided by another Registered Health Insurer. C.1.8 Dual Membership a) In the Company s discretion, a Member insured under a General Treatment Product of the Fund may be insured under a concurrent General Treatment Product of the Fund. Where this dual Membership exists, portability does not apply between either Membership. b) At the absolute discretion of the Company, where a Child Dependant(s) or Student Dependant(s) of a Contributor needs to be covered under both a Contributor s Membership and the Membership of an estranged Contributor's Partner, dual Memberships of Hospital Treatment Products, Combined Hospital and General Treatment Products and General Treatment Products will be accepted, for an agreed period of time, by the Company. C.1.9 Eligibility for Benefits Unless otherwise agreed to by the Company, only persons who are registered as Members on a Membership are eligible to receive Benefits under a Membership. C2 Eligibility for Membership C.2.1 Eligibility Subject to these Fund Rules, all natural persons are eligible to become Members of the Fund. The Fund shall consist of an unlimited number of Members. 24

25 C.2.2 Minimum Age of Contributor Unless the Company otherwise determines, a person may be a Contributor at any age. In the case where the Contributor is under the age of 16 years of age however, the submission of an application for Membership must be by the legal parent/guardian who accepts all terms and conditions of Membership, including these Fund Rules, on behalf of the Contributor. C.2.3 State of Residence A Member may hold Membership for the version of the Product applicable to the Member's State of Residence. C3 Dependants C.3.1 Types of Dependants The two types of Dependants are: a) Student Dependant; and b) Child Dependant. C.3.2 Registration of Dependants and Contributor's Partner Subject to the eligibility requirements in Fund Rule C2, a Contributor may register a person as a Dependant or Contributor's Partner on a Membership by providing the personal details of the person in the form and in the manner reasonably required by the Company. Where the Membership was a Single Membership prior to a Dependant or Contributor's Partner being added, the Membership category (as described in Fund Rule C.1.1) will be amended from the date the Dependant or Contributor's Partner is added. Contributions for the Membership will be adjusted accordingly. C.3.3 Rights of Dependants and the Contributor's Partner In relation to a Membership, the rights of Dependants and the Contributor's Partner are set out in Fund Rule C.1.5. C.3.4 Continuity of cover - former Student and Child Dependants A Student Dependant or Child Dependant over the age of 16 years may transfer from a Family Membership to his or her own Product, becoming a Contributor and Member on his or her own right (Own Product) with no Waiting Periods applying to the Product, subject to the following: a) an application for cover must be received by the Fund within three months of the Dependant ceasing to be covered under the Family Membership held with the Company; b) the applicant must transfer to an own Product that offers an equivalent or lower level of benefits to that offered under the Family Membership; c) the applicant must have served all Waiting Periods that apply to the Family Membership; 25