HIF Fund Rules ACN

Transcription

1 HIF Fund Rules ACN

2 A INTRODUCTION A1 Rules Arrangement A2 Health Benefits Fund A3 Obligations to Insurer A4 Governing Principles A5 Use of Funds A6 No Improper Discrimination A7 Changes to Rules A8 Dispute Resolution A9 Notices A10 Winding Up A11 Other B INTERPRETATION AND DEFINITIONS B1 Interpretation B2 Definitions B3 Other C MEMBERSHIP C1 General Conditions of Membership C2 Eligibility for Membership C3 Dependents C4 Membership Applications C5 Duration of Membership C6 Transfers C7 Cancellation of Membership C8 Termination of Membership C9 Temporary Suspension of Membership... 58

3 C10 Other D CONTRIBUTIONS D1 Payment of Contributions D2 Contribution Rate Changes D3 Contribution Discounts D4 Lifetime Health Cover D5 Arrears in Contributions D6 Other E BENEFITS E1 General Conditions E2 Hospital Treatment E3 General Treatment E4 Other F LIMITATION OF BENEFITS F1 Co Payments F2 Excesses F3 Waiting Periods F4 Exclusions F5 Benefit Limitation Periods F6 Restricted Benefits F7 Compensation Damages and Provisional Payment of Claims F8 Other G CLAIMS G1 General G2 Other H1 SCHEDULE HOSPITAL TREATMENT TABLES H1 1 Table Name or Group of Table Names H1 2 Eligibility... 93

4 H1 3 General Conditions H1 4 Hospital Treatment Payments H1 5 Medical Services Payments while admitted H1 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals H1 7 Non PBS Pharmaceuticals H1 8 Surgically Implanted Prostheses H1 9 Nursing Home Type Patients H1 10 Co Payments H1 11 Excesses H1 12 Benefit Limitation Periods H1 13 Restricted Benefits H1 14 Exclusions H1 15 Loyalty Bonuses H1 16 Other Special H2 SCHEDULE HOSPITAL TREATMENT TABLES H2 1 Table Name or Group of Table Names H2 2 Eligibility H2 3 General Conditions H2 4 Hospital Treatment Payments H2 5 Medical Services Payments while admitted H2 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals H2 7 Non PBS Pharmaceuticals H2 8 Surgically Implanted Prostheses H2 9 Nursing Home Type Patients H2 10 Co Payments H2 11 Excesses H2 12 Benefit Limitation Periods H2 13 Restricted Benefits

5 H2 14 Exclusions H2 15 Loyalty Bonuses H2 16 Other Special H3 SCHEDULE HOSPITAL TREATMENT TABLES H3 1 Table Name or Group of Table Names H3 2 Eligibility H3 3 General Conditions H3 4 Hospital Treatment Payments H3 5 Medical Services Payments while admitted H3 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals H3 7 Non PBS Pharmaceuticals H3 8 Surgically Implanted Prostheses H3 9 Nursing Home Type Patients H3 10 Co Payments H3 11 Excesses H3 12 Benefit Limitation Periods H3 13 Restricted Benefits H3 14 Exclusions H3 15 Loyalty Bonuses H3 16 Other Special H4 SCHEDULE HOSPITAL TREATMENT TABLES H4 1 Table Name or Group of Table Names H4 2 Eligibility H4 3 General Conditions H4 4 Hospital Treatment Payments H4 5 Medical Services Payments while admitted H4 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals H4 7 Non PBS Pharmaceuticals

6 H4 8 Surgically Implanted Prostheses H4 9 Nursing Home Type Patients H4 10 Co Payments H4 11 Excesses H4 12 Benefit Limitation Periods H4 13 Restricted Benefits H4 14 Exclusions H4 15 Loyalty Bonuses H4 16 Other Special H6 SCHEDULE HOSPITAL TREATMENT TABLES H6 1 Table Name or Group of Table Names H6 2 Eligibility H6 3 General Conditions H6 4 Hospital Treatment Payments H6 5 Medical Services Payments while admitted H6 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals H6 7 Non PBS Pharmaceuticals H6 8 Surgically Implanted Prostheses H6 9 Nursing Home Type Patients H6 10 Co Payments H6 11 Excesses H6 12 Benefit Limitation Periods H6 13 Restricted Benefits H6 14 Exclusions H6 15 Loyalty Bonuses H6 16 Other Special H7 SCHEDULE HOSPITAL TREATMENT TABLES H7 1 Table Name or Group of Table Names

7 H7 2 Eligibility H7 3 General Conditions H7 4 Hospital Treatment Payments H7 5 Medical Services Payments while admitted H7 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals H7 7 Non PBS Pharmaceuticals H7 8 Surgically Implanted Prostheses H7 9 Nursing Home Type Patients H7 10 Co Payments H7 11 Excesses H7 12 Benefit Limitation Periods H7 13 Restricted Benefits H7 14 Exclusions H7 15 Loyalty Bonuses H7 16 Other Special I1 SCHEDULE GENERAL TREATMENT TABLES I1 1 Table Name or Group of Table Names I1 2 Eligibility I1 3 General Conditions I1 4 Loyalty Bonuses I1 5 Dental I1 6 Optical I1 7 Physiotherapy I1 8 Chiropractic I1 9 Non PBS Pharmaceuticals I1 10 Podiatry I1 11 Psychology and Counselling I1 12 Alternative Therapies

8 I1 13 Natural Therapies I1 14 Speech Therapy I1 15 Orthotics I1 16 Dietetics I1 17 Occupational Therapy I1 18 Naturopathy I1 19 Acupuncture I1 20 Other Therapies I1 21 Non Surgically Implanted Prostheses and Appliances I1 22 Hearing Aids I1 23 Prevention Health Management I1 24 Ambulance Transportation I1 25 Accident Cover I1 26 Accidental Death Funeral Expenses I1 27 Other Special I2 SCHEDULE GENERAL TREATMENT TABLES I2 1 Table Name or Group of Table Names I2 2 Eligibility I2 3 General Conditions I2 4 Loyalty Bonuses I2 5 Dental I2 6 Optical I2 7 Physiotherapy I2 8 Chiropractic I2 9 Non PBS Pharmaceuticals I2 10 Podiatry I2 11 Psychology and Counselling I2 12 Alternative Therapies

9 I2 13 Natural Therapies I2 14 Speech Therapy I2 15 Orthotics I2 16 Dietetics I2 17 Occupational Therapy I2 18 Naturopathy I2 19 Acupuncture I2 20 Other Therapies I2 21 Non Surgically Implanted Prostheses and Appliances I2 22 Hearing Aids I2 23 Prevention Health Management I2 24 Ambulance Transportation I2 25 Accident Cover I2 26 Accidental Death Funeral Expenses I2 27 Other Special I3 SCHEDULE GENERAL TREATMENT TABLES I3 1 Table Name or Group of Table Names I3 2 Eligibility I3 3 General Conditions I3 4 Loyalty Bonuses I3 5 Dental I3 6 Optical I3 7 Physiotherapy I3 8 Chiropractic I3 9 Non PBS Pharmaceuticals I3 10 Podiatry I3 11 Psychology and Counselling I3 12 Alternative Therapies

10 I3 13 Natural Therapies I3 14 Speech Therapy I3 15 Orthotics I3 16 Dietetics I3 17 Occupational Therapy I3 18 Naturopathy I3 19 Acupuncture I3 20 Other Therapies I3 21 Non Surgically Implanted Prostheses and Appliances I3 22 Hearing Aids I3 23 Prevention Health Management I3 24 Ambulance Transportation I3 25 Accident Cover I3 26 Accidental Death Funeral Expenses I3 27 Other Special I5 SCHEDULE GENERAL TREATMENT TABLES I5 1 Table Name or Group of Table Names I5 2 Eligibility I5 3 General Conditions I5 4 Loyalty Bonuses I5 5 Dental I5 6 Optical I5 7 Physiotherapy I5 8 Chiropractic I5 9 Non PBS Pharmaceuticals I5 10 Podiatry I5 11 Psychology and Counselling I5 12 Alternative Therapies

11 I5 13 Natural Therapies I5 14 Speech Therapy I5 15 Orthotics I5 16 Dietetics I5 17 Occupational Therapy I5 18 Naturopathy I5 19 Acupuncture I5 20 Other Therapies I5 21 Non Surgically Implanted Prostheses and Appliances I5 22 Hearing Aids I5 23 Prevention Health Management I5 24 Ambulance Transportation I5 25 Accident Cover I5 26 Accidental Death Funeral Expenses I5 27 Other Special I6 SCHEDULE GENERAL TREATMENT TABLES I6 1 Table Name or Group of Table Names I6 2 Eligibility I6 3 General Conditions I6 4 Loyalty Bonuses I6 5 Dental I6 6 Optical I6 7 Physiotherapy I6 8 Chiropractic I6 9 Non PBS Pharmaceuticals I6 10 Podiatry I6 11 Psychology and Counselling I6 12 Alternative Therapies

12 I6 13 Natural Therapies I6 14 Speech Therapy I6 15 Orthotics I6 16 Dietetics I6 17 Occupational Therapy I6 18 Naturopathy I6 19 Acupuncture I6 20 Other Therapies I6 21 Non Surgically Implanted Prostheses and Appliances I6 22 Hearing Aids I6 23 Prevention Health Management I6 24 Ambulance Transportation I6 25 Accident Cover I6 26 Accidental Death Funeral Expenses I6 27 Other Special J2 SCHEDULE COMBINED HOSPITAL TREATMENT and GENERAL TREATMENT TABLES J2 1 Table Name or Group of Table Names J2 2 Eligibility J2 3 General Conditions J2 4 Hospital Treatment Payments J2 5 Medical Services Payments while admitted J2 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals J2 7 Non PBS Pharmaceuticals J2 8 Surgically Implanted Prostheses J2 9 Nursing Home Type Patients J2 10 Co Payments J2 11 Excesses

13 J2 12 Benefit Limitation Periods J2 13 Restricted Benefits J2 14 Exclusions J2 15 Loyalty Bonuses J2 16 Other Special Hospital Treatment J2 17 Dental J2 18 Optical J2 19 Physiotherapy J2 20 Chiropractic J2 21 Non PBS Pharmaceuticals J2 22 Podiatry J2 23 Psychology and Counselling J2 24 Alternative Therapies J2 25 Natural Therapies J2 26 Speech Therapy J2 27 Orthotics J2 28 Dietetics J2 29 Occupational Therapy J2 30 Naturopathy J2 31 Acupuncture J2 32 Other Therapies J2 33 Non Surgically Implanted Prostheses and Appliances J2 34 Hearing Aids J2 35 Prevention Health Management J2 36 Ambulance Transportation J2 37 Accident Cover J2 38 Accidental Death Funeral Expenses J2 39 Other Special General Treatment

14 J2 40 Hospital-Substitute Treatment J10 SCHEDULE COMBINED HOSPITAL TREATMENT and GENERAL TREATMENT TABLES J10 1 Table Name or Group of Table Names J10 2 Eligibility J10 3 General Conditions J10 4 Hospital Treatment Payments J10 5 Medical Services Payments while admitted J10 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals J10 7 Non PBS Pharmaceuticals J10 8 Surgically Implanted Prostheses J10 9 Nursing Home Type Patients J10 10 Co Payments J10 11 Excesses J10 12 Benefit Limitation Periods J10 13 Restricted Benefits J10 14 Exclusions J10 15 Loyalty Bonuses J10 16 Other Special Hospital Treatment J10 17 Dental J10 18 Optical J10 19 Physiotherapy J10 20 Chiropractic J10 21 Non PBS Pharmaceuticals J10 22 Podiatry J10 23 Psychology and Counselling J10 24 Alternative Therapies J10 25 Natural Therapies

15 J10 26 Speech Therapy J10 27 Orthotics J10 28 Dietetics J10 29 Occupational Therapy J10 30 Naturopathy J10 31 Acupuncture J10 32 Other Therapies J10 33 Non Surgically Implanted Prostheses and Appliances J10 34 Hearing Aids J10 35 Prevention Health Management J10 36 Ambulance Transportation J10 37 Accident Cover J10 38 Accidental Death Funeral Expenses J10 39 Other Special General Treatment J10 40 Hospital-Substitute Treatment K SCHEDULE CONTRIBUTION RATE L SCHEDULE OVERSEAS L1.1 Table Name/Group of Table Names L1.2 Eligibility L1. 3 General Conditions L1.4 Hospital Treatment Payments L1 5 Medical Services Payments while admitted L1 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals L1 7 Non PBS Pharmaceuticals L1 8 Surgically Implanted Prostheses L1 9 Nursing Home Type Patients L1 10 Co Payments L1.11 Excesses

16 L1 12 Benefit Limitation Periods L1 13 Restricted Benefits L1.14 Excluded services L1 15 Loyalty Bonuses L1.16 Other Special Table: Hospital and Admitted Patient Services Covered

17 A INTRODUCTION A1 Rules Arrangement 1. Composition Health Insurance Fund of Australia Limited [ACN ] ( HIF ) Fund Rules consist of: 1.1 Sections A to G of this document; and 1.2 Schedules H to M of this document. Unless otherwise stipulated, in these Fund Rules the terms Business Rules, Fund Rules and Rules mean the same. A2 Health Benefits Fund 1. Registered Legal Entity HIF is a public company limited by guarantee registered pursuant to the Corporations Act 2001 (Cth) and is registered with the Australian Prudential Regulation Authority ( APRA ) as a private health insurer. 2. Purpose HIF has a health benefits fund established in its records. HIF may have more than one health benefits fund but must not have more than one of them in respect of a particular risk equalisation jurisdiction. Unless otherwise stipulated or unless the context requires otherwise or a contrary intention exists, in these Business Rules the terms health benefits fund and fund mean the same. HIF s Rules operate to guide, clarify, govern or regulate as the case may be the business operations and any other relevant or related activities of HIF in respect of its health benefits fund that relates solely to: Health insurance business or a particular part of that business, or health insurance business, or a particular part of that business, and some or all of its health-related businesses, or particular parts of those businesses. A3 Obligations to Insurer To the extent that the law permits, an applicant for a Fund Membership shall provide any information relevant to that application that HIF may reasonably require. Information relevant to an application for a Fund Membership includes but is not limited to information relating to any or all persons who the applicant proposes in the application to be covered by or to benefit from the Fund Membership.

18 HIF shall determine the manner by which an application for a Fund Membership is to be lodged with HIF. An applicant for a Fund Membership agrees to be and shall during the time they remain a Fund Member be bound by the Fund Rules. A4 Governing Principles 1. Risk Equalisation Trust Fund HIF shall at all times participate in the operation of the Risk Equalisation Trust Fund in accordance with the Relevant Laws, principles or Rules as the case may be. HIF, its Fund Members and persons recognised under HIF Fund Memberships acknowledge and agree that HIF shall do all things necessary to ensure it complies with the Relevant Laws, principles or Rules as the case may be in relation to the Risk Equalisation Trust Fund including assisting and/or complying with the lawful instructions of APRA relating to its administration of the Risk Equalisation Trust Fund. 2. Compliance with Federal and State Laws HIF shall at all times comply with any relevant State law, except where such law is inconsistent with the laws of the Commonwealth of Australia ( Commonwealth ) then the law of the Commonwealth shall prevail. HIF shall at all times comply with any relevant Commonwealth law, including but not limited to, the Private Health Insurance Act 2007 (Cth) ( PHI Act 2007 ) and Private Health Insurance Rules (Cth) ( PHI Rules ), the National Health Act 1953 (Cth), the Health Insurance Act 1973 (Cth) and the Corporations Act 2001 (Cth). A5 Use of Funds 1. Health Benefits Fund business A Fund shall relate solely to: 1.1 health insurance business or a particular part of that business; or 1.2 health insurance business, or a particular part of that business, and some or all of its health-related businesses, or particular parts of those businesses. 2. Assets of a Fund(s) Assets of a Fund shall be kept distinct and separate from assets of any other Fund that HIF might have and from all other money, assets or investments of HIF. HIF must maintain separate bank accounts for each Fund that it has. Assets of a Fund include: 2.1 the balance of money represented by amounts credited to the relevant Fund in accordance with section of the PHI Act 2007;

19 2.2 assets of HIF obtained as a result of the expenditure or application of money credited to a Fund; 2.3 investments held by HIF as a result of the expenditure or application of money credited to a Fund; 2.4 other money, assets or investments of HIF transferred to a Fund, whether under the PHI Act 2007 or otherwise. Assets or investments obtained by the application of assets (other than money) of a Fund are themselves assets of the relevant Fund. Assets of a Fund: 2.5 include assets that, in accordance with a restructure or arrangement approved under Division 146 of the PHI Act 2007, are to be assets of the relevant Fund; but 2.6 do not include assets that, in accordance with such a restructure or arrangement, are no longer to be assets of the relevant Fund. Notwithstanding subparagraphs 2.2 and 2.3 above and that assets or investments obtained by the application of assets (other than money) of a Fund are themselves assets of the relevant Fund, assets or investments obtained by the expenditure of money of, or the application of other assets of a Fund are not assets of the Fund if: 2.7 HIF is registered as a for profit insurer; and 2.8 the expenditure or application was not done for the purposes of the relevant Fund. 3. Payments to HIF s Fund(s) HIF shall credit the following amounts to the Fund: 3.1 premiums payable under policies of insurance that are Referable to the Fund; 3.2 amounts paid to HIF in relation to a liability under Division 152 of the PHI Act 2007 in relation to the Fund; 3.3 income from the investment of assets of the Fund; 3.4 money paid to or by HIF under a judgment of a court relating to any matter concerning the business of the Fund or any failure to comply with Part 4-4 of the PHI Act 2007 in relation to the Fund; 3.5 any other money received by HIF in connection with its conduct of the business of the Fund; 3.6 any other amounts that the PHI (Health Benefits Fund Policy) Rules (Cth) specify. The PHI Act 2007 does not prevent HIF from making a capital payment to a Fund. A capital payment to a Fund would occur if HIF credits to the fund an amount that is not required to be credited to the Fund pursuant to paragraphs above and either: 3.7 does not represent any part of the assets of another health benefits fund; or

20 3.8 is credited to the Fund with APRA s written approval. 4. Expenditure and application of health benefits funds HIF shall not apply, or deal with, assets of a Fund, whether directly or indirectly, except in accordance with section 137 of the PHI Act The assets of a Fund shall not be applied for any purpose other than: 4.1 meeting Insurance Product liabilities and other liabilities, or expenses incurred for the purposes of the business of the Fund (including Insurance Product liabilities and other liabilities that are treated, in accordance with a restructure or arrangement approved under Division 146 of the PHI Act 2007, as Insurance Product liabilities and other liabilities incurred for the purposes of the Fund); or 4.2 making investments in accordance with section of the PHI Act 2007; or 4.3 making a distribution under Division 149 of the PHI Act 2007; or 4.4 a purpose specified in the PHI (Health Benefits Fund Policy) Rules (Cth) for the purposes of this Rule; or for a purpose specified in the PHI (Health Benefits Fund Policy) Rules (Cth) for the purposes of this Rule. HIF shall not mortgage or charge any of the assets of a Fund except: 4.5 to secure a bank overdraft; or 4.6 for such other purposes, and subject to such conditions, as are specified in the PHI (Health Benefits Fund Administration) Rules (Cth) for the purposes of this Rule. HIF shall not borrow money for the purposes of the business of a Fund except in accordance with the PHI (Health Benefits Fund Administration) Rules (Cth). Despite paragraphs , if HIF is registered as a for profit insurer, the assets of a Fund conducted by HIF may be applied for any purpose, except an application of the assets that is inconsistent with: 4.7 the solvency standard; or 4.8 the capital adequacy standard; or 4.9 a solvency direction or capital adequacy direction given to HIF. This Rule does not apply to the transfer of assets: 4.10 from one Fund to another in accordance with Division 146 of the PHI Act 2007; or 4.11 in accordance with a direction under sub-section (2) of the PHI Act 2007.

21 A6 No Improper Discrimination 1. Community rating principle HIF shall not: 1.1 take or fail to take any action; or 1.2 in making a decision, have regard or fail to have regard to any matter; that would result in HIF improperly discriminating between people who are or wish to be insured under any of HIF s complying health insurance policies. 2. Improper discrimination Improper discrimination is discrimination that relates to: 2.1 the suffering by a person from a chronic disease, illness or other medical condition or from a disease, illness or medical condition of a particular kind; 2.2 the gender, race, sexual orientation or religious belief of a person; 2.3 the age of a person, except to the extent allowed under Part 2-3 (Lifetime Health Cover) of the PHI Act 2007; 2.4 where a person lives, except to the extent allowed under sub-section 66-10(2) or section of the PHI Act 2007; or 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; 2.5 the frequency with which a person needs Hospital Treatment or General Treatment; 2.6 the amount or extent of the benefits to which a person becomes entitled during a period under an Insurance Product, except to the extent allowed under section of the PHI Act 2007; or 2.7 any matter set out in the PHI (Complying Product) Rules 2007 (Cth) for the purposes of this Rule. 3. Closed products The community rating principle in this Rule does not prevent HIF from refusing to make available to a person an Insurance Product that HIF is no longer making available to anyone. A7 Changes to Rules 1. Standard information statement HIF shall ensure that it maintains at all times an up to date Standard Information Statement ( SIS ): 1.1 for each product sub-group of each Insurance Product that it makes available; and 1.2 for each product sub-group of each Insurance Product under which it insures people.

22 A single SIS may be the SIS for more than one product sub-group of an Insurance Product if the premiums payable under policies in the sub-groups the SIS covers are the same. The SIS for a product sub-group of an Insurance Product is up to date at a particular time, if, at that time, the information in the statement is accurate. A SIS for a product sub-group of an Insurance Product is a statement about the product subgroup that contains the information, and is in the form, set out in the PHI (Complying Product) Rules (Cth). The PHI (Complying Product) Rules (Cth) may set out methods by which SIS s are to be made available to people who ask for information about Insurance Products. HIF shall ensure that, if a person asks an officer, employee or authorised agent of HIF for information about an Insurance Product of HIF: 1.3 the person is told about the SIS for the product sub-group that is likely to apply to the person and how to obtain a copy of the SIS; and 1.4 if the person asks for a copy the person is given an up to date copy of the SIS for that sub-group. HIF shall ensure that, when an adult first becomes insured under an I Product, the adult is given: 1.5 an up to date copy of the SIS for the product sub-group that the Insurance Product belongs to, by a method (if any) set out in the PHI (Complying Product) Rules (Cth); and 1.6 details about what the Insurance Product covers and how benefits provided under it are worked out; and 1.7 a statement identifying the Fund to which the policy is Referable. If more than one adult becomes insured under a single Insurance Product, HIF is taken to comply with these requirements (sub-paragraphs of this Rule) if HIF complies with those requirements in relation to only one of those adults. HIF shall ensure that an adult insured under an Insurance Product is given the SIS for the product sub-group that the Insurance Product belongs to, at least once every 12 months. HIF shall ensure that, if a proposed change to the Rules is or might be detrimental to the interests of an insured person and will require an update to the SIS s for an Insurance Product, an adult insured under each Insurance Product is informed about the proposed change within a reasonable period before the change takes effect and is given the updated SIS for the product sub-group that the Insurance Product belongs to as soon as practicable after the SIS is updated. HIF shall ensure that, if an adult who is insured under an Insurance Product of the insurer asks an officer, employee or authorised agent of HIF for information about what the Insurance Product

23 covers or the Benefits the Insurance Product provides, the adult is given the information as soon as practicable. If HIF changes the Fund to which an Insurance Product is Referable, HIF must ensure that before the change takes effect, an adult insured under the Insurance Product is given a statement identifying the Fund to which the Insurance Product will be Referable as a result of the change or within 2 weeks after the change takes effect, an adult insured under the Insurance Product is given a statement identifying the Fund to which the Insurance Product is Referable as a result of the change. The Fund to which an Insurance Product is Referable may change in accordance with Division 146 of the PHI Act If more than one adult is insured under an Insurance Product, HIF is taken to have complied with this Rule if HIF complies with the Rule in relation to only one of those adults. 2. Detrimental changes 1. HIF shall ensure an adult insured under an Insurance Product is informed about any proposed change to HIF s Rules, other than a change to which sub-section 93-20(2) of the PHI Act 2007 applies, a reasonable time before the change takes effect, if the proposed change is or might be detrimental to the interests of insured persons. For the purposes of this Rule, a reasonable time shall be not less than the lesser of two calendar months or sixty calendar days. If more than one adult is insured under an Insurance Product, HIF is taken to comply with this Rule if HIF complies with this Rule in relation to only one of those adults. 3. Giving information relating to standard information statements In relation to a request from the Secretary of the Department of Health ( DoH ), APRA or the Ombudsman for HIF s SIS s or any one or some of them, HIF shall supply up to date copies to the relevant person as soon as practicable and in the manner or by the method so requested. A request by the Secretary of the DoH, APRA or the Ombudsman for information about an Insurance Product or products, shall be in writing and must specify the time by which the information requested is to be given. Such a request may specify the manner and form in which the information requested is to be given. In relation to new Insurance Products, HIF shall supply a SIS in respect of each and every new product to DoH, APRA and the Ombudsman no later than the first day on which HIF commences to make the product(s) available. In relation to updated SIS s, HIF shall supply an updated SIS to the DoH, APRA and the Ombudsman as soon as practical after HIF has updated the relevant SIS(s). HIF shall comply with any requirement set out in the PHI (Complying Product) Rules (Cth) in relation to: 3.1 information in relation to Insurance Products;

24 3.2 persons to whom such information is to be given to, including but not limited to the Secretary of the DoH, APRA or the Ombudsman; 3.3 the time during which, or the intervals at which, the information is to be given to a person; or 3.4 the manner and form in which the information is to be given to a person. A8 Dispute Resolution 1. Definitions In A8 Dispute Resolution, unless a contrary intention appears: complaint Means an expression of dissatisfaction with an Insurance Product, Benefit or service offered or provided. complainant Means a person, organisation or entity making a complaint. dispute Means a pursued unsatisfied complaint. service Means the provision of assistance, help and support to all Fund Members and prospective new Fund Members, to facilitate, improve, and assist in the answering of a question, problem or query that a Fund member or non-fund Member may have in respect to their Fund Membership or proposed Fund Membership as the case may be. 2. Matters not covered by HIF s Rules If any dispute, question, matter, inquiry, issue or complaint arises that is not or appears not to be covered in these Rules, the question, matter, inquiry, issue or complaint as the case may be shall be referred to the Managing Director or their authorised nominee for a determination. In the case of a complaint by a Fund Member, HIF shall apply the principles, Rules and procedures as are contained in HIF s complaints handling system, or if in the opinion of the Managing Director or their authorised nominee, the nature or / and circumstances of the complaint warrants, the Managing Director or their authorised nominee may use additional or other appropriate means to determine the complaint. HIF may at its absolute and unfettered discretion make such decisions, determinations and interpretations of these Rules in the best interests of Fund Members and HIF. Fund Members shall be informed of the existence of the Private Health Insurance Ombudsman. 3. HIF s complaint handling The primary objectives of the HIF s complaint handling policy includes to: 3.1 recognise and protect Fund Members' rights including the right to make a comment or complain; 3.2 increase the level of Fund Member satisfaction; 3.3 increase the level of service provided to Fund Members and prospective new Fund Members;

25 3.4 provide an efficient and fair process that is easily accessible by Fund Members; 3.5 provide clear information to Fund Members about a process or procedure; 3.6 record and monitor the nature of complaints for identification of common themes and issues; and 3.7 report the nature of complaints for review of current Insurance Products, Benefits and services with a view to improvement. 4. Commitment HIF is committed to providing Fund Members with access to the highest possible level of service and we value the feedback that Fund Members provide. As part of HIF s commitment to continuous improvement if any person should have a concern regarding a Fund Membership, Insurance Product Benefits or the level of service HIF provides, HIF would be happy to hear from you. 5. Access HIF s complaint handling process can be accessed without charge by any person who wishes to lodge a concern or complaint about any Insurance Products Benefit and / or services. Access to HIF s complaint handling process and procedures can be undertaken by any one of following means: 5.1 Telephone: In writing addressed to: Executive Manager Member Experience Health Insurance Fund of Australia Ltd GPO Box X2221 PERTH WA By info@hif.com.au Information on how to access HIF s complaint handling procedure is available in HIF s current brochure and on HIF s website: HIF s complaint handling process ensures that where HIF staff are unable to assist the complainant with their concern or complaint, the matter will be escalated to a team leader or senior manager. 6. Escalation The process for escalating a dispute, question, matter, inquiry, issue, concern or complaint is as follows: 6.1 the matter giving rise to the dispute, question, matter, inquiry, issue, concern or complaint is firstly logged with a customer service representative; and 6.2 if the customer service representative is unable to assist the complainant, they are referred to the relevant Team Leader; and 6.3 in the case where the Team Leader/Manager is unable to assist the complainant, the complainant shall be referred to the Executive Manager - Member Experience or the Managing Director; and

26 6.4 in the event that a complaint relates to an area of HIF s business that falls outside these Rules, the complaint shall be referred to the (Fund) Member Action Review Committee ( MARC ) for its determination and decision; and 6.5 where a complaint cannot be resolved to the mutual satisfaction of all of the parties included in the dispute, and the complainant wishes to take the matter further, they may: 6.6 Contact the Commonwealth Ombudsman (a) Via the website at (b) By ringing on ; or (c) By writing to: Commonwealth Ombudsman GPO Box 442 CANBERRA, ACT 2601 Nothing in this Rule shall operate to prevent a person from referring a complaint, whether or not it is in dispute, directly to the relevant statutory authority or body, including but not limited to PHIO and APRA, either instead of or in addition to referring the complaint to HIF. A9 Notices Unless stated otherwise in these Fund Rules, a written notice sent by post to the address last supplied by the Primary Fund Member will be deemed to be notice to all persons named in the Insurance Product under these Fund Rules. Fund Members may contact HIF to request a copy of the Fund Rules at any reasonable time. Fund Rules may also be available on HIF s website. A10 Winding Up In the event that HIF is to be wound up or the Fund dissolved, subject to the PHI Act 2007, HIF shall be wound up or the Fund dissolved in accordance with HIF s Constitution. A11 Other B INTERPRETATION AND DEFINITIONS B1 Interpretation Notwithstanding anything contained in these Fund Rules, subject to relevant legislation and/or other authority, including but not limited to the PHI Act 2007, the PHI Rules and the Corporations Act 2001 (Cth), HIF may at its absolute and unfettered discretion make such decisions, determinations and / or interpretations in relation to these Fund Rules as are, in the opinion of the

27 Managing Director or his/her authorised delegate nominee, required to serve the interests of the Fund Members and/or HIF. B2 Definitions In these Rules: ACCESS GAP Means, unless a contrary intention appears, the difference between the standard contribution charge and the Health Care Provider charge under Access Gap Cover. ACCESS GAP COVER Means the system operated by Australian Health Service Alliance on behalf of members funds including HIF, that is aimed at covering some or all of the cost of medical services and / or treatments provided to a person insured under a Hospital cover including an Overseas Visitors Hospital cover of a Fund Member, provided that the services and / or treatments are received by that person whilst an Inpatient in a registered Hospital or Day Hospital Facility. ACCESS GAP SCHEDULE Means the Access Gap Cover schedule containing the maximum amount or a maximum percentage of rebate benefit payable by HIF for Inpatient medical services and / or treatments charges and / or fees in excess of the standard Contribution as contained in the Medicare Benefit Schedule, provided that if a person is covered under an Overseas Visitors Hospital cover, Access Gap Schedule rebate benefits are payable for Hospital Inpatient and non-hospital (i.e. non- Inpatient) related medical services. ACCIDENT Means an unplanned or unexpected and unintentional event without apparent cause. ACCREDITED Means in relation to the provision of Hospital Treatment, Hospital-Substitute Treatment or General Treatment, a person authorised, approved or sanctioned: (a) By the Minister or a person authorised by the Minister; (b) (c) ACT By a governing, professional or industry body; or By virtue of the issue of a written instrument evidencing a minimum standard, qualification or level of achievement or proficiency. Means, unless a contrary intention appears, the Private Health Insurance Act 2007 (Cth) as amended from time to time.

28 ADMISSION Means the period of time when admitted as an Inpatient for a condition or illness into a Hospital or Day Hospital Facility for the purpose of receiving Hospital Treatment until discharged. ADULT DEPENDENT Means a Fund Member who is a Partner of the Primary Fund Member and who is covered under the same Fund Membership as the Primary Fund Member. AGENT Means a person who HIF approves to act on its behalf: (a) to accept premium Contributions and pay rebate benefits to a Fund Member; (b) to promote HIF s products and services including Insurance Products; or (c) to refer people (including a group employer of people) to HIF in anticipation of commission. AHSA Means Australian Health Service Alliance. ANNUAL Means unless a contrary intention appears, the period starting on the 1 st January and ending on the 31 st December. ANNUAL FINANCIAL LIMIT Means the maximum financial limit of rebate benefits payable to a Fund Member or another person in respect of a Fund Membership in a year. ANNUAL LIMIT Means an Annual Financial Limit or some other Annual limitation restricting or preventing access to an unlimited amount or number of goods, services or treatments. APPLICABLE BENEFITS ARRANGEMENT Means an Applicable Benefits Arrangement within the meaning of the National Health Act 1953(Cth) as in force before the 1 st April APPLICATION Means, unless a contrary intention appears, a Fund Membership Application.

29 APRA Means Australian Prudential Regulation Authority. APPROVED Means formally recognised in writing by HIF. APPROVED FACILITY Means a Facility including an Approved Hospital Facility provide goods, services or treatments to Fund Members. APPROVED HEALTH MANAGEMENT PROGRAM Means an Approved program that is intended to ameliorate a person's specific health condition or conditions, provided that the program may include treatment that primarily takes the form of sport, recreation or entertainment. APPROVED HEALTH CARE PROVIDER Means a Health Care Provider who, at the absolute discretion of HIF, is Approved to provide goods, services or treatments to Fund Members. APPROVED SERVICE PROVIDER Means, unless a contrary intention appears, an Approved Health Care Provider. ARREARS Means in relation to a Fund Member or Fund Membership, the amount owing to HIF in respect of a period between the last date paid to and the current date or other date determined by HIF. ART Means Assisted Reproductive Technology. ASSISTED REPRODUCTIVE SERVICES Includes IVF and ART services or treatments and any investigation related to fertility provided that, subject to these Rules, only basic rebate benefits are payable for the first three years of a Fund Membership. AUSTRALIAN HEALTH SERVICE ALLIANCE Means Australian Health Service Alliance Ltd ABN , comprising a group of likeminded health insurers that have banded together by the signing of an agency agreement to

30 become Fund Members, to negotiate contracts with Health Care Providers on a collective basis and to provide other services as required. BASE RATE Means for Hospital cover the amount of premium that would be payable for that cover if: (a) the premium were not increased under Division 34 of Part 2-3 of the PHI Act 2007; and (b) there was no discount of the kind allowed under these Rules pursuant to section 66-5(2) of the PHI Act BENEFIT Means, unless a contrary intention appears, an entitlement including a rebate that is available under an Insurance Product. BENEFIT EXCLUSION Means, in relation to an Insurance Product, a charge or fee of a provider for a service or treatment, including the provision of goods and services by the Health Care Provider, supplied to a Fund Member, that HIF will not pay a rebate Benefit on. BENEFIT LIMITATION PERIOD Means a period, commencing immediately after joining HIF or joining a higher benefiting table, during which either some or all Fund rebate Benefits are either reduced or not payable. BENEFIT RESTRICTION Means, in relation to an Insurance Product, a charge or fee of a Health Care Provider for a service or treatment, including the provision of goods and services by the Health Care Provider, supplied to a Fund member, which HIF will only pay a Minimum Benefit on. BOARD Means the Board of Directors of HIF. BOARD OF DIRECTORS Means the Board of Directors of HIF duly constituted in accordance with the Constitution. BUSINESS RULES Means, unless a contrary intention appears, these Fund Rules. CALENDAR YEAR Means the period from the 1 st January to the 31 st December.

31 CERTIFIED AGE AT ENTRY Means Lifetime Health Cover age. CHILD Means a person who is less than 21 years of age and is: (a) a child of a father or mother or father and mother; (b) a step-child; (c) a legally adopted child; (d) a child of a guardian. CLEARANCE CERTIFICATE Means transfer certificate. CLINICALLY RELEVANT SERVICE Means a service or treatment rendered by a medical or Dental Practitioner or an Optometrist that is generally accepted in the medical, dental or optometry profession as the case may be as being necessary for the appropriate treatment of the patient to whom it is rendered. COMMONWEALTH OMBUDSMAN Means Ombudsman appointed for the purposes of Part 6-2 of the PHI Act COMPENSATION Means: (a) (b) (c) (d) (e) payment by way of damages; payment, other than a payment of Benefits from the Fund, under a scheme of insurance or Compensation provided for by a law of a State or Territory; payment, whether with or without admission of liability, in settlement of a claim for damages or of a claim under a scheme referred to in (b); payment by way of damages or, whether with or without admission of liability, in settlement of a claim for damages for professional negligence in relation to a claim for payment referred to in (a), (b) or (c); or any other payment that, in the opinion of HIF, is a payment in the nature of compensation or damages. CONSTITUTION Means the constitution of HIF last lodged with the Australian Securities and Investments Commission.

32 CONSULTATION Means an attendance by a HIF Approved Service Provider or Health Provider, who provides an Approved Ancillary, Hospital or Hospital-Substitute treatment, to an eligible member in a face to face setting, or as otherwise approved by HIF. For the removal of doubt, telephone or online services, with the exception of HIF Approved Hospital-Substitute treatment or Chronic Health Disease Management programs, are not consultations. CONTINUOUS PERIOD OF HOSPITALISATION Means, for the purpose of counting days of Hospital Treatment, includes any two periods during which a patient was, or is, receiving Hospital Treatment as a patient at a Hospital, whether or not the same Hospital, where the periods are separated from each other by a period of not more than 7 days during which the patient was not receiving Hospital Treatment as a patient at any Hospital. CONTRACTED HOSPITAL Means a Hospital including a Hospital group that is under contract either directly with HIF or indirectly with HIF via the Australian Health Service Alliance in its capacity as agent of HIF, to provide Inpatient services or treatments to Fund Members. CONTRIBUTION Means a financial payment in advance in Australian legal tender to HIF, entitling a person(s) to be, subject to these Rules, a Fund Member. COSMETIC SURGERY Means a surgical procedure that is: (a) listed in Group T8 Surgical Operations, Subgroup 13 - Plastic and Reconstructive Surgery of the Medicare Benefits Schedule that: (1) is not clinically relevant, or (2) does not meet the eligibility conditions for the payment of a Medicare Benefit; or (b) a plastic or reconstructive surgical procedure that is not listed in the Medicare Benefits Schedule. COUNCIL Means, unless a contrary intention appears, Private Health Insurance Administration Council. CURRENT Means in relation to a Fund Member or Fund Membership, they are or it is financial. DAY HOSPITAL FACILITY

33 Means a Facility that operates as a day only Facility that is registered or licensed as the case may be with a Commonwealth, State or Territory Government and is approved to render services or treatments to Fund Members without involving overnight accommodation. DENTAL BENEFIT Means an entitlement including a rebate in respect of a dental service or treatment that is available under an Insurance Product, including goods supplied or consumed in the provision of the service or treatment, by an Approved Dental Practitioner. DENTAL PRACTITIONER Means a person who is: (a) in private practice; (b) registered by the Dental Board of Western Australia; and (c) Approved by HIF. DEPENDENT Means, unless a contrary intention appears, is: (a) a Dependent Child; (b) a Student Dependent; or (c) an Adult Dependent. DEPENDENT CHILD Means a Fund Member who is aged less than twenty one years and does not have a partner. ELIGIBLE PERSON Means, in relation to Fund Membership, a person who: (a) is aged at least eighteen and any Dependents; and (b) pursuant to the PHI Act 2007 and / or the PHI Rules, is not prevented from being or becoming a Fund Member. EPISODE DURATION Means the period of time associated with a specified episode of care. EXCLUDED BENEFIT Means Benefit Exclusion. EXTRAS BENEFIT

34 Means a benefit including a payment of a rebate in respect of a service or treatment including a treatment that is Hospital-Substitute Treatment, including the provision of goods and services by an Approved Health Care Provider in private practice. EXTRAS PRODUCT Means an Insurance Product that is an Insurance Product covering General Treatment, whether or not it is Hospital-Substitute Treatment, including the provision of goods and services, that: (a) is intended to manage or prevent a disease, injury or condition; and (b) is not Hospital Treatment. EXTRAS SERVICE Means a service or treatment including a Hospital-Substitute Treatment, including the provision of goods and services, which are provided to a Fund Member by an Approved Provider in private practice. FACILITY Means a Public Hospital, a Private Hospital, a public Day Hospital or a private Day Hospital. FUND Means a health benefits fund conducted by HIF. FUND CONTRIBUTOR Means a person who makes Contribution payments to and in favour of HIF in respect of a Fund Membership. FUND MEMBER Means a Primary Fund Member or a Dependent in respect of whom premium Contributions have been paid in advance by a Fund Contributor, towards a Current Insurance Product that provides a person named in the Insurance Product cover of a type permitted by the PHI Act 2007 and PHI Rules. FUND MEMBERSHIP Means, unless a contrary intention appears, a system operated by HIF, involving a person being admitted to the Fund as a Fund Member pursuant to the Rules, for identifying Fund Members. FUND MEMBERSHIP APPLICATION Means an Application, in the form prescribed by HIF, to be admitted to the Fund as a Fund Member.

35 FUND MEMBERSHIP CESSATION Means, unless a contrary intention appears, at the time: (a) in the case of a single Fund Member, of death of the Fund Member; (b) the Fund Membership becomes unfinancial, provided that the Fund Membership has not been returned to a Current financial Fund Membership during two months following the time it became unfinancial; (c) a Fund Membership is cancelled; or (d) a Fund Membership is terminated; Provided that HIF shall give reasonable written notice to the Primary Member or their authorised representative, that the Fund Membership has ceased according to these Business Rules. FUND MEMBERSHIP TERMINATION Means, unless a contrary intention appears, at the time: (a) determined pursuant to the Constitution; (b) a Fund Contributor or Fund Member of a Membership, acting alone or in concert with another person, obtains or attempts to obtain an improper advantage, financial or otherwise, from HIF; or (c) HIF, at its absolute discretion, determines that, under the circumstances, a Fund Membership is terminated; Provided that HIF shall give reasonable written notice, including reasons and the amount (if any) to be refunded for Contributions received in advance of the date of termination, to the Primary Member that the Fund Membership is terminated according to this Business Rule. FUND RULES Means, unless a contrary intention appears, these Rules. GAP COVER SCHEME Means, unless a contrary intention appears, the same as Access Gap Cover. GENERAL TREATMENT Means treatment that is: (a) of a kind that is covered under an Ancillary Product of HIF; (b) not Hospital Treatment. GOLD CARD Means a card that evidences a person s entitlement to be provided with treatment: (a) in accordance with the Treatment Principles prepared under section 90 of the Veterans Entitlements Act 1986 (Cth); or (b) in accordance with a determination made under section 286 of the Military Rehabilitation and Compensation Act 2004 (Cth) in respect of the provision of treatment.

36 HEALTH CARE PROVIDER Means: (a) (b) a person who provides goods or services as or as part of Hospital Treatment or General Treatment; or a person who manufactures or supplies goods provided as or as part of Hospital Treatment or General Treatment. HEALTH INSURANCE FUND OF AUSTRALIA LIMITED Means Health Insurance Fund of Australia Limited ACN , being an Australian public company limited by guarantee that is registered with APRA as a private health insurer. HIF Means Health Insurance Fund of Australia Limited. HOLDER Means, in relation to an Insurance Product, a person who is insured under the Insurance Product and who is not a Dependent Child. HOSPITAL Means a Facility that the Minister has, pursuant to sub-section 121-5(6) of the PHI Act 2007, declared in writing is a Hospital, provided that the declaration is at no time revoked. HOSPITAL PATIENT Means, in relation to a Hospital, an Inpatient in respect of whom the Hospital provides Hospital Treatment. HOSPITAL PRODUCT Means an Insurance Product that is a complying health insurance policy covering Hospital Treatment. HOSPITAL PURCHASER PROVIDER AGREEMENT Means an agreement entered into between HIF or HIF through AHSA acting in its capacity as agent for HIF, and a Health Care Provider that operates a hospital or Day Hospital Facility. HOSPITAL-SUBSTITUTE TREATMENT Means General Treatment that: (a) substitutes for an episode of Hospital Treatment; and

37 (b) (c) 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; and is not specified in the PHI (Complying Products) Rules 2007 (Cth) as a treatment that is excluded from this definition. HOSPITAL TREATMENT Means treatment (including the provision of goods and services) that: (a) is intended to manage a disease, injury or condition; and (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; (d) any other treatment or class of treatments specified in the PHI Rules as being Hospital Treatment; and (e) includes any of, or any combination of, accommodation, 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 TABLE Means the schedule of Benefits and entitlements associated with hospital tables as contained in the AHSA Hospital Purchased Provider Agreement or other Benefits as prescribed by the Commonwealth. INDEPENDENT PRIVATE PRACTICE Means a professional practice (whether sole, partnership, company, group or other identifiable person) that is a Self-Supporting Approved Provider. INPATIENT Means in relation to a hospital Admission, a person who occupies a licensed bed for the purpose of Hospital Treatment. INSURANCE POLICY BENEFIT Means, unless a contrary intention appears, disbursements from the Fund to meet Insurance Product liabilities and other liabilities or expenses incurred for the purposes of the business of the Fund. INSURANCE PRODUCT Means any Hospital or Ancillary Product of HIF, or combinations of those products.

38 IVF Means in vitro-fertilisation. LEGAL GUARDIAN Means a person who the Commonwealth, State and Territory Governments recognise as holding full legal responsibility for another person. LIFETIME HEALTH COVER Means the scheme to encourage people to take out Hospital cover by the time they turn 30, including Rules contained in these Rules at D4 Lifetime Health Cover that require persons to pay higher premiums for Hospital cover where they are older than 30 when they take out hospital cover for the first time, or they drop Hospital cover for a period after having turned 30. LIFETIME HEALTH COVER AGE Means, in relation to an adult who takes out hospital cover after his or her Lifetime Health Cover base day, means the adult s age on the 1st July before the day on which the adult took out the hospital cover. LONG TERM BENEFITS Means those categories of Ancillary Services which have provision for Benefit levels to increase on a year by year basis. MBS Means Medical Benefit Schedule. MEDICAL PRACTITIONER Means, unless a contrary intention appears, a person registered or licensed as a medical practitioner under a law of a State or Territory that provides for the registration or licensing of medical practitioners but does not include a person so registered or licensed: (a) whose registration, or licensed to practice, as a medical practitioner in any State or Territory has been suspended, or cancelled, following an inquiry relating to his or her conduct; and (b) who has not, after that suspension or cancellation, again been authorised to register or practice as a Medical Practitioner in that State or Territory. MEDICAL PURCHASER PROVIDER AGREEMENT Means an agreement entered into between HIF or HIF through AHSA acting in its capacity as agent for HIF, and a medical practitioner.

39 MEDICARE BENEFIT SCHEDULE Means the schedule comprised of tables that list general medical services, diagnostic imaging services and pathology services, including for each service, a Schedule Benefit as defined in the Health Insurance Act 1973 (Cth). MINIMUM BENEFIT Means at least the amount set out, or worked out using the method set out, in the PHI (Benefit Requirements) Rules as the Minimum Benefit, or method for working out the Minimum Benefit, for that treatment, provided that HIF may reduce the Minimum Benefit by the amount of any copayment or excess that is required to be paid under the Insurance Product in respect of that treatment. MINISTER Means the Commonwealth Minister for Health. NON-CONTRACTED PRIVATE HOSPITAL Means a Private Hospital not contracted by the Australian Health Service Alliance or HIF, to provide services to Fund Members. Out of pocket costs cannot be guaranteed in these Hospitals. NON-PBS PHARMACEUTICAL BENEFIT Means a Benefit that is available under an ancillary Insurance Product that relates to medicines / pharmaceutical products, other than contraceptive medicines, not included on the Schedule of Pharmaceutical Benefits for approved Pharmacists and Medical Practitioners, given or issued by a registered Medical Practitioner or dentist pursuant to a prescription, provide that a Benefit is payable in respect of a contraceptive medicine where it is prescribed by the Medical Practitioner as a treatment for acne in respect of an uninterrupted six month period. NURSING CARE Means nursing care given by or under the supervision of a registered nurse. NURSING HOME Means premises: (a) that are fitted, furnished and staffed for the purpose of providing accommodation and Nursing Care for patients who, by reason of infirmity or illness, disease, incapacity or disability, have a continuing need for Nursing Care; and (b) in which patients of that kind are received and lodged exclusively for the purpose of providing them with accommodation and Nursing Care. NURSING HOME TYPE PATIENT

40 Means, in relation to a Hospital, a patient who has been provided with Hospital Treatment whether: (a) acute care; or (b) accommodation and Nursing Care, as an end in itself; or (c) a mixture of both, for a Continuous Period of Hospitalisation exceeding 35 days (35-day period), but a patient receiving acute care immediately after the 35-day period does not become a Nursing Home Type Patient unless the period of acute care ends and the patient is then provided with accommodation and Nursing Care, as an end in itself, as part of a Continuous Period of Hospitalisation. Note 1: See definition of continuous period of hospitalization in section B2 of these Rules. Note 2: If a Nursing Home Type Patient is provided with acute care at the hospital (the first hospital), or at another hospital, the patient: (a) ceases to be a Nursing Home Type Patient only for the days on which the acute care is provided; and (b) again becomes a Nursing Home Type Patient when the provision of acute care ends and the patient is then provided with accommodation and Nursing Care as an end in itself, whether at the first hospital or another hospital. Note 3: If there is disagreement as to whether a patient is, or is not, a Nursing Home Type Patient, an insured person, a private health insurer or a Health Care Provider may make a complaint to the Commonwealth Ombudsman under Part 6-2 of the PHI Act The Ombudsman has various powers to deal with complaints, including conducting mediation if the complainant agrees. OMBUDSMAN Means Commonwealth Ombudsman. OPTIONS Means a brand name word that is combined with other brand name words to describe HIF s Ancillary Products. OVERSEAS VISITOR Means a person who: (a) is not a permanent Australian resident; (b) is not entitled to full Medicare Benefits; (c) is visiting Australia on a temporary visa. PARTNER Means a person who lives with a Fund Member of the same or different gender in a marital or de facto relationship and who is covered under the same Fund Membership notwithstanding the Primary Fund Member and a Partner may live apart temporarily. PBS

41 Means Pharmaceutical Benefits Scheme. PHARMACEUTICAL BENEFIT Means a Benefit attributable to any medicine or pharmaceutical product listed in the Schedule of Pharmaceutical Benefits for approved Pharmacists and Medical Practitioners. PHARMACEUTICAL BENEFITS SCHEME Means the schedule of medicines and pharmaceutical products approved for clinical use and subsidised by the Commonwealth Department of Health. PHI ACT 2007 Means Private Health Insurance Act 2007(Cth). PHI RULES Means Private Health Insurance Rules (Cth). POLICY HOLDER Means a Holder of an Insurance Product that is referrable to HIF. PORTABILITY Means the requirements that HIF has in relation to transfers between Insurance Products, pursuant to Division 78 of the PHI Act PRACTITIONER IN PRIVATE PRACTICE Means a practitioner who: (a) does not use any publicly funded hospital, clinic, health centre or other such Facility, including a Facility provided by a municipal authority for or in connection with the provision of an Ancillary Service for which a Benefit is claimable by a Fund Member under an Ancillary Product; (b) does not receive publicly funded assistance or support, whether by way of remuneration, subsidy or otherwise, in connection with the provision of an Ancillary Service, except where the Ancillary Service is provided at an Approved Facility of a strategic alliance partner or joint venture partner of HIF, or at a HIF Facility; and (c) is Self-Supporting, provided that HIF may at its absolute discretion include a practitioner not in private practice or a practitioner not in private practice in certain circumstances as if the practitioner is a Practitioner in Private Practice, including:

42 1. Dental services and treatments (including the supply of materials) provided by an Approved person who is registered with the Dental Board of a State or Territory of Australia to which paragraph (a) refers. PRE-EXISTING AILMENT Means Pre-Existing Condition. PRE-EXISTING CONDITION Means in relation to a person insured under an Insurance Product the person has a Pre-Existing Condition if: (a) the person has an ailment, illness or condition; and (b) in the opinion of a Medical Practitioner appointed by HIF, the signs or symptoms of that ailment, illness or condition existed at any time in the period of 6 months ending on the day on which the person became insured under the Insurance Product. PREGNANCY-RELATED SERVICES Means all services and treatments provided or rendered to a Fund Member during their confinement, including ultra-sounds and all services and treatments directly related to the delivery of a baby. PRIMARY FUND MEMBER Means the Fund Member who is the person named in the Fund Membership Application form as the applicant in respect of a Fund Membership and is the person ultimately responsible for ensuring the Fund Membership remains current at all times. PRIVATE HOSPITAL Means a Facility that the Minister has, pursuant to sub-section 121-5(6) of the PHI Act 2007, declared in writing is a hospital and is, pursuant to sub-section 121-5(8), a private hospital, provided that the declaration is at no time revoked. PUBLIC HOSPITAL Means a Facility that the Minister has, pursuant to sub-section 121-5(6) of the PHI Act 2007, declared in writing is a hospital and is, pursuant to sub-section 121-5(8), a public hospital, provided that the declaration is at no time revoked. QUALIFYING PERIOD Means any period, occurring immediately after joining HIF or joining a higher benefiting Insurance Product, during which either some or all Benefits are either reduced or not payable.

43 RECOGNISED EDUCATIONAL INSTITUTION Means an educational institution including but not limited to a school, college or university, recognised by the Commonwealth, State or Territory Governments. RECOGNISED HOSPITAL Means Hospital. REFERABLE Means, in relation to an Insurance Product, that: (a) HIF is identified under sub-section 93-15(1)(c) of the PHI Act 2007 as the Fund to which the Insurance Product is referable (and the Insurance Product has not been made referable to another health benefits fund under Division 146 of the PHI Act 2007); or (b) the Insurance Product has been made referable to HIF under Division 146 of the PHI Act REGISTERED Means, unless a contrary intention appears, a private health insurer registered under Part 4-3 of the PHI Act REGISTERED OFFICE Means the Registered Office of HIF as is recorded by the Australian Securities and Investments Commission. RELEVANT LAW Means: (a) (b) (c) (c) Act; Health Insurance Act 1973 (Cth); Private Health Insurance Act 2007 (Cth); and Any other present or future law of the Commonwealth of Australia or any State or Territory of Australia which HIF may determine to be a Relevant Law for the purposes of these Rules. RESTRICTED BENEFIT Means Benefit Restriction. "RISK EQUALISATION TRUST FUND" Means the Private Health Insurance Risk Equalisation Trust Fund continued in existence under Part 6-7 of the PHI Act 2007.

44 RULES Means, unless a contrary intention appears, these Fund Rules. SCHEDULE OF PHARMACEUTICAL BENEFITS Means Pharmaceutical Benefits Scheme. SECOND TIER DEFAULT BENEFIT Means at least the amount set out, or worked out using the method set out, in the PHI (Benefit Requirements) Rules 2007 (Cth) as the Minimum Benefit, or method for working out the Minimum Benefit, for an episode of Hospital Treatment at a Facility that does not have a negotiated agreement with HIF, provided that HIF may reduce the Minimum Benefit by the amount of any co-payment or excess that is required to be paid under the Insurance Product in respect of that treatment. SELF-SUPPORTING Means to be able to continue in and for the purpose of existence and pay costs and other expenses relating to or incidental to that existence from internal sources or from proceeds or Benefits derived or received through personal exertion including personal exertion of a principal s agent acting in the same or substantially similar way, provided that no proceed or Benefit shall be derived or received through receipt of a payment, subsidy, rebate, financial exemption or similar credit for value or its equivalent, whether or not it is received directly or indirectly from a publicly funded entity or person acting on behalf of a publicly funded entity or person. SERVICE PROVIDER Means, unless a contrary intention appears, an Approved Health Care Provider. SIS Means Standard Information Statement. STANDARD INFORMATION STATEMENT Means a summary of the features of a Complying Health Insurance Product pursuant to the Private Health Insurance Act 2007 (Cth) that contains the information and is in the form set out in the Private Health Insurance (Complying Product) Rules (Cth). STUDENT DECLARATION Means a written declaration, in the form prescribed or otherwise accepted by HIF, that satisfies HIF that the Fund Member is a Student Dependent. STUDENT DEPENDENT

45 Means a Fund Member who: (a) is aged twenty one years and less than twenty five years; (b) does not have a partner; (c) is enrolled and studying on a full time basis at an HIF recognised educational or training institution. THIRD PARTY Means a person other than HIF or a person covered under an Insurance Product. TRANSFER CERTIFICATE Means a form approved pursuant to section of the PHI Act 2007 relating to a transfer of a person from a (the old) policy of a health insurer to another (the new) policy of another health insurer. VISIT Means a Consultation. WAITING PERIOD Means the period that applies to a Fund Member for a Benefit under an Insurance Product: (a) starting at the time the person becomes insured under the Insurance Product; and (b) ending at the time specified in the Insurance Product; during which the Fund Member is not entitled to a Benefit. WORKCOVER Means the Western Australian statutory authority that is responsible for administering the Workers' Compensation and Injury Management Act 1981 on behalf of the state. YEAR Means, unless a contrary intention appears, the period from the 1 st January to the 31 st December. B3 Other

46 C MEMBERSHIP C1 General Conditions of Membership Subject to the PHI Act 2007, PHI Rules and the Constitution, upon acceptance of a Fund Membership Application by the Managing Director or his/her authorised delegate and payment of such amount(s) of premium(s) as the Board may determine from time to time, any Eligible Person may become a Fund Member of HIF and they shall upon becoming a Fund Member, but subject to these Rules, be entitled to participate in Benefits for themselves and Dependents included under the Fund Membership. 1. Change of Fund Membership details (a) Subject to these Rules, where Fund Membership details change, a Primary Fund Member shall inform HIF within two (2) months of such change. The Primary Fund Member may, in writing addressed to HIF, authorise another Fund Member to contact HIF on their behalf, to give effect to the required changes. (b) Changes to Fund Membership details include, but are not limited to: (1) change of address of any Fund Member; (2) change of contact details (e.g. phone, , or fax number); (3) change of Australian residency status; (4) change of name; (5) in the case of a Student Dependent, cessation or deferral of full-time study; (6) change of marital status or de facto status of a Dependent; or (7) a Dependent is no longer eligible to be a Dependent. 2. Insured groups HIF provides cover for the following insured groups: (a) (b) (c) (d) only one person; 2 Adults (and no-one else); 2 or more people, only one of whom is an Adult; or 3 or more people, only 2 of whom are Adults. 3. Levels of cover HIF currently provides the following levels of cover, being levels of cover that include the coverage requirements pursuant to Division 69 of the PHI Act 2007 and the PHI (Complying Products) Rules (Cth): 3.1 Hospital Treatment Products Gold No Excess cover Gold Excess $100/ $200 cover

47 Gold Excess $200/ $400 cover Gold Excess $400/ $800 cover GoldStar No Excess cover GoldStar Excess $200/ $400 cover GoldStar Excess $400/ $800 cover GoldStar Excess $500/ $1,000 cover GoldSaver Excess $200/ $400 cover GoldStarter Excess $200/ $400 cover GoldVital Excess $500/ $1,000 cover Comprehensive Working Visa cover Comprehensive Working Visa $500/ $1,000 Excess cover Intermediate Working Visa cover Essentials Working Visa cover Basic Working Visitors Excess cover Visitor Advantage Excess $200/ $400 cover Visitor Value Excess $250/ $500 cover Visitor Saver cover Basic No Excess 3.2 Combined Hospital Treatment and General Treatment (i.e. Ancillary Products) Health Max Saver Excess 100/200 cover No Maternity Hospital with Mid Extras Combo cover 3.3 General Treatment (i.e. Ancillary Products) Premium Options Super Options Special Options Saver Options Vital Options C2 Eligibility for Membership 1. Fund Membership eligibility (generally) Subject to these Rules, any Eligible Person may become a Fund Member. An application for Fund Membership shall not be denied on the grounds that the applicant or other person to be covered under an Insurance Product is not eligible for Medicare Benefits. 2. Portability HIF recognises Portability when new Fund Members transfer from another registered private health insurer (refer C6 for details). C3 Dependents 1. Types of Dependent

48 HIF recognises the following three types of Dependents: (a) (b) (c) Adult Dependent - a Fund Member who is a Partner of the Primary Fund Member and who is covered under the same Fund Membership as the Primary Fund Member (i.e. being a person who is a dependent of the Primary Fund Member and who is not a Dependent Child or Student Dependent); Dependent Child - a Fund Member who is aged less than twenty one (21) years including but not limited to a dependent s own child, step-child, legally adopted child, or a Child to whom the Primary Fund Member is the Legal Guardian, provided that the Dependent Child and their Child (if any) does not have a partner; Student Dependent - a person who is aged twenty one (21) years and less than twenty five (25) years including a Student Dependent s own Child, step-child, legally adopted child, or a Child to whom the Primary Fund Member is the Legal Guardian, provided that the Student Dependent does not have a partner and provided that the Student Dependent is enrolled and studying on a full time basis at an HIF recognised educational or training institution. An Adult Dependent, Dependent Child or a Student Dependent as the case may be shall only be covered: (a) (b) for the period that they remain eligible; and in relation to a Student Dependent, during the period covered by a Student Declaration. For the purpose of determining coverage in respect of a Dependent under a Fund Membership, HIF shall only recognise a Fund Member. To be a Fund Member of a Fund Membership, a Primary Fund Member must supply HIF a valid notice in the prescribed form. Upon registration by the Primary Fund Member in the prescribed form, of a Fund Member s Child who is born after the maternity Waiting Period, the Child will be immediately entitled to Benefits on the same level of cover as provided by the Primary Fund Member s Membership, provided that: (a) (b) in the case of a single person Fund Membership or couples Fund Membership, the Child is registered within 2 months from the date of their birth and the appropriate Contribution premium for the Family Membership level of cover required to include the baby from the birth date, is paid; and in the case of a family Fund Membership, the Child is registered within 4 years from the date of their birth or adoption. The Benefits of a family Fund Membership for a Dependent Child or Student Dependent applies to them regardless of whether or not they are working or living away from home, or working or living away from home.

49 2. Student Dependent Student Dependent Benefits under the family Fund Membership will apply from the 1st March to the 28th (or 29 th in the case of a leap year) of February of each Year, provided that a Student Dependent remains validly registered with HIF continuously. A registration, in the form of a Student Declaration, must be submitted to HIF within two (2) months of the commencement of academic or training program or course of study each year. A Student Dependent who has not held continuous cover with HIF during the Calendar Year commencing the 1 st March, may be required to serve Waiting Periods when cover is resumed. A Fund Member s registration as a Dependent Student is effective from the date a properly completed Student Declaration that satisfies HIF is received by HIF at its Registered Office. Ceasing to be a Dependent Subject to these Fund Rules, a person who ceases to be eligible to be a Dependent Child Fund Member or a Student Dependent Fund Member of HIF or of another (previous) fund may join HIF as an adult Fund Member, without having to serve an additional Waiting Period provided that: (a) (b) (c) the new level of cover is no higher than the existing level of cover; the ex-dependent person applies for Fund Membership within 2 months of ceasing to be a Dependent Child or Student Dependent; and all Waiting Periods (if any) of a previous Fund Membership of another (previous) fund have been served. C4 Membership Applications 1. Commencement of Fund Membership Subject to these Fund Rules, Fund Membership shall commence on the date the person lodges a Fund Membership Application (i.e. Application ) together with payment for Admission as a Primary Fund Member or on such other date as is nominated and recorded by HIF ( nominated date ) on the Application provided the nominated date is not earlier than (a) the date of lodgement of an Application or (b) the date on which the Primary Fund Member entered into or intended there be to HIF s satisfaction a binding commitment with HIF to become a Fund Member, whichever is the earlier. HIF shall in its absolute discretion determine the date on which the Primary Fund Member entered into a binding commitment with HIF to become a Fund Member.

50 For avoidance of doubt, Fund Membership cannot commence on a date earlier than the date of lodgement of an Application together with payment or the date on which the Primary Fund Member entered into a binding commitment with HIF to become a Fund Member. The lodgement date of an Application is the date it is received by HIF at its Registered Office or other receiving point authorised by HIF or the date it is received by an authorised agent of HIF. 2. Payment of Premium Contributions Other than payment of premium Contributions by way of payroll group deduction or direct debit, all payments of premium Contributions shall be for a minimum period of one month in advance. Where a Fund Member elects to pay premium Contributions via a group payroll deduction scheme authorised by HIF, if deductions do not commence immediately after the lodgement date or nominated date, a Fund Member shall make a payment (of the Arrears amount) to HIF to cover the period from the date of lodgement of a Fund Membership Application or nominated date and the date when the payroll deduction commenced. If the Fund Member does not pay the Arrears amount, the Fund Membership commencement date shall be amended to coincide with the date the payroll deduction commenced. Where the Fund Member elects to pay premium Contributions via HIF s direct debit Facility and they have nominated a specific date in accordance with HIF s direct debit Facility, the Fund Member shall be notified of any additional Contributions from the join date to the nominated commencing direct debit date and an automatic deduction including the Arrears will be deducted. HIF may require a minimum of one (1) month payment to commence Fund Membership regardless of the chosen payment method.

51 3. Change of Fund Membership details (a) The Primary Fund Member shall inform HIF, within two (2) months, of the details of any change to a Fund Membership. The Primary Fund Member may authorise, in writing, another person to advise HIF of a change to a Fund Membership. (b) Changes to a Fund Membership includes, but shall not be limited to a: (1) change of address of any Fund Member; (2) change of contact details (such as phone, , or fax numbers) of any Fund Member who is covered under the Insurance Product; (3) change of Australian residency status; (4) change of name; (5) in relation to a Student Dependent cessation or deferral of full-time study; (6) change of marital status or de facto status of a Dependent, or (7) Dependent is no longer eligible to be a Dependent. HIF accepts Applications for Fund Membership or changes to Fund Memberships only in the prescribed form. 4. Standard Information Statements ( SIS ) In accordance with Division 93 of the PHI Act 2007, HIF will, inter alia: (a) (b) (c) (d) (e) (f) maintain up to date SIS s; supply a SIS to the Primary Fund Member at least once every twelve months; upon request, explain the nature, purpose and (generally) the contents of a SIS, and how to obtain a copy of a SIS; upon request, supply a copy of a SIS of HIF; supply a new Primary Fund Member a SIS, details of the Insurance Product, including details of the amounts paid for Benefits or how Benefits are determined; supply a new Primary Fund Member a statement confirming the identity of the Fund to which the Insurance Product is Referable; and

52 (g) Give the Primary Fund Member reasonable notice of changes to these Rules that are detrimental. C5 Duration of Membership 1. Fund Membership Commencement A Fund Membership commences under this Fund Rule at the time: (a) an Application in the prescribed form is lodged with HIF; (b) a phone enrolment is accepted and logged on HIF s database system, provided that, within a reasonable time, an Application in the prescribed form is lodged with HIF; or (c) (d) where HIF agrees, nominated in an Application in the prescribed form; and in the case of visitors cover, the date of arrival in Australia of the Primary Fund Member. 2. Fund Membership Cessation A Fund Membership ceases under this Fund Rule, at the time: (a) (b) (c) (d) in the case of a single Fund Member, of death of the Fund Member; it becomes unfinancial, provided that the Fund Membership has not been returned to a Current financial Fund Membership during two months following the time it became unfinancial; it is cancelled; or it is terminated. C6 Transfers 1. Portability Portability refers to a person s ability to transfer from one Insurance Product, including one of another insurer, to another Insurance Product without having to serve a Waiting Period that has already been served under the first-mentioned Insurance Product. HIF administers its responsibilities and obligations in relation to Waiting Periods and Portability in accordance with Divisions 75 and 78 of the PHI Act Waiting Periods A Waiting Period under an Insurance Product that applies to a person who did not transfer to the Insurance Product is:

53 (a) for a Benefit for Hospital Treatment or Hospital-Substitute Treatment that is obstetric treatment or treatment for a Pre-Existing Condition (other than treatment covered by paragraph (b) - 12 months; and (b) for a Benefit for Hospital Treatment or Hospital-Substitute Treatment that is psychiatric care, rehabilitation or palliative care (whether or not for a Pre-Existing Condition) - 2 months; and (c) for any other Benefit for Hospital Treatment or Hospital-Substitute Treatment - 2 months. 3. Transfers A person transfers to a policy of a health insurer (the new policy) from another policy of a health insurer (the old policy) if: (a) either: (1) the person is insured under the old policy at the time the person becomes insured under the new policy; or (2) the person ceased to be insured under the old policy no more than 7 days, or a longer number of days allowed by HIF for this purpose, before becoming insured under the new policy; and (b) the old policy is a complying health insurance policy; and (c) the person s premium payments under the old policy were up to date at the time the person became insured under the new policy. 3.1 New Fund Members transfers from Australian registered private health insurers. HIF will give new Fund Members full continuity of cover to the level that is, at the time of transfer, equivalent to but not better than the level of cover with their old insurer, provided that: (a) the new Fund Member has served all Waiting Periods with their old insurer; (b) a Transfer Certificate detailing the level of cover, period of cover, persons covered, Certified Age at Entry and a claims history is received from the old insurer; and (c) the financial date paid to with the old insurer is no greater than 2 months from the commencement date with HIF.

54 3.2 New Fund Members - transfers from Australian Registered private health insurers with a gap in cover greater than 2 months A Fund Member who transfers from their old insurer shall be subject to Waiting Periods where the time from the financial date paid to with the old insurer to commencement is greater than 2 months. Any of the following days that occur after an adult Fund Member ceases, for the first time after their Lifetime Health Cover base day to have hospital cover are permitted days without hospital cover in respect of that adult: (a) days on which the cover is suspended by HIF in accordance with the Rules for suspensions set out in the PHI (Lifetime Health Cover) Rules (Cth); (b) days, not counting days covered by paragraph (a), on which the adult is overseas that form part of a continuous period overseas of more than one year; (c) the first 1,094 days (not counting days covered by paragraph (a) or (b) on which they did not have hospital cover. If the number of days without hospital applying to an adult Fund Member is greater than the number of permitted days without hospital cover, then an increased premium (a loading) shall apply to the Fund Membership in accordance with these Rules and Part 2-3 of the PHI Act New Fund Members transfers from Australian Registered private health insurers where Waiting Periods have not been fully served Waiting Periods under an Insurance Product that applies to a person who transferred to the Insurance Product shall be equal to the periods referred to in paragraphs 2(a) (c) of this Rule, less the Waiting Periods served (if any) with the old insurer at the time of transfer to the Insurance Product. During a Waiting Period under an Insurance Product, persons covered under the Insurance Product shall not be entitled to Benefits. 3.4 New Fund Members - transfer from a Registered international health insurer A new Fund Member who transfers from a policy of an international health insurer will be accepted with continuity of Benefits applicable to Basic No Excess Hospital and Saver Options only during Waiting Periods of HIF, provided that: (a) the financial date paid to with the old insurer is no greater than 2 months from the HIF joining date;

55 (b) the person s old insurer provides HIF with relevant supporting documentation as may reasonably be required by HIF detailing, inter alia, the person s previous level of cover, period of cover and those persons covered by that policy; (c) the person has served all Waiting Periods of their old insurer. The balance of a person s 12 month Waiting Period with an old insurer shall be the greater of: (a) 12 months minus the actual Waiting Period served; and (b) 0 month. The balance of a person s 12 month Waiting Period with an old insurer shall be added to HIF s Waiting Period (if any). 3.5 New Fund Members transfers from a lower level of cover of an Australian Registered private health insurer A person who transfers from a lower level of cover under a policy of their old health insurer to a higher level of cover under an Insurance Product, in addition to any other Waiting Periods, shall serve HIF Waiting Periods in relation to those parts of the policy of HIF that were not available or not included under the policy of the old insurer. To assist in removing doubt, the following situations would attract a HIF Waiting Period: (a) where the Insurance Product does not include an excess or co-payment and the policy of the old insurer did, the excess or co-payment as the case may be shall apply to the person during the relevant HIF Waiting Period; (b) where the Insurance Product does not include restricted services or treatments and the policy of the old insurer did, the restriction shall apply to the person during the relevant HIF Waiting Period; (c) where the Insurance Product does include certain services or treatments and the policy of the old insurer did not include them or specifically excluded them, the exclusion shall apply to the person during the relevant HIF Waiting Period. 3.6 Waiting Periods former Gold Card Holders An Insurance Product that covers a person who:

56 (a) held a Gold Card, or was entitled to treatment under a Gold Card, before applying for the insurance; and (b) applies for the insurance no longer than 2 months after the person ceased to hold, or be entitled under, the Gold Card, shall not apply to the person any Waiting Period or Benefit Limitation Period for any Hospital Treatment or General Treatment covered by the Insurance Product. 3.7 Transfer Certificates Certificate for the insured person HIF (the old insurer) must, if a person ceases to be insured under an Insurance Product and does not become insured under another Insurance Product, give the person a certificate under this Rule: (a) in the approved form; and (b) within the period set out in the PHI (Complying Product) Rules (Cth) Certificate for the new insurer HIF (the new insurer) must request a certificate from an old insurer if: (a) a person who is or has been insured under a complying health insurance policy of the old insurer transfers to an Insurance Product; and (b) the person does not give HIF the certificate the old insurer gave the person under sub-rule (1) within 7 days of becoming insured by HIF. The request must be made: (c) in the approved form; and (d) within the period set out in the PHI (Complying Product) Rules (Cth), or otherwise, within 14 days. HIF shall not request a certificate except in the circumstances set out in sub-rule If a certificate is requested by HIF (whether or not the request is in the approved form or made within the period mentioned in sub-paragraph 3.7.2(d), the old insurer must give HIF a certificate in the approved form and within the period set out in the PHI (Complying Product) Rules (Cth), or otherwise, within 14 days.

57 C7 Cancellation of Membership 1. Cancellation HIF will cancel a Fund Member s Fund Membership in the following circumstances: (a) (b) (c) (d) upon receipt by HIF of a request, in the prescribed form, from the Primary Fund Member to cancel the Fund Membership entirely; upon receipt by HIF of a request, in the prescribed form, from the Primary Fund Member to remove a Fund Member from the Fund Membership; upon receipt by HIF of a request, in the prescribed form, from a Fund Member covered under the Insurance Product other than the Primary Fund Member to remove that Fund Member from the Fund Membership; or immediately after 2 months after the Fund Membership becomes unfinancial (in Arrears). HIF may at its absolute discretion and under such terms and conditions as HIF determines are appropriate, reinstate a previously cancelled Fund Membership. In considering a request of a previous Fund Member (requester) to reinstate, HIF may determine the matter in favour of the requestor and give effect to continuity of service and related Fund Membership entitlements, provided that the reinstatement is subject to Rule D5. 2. Refund of Premium Contributions (a) (b) (c) HIF will refund premium Contributions relating to the period after the date that a request in the prescribed form, to cancel a Fund Membership, is received by HIF or the period after the date specified in the prescribed form, whichever is the latter. HIF may at its absolute discretion, charge an administration fee in relation to a cancellation. HIF may, in the case of a refund of premium Contributions resulting from a cancellation, deduct the administration fee (if any). C8 Termination of Membership Termination of Fund Membership - Fund Member acting improperly

58 1. Termination A Fund Membership may be terminated by HIF under this Fund Rule, at the time: (a) (b) (c) (d) (e) determined pursuant to the Constitution; a Fund Contributor or Fund Member, acting alone or in concert with another person, obtains or attempts to obtain an improper financial or other advantage from HIF; in the opinion of HIF, a Fund Contributor or Fund Member, acting alone or in concert with another person, deceives or misleads HIF, or attempts to mislead or deceive HIF; a Fund Contributor or Fund Member does not provide HIF with true, accurate or full information with respect to the Fund Membership of a Fund Member or a Fund Member; or HIF, at its absolute discretion, determines that it is reasonable and appropriate in the circumstances that the Fund Membership be terminated; provided that HIF shall give written notice to the Primary Fund Member, including reasons and the amount (if any) to be refunded for premium Contributions received in advance of the date of termination, that the Fund Membership is terminated according to this Fund Rule. 2. Reinstatement Where a Fund Membership has been terminated under this Fund Rule, subject to a provision of a law to the contrary, HIF shall, upon receipt of a written request from a terminated Fund Contributor or Fund Member, have an absolute discretion to reinstate a Fund Membership, including the giving of continuity of Fund Membership and entitlements, provided that the Fund Membership becomes financial at the date of reinstatement. C9 Temporary Suspension of Membership 1. Suspension of Fund Membership and Insurance Product HIF may approve a request, in the prescribed form, from a Primary Fund Member to suspend their Fund Membership including the insurance cover under the Fund Membership for any one of the following reasons, provided that the Fund Membership has been financial and held continuously for no less than 3 months ( Suspension Qualifying Period ) prior to the date specified in the request as being the proposed effective date of suspension:

59 (a) (b) (c) (d) Unemployment - where a Fund Member wishes to suspend their Fund Membership due to unemployment, the maximum period of suspension is 12 continuous months, provided that the Fund Member supplies HIF supporting documentation in the form of a health care card, supporting documents from Centrelink or other documentation as may be reasonably required by HIF; Financial hardship - where a Fund Member wishes to suspend their Fund Membership due to financial hardship, the maximum period of suspension is 6 continuous months, provided that a written request including supporting documentation as may be reasonably required by HIF, is made to HIF s Fund Member Action Review Committee ( MARC ); Overseas travel - where a Fund Member wishes to suspend their Fund Membership due to overseas travel, the minimum period of suspension is 2 continuous months and the maximum period of suspension is 24 continuous months; Other - HIF may at its absolute discretion approve suspension of Fund Membership for a reason other than a reason detailed in subparagraphs (a) (c) for a maximum of 12 continuous months provided that a written request, including supporting documentation, is made to HIF s MARC. Upon written request by the Primary Fund Member, HIF may, at its absolute discretion, reduce or waive the Suspension Qualifying Period or increase the relevant maximum period of suspension under sub-paragraphs (a) (d). 2. Overseas Visitors cover - sole reason and time limits (a) (b) A request in the form referred to in sub-rule (1) of this Fund Rule relating to an Overseas Visitor's Insurance Product shall only be considered by HIF where all persons covered under the Insurance Product are overseas during the (requested) period of suspension. The minimum period a Fund Membership may be suspended under this sub-rule is 14 days. (c) The maximum duration a Fund Membership may be suspended in any continuous 12 month period shall not exceed 4 months. 3. Fund Membership and Insurance Product to be paid in advance A Fund Membership shall not be suspended unless premium Contributions paid to HIF cause the Fund Membership to be financial up to and including the day prior to commencement of the period of suspension.

60 4. All parts of the Fund Membership and Insurance Product to be suspended A Fund Membership that includes an Insurance Policy comprising a component relating to Hospital Treatment and a component relating to General Treatment cannot be partly suspended by suspending either the Hospital Treatment component or the General Treatment component but not both components. 5. Arrangements during Fund Membership and Insurance Product suspension period During the period a Fund Membership is suspended: The Fund Membership category (Fund Membership status) will be adjusted to reflect the suspension; The Fund Membership shall not be taken into account for the purposes of generating a premium Contribution charge; Benefits shall not be payable for services and treatments received by any person covered under the Fund Member s Insurance Product; and The period of suspension does not count for any purpose in relation to the Fund Membership, including but not limited to Waiting Periods and Benefit Limitation Periods. 6. Minimum period between suspension periods The period between two suspension periods that were Approved for the same reason shall be no less than 12 months. 7. Documentation to be provided The Primary Fund Member of a Fund Membership who wishes to either suspend or reactivate the Fund Membership shall make a request to HIF for the relevant change in the prescribed form and at the same time supply HIF with relevant documentary information including documentary information specifically requested by HIF. 8. Reactivation to occur within one month Where the relevant reason for approving suspension ceases to apply to a Fund Membership, or the maximum period of suspension has been reached, then: (a) If the Primary Fund Member reactivates the Fund Membership within one month, continuity of Fund Membership will apply;

61 (b) If the Primary Fund Member reactivates the Fund Membership later than one month, the Fund Membership will be deemed to be a new Fund Membership for all purposes. 9. Early reactivation - Waiting Periods Where a suspended Fund Membership is reactivated while the relevant reason that gave rise to the approval for suspension continues to apply, and the maximum suspension period has not been reached, a new Waiting Period of two months shall apply to all persons covered under the relevant Fund Membership from the date of reactivation. 10. Lifetime Health Cover Days on which an adult is overseas that form part of a continuous period overseas of more than one year count as permitted days without Hospital cover. Lifetime Health Cover loading (if any) shall not include permitted days overseas that form part of a continuous period overseas of more than one year. A person is taken to be overseas: (a) During any period in which the person returns to Australia for less than 90 days. A person is taken to have returned from overseas if the person returns to Australia for a period of at least 90 days. C10 Other D CONTRIBUTIONS D1 Payment of Contributions 1.1 Definition and Contributor or Member Obligation A premium Contribution is an amount paid or payable by a Fund Contributor or Fund Member to HIF in consideration for an Insurance Product that covers Hospital Treatment or General

62 Treatment or both (whether or not it also covers any other treatment or provides a Benefit for anything else) in respect of a Fund Member(s). In these Fund Rules, unless otherwise stipulated, premium Contribution, premium and Contribution mean the same. 1.2 Contribution Methods and Frequency HIF accepts premium Contributions on weekly, fortnightly, monthly, quarterly, half yearly and yearly payment cycles. Only the following premium Contribution payment cycles are available to Fund Members: Payment Method Available Payment Cycles 1. Direct payment (except 2. & 3. quarterly, half yearly, yearly below) 2. Direct debit fortnightly, monthly, quarterly, half yearly, yearly 3. Payroll deduction weekly, fortnightly, monthly, quarterly half yearly, yearly A Fund Member can elect to alter their payment cycle at reasonable intervals. A Fund Contributor or a Fund Member may by request nominate the day on which a payment cycle commences. The day on which a payment cycle commences shall not include a Saturday or a Sunday. Where a payment cycle commencement occurs on a public holiday, HIF shall determine an alternative day on which the relevant premium Contribution is to be paid. Fund Members must pay premium Contributions in Australian legal tender currency by cash, cheque, money order, payroll deduction as part of a payroll group comprising not less than five Fund Memberships, direct debit, HIF accepted debit card, HIF accepted credit card or other method as might be agreed by the Fund Member and the Managing Director of HIF. Excepting payroll deduction or direct debit, the minimum period a premium Contribution payment shall cover is one month. Contributions shall be paid in advance. 1.3 State Premium Contribution Rates Premium Contributions may differ for the same Insurance Product, based upon the State or Territory in which the Fund Contributor permanently resides. Where upon relocation a Fund Contributor does not advise HIF of their new State or Territory residential status and HIF determines this to be the case, it may reasonably backdate the change of premium Contributions for that Fund Contributor.

63 D2 Contribution Rate Changes 1. Effective Date Premium Contribution rates may change from time to time. The date that a new or changed premium Contribution rate becomes applicable is the effective date. The published date, being a date prior to the effective date, is the date that HIF notifies its Fund Members that premium Contribution rates will change on the effective date. 2. Published Date Where a premium Contribution payment made prior to a published date causes (i.e. without the imposition of a premium Contribution rate change) a Fund Member s paid to date to be later than the effective date of a change in premium Contribution rates, that paid to date shall not be altered as a consequence of that rate change. Where a premium Contribution payment is made after a published date and before the effective date of a change to premium Contributions, so much of that payment as relates to the period from the day after the previous paid to date to the day before the effective date shall be applied at the premium Contribution rates existing before the change, and the remainder of the payment (if any) shall be applied to the period commencing on the effective date to the next paid to date at the premium Contribution rates existing after the change. 3. Payment in Advance Maximum Period The maximum period payable in advance for cover under an Insurance Product is 12 months from the date of payment of a premium Contribution. 4. State or Territory Premiums HIF may apply different premium Contribution rates based on the Australian State or Territory in which the Fund Member permanently resides. D3 Contribution Discounts HIF may, at its absolute discretion, discount premium Contributions for any or all of the following reasons: (a) (b) they are paid at least three months in advance; they are paid by payroll deduction;

64 (c) (d) (e) (f) (g) they are paid by pre-arranged automatic transfer from an account at a bank or other financial institution; Fund Members have agreed to communicate with HIF, or make claims under their Insurance Product, by electronic means; Fund Members insured under an Insurance Product are, under these Fund Rules, treated as belonging to a Contribution group; HIF is not required to pay a levy in relation to an Insurance Product under a law of a State or Territory; or it is permitted under the PHI (Complying Product) Rules (Cth). A discount in respect of an Insurance Product is the difference between the full premium and the net premium. The discount percentage (if any) is the percentage determined by dividing the monetary amount of discount for the relevant period by the monetary amount of the full premium for the same period. The maximum percentage discount allowable is 12 %. If during the relevant year, premium Contributions are discounted by more than 12%, HIF shall be entitled to recover from the Fund Contributor of the Fund Membership the amount(s) necessary to ensure the premium Contributions for the relevant year are not discounted by more than 12%. A discount includes any of the following: (a) incentive payment; (b) promotional payment; (c) rebate; and (d) any other inducement whatsoever, made available by HIF to another person, including to an insured person, in respect of the payment of a premium Contribution for an Insurance Product, including inducing a person to purchase or maintain an Insurance Product. A discount does not include the following:

65 (a) a brokerage fee or commission paid in respect of an Insurance Product; and (b) the cost of any discount, product, service, waiver or other thing (promotion) offered to a person at the time the person first purchases a Product from HIF if: (i) the cost of the promotion does not exceed 12% of the full premium, for a year, for the Insurance Product purchased; and (ii) the promotion is provided in the first year after a person purchases an Insurance Product. Excepting payments in advance from Contribution groups, the following discounts apply automatically to full premiums: (a) 2% in relation to a single payment in advance covering not less than six months but less than twelve months; (b) 4% in relation to a single payment in advance covering not less than twelve months. HIF may, at its absolute discretion, discount the full premium of all policies included in a premium Contributions group by between 4% and 12%.

66 D4 Lifetime Health Cover Subject to the PHI Act 2007, from the 1 st July 2000, adult Fund Members who take out Hospital cover late will have to pay increased premiums. An adult Fund Member takes out Hospital cover late when he or she does not have Hospital cover on their Lifetime Health Cover base day. Lifetime Health Cover base day is determined by using the following diagram: Working out a person s lifetime health cover base day Has the 1 July following the person s 31 st birthday? No Lifetime health cover does not yet apply to the person. Yes Was the person born on or before 1 July 1934? Yes Lifetime health cover does not apply to the person. No Is the person a new arrival? Yes The person s lifetime health cover base day is the later of; (a) the 1July following the person s 31 st birthday; and No Did the person turn 31on or before 1 July 2000? Yes The person s lifetime health cover base day is 1 July No Was the person overseas on the 1 July following his or her 31 st birthday? Yes The person s lifetime health cover base day is the first anniversary of the person s return from overseas. No The person s lifetime health cover base day is the 1 July following his or her 31 st birthday.

67 The amount of increased premium is determined using the following formula: (Lifetime Health Cover age 30) X 2 % X Base rate, where: Base rate for Hospital cover is the amount of premium that would be payable for that cover if: (a) the premium were not increased under this Rule; and (b) there was no discount of the kind allowed under these Rules pursuant to section 66-5(2) of the PHI Act Lifetime Health Cover age, in relation to an adult who takes out Hospital cover after his or her Lifetime Health Cover base day, means the adult s age on the 1st July before the day on which the adult took out the Hospital cover. If after the adult s Lifetime Health Cover base day, the adult ceases to have Hospital cover, HIF must increase the adult s premium determined using the following formula: Years without Hospital cover X 2 % X Base rate, where: Base rate is the base rate for the Hospital cover (see above), and Years without Hospital cover is the number obtained by: (a) dividing by 365 the number of days (other than permitted days without Hospital cover), after the first day on which the adult did not have Hospital cover; and (b) rounding up the result to the nearest whole number. HIF must stop increasing the amount of premiums payable for Hospital cover in respect of an adult under this Rule if the adult has had Hospital cover (including under an applicable Benefits arrangement), the premiums for which have been increased under this Rule or Schedule 2 to the National Health Act 1953 as in force before the 1st April 2007: (a) for a continuous period of 10 years; or (b) for a period of 10 years that has been interrupted only by permitted days without Hospital cover or periods during which the adult was taken to have had Hospital cover otherwise

68 than at any time during which the adult was covered by an applicable Benefits arrangement within the meaning of the National Health Act 1953 as in force before the 1 st April 2007 (none of which count towards the 10 years). The amount must stop being increased on the day after the last day of the 10 year period. The amount of premiums payable for Hospital cover in respect of an adult must start to be increased under this Rule again if: (a) after the end of the 10 year period, the adult ceases to have Hospital cover; and (b) the adult later takes out Hospital cover again; and (c) the days in the period between ceasing to have the cover and taking it out again are not all permitted days without Hospital cover in respect of the adult. These Rules are not prevented from applying again in respect of any later 10 year period. Hospital cover is so much of an Insurance Products covers Hospital Treatment. An adult has hospital cover if he or she is insured under an Insurance Product that covers Hospital Treatment. An Adult is taken to have Hospital cover: (a) at any time during which the adult was covered by an applicable Benefits arrangement; or (b) at any time during which the adult holds a Gold Card; or (c) at any time during which the adult is in a class of adults specified in the PHI (Lifetime Health Cover) Rules 2007 (Cth) for the purposes of this Rule. Gold Card means a card that evidences a person s entitlement to be provided with treatment: (a) in accordance with the Treatment Principles prepared under section 90 of the Veterans Entitlements Act 1986 (Cth); or (b) in accordance with a determination made under section 286 of the Military Rehabilitation and Compensation Act 2004 (Cth) in respect of the provision of treatment. Subject to the PHI Act 2007, persons born on or before the 1 st July 1934 shall be exempt from increased premiums for Lifetime Health Cover (i.e. a loading ) under this Rule. Subject to the PHI Act 2007, the maximum that the Base Rate can increase by under this Rule is 70 %.

69 In determining whether or not a person had Hospital cover at a particular time or for a particular period, the following types of evidence shall be accepted by HIF: (a) the Annual statement issued to, or on behalf of, the person by the private health insurer (if any) providing the cover at the particular period; (b) a determination referred to in the PHI Act 2007 in respect of the person, if the date to which the determination applies is the particular time or is included in the particular period; (c) a written statement issued by the Australian Antarctic Division of the Department of the Environment and Heritage, that the person had health services provided by or through the Australian Antarctic Division at the particular time or during the particular period; (d) a written statement issued by the Australian Defence Force that the person had health services provided by or through the Australian Defence Force at the particular time or during the particular period. In establishing a person s age for the purpose of determining whether or not increased premiums (i.e. a loading ) under Lifetime Health Cover provisions of the PHI Act 2007 apply, HIF shall accept the following kinds of evidence as conclusive evidence of that person s age: (a) an original birth certificate in respect of the person; (b) a current driver s licence issued to the person; (c) a current passport issued to the person. HIF may accept other evidence if a document of a kind mentioned in this Rule is not available to be given as evidence. D5 Arrears in Contributions A Fund Membership (other than a suspended Fund Membership) is in Arrears or in a period of Arrears whenever the date to which premium Contributions have been paid (i.e. the paid to date ) is earlier than the current date. A Fund Membership that is in Arrears is deemed to be unfinancial and one that is not financial. Rebates are not payable for services or treatments provided to a Fund Member or a person covered under a Fund Member s Fund Membership during a period of Arrears whilst a Fund Membership is in Arrears.

70 A Fund Member, who has fallen into Arrears, may with HIF s approval, within 2 months after the date of falling into Arrears, pay HIF the sum of: (a) premium Contributions that are in Arrears; and (b) one month s premium Contributions. A Fund Member s claim that has not been assessed, processed or dealt with including a rebate that has been withheld because or whilst a Fund Membership remains in Arrears, shall become assessable, capable of being processed or dealt with or remitted as the case may be, upon payment of the amounts specified under (a) and (b) in the preceding paragraph. On the day immediately after 2 months after an unfinancial Fund Membership was last financial, the Fund Membership shall automatically terminate from the day the Fund Membership was last financial. A terminated Fund Membership may, at the absolute discretion of the Managing Director or his/her authorised delegate nominee, be reinstated under such terms and conditions as might under the circumstances, in the opinion of the Managing Director or their authorised delegate nominee, be reasonable having, inter alia, regard to the interests of all Fund Memberships. D6 Other In the event that a Fund Member properly advises HIF that they have decided to transfer to another fund not operated by HIF, then if at the date of transfer the Fund Membership is paid in advance, HIF shall refund the net amount paid in advance, less an administration fee (if any), provided that such fee shall not exceed $50.

71 E BENEFITS E1 General Conditions The amount of any rebate Benefit paid or payable by HIF in relation to a claim by a person covered under an Insurance Product shall not result in the person receiving a greater amount than the fee or charge of the Health Care Provider in relation to that claim. 1. Services and treatments supplied by HIF recognised Health Care Providers HIF shall only pay a rebate Benefit in respect of a service or treatment, including goods supplied as part of or integral to the provision of a service or treatment, if it is supplied by a Health Care Provider that is recognised by HIF, including: (a) (b) a Hospital declared by the Minister to be a Hospital pursuant to section 121-5(5) of the PHI Act 2007; a Health Care Provider other than a Hospital under sub-paragraph (a) of this Rule; and The Health Care Provider provides the service or treatment whilst they are in Independent Private Practice. HIF may at its absolute discretion, determine if a Health Care Provider is to be recognised, irrespective of whether or not the Health Care Provider meets all or only some of the HIF criteria for recognition. In determining a Health Care Provider s eligibility for recognition, HIF shall have regard for, inter alia, the Health Care Provider s ability to demonstrate to HIF s absolute satisfaction that; (a) (b) they have the required skills, experience, standards, competencies and qualifications to supply the relevant service or treatment; or a service or treatment of the Health Care Provider is clinically relevant or appropriate. 2. Health Care Provider For the purposes of this Rule, a Health Care Provider is: (a) (b) a person who provides goods or services as, or as part of, Hospital Treatment or General Treatment; or a person who manufactures or supplies goods provided as, or as part of, Hospital Treatment or General Treatment.

72 3. Health Care Provider fails to meet recognition requirements HIF shall not pay a rebate Benefit in respect of a service or treatment, including goods supplied as part of or integral to the provision of a service or treatment, if or HIF has reasonable grounds to believe: (a) (b) (c) (d) premises or facilities do not meet the definition of Hospital as set out in Sub-Rule 1(a) above; a Health Care Provider is not in Independent Private Practice; a Health Care Provider does not meet a recognition criteria of HIF; a Health Care Provider does not supply a clinically relevant or appropriate service or treatment. 4. Recognised Health Care Provider ceases to meet recognition requirements At the time that a previously recognised Health Care Provider no longer meets the HIF requirements for recognition, HIF shall, in addition to the right in Rule E1 (3) above, have the following rights: (a) suspend the Health Care Provider s recognition; (b) cancel the Health Care Provider s recognition. 5. Benefit reduction Where a rebate Benefit is payable in respect of a claim by a person covered under an Insurance Product, the rebate Benefit shall be reduced in the following circumstances: (a) (b) (c) where the Health Care Provider s fee or charge is lower that the rebate Benefit that would otherwise have been payable by HIF, the rebate Benefit shall be reduced to equal the amount of the Health Care Provider s fee or charge; where money is payable or a Benefit accrues, or both, to a claimant who is covered under an Insurance Product, from another source other than from HIF for a service or treatment that HIF would, but for the other source, pay, HIF shall pay a rebate Benefit to the claimant of such amount as to cause the total money and Benefit accruing to the claimant to equal the fee or charge of the Health Care Provider; and where in the reasonable opinion of HIF a fee or charge of a Health Care Provider is higher than their usual charge for a service or treatment, HIF shall when assessing a

73 claim that includes a higher fee or charge, adopt the Health Care Provider s usual fee or charge as if it had applied from the outset. 6. Benefit liability where false or misleading information is provided HIF shall not pay a rebate Benefit in respect of a service or treatment, including goods supplied as part of or integral to the provision of a service or treatment, if or HIF has reasonable grounds to believe that the rebate Benefit would have, had it been paid, resulted from false or misleading information. E2 Hospital Treatment 1. Benefits applicable to all Hospital Treatment For the purposes of this Fund Rule, Hospital Treatment is treatment (including the provision of goods and services) that: (a) (b) is intended to manage a disease, injury or condition; and is provided to a person: (i) (ii) by a person who is authorised by a Hospital to provide the treatment; or under the management or control of such a person; and (c) either: (i) (ii) is provided at a Hospital; or is provided, or arranged, with the direct involvement of a Hospital; (d) is specified in the PHI (Health Insurance Business) Rules 2007 (Cth) as being Hospital Treatment. 2. Treatment included under Hospital Treatment A reference to treatment in these Fund Rules includes a reference to any of, or any combination of accommodation, nursing, medical, surgical, podiatric surgical, diagnostic, therapeutic, prosthetic, pharmacological, pathology or other services or goods intended to manage a disease, injury or condition. 3. Continuous Period of Hospitalisation

74 HIF calculates a Continuous Period of Hospitalisation by counting consecutive days of Hospital Treatment, including any 2 periods of consecutive days during which a patient was or is receiving Hospital Treatment as an Inpatient of a Hospital, whether or not the same Hospital, where the periods are separated from each other by a period of not more than 7 consecutive days during which the Inpatient was not receiving Hospital Treatment as an Inpatient at any Hospital. 4. Hospital Benefits not payable in certain circumstances HIF shall not pay a hospital Benefit in the following circumstances: (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) (m) where, pursuant to section 75-1 of the PHI Act 2007, a Fund Member has not served the applicable Waiting Periods for the service or treatment being undertaken; where the Fund Membership is unfinancial at the date of service or treatment; where, pursuant to section of the PHI Act 2007, the service or treatment being undertaken is a Pre-Existing Condition; in respect of a claim or that part of a claim in respect of a service or treatment, pursuant to Fund Rule F7, which has been or could be met out of a Third Party Compensation claim; where a claim is not submitted to HIF in the prescribed form; for a medical service or treatment that is classified as cosmetic or where a Benefit is not payable by Medicare Australia; for a medical service or treatment not recognised by Medicare Australia; for a medical service or treatment rendered or supplied outside of Australia; where a service or treatment is classified as a Type C procedure and would not normally require hospitalisation and where certification is not supplied by a medical practitioner; where a service or treatment has been rendered or supplied to a newborn who is not admitted in their own right as an Inpatient in Hospital; where a service or treatment has been rendered or supplied as part of an attendance at an emergency department of a Hospital; the cost of care or accommodation in an aged care service (within the meaning of the Aged Care Act 1997); where there is a charge for a pharmaceutical Benefit supplied under Part V11 of the National Health Act 1953 (Cth) unless the charge is covered by section 92B of that Act;

75 (n) any other treatment specified in the PHI (Complying Products) Rules 2007 (Cth) as treatment for which Benefits must not be provided. 5. Contracted Hospitals Benefits shall be paid at Contracted Hospital Purchaser Provider Agreement rates that are agreed to between a Hospital and the AHSA. A full list of Contracted Hospitals is available from HIF. 6. Non-contracted and public Hospitals HIF Benefits shall be paid in accordance with the following table, pursuant to the PHI (Benefit Requirements) Rules 2007 (Cth) and section 72-1 of the PHI Act 2007: Requirements of an Insurance Product that covers Hospital Treatment must meet Item There must be a Benefit for: The amount of the Benefit must be: 1. Any part of Hospital Treatment that is one or more of the following: (a) psychiatric care; (b) rehabilitation; (c) palliative care; At least the amount set out, or worked out using the method set out, in the Private Health Insurance (Benefit Requirements) Rules as the Minimum Benefit, or method for working out the Minimum Benefit, for that treatment. if the treatment is provided in a Hospital and no Medicare Benefit is payable for that part of the treatment. 2. Hospital Treatment covered under the Insurance Product for which a Medicare Benefit is payable. (a) If the charge for the treatment is less than the schedule fee for the treatment so much of the charge (if any) as exceeds 75% of the schedule fee; and (b) Otherwise at least 25% of the treatment. 3. If the Insurance Product covers Hospital-Substitute Treatment (a) If the charge for the treatment is less than the schedule fee for the

76 Hospital-Substitute Treatment covered under the Insurance Product for which a Medicare Benefit is payable. 4. (a) Hospital Treatment *covered under the Insurance Product; and (b) if the Insurance Product covers hospital-substitute treatment Hospital-Substitute Treatment covered under the Insurance Product; that is the provision of a prosthesis of a kind listed in the Private Health Insurance (Prostheses) Rules 2007 (Cth) in circumstances: (c) in which a Medicare Benefit is payable; or (d) set out in the Private Health Insurance (Prostheses) Rules for the purposes of this table item. 5. Any treatment for which the Private Health Insurance (Benefit Requirements) Rules specify there must be a Benefit. treatment so much of the charge (if any) as exceeds 75% of the schedule fee; and (b) Otherwise at least 25% of the schedule fee for the treatment; but the Benefit must not be provided if a Medicare Benefit of an amount that is at least 85% of the schedule fee is claimed for the treatment. (a) At least the amount set out, or worked out using the method set out, in the Private Health Insurance (Prostheses) Rules as the Minimum Benefit, or method for working out the Minimum Benefit, for the prosthesis; and (b) If the Private Health Insurance (Prostheses) Rules set out an amount, or a method for working out an amount, as the maximum Benefit, or method for working out the maximum Benefit, for the prosthesis no more than that amount or the amount worked out using that method. At least the amount set out, or worked out using the method set out, in the Private Health Insurance (Benefit Requirements) Rules as the Minimum Benefit, or method for working out the Minimum Benefit, for that treatment. 7. Medical Benefits

77 (a) HIF shall pay medical Benefits in accordance with section 72-1 of the PHI Act 2007; (b) (c) (d) HIF shall pay a Benefit for all Inpatient medical procedures that are covered under an Insurance Product where a Medicare Benefit is payable by Medicare Australia; HIF shall pay a Benefit towards outpatient and Inpatient procedures that are covered under an overseas Hospital Insurance Product and HIF shall pay a Benefit in accordance with Access Gap Cover for all Hospital Treatment that is covered under an Insurance Product. 8. Access Gap Cover (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) HIF shall pay Benefits in relation to eligible Inpatient medical services and treatments in accordance with the AHSA Access Gap Scheme; Access Gap Cover is payable for all HIF Hospital Products; Access Gap Cover shall comprise known gap and no gap Benefits; Access Gap Cover is automatically included in all eligible Hospital Products HIF reserves the right to review the cost attributable to Access Gap Cover and to make changes to premium Contributions in all eligible Hospital Products; A Benefit paid to participating doctors under Access Gap Cover is determined by reference to the HIF schedule of Benefits which are set as a percentage above the Medicare Benefits Schedule; The average HIF Benefit under Access Gap Cover is 129 % of the Medicare Benefits Schedule fee; If a doctor chooses to charge in excess of the HIF Access Gap Cover fee, there will be an out of pocket expense to the patient; If a doctor is participating in the scheme, the maximum out of pocket expense shall not exceed $ 400, except in respect of a confinement undertaken by a participating obstetrician in which case the fee may be up to $ 800 (per baby); Informed financial consent - HIF shall provide a Batch Header form which will contain a declaration as to the Health Care Provider s obligation to supply informed financial consent and a disclosure of their financial interest. Where the Health Care Provider passes the account to the patient to lodge on their behalf, the patient must complete an HIF Gap Claim form that includes a declaration as to the provision of informed

78 financial consent by the Health Care Provider. HIF reserves the right to conduct audits to ensure that consent has been obtained in the appropriate manner; (k) (l) (m) (n) Lodgement of claims - Medical practitioners may either lodge their claims directly with HIF with the approved Batch Header or pass the claim to the patient. If the patient lodges the claim, they will be required to complete and sign the HIF Gap Claim form. HIF will then claim the appropriate Medicare rebate, add an Access Gap component and forward the full payment to the Health Care Provider. A statement, outlining the rebate paid will be forwarded to the patient; The Medical Practitioner may elect to forward their account directly to HIF or to their patient. If the account is forwarded to their patient, the patient must lodge the unpaid claim with HIF. HIF will lodge the claim with Medicare via EFT and on receipt of the payment from Medicare will forward that amount and any other entitlement payable by HIF to the medical practitioner; Where there is a gap to the patient, the Medical Practitioner shall inform their patient in writing of the treatment costs before treatment, or if this is not possible, as soon as practicable after treatment, and the patient shall acknowledge this advice; The Medical Practitioner shall advise their patient of any financial interest they may have in respect of any product, service or treatment offered to the patient. A Medical Practitioner who agrees to participate in the Access Gap Scheme may elect to be included on the Access Gap Participating Provider List. Details of Health Care Providers who request to be listed will be made available to Fund Members who request this information. A participating Medical Practitioner may withdraw from the Participating Provider List by giving HIF 30 calendar days notice in writing. HIF may withdraw the medical practitioner s name from the Participating Provider List by giving the Medical Practitioner 30 days notice in writing. HIF may withdraw the medical practitioner s name from the Participating Provider List immediately where: (a) (b) (c) there is evidence that the Medical Practitioner has not complied with a term or condition of the Access Gap Scheme or claiming guidelines; there is evidence that the Medical Practitioner has not complied with the conditions for charging their patients; the Medical Practitioner is or becomes unregistered or suspended under the laws of the relevant State in which case they shall immediately notify HIF; or

79 (d) the Medical Practitioner no longer caries professional indemnity with a recognised indemnity Health Care Provider in which case they shall immediately notify HIF. 9. Multiple procedures Where an Inpatient undergoes more than one procedure in a Hospital theatre, the procedure with the highest fee in the Medicare Benefits Schedule shall determine the Inpatient s classification. Where an Inpatient undergoes a procedure in a Hospital theatre subsequent to an initial procedure in a Hospital theatre as part of the same period of hospitalisation (Admission): (a) (b) (c) (d) where the subsequent procedure results in the Inpatient having a higher classification, the Inpatient s classification increases from the date of the subsequent procedure; where the subsequent procedure would otherwise have resulted in the Inpatient moving to a lower classification, the Inpatient s classification shall remain the same as applies to the first classification; where the Inpatient is discharged, and within seven days is admitted to the same or a different Hospital for the same or a related condition, the two Admissions are regarded as forming one period of continuous hospitalisation; where the Inpatient is discharged, and within seven days is admitted to a different Hospital, Benefits at the advanced surgical, surgical or obstetric levels shall only be payable in respect of the subsequent Admission only if an appropriate procedure is rendered following that Admission. 10. Minimum Benefits HIF shall pay the Minimum Benefit payable in respect to the following treatments pursuant to section 72-1 of the PHI Act 2007: (a) (b) psychiatric care, rehabilitation and palliative care; and prostheses. The Minimum Benefit payable in respect to treatment for psychiatric care, rehabilitation and palliative care may be reduced by any applicable excess or co-payment in accordance with the relevant product held by the Fund Member at the time of Admission. 11. Prostheses HIF shall pay a Benefit towards prostheses in accordance with the PHI (Prostheses) Rules 2007 (Cth) and section 72-1 of the PHI Act 2007.

80 12. Boarder Benefits 12.1 Contracted Hospital Unless covered under rule E2.12.3, a boarder Benefit is payable in accordance with the relevant Hospital contract where a separate charge for a boarder has been raised by the Hospital. Where a Hospital contract does not specify the circumstances upon which a charge shall be raised for a boarder Benefit, the following shall apply: (a) (b) (c) (d) (e) Benefits are payable in respect of a parent of a Dependent Child who is admitted where all Fund Members are covered under the same Insurance Product; Benefits are payable for 2 parents where 2 or more Dependent children are admitted where all Fund Members are covered under the same Insurance Product; Benefits are payable for a Dependent Child or children where a sole parent Fund Member is admitted and all Fund Members are covered under the same Insurance Product; applicable excess or co-payments under an Insurance Product will not be deducted from the boarder Benefit; boarder Benefits will be paid to a maximum of 10 days per Admission Public Hospital Unless covered under rule E2.12.3, a boarder Benefit of $ 20 per day will be payable in accordance with the HIF criteria detailed for Contracted Hospitals Maternity Admission Boarder Fees a) Benefit will be paid in respect of boarder fees incurred in relation to an eligible maternity hospital admission for a Fund Member covered by a GoldStar, Gold or GoldSaver Hospital product b) An eligible maternity admission is admission for management of labour and delivery, and where the Fund Member is admitted as a private patient c) The boarder s presence must be integral to the management of the patient s condition however the boarder can be any person nominated by the Fund Member

81 d) Benefit will only be paid where boarder services are provided within the hospital facility to which the member is admitted (cannot be outsourced accommodation). e) A daily maximum Benefit of $ will apply to each border day, charged by the hospital f) The maximum number of boarder days claimable per eligible maternity admission will be: GoldStar Hospital no more than the days accommodation associated with the eligible maternity admission of the Fund member Gold Hospital no more than the greater of 5 days or the days accommodation associated with the eligible maternity admission of the Fund Member GoldSaver Hospital no more than the greater of 3 days or the days accommodation associated with the eligible maternity admission of the Fund Member E3 General Treatment General Treatment is treatment (including the provision of goods and services) that: (a) (b) is intended to manage or prevent a disease, injury or condition; and is not Hospital Treatment. Without limiting the above definition, General Treatment includes any other treatment, or treatment included in a class of treatments, specified in the PHI (Health Insurance Business) Rules 2007 (Cth) as may affect this Fund Rule. General Treatment shall not include: (a) (b) rendering in Australia of a service for which a Medicare Benefit is payable, unless the PHI (Health Insurance Business) Rules 2007 (Cth) provide otherwise. Or any other treatment, or treatment included in a class of treatments, specified in the PHI (Health Insurance Business) Rules 2007 (Cth) as may affect this Fund Rule. The term Extras is used by HIF to mean General as it applies to General Treatment (i.e. not Hospital Treatment), and is intended to be used to include or in lieu of:

82 (a) (b) (c) (d) (e) a service; a good; a product; a cover; or an Insurance Product; that does not relate to Hospital Treatment. Benefits in respect of General Treatment are payable by HIF in the following circumstances: (a) (b) (c) (d) (e) where all relevant Waiting Periods have been served; where the Fund Membership is financial at the date of service; where a claim has been submitted in the prescribed form; where the treatment or service has been rendered by a HIF recognised Health Care Provider; where the treatment or service has been rendered within Australia. Benefits in respect of General Treatment shall not be payable by HIF in the following circumstances: (a) (b) (c) (d) (e) (f) (g) (h) where the Fund Member has not served a relevant Waiting Period that must be served prior to a treatment or service being rendered or supplied to the Fund Member; where the Fund Membership is unfinancial at the date of service; where a claim is the subject of a Third Party Compensation claim (refer to F7); where a claim has not been submitted in the prescribed form (refer to G); where a service or treatment was rendered or supplied outside of Australia; where a service or treatment provided by an allied health professional is eligible for a Benefit from Medicare Australia; where the date the treatment or service was rendered exceeds two years from the date the claim is submitted for payment; for the cost of care or accommodation in an aged care service;

83 (i) (j) (k) (l) (m) (n) for a charge for a Pharmaceutical Benefit supplied under Part V11 of the National Health Act 1953 unless the charge is covered by section 92B of that Act; any treatment specified in the PHI (Complying Product) Rules 2007 (Cth) as treatment for which Benefits must not be provided; any treatment which primarily takes the form of sport, recreation or entertainment other than such treatment which is part of a chronic disease management program or an Approved Health Management Program if the programs have been Approved; for any item supplied is second hand or reconditioned for re-sale. where treatment is provided via telephone or online service and does not form part of an HIF approved Hospital-Substitute treatment or Chronic Health Disease Management program. where the claim is for a service which was provided less than two hours after an identical or similar service or treatment was provided by the same Health Provider. E4 Other 1. Services rendered overseas HIF Benefits are not payable under any HIF cover in respect of a service or treatment, including goods supplied as part of or integral to the provision of a service or treatment, if it is supplied or rendered outside Australia.

84 F LIMITATION OF BENEFITS F1 Co Payments A Fund Member can elect to take the highest cover available or they may elect to reduce their Contribution premium by reducing the size and / or scope of Benefits payable. This may be achieved by reducing the amount of Benefit payable by HIF, by the Fund Member electing to pay an agreed amount to the Hospital in lieu of Benefits payable by HIF. This amount may take the form of a: (a) Co-payment an agreed amount payable by the Fund Member for each day a person covered under the Insurance Product is hospitalised; Provided that the co-payment option may operate with or without an Annual Limit. F2 Excesses 1. Introduction A Fund Member can elect to take the highest cover available or they may elect to reduce their Contribution premium by reducing the size and / or scope of Benefits payable. This may be achieved by reducing the amount of Benefit payable by HIF, by the Fund Member electing to pay an agreed amount to the Hospital in lieu of Benefits payable by HIF. This amount may take the form of an: (a) Excess an agreed amount payable for each episode a person covered under the Insurance Product is hospitalised; Provided that the payment option referred to at (a) above may operate with or without an Annual Limit. 2. Medicare levy surcharge Where a Fund Member elects to reduce the amount of Benefit payable by HIF by agreeing to an excess under an Insurance Product in exchange for a reduced Contribution premium, the Fund Member should ensure that, if the total amount of the excess in any one year is greater than $500 for a single cover Insurance Product or $1,000 for any other cover Insurance Product, they are eligible for exemption from the Medicare Levy Surcharge (MLS). As a general guide, single people with a taxable annual income in excess of $90,000 who have Hospital insurance with a front-end deductible (excess) greater than $500 per annum, if this

85 product was purchased after 24 May 2000, or who have no Hospital insurance at all, will be subject to the MLS. Couples and families with a taxable annual income in excess of $180,000 (this income threshold increases by $1,500 for each Child after the first) who have Hospital insurance with a front-end deductible (excess) greater than $1,000 per annum, if this product was purchased after 24 May 2000, or who have no Hospital insurance at all, will be subject to the MLS. This means that for a couple and family Fund Membership, you will incur the MLS if, in aggregate, the front-end deductible (excess) payable for all persons covered by the Insurance Product, exceeds $ 1,000 per annum. High-income earners who had a Hospital Insurance Product on or before 24 May 2000, with a front-end deductible greater than $500 for singles or $1,000 for families/couples, will be exempt from the MLS if they maintain continuous Fund Membership to the same Hospital table of HIF. You must also pay the MLS if you are a prescribed person with a taxable income over the threshold, and have any Dependents who are not prescribed persons and who are not covered by a low front-end deductible Hospital Insurance Product. HIF may offer Fund Members access to Insurance Products with an excess greater than $500 for single Fund Members and greater than $1,000 for couples and families. F3 Waiting Periods 1. Introduction A Waiting Period of HIF that applies to a person for a Benefit under an Insurance Product is the period: (a) (b) starting at the time the person becomes insured under the Insurance Product; and ending at the time specified in the Insurance Product; During which the person is not entitled to the Benefit. 2. Waiting Period requirements An Insurance Product meets the Waiting Period requirements in this Fund Rule if the Waiting Period that applies to a person who did not transfer to the Insurance Product is no longer than:

86 (a) (b) for a Benefit for Hospital Treatment or Hospital-Substitute Treatment that is obstetric treatment or treatment for a Pre-Existing Condition (other than treatment covered by paragraph (b) - 12 months; and for a Benefit for Hospital Treatment or Hospital-Substitute Treatment that is psychiatric care, rehabilitation or palliative care (whether or not for a Pre-Existing Condition) - 2 months; and (c) for any other Benefit for Hospital Treatment or Hospital-Substitute Treatment - 2 months. The PHI (Complying Product) Rules 2007 (Cth) may modify the requirements in this Fund Rule in relation to all or particular kinds of private health insurers, Benefits or insured persons. To the extent the Fund Rules do so, the Waiting Period requirements in this Fund Rule are taken to be met if the conditions in the PHI (Complying Product) Rules 2007 (Cth) are met. 3. Pre-Existing Condition A person insured under an Insurance Product has a Pre-Existing Condition if: (a) (b) the person has an ailment, illness or condition; and in the opinion of a Medical Practitioner appointed by HIF, the signs or symptoms of that ailment, illness or condition existed at any time in the period of 6 months ending on the day on which the person became insured under the Insurance Product. In forming an opinion for the purposes of paragraph (b), the Medical Practitioner must have regard to any information in relation to the ailment, illness or condition that the Medical Practitioner who treated the ailment, illness or condition gives him or her. If: (a) (b) HIF replaces an Insurance Product with another Insurance Product; and a person who was insured under an Insurance Product that was in the replaced product is transferred by HIF to an Insurance Product that is in the replacement product; The reference in paragraph (b) to the day on which the person became insured under the Insurance Product is taken to be a reference to the day on which the person became insured under the replaced Insurance Product. 4. Waiting Periods and the Pre-Existing Conditions The following Waiting Periods and the Pre-Existing Condition Fund Rule applies to all Fund Members who join HIF, or upgrade their level of Hospital or ancillary cover. Fund Members who

87 transfer to HIF from another registered health fund will not be subject to these restrictions if they have already served the Waiting Periods on an equivalent level of cover. (a) Hospital cover Waiting Periods For All Hospital Covers except Essential Visitors Cover, Intermediate Visitors Cover, Comprehensive Visitors Cover (No Excess) and Comprehensive Visitors Cover $500/$1000 Excess Waiting Period Condition or treatment (where applicable) 0 month Accidents. 2 months Treatment for psychiatric care, rehabilitation and palliative care and all other treatment (except where otherwise specified). 12 months Obstetric treatment and or treatment for a Pre-Existing Condition but not including pre-existing conditions for psychiatric care, rehabilitation or palliative care. For Essential Visitors Cover, Intermediate Visitors Cover, Comprehensive Visitors Cover (No Excess) and Comprehensive Visitors Cover $500/$1000 Excess Waiting Period Condition or treatment (where applicable) 0 month All covered treatment (except where specified below). 2 months Treatment for psychiatric care, rehabilitation and palliative care. 12 months Obstetric treatment and or treatment for a Pre-Existing Condition but not including pre-existing conditions for psychiatric care, rehabilitation or palliative care. (b) Ancillary cover Waiting Periods (where applicable and depending on level of cover) Waiting Period Condition or treatment (where applicable / depending on level of cover) 2 months All services unless specified in this list.

88 12 months Blood glucose / pressure monitor. 12 months Non-general / major dental. 12 months Nebuliser / humidifier. 12 months Podiatry orthotic appliances. 12 months Prosthesis non-surgically implanted. 12 months Psychological consultations. 36 months Assisted reproductive drugs. 36 months Hearing aids. (c) Waiting Periods newborns HIF shall waive all Waiting Periods and Pre-Existing Conditions (if any) for newborns where: (i) (ii) (iii) the newborn s mother has served all Waiting Periods before the newborn s birth; the mother is covered under a family Insurance Product at the time of the birth of the newborn and supplies HIF with relevant information about the newborn to enable HIF to include the newborn onto the family Insurance Product within a reasonable period, which period shall be determined by HIF at its absolute discretion, provided that it shall not exceed 4 years; The newborn s mother is an existing HIF member on a one adult class of Insurance Product and subsequently changes to a family Insurance product within two months of the birth of the newborn. However should this change include an upgrade of cover; the newborn will be required to serve the same waiting period which the mother has to serve, for any upgraded cover or benefits, relative to the mother s prior level of cover. (d) Waiting Periods Psychiatric Care upgrade waiting period exemption An insured person who holds a restricted Complying Hospital Product may be entitled to upgrade their hospital cover and apply for the Psychiatric care waiting period exemption if; (i) The insured person has held a restricted Complying Hospital Product for at least 2 months (ii) The insured person has not yet applied for this exemption The psychiatric care upgrade applies to the shared room accommodation benefit only.

89 Standard waiting periods will therefore apply to all other upgraded benefits included in the higher level of hospital cover. F4 Exclusions A Fund Member can elect to take the highest cover available or they may elect to reduce their Contribution premium by reducing the size and / or scope of Benefits payable. This may be achieved by reducing the amount of Benefit payable by HIF by the Fund Member electing to pay an agreed amount to the Hospital in lieu of Benefits payable by HIF. This amount may take the form of a reduction in the scope of Benefits payable by HIF, by the Fund Member electing to take a level of cover that does not cover all episodes of hospitalisation. This option can occur in the following way: (a) Exclusion no Benefit is payable for a specific condition or a selected range of conditions. Hospital Products No Maternity Hospital with Mid Extras Combo Cover (hospital component) GoldStarter Excess $200/$400 cover GoldSaver Excess $200/$400 cover GoldVital Excess $500/$1,000 cover HealthMax Saver Plus Excess $100/$200 Cover (hospital component) Intermediate Working Visa cover Essentials Working Visa cver Basic Working Visa Excess $500 cover Visitor Advantage Excess $200/ $400 cover Visitor Value Excess $250/ $500 cover Visitor Saver Excess $250/ $500 cover F5 Benefit Limitation Periods Benefit Limitation Periods do not apply. F6 Restricted Benefits A Fund Member can elect to take the highest cover available or they may elect to reduce their Contribution premium by reducing the size and / or scope of Benefits payable. This may be achieved by reducing the amount of Benefit payable by HIF, by the Fund Member electing to pay an agreed amount to the Hospital in lieu of Benefits payable by HIF. This amount may take the form of a reduction in the scope of Benefits payable by HIF, by the Fund Member electing to take a level of cover that does not cover all episodes of hospitalisation. This option can occur in the following way:

90 (a) Restriction Benefits are only payable at the Minimum Benefit for a condition or a selected range of conditions. Where a service / treatment attracts a Restricted Benefit under a HIF Insurance Product, HIF will pay a Benefit in accordance with the Minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 (Cth) and the Minimum Benefit requirements in section 72-1 of the PHI Act Restricted Benefits apply in respect of certain conditions under the following HIF Insurance Products: Hospital Product: No Maternity Hospital with Mid Extras Combo cover GoldSaver Excess $200/ $400 cover GoldStarter Excess $200/ $400 cover GoldVital Excess $500/ $1,000 cover HealthMax Saver Excess $100/ $200 cover Basic Working Visa Excess $500 cover F7 Compensation Damages and Provisional Payment of Claims 1. Entitlements to Benefits as the result of a condition, ailment, injury or Accident Unless permitted elsewhere in this Fund Rule, a Fund Member shall not be entitled to a rebate or other Benefit in respect of a cost or expense, whether or not it is paid or payable, unforeseen or into the future and whether or not it is certain in value or otherwise, of a service or treatment, including the provision of goods and services, that relates to a condition, ailment, injury or Accident suffered by a Fund Member, where a person: (a) (b) (c) has received Compensation; or is entitled to receive or forego damages Compensation; or has abandoned an entitlement to receive or forego Compensation; in respect of that condition, ailment, injury or Accident. 2. Obligations of a Fund Member A Fund Member who commences or initiates, or has a claim for, asserts or could properly assert a right to, foregoes a right to, receives or is entitled to receive, or discontinues an action for, damages Compensation in respect of a condition, ailment, injury or Accident (the matter ), must:

91 (a) (b) (c) (d) (e) (f) inform HIF, as soon as practicable, of details relating to the matter as might reasonably be expected in the circumstances or asked for by HIF; inform HIF of any decision that the Fund Member has made, intends to make, or is contemplating making in relation to the matter; in the case of a claim action relating to the matter, include the full amount of all costs and expenses for which Benefits are or would otherwise be payable; take all reasonable steps to pursue the matter to HIF s reasonable satisfaction; keep HIF informed of and updated as to the progress of a claim relating to the matter; and inform HIF immediately upon the determination or settlement of a claim relating to the matter. 3. Provisional payment or Benefit In the event that a required payment of damages and other costs pursuant to a finalised claim for Compensation to a Fund Member in respect of a condition, ailment, injury or Accident remains unpaid, HIF may at its absolute discretion, having regard to, but not limited to such matters as unemployment, hardship or other factors HIF considers relevant, effect a provisional Benefit payment to the claimant Fund Member in respect of out-of-pocket costs and expenses incurred by them, provided that those costs or expenses were paid in respect of the condition, ailment, injury or Accident that gave rise to the claim. A provisional Benefit payment will only be made by HIF if an irrevocable and unconditional written undertaking is given to HIF to repay it, firstly from the damages payment, secondly, where there is a deficiency after repayment from the damages payment, by any other means. HIF may, at its absolute discretion, having regard to, but not limited to such matters as unemployment, hardship or other factors HIF considers relevant, accept a repayment pursuant to an irrevocable and unconditional written undertaking, that is less than the sum of all Benefit payments made in favour of the Fund Member that relates to the matter. F8 Other

92 G CLAIMS G1 General 1. Claims for Benefits must: 2. be made in a manner Approved by HIF; and 3. be supported by a tax invoice, statement of account or receipt on a Health Care Provider s official letterhead and inter alia other documents (as required by HIF) that will disclose the following information: 4. the Health Care Provider s name, number and address; 5. the patient s full name and address; 6. the date of service; 7. the description of the service; 8. the amount(s) charged; and 9. any other information that HIF reasonably requests. 10. All documents submitted in connection with a claim become the property of HIF, unless otherwise agreed to by HIF 11. Benefits are not payable where a claim is lodged more than two years after the date of service. HIF may waive this Rule at its absolute discretion. 12. Subject to practical limitations, HIF shall within two months of receipt of a claim, assess it and pay any Benefit in accordance with these Rules and / or where specified or required pursuant to the PHI Act 2007 and PHI Rules G2 Other 1. Claim Benefit recovery Where HIF has paid a Benefit or portion of Benefit for which a Fund Member was not entitled, it will seek recovery of the overpaid Benefit amount from the Fund Member. HIF may in its absolute discretion reduce the Benefit paid for a future claim in order to recover a prior Benefit overpayment.

93 H1 SCHEDULE HOSPITAL TREATMENT TABLES H1 1 Table Name or Group of Table Names Gold No Excess Gold Excess 100/200 Gold Excess 200/400 Gold Excess 400/800 H1 2 Eligibility H1 3 General Conditions H1 4 Hospital Treatment Payments 1. Contracted Hospitals Benefits will be paid at the Contracted Hospital Purchaser Provider Agreement rate agreed between the Hospital and Australian Health Service Alliance and in accordance with the following table. Subject to any excess or co-payment listed below. Service Shared Accommodation including: Day patient, neo-natal, ICU, CCU, HDU Private Accommodation including: Day patient, neo-natal, ICU, CCU, HDU Benefit In accordance with HPPA The agreed shared room fee. The Fund Member will pay an out of pocket cost which may vary depending on the Hospital. Benefit will be paid at the private accommodation rate for the first five nights for an admission for management of labour and delivery, and at the shared accommodation rate thereafter. Theatre and labour ward fees Prostheses In accordance with HPPA In accordance with the PHI (Prostheses) Rules 2007 (Cth)

94 Procedure room fees Outpatient fees All episodic items Inpatient Pharmaceutical drugs In accordance with HPPA In accordance with HPPA In accordance with HPPA In accordance with HPPA 2. Non-contracted Hospitals and public Hospitals Where an HPPA does not exist between the Fund and the Health Care Provider Benefits will be paid in accordance with the Minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 (Cth) and in accordance with the Minimum benefit requirements in section 72-1 of the PHI Act Miscellaneous Benefits shall be payable for 365 days per year on all Hospital covers subject to acceptance of an Acute Care Certificate after 35 days. H1 5 Medical Services Payments while admitted Benefits are payable up to 25% of the Medicare Benefits Schedule Fee where Benefits are payable by Medicare. Where the medical practitioner meets the requirements of the Access Gap Scheme Benefits are payable to the agreed rate under that scheme. Limited benefits will be paid toward the cost of services provided in an approved hospital facility by HIF recognised podiatric surgeons. H1 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals Where the cost of a non-pbs item is less than the Pharmaceutical co-payment (as determined by the Commonwealth department of health and ageing) these drugs will not be covered. H1 7 Non PBS Pharmaceuticals The cost of approved pharmaceuticals is included in the charges agreed between the hospital and HIF.

95 H1 8 Surgically Implanted Prostheses Benefits will be paid in accordance with the PHI (Prostheses) Rules H1 9 Nursing Home Type Patients HIF will pay Benefits towards Nursing Home Type Patients in accordance with the minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 and in accordance with the minimum Benefit requirements in section 72-1 of the PHI Act H1 10 Co Payments Private overnight ward accommodation shall attract a co-payment as follows: 1. Contracted hospitals Equitable payment model [ EPM ] payments For private ward accommodation in respect of hospitals which have a Hospital Purchaser Provider Agreement [ HPPA ] with Australian Health Services Alliance [ AHSA ] using the AHSA s DRG [i.e. Diagnostic Related Group] based payment model or EPM ], the copayment shall be the difference between the amount charged by the hospital for a shared room and the amount charged by that hospital for a private room, per overnight stay for the total number of overnight stays. The co-payment will not apply for the first five nights of any hospital private ward accommodation episode, required due to management of labour and delivery. Per diem payments For private ward accommodation in respect of hospitals which have a HPPA with AHSA using the AHSA s per diem based payment model or other Non-EPM payment model, the copayment rate per each overnight stay shall be the difference between the per diem or other private room accommodation charge and the per diem or other shared room accommodation charge and shall apply to the total number of overnight stays. The co-payment will not apply for the first five nights of any hospital private ward accommodation episode, required due to management of labour and delivery. 2. Non-contracted hospitals For private ward accommodation, the co-payment rate per each overnight stay shall be the difference between the per diem or other private room accommodation charge and the per diem or other shared room accommodation charge and shall apply to the total number of

96 overnight stays. The co-payment will not apply for the first five nights of any hospital private ward accommodation episode, required due to management of labour and delivery. H1 11 Excesses The Fund Benefits payable under the Excess Tables R2, R6, and R7 shall be reduced by the amounts detailed below. The excess will apply to the first amount of Hospital Benefit otherwise payable in any Calendar Year. The excess will apply to overnight accommodation. The excess will not apply to Hospital charges associated with same-day or outpatient treatment or in any circumstance to a child Dependent under the age of 18 years. Product Description Code Excess per person per year Maximum per Insurance Product per year Gold No Excess H2 Nil Nil Gold Excess $100/ $200 Gold Excess $200/ $400 Gold Excess $400/ $800 Single $100 $100 R2 Family $100 $200 Single $200 $200 R6 Family $200 $400 Single $400 $400 R7 Family $400 $800 H1 12 Benefit Limitation Periods Benefit Limitation Periods do not apply. H1 13 Restricted Benefits H1 14 Exclusions Cosmetic Surgery: Patients who undergo cosmetic surgery will not be eligible for payment of Benefits under this cover.

97 Other: Hospital Treatment for which Medicare does not pay a benefit will be ineligible for Benefits on this cover, with the exception of services provided by an HIF recognised podiatric surgeon. H1 15 Loyalty Bonuses H1 16 Other Special H2 SCHEDULE HOSPITAL TREATMENT TABLES H2 1 Table Name or Group of Table Names GoldStar No Excess GoldStar Excess 200/400 GoldStar Excess 400/800 GoldStar Excess 500/1000 H2 2 Eligibility H2 3 General Conditions H2 4 Hospital Treatment Payments 1. Contracted Hospitals Benefits will be paid at the Contracted Hospital Purchaser Provider Agreement rate agreed between the Hospital and Australian Health Service Alliance, and in accordance with the following table. Subject to any excess or co-payment listed below. Service Private and Shared Accommodation including: Day patient, neo-natal, ICU, CCU, HDU Theatre and labour ward fees Benefits In accordance with HPPA In accordance with HPPA

98 Prostheses Procedure room fees Outpatient fees All episodic items Inpatient Pharmaceutical drugs In accordance with the PHI (Prostheses) Rules 2007 (Cth) In accordance with HPPA In accordance with HPPA In accordance with HPPA In accordance with HPPA 2. Non-contracted Hospitals and public Hospitals Where an HPPA does not exist between the Fund and the Health Care Provider Benefits will be paid in accordance with the Minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 (Cth) and in accordance with the Minimum Benefit requirements in section 72-1 of the PHI Act Miscellaneous Benefits shall be payable for 365 days per year on all Hospital covers subject to acceptance of an Acute Care Certificate after 35 days. H2 5 Medical Services Payments while admitted Benefits are payable up to 25% of the Medicare Benefits Schedule Fee where Benefits are payable by Medicare Australia. Where the medical practitioner meets the requirements of the Access Gap Scheme Benefits are payable to the agreed rate under that scheme. Limited benefits will be paid toward the cost of services provided in an approved hospital facility by HIF recognised podiatric surgeons. H2 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals Where the cost of a non-pbs item is less than the Pharmaceutical co-payment (as determined by the Commonwealth department of health and ageing) these drugs will not be covered. H2 7 Non PBS Pharmaceuticals The cost of approved pharmaceuticals is included in the charges agreed between the hospital and HIF

99 H2 8 Surgically Implanted Prostheses Benefits will be paid in accordance with the PHI (Prostheses) Rules H2 9 Nursing Home Type Patients HIF will pay Benefits towards Nursing Home Type Patients in accordance with the minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 and in accordance with the minimum Benefit requirements in section 72-1 of the PHI Act H2 10 Co Payments H2 11 Excesses The Fund Benefits payable under the Excess Tables R3, R4 and R5 shall be reduced by the amounts detailed below. The excess will apply to the first amount of Hospital Benefit otherwise payable in any Calendar year. The excess will apply to overnight accommodation. The excess will not apply to Hospital charges associated with same-day or outpatient treatment or in any circumstance to a child Dependent under the age of 18 years. Product Description Code Excess per person per year Maximum excess per policy per year GoldStar H3 Nil Nil GoldStar Excess $200/ $400 GoldStar Excess $400/ $800 GoldStar Excess $500/ $1,000 Family $200 $200 R3 Single $200 $400 Family $400 $400 R4 Single $400 $800 Family $500 $500 R5 Single $500 $1,000 H2 12 Benefit Limitation Periods Benefit Limitation Periods do not apply.

100 H2 13 Restricted Benefits H2 14 Exclusions Cosmetic Surgery: Patients who undergo Cosmetic Surgery where a Benefit is not payable by Medicare Australia will not be eligible for payment of Benefits under this Hospital table. Other: Hospital Treatment for which Medicare does not pay a benefit will be ineligible for Benefits on this cover, with the exception of services provided by an HIF recognised podiatric surgeon. H2 15 Loyalty Bonuses H2 16 Other Special H3 SCHEDULE HOSPITAL TREATMENT TABLES H3 1 Table Name or Group of Table Names Basic No Excess Cover H3 2 Eligibility This product is closed to persons wishing to join HIF and existing HIF members seeking to change to this hospital cover. H3 3 General Conditions H3 4 Hospital Treatment Payments The Hospital Benefits payable shall be in accordance the Minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 (Cth) and in accordance with the Minimum Benefit requirements in section 72-1 of the PHI Act The Benefits payable under this Table will cover the cost of accommodation in a Public Hospital, but will only provide the minimum cover in respect of a Private or Shared Room in a Private Hospital.

101 H3 5 Medical Services Payments while admitted Benefits are payable up to 25% of the Medicare Benefits Schedule Fee where Benefits are payable by Medicare Australia. Where the medical practitioner meets the requirements of the Access Gap Scheme Benefits are payable to the agreed rate under that scheme. H3 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals Where the cost of a non-pbs item is less than the Pharmaceutical co-payment (as determined by the Commonwealth Department of Health) these drugs will not be covered. H3 7 Non PBS Pharmaceuticals H3 8 Surgically Implanted Prostheses Benefits will be paid in accordance with the PHI (Prostheses) Rules H3 9 Nursing Home Type Patients HIF will pay Benefits towards Nursing Home Type Patients in accordance with the minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 and in accordance with the minimum Benefit requirements in section 72-1 of the PHI Act H3 10 Co Payments H3 11 Excesses H3 12 Benefit Limitation Periods H3 13 Restricted Benefits H3 14 Exclusions Cosmetic surgery: Patients who undergo cosmetic surgery where a Benefit is not payable by Medicare Australia will not be eligible for payment of Benefits under this Hospital table.

102 Other: Hospital Treatment for which Medicare does not pay a benefit will be ineligible for benefit on this cover. H3 15 Loyalty Bonuses H3 16 Other Special H4 SCHEDULE HOSPITAL TREATMENT TABLES H4 1 Table Name or Group of Table Names GoldSaver Excess $200/ $400 Cover H4 2 Eligibility H4 3 General Conditions H4 4 Hospital Treatment Payments 1. Contracted Hospitals Benefits will be paid at the Contracted Hospital Purchaser Provider Agreement rate agreed between the Hospital and Australian Health Service Alliance, and in accordance with the following table. Subject to any excess or co-payment listed below. Service Shared Accommodation including: Day patient, neo-natal, ICU, CCU, HDU Private Accommodation including: Day patient, neo-natal, ICU, CCU, HDU Benefits In accordance with HPPA In accordance with HPPA. The Fund Member will pay an out of pocket cost which may vary depending on the Hospital. Benefit will be paid at the private accommodation rate for the first three nights for an admission for management of labour and delivery, and

103 at the shared accommodation rate thereafter. Theatre and labour ward fees Prostheses Procedure room fees Outpatient fees All episodic items Inpatient Pharmaceutical drugs In accordance with HPPA In accordance with the PHI (Prostheses) Rules (Cth) 2007 In accordance with HPPA In accordance with HPPA In accordance with HPPA In accordance with HPPA 2. Non-contracted Hospitals and public Hospitals Where an HPPA does not exist between the Fund and the Health Care Provider Benefits will be paid in accordance with the Minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 (Cth) and in accordance with the Minimum Benefit requirements in section 72-1 of the PHI Act Miscellaneous Benefits shall be payable for 365 days per year on all Hospital covers subject to acceptance of an Acute Care Certificate after 35 days. H4 5 Medical Services Payments while admitted Benefits are payable up to 25% of the Medicare Benefits Schedule Fee where Benefits are payable by Medicare Australia. Where the medical practitioner meets the requirements of the Access Gap Scheme Benefits are payable to the agreed rate under that scheme. H4 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals Where the cost of a non-pbs item is less than the Pharmaceutical co-payment (as determined by the Commonwealth Department of Health) these drugs will not be covered. H4 7 Non PBS Pharmaceuticals The cost of approved pharmaceuticals is included in the charges agreed between the hospital and HIF. H4 8 Surgically Implanted Prostheses Benefits will be paid in accordance with the PHI (Prostheses) Rules 2007.

104 H4 9 Nursing Home Type Patients HIF will pay Benefits towards Nursing Home Type Patients in accordance with the minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 and in accordance with the minimum Benefit requirements in section 72-1 of the PHI Act H4 10 Co Payments Private overnight ward accommodation shall attract a co-payment as follows: 1. Contracted Hospitals 1.1. Equitable payment model [ EPM ] payments For private ward accommodation in respect of Hospitals which have a Hospital Purchaser Provider Agreement [ HPPA ] with Australian Health Service Alliance [ AHSA ] using the AHSA s DRG [i.e. Diagnostic Related Group] based payment model or EPM ], the copayment shall be the difference between the amount charged by the Hospital for a shared room and the amount charged by that Hospital for a private room, per overnight stay for the total number of overnight stays. The co-payment will not apply for the first 3 nights of any hospital private ward accommodation episode, required due to management of labour and delivery Per diem payments For private ward accommodation in respect of Hospitals which have a HPPA with AHSA using the AHSA s per diem based payment model or other Non-EPM payment model, the copayment rate per each overnight stay shall be the difference between the per diem or other private room accommodation charge and the per diem or other shared room accommodation charge and shall apply to the total number of overnight stays. The co-payment will not apply for the first 3 nights of any hospital private ward accommodation episode, required due to management of labour and delivery. 2. Non-contracted Hospitals For private ward accommodation, the co-payment rate per each overnight stay shall be the difference between the per diem or other private room accommodation charge and the per diem or other shared room accommodation charge and shall apply to the total number of overnight stays. The co-payment will not apply for the first 3 nights of any hospital private ward accommodation episode, required due to management of labour and delivery. H4 11 Excesses The Fund Benefits payable under this table shall be reduced by the amounts detailed below. The excess will apply to the first amount of Hospital Benefit otherwise payable. The excess will apply

105 to hospital charges associated with overnight accommodation, same-day and outpatient treatment. GoldSaver Single Family Excess per person per year $200 $200 Maximum excess per policy per year $200 $400 H4 12 Benefit Limitation Periods Benefit Limitation Periods do not apply. H4 13 Restricted Benefits Benefits are payable for the services as specified below in accordance with the minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 and in accordance with the minimum Benefit requirements in section 72-1 of the PHI Act 2007: Heart (Cardiac) procedures including medical treatment or surgical procedures for cardiac conditions such as, arrhythmias, artery bypass grafts, coronary angioplasty, congenital defects, heart disease, heart transplants, pacemakers and defibrillators, stent insertion Joint replacement Eye surgery (e.g. cataracts, intraocular lenses) Assisted reproductive services Psychiatric care and attention H4 14 Exclusions Cosmetic Surgery: Patients who undergo cosmetic surgery where a Benefit is not payable by Medicare Australia will not be eligible for payment of Benefits under this Hospital table. Gastric banding and obesity surgery: is ineligible for Benefits on this cover. Other: Hospital Treatment for which Medicare does not pay a benefit will be ineligible for Benefits on this cover. H4 15 Loyalty Bonuses H4 16 Other Special

106 H6 SCHEDULE HOSPITAL TREATMENT TABLES H6 1 Table Name or Group of Table Names GoldStarter Excess $200/ $400 Cover H6 2 Eligibility H6 3 General Conditions H6 4 Hospital Treatment Payments 1. Contracted Hospitals Benefits will be paid at the Contracted Hospital Purchaser Provider Agreement rate agreed between the Hospital and Australian Health Service Alliance, and in accordance with the following table. Subject to any excess or co-payment listed below. Service Shared Accommodation including: Day patient ICU, CCU, HDU Private Accommodation including: Day patient, ICU, CCU, HDU Theatre fees Prostheses Procedure room fees Outpatient fees All episodic items Inpatient Pharmaceutical drugs Benefits In accordance with HPPA In accordance with HPPA The Fund Member will pay an out of pocket cost which may vary depending on the Hospital In accordance with HPPA In accordance with the PHI (Prostheses) Rules 2007 In accordance with HPPA In accordance with HPPA In accordance with HPPA In accordance with HPPA 1. Non-contracted Hospitals and Public Hospitals

107 Where an HPPA does not exist between the Fund and the Health Care Provider Benefits will be paid in accordance with the Minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 (Cth) and in accordance with the Minimum Benefit requirements in section 72-1 of the PHI Act Miscellaneous Benefits shall be payable for 365 days per year on all Hospital covers subject to acceptance of an Acute Care Certificate after 35 days. H6 5 Medical Services Payments while admitted Benefits are payable up to 25% of the Medicare Benefits Schedule Fee where Benefits are payable by Medicare Australia. Where the medical practitioner meets the requirements of the Access Gap Scheme, Benefits are payable to the agreed rate under that scheme, provided that where a service is specifically excluded under Rule H6 13, no Benefit is payable. H6 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals Where the cost of a non-pbs item is less than the Pharmaceutical co-payment (as determined by the Commonwealth Department of Health and Ageing) these drugs will not be covered. H6 7 Non PBS Pharmaceuticals The cost of approved non-pbs pharmaceuticals is included in the charges agreed between the hospital and HIF. H6 8 Surgically Implanted Prostheses Benefits will be paid in accordance with the PHI (Prostheses) Rules H6 9 Nursing Home Type Patients HIF will pay Benefits towards Nursing Home Type Patients in accordance with the minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 and in accordance with the minimum benefit requirements in section 72-1 of the PHI Act H6 10 Co Payments Private overnight ward accommodation shall attract a co-payment as follows: 1. Contracted Hospitals 1.1 Equitable payment model [ EPM ] payments For private ward accommodation in respect of Hospitals which have a Hospital Purchaser Provider Agreement [ HPPA ] with Australian Health Service Alliance [ AHSA ] using the AHSA s DRG [i.e. Diagnostic Related Group] based payment model [or EPM ], the co-

108 payment shall be the difference between the amount charged by the Hospital for a shared room and the amount charged by that Hospital for a private room, per overnight stay for the total number of overnight stays. 1.2 Per Diem payments For private ward accommodation in respect of Hospitals which have a HPPA with AHSA using the AHSA s per diem based payment model or other Non-EPM payment model, the copayment rate per each overnight stay shall be the difference between the per diem or other private room accommodation charge and the per diem or other shared room accommodation charge and shall apply to the total number of overnight stays. 2. Non-contracted Hospitals For private ward accommodation, the co-payment rate per each overnight stay shall be the difference between the per diem or other private room accommodation charge and the per diem or other shared room accommodation charge and shall apply to the total number of overnight stays. H6 11 Excesses The Fund Benefits payable under this table shall be reduced by the amounts detailed below. The excess will apply to the first amount of Hospital Benefit otherwise payable. The excess will also apply to Hospital charges associated with same-day or outpatient treatment. GoldStarter Single Family Excess per person per year $200 $200 Maximum excess per policy per year $200 $400 H6 12 Benefit Limitation Periods Benefit Limitation Periods do not apply. H6 13 Restricted Benefits Benefits are payable for the services as specified below in accordance with the minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 and in accordance with the minimum Benefit requirements in section 72-1 of the PHI Act Psychiatric care and attention Rehabilitation Palliative care

109 H6 14 Exclusions Benefits are not payable in respect of the following treatments or services: All obstetric related services Joint replacement Eye surgery Assisted reproductive technologies and IVF Heart (Cardiac) procedures including medical treatment or surgical procedures for cardiac conditions such as, arrhythmias, artery bypass grafts, coronary angioplasty, congenital defects, heart disease, heart transplants, pacemakers and defibrillators, stent insertion Cosmetic Surgery Gastric banding and obesity surgery Other: Hospital Treatment, for which Medicare does not pay a benefit, including cosmetic surgery, will be ineligible for Benefits on this cover. H6 15 Loyalty Bonuses H6 16 Other Special

110 H7 SCHEDULE HOSPITAL TREATMENT TABLES H7 1 Table Name or Group of Table Names GoldVital Excess $500/ $1,000 Cover H7 2 Eligibility This product is available to single adult and two adult insured groups only, commencing 1st February H7 3 General Conditions H7 4 Hospital Treatment Payments 1. Contracted Hospitals Benefits will be paid at the Contracted Hospital Purchaser Provider Agreement rate agreed between the Hospital and Australian Health Service Alliance, and in accordance with the following table. Subject to any excess or co-payment listed below. Service Shared Accommodation including: Day patient ICU, CCU, HDU Private Accommodation including: Day patient, ICU, CCU, HDU Theatre fees Prostheses Procedure room fees Outpatient fees All episodic items Inpatient Pharmaceutical drugs Benefits In accordance with HPPA In accordance with HPPA The Fund Member will pay an out of pocket cost which may vary depending on the Hospital In accordance with HPPA In accordance with the PHI (Prostheses) Rules 2007 In accordance with HPPA In accordance with HPPA In accordance with HPPA In accordance with HPPA 2. Non-contracted Hospitals and Public Hospitals

111 Where an HPPA does not exist between the Fund and the Health Care Provider Benefits will be paid in accordance with the Minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 (Cth) and in accordance with the Minimum Benefit requirements in section 72-1 of the PHI Act Miscellaneous Benefits shall be payable for 365 days per year on all Hospital covers subject to acceptance of an Acute Care Certificate after 35 days. H7 5 Medical Services Payments while admitted Benefits are payable up to 25% of the Medicare Benefits Schedule Fee where Benefits are payable by Medicare Australia. Where the medical practitioner meets the requirements of the Access Gap Scheme, Benefits are payable to the agreed rate under that scheme, provided that where a service is specifically excluded under Rule H7 13, no benefit is payable. Service covered include: Hospital treatment as the result of an accident* Surgical removal of wisdom teeth (includes hospital and theatre changes, and services that attract a Medicare rebate) Removal of tonsils and adenoids Removal of appendix Minor Gynaecological procedures provided as a Day Only Admission to hospital Joint reconstructions and investigations * An accident means an unforeseen event, occurring by chance and caused by an external force or object which results in an injury to the body requiring immediate medical treatment in hospital within 24 hours of the accident. If further hospital treatment (as an admitted patient) is required, the patient must be re-admitted to a hospital within 90 days of the initial hospital treatment. Limited benefits are also payable toward: Psychiatric treatment Rehabilitation Palliative care H7 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals Where the cost of a non-pbs item is less than the Pharmaceutical co-payment (as determined by the Commonwealth Department of Health) these drugs will not be covered.

112 H7 7 Non PBS Pharmaceuticals The cost of approved non-pbs pharmaceuticals is included in the charges agreed between the hospital and HIF. H7 8 Surgically Implanted Prostheses Benefits will be paid in accordance with the PHI (Prostheses) Rules H7 9 Nursing Home Type Patients HIF will pay Benefits towards Nursing Home Type Patients in accordance with the minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 and in accordance with the minimum Benefit requirements in section 72-1 of the PHI Act H7 10 Co Payments H7 11 Excesses The Fund Benefits payable under this table shall be reduced by the amounts detailed below. The excess will apply to the first amount of Hospital Benefit otherwise payable. The excess will also apply to Hospital charges associated with overnight accommodation, same-day or outpatient treatment. GoldVital Hospital Family Single Excess per person per year $500 $500 Maximum excess per policy per year $500 $1,000 H7 12 Benefit Limitation Periods Benefit Limitation Periods do not apply. H7 13 Restricted Benefits Benefits are payable for the services as specified below in accordance with the minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 and in accordance with the minimum Benefit requirements in section 72-1 of the PHI Act Psychiatric care and attention Rehabilitation

113 Palliative care H7 14 Exclusions Unless due to an accident and subject to accident definition, Benefits are not payable in respect of the following treatments or services: All obstetric related services Assisted reproductive technologies and IVF Sterility reversals Eye surgery Dialysis Spinal fusion Joint replacement Heart (Cardiac) procedures including medical treatment or surgical procedures for cardiac conditions such as, arrhythmias, artery bypass grafts, coronary angioplasty, congenital defects, heart disease, heart transplants, pacemakers and defibrillators, stent insertion. Cosmetic Surgery Gastric banding and obesity surgery, including reversal and adjustment procedures All other in hospital services not listed at Rule H7 5 Hospital Treatment for which Medicare does not pay a benefit, including cosmetic surgery, will be ineligible for Benefits on this cover, including where due to an accident. H7 15 Loyalty Bonuses This section is intentionally left blank. H7 16 Other Special I1 SCHEDULE GENERAL TREATMENT TABLES I1 1 Table Name or Group of Table Names Premium Options I1 2 Eligibility

114 I1 3 General Conditions I1 4 Loyalty Bonuses I1 5 Dental Item Number Annual Limits Year 1 Year 2 Year 3 Year 4 Year 5 After 5 Years General - Unlimited General - Limited No Limit No Limit No Limit No Limit No Limit No Limit $1,500 $1,800 $2,100 $2,400 $2,700 $3,000 Inlay/Onlay $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 Denture, Crown, Bridge $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 Periodontic & Endodontic $700 $800 $900 $1,000 $1,100 $1,200 Orthodontic $1,500 $1,800 $2,100 $2,400 $2,700 $3,000 Annual Limit per Person $1,500 $1,800 $2,100 $2,400 $2,700 $3,000 HIF calculates dental rebates by applying a percentage (%) to:

115 the actual fee charged by the dentist and then compares this value (i.e. % of dentist s fee) with; the maximum Benefit (refer Schedule M1 1 Dental Schedule). The rebate Benefit payable by HIF is the lower of the calculated value at (a) and the value at (b) above. The value at (b) above is the set maximum rebate Benefit payable. The orthodontic Annual Limit is also the lifetime limit for these dental items. HIF s dental rebate Benefits are based on the Australian Dental Association Schedule (item numbers). HIF recommends that Fund Members contact the Fund prior to commencing treatment to obtain an estimate of the rebate Benefit entitlement for each relevant item number. HIF may restrict or not pay dental rebate Benefits in any of the following circumstances: 1. for replacement dentures and partial dentures within 3 years of a previous supply of replacement or partial dentures; 2. a charge from a Dental Prosthetist for an item that they are not registered or authorised to perform or supply; 3. an item from the Australian Dental Association Schedule that is not included in the HIF schedule of Benefits; 4. an item is performed or supplied in conjunction with another item as part of the same course of treatment; 5. where the relevant Annual Limit has been reached; 6. where the relevant Waiting Period has not been served; 7. where the Fund Membership is unfinancial at the date of service. I1 6 Optical Item Description Quantity Item No Spectacle Frames 110 Repairs to Frame 120 Spectacle lenses Benefit up to 5 yrs 100% of charge up to Annual Limit Benefit over 5 yrs 100% of charge up to Annual Limit Single Vision Stock Lens Single Vision specially worked Lens Single 211 Pair 212 Single 221 Pair 222 Change applies as of 1 st June 2015 Change applies as of 1 st June 2015

116 Item Description Bifocal Spectacle Lens Quantity Item No Single 311 Pair 312 Benefit up to 5 yrs Benefit over 5 yrs Trifocal Spectacle Lens Single 411 Pair 412 Progressive Spectacle Lens Single 511 Pair 512 Contact lens items Rigid Spherical Lens Single 811 Pair 812 Rigid Toric Lens Single 821 Pair 822 Soft Spherical Lens Single 831 Pair 832 Soft Toric Lens Single 841 Pair 842 Frequent Replacement Spherical Lens Single 851 Pair 852 Frequent Replacement Toric Lens Single 853 Pair 854 Bifocal contact Lens Single 861 Pair 862 Other Contact Lens Single 871 Pair 872 Annual Limits $ $

117 HIF Benefits are payable: (a) on glasses and contact lenses that are necessary to correct, remedy or relieve any optical defect of sight; (b) on glasses or contact lenses that are supplied by a registered optometrist or optical dispenser; (c) Fund Members or Fund Contributors who have been covered by HIF Premium Options continuously for more than 5 years are entitled to a higher Annual Limit as specified above. HIF Benefits are not payable on: (a) non-prescription safety glasses, protective glasses, sunglasses, cosmetic glasses or cosmetic contact lenses; (b) for the component where a Fund Member or Fund Contributor is eligible for pensioner subsidy claim from any state, territory or federal government. I1 7 Physiotherapy 1 st visit $ nd to 10 th visit $ th and subsequent visits $30.00 Hydrotherapy $15.00 Antenatal $15.00 Group $15.00 per person annual limits Up to 5 years: $1,200 Over 5 years: $1,500 per person group sub-limit $600 Note: Combined limit for Orthoptics, Physiotherapy, Occupational and Speech Therapies

118 I1 8 Chiropractic 1 st visit $ nd to 10 th visit $ th and subsequent visits $18.00 per person annual limits Up to 3 years: $650 Over 3 years: $750 per Fund Membership annual limits Up to 3 years: $1,300 X-ray $ Over 3 years: $1,500 annual limit 1 X-ray per person Note: Combined limit for Osteopathy and Chiropractic I1 9 Non PBS Pharmaceuticals Benefit is payable only on non-government Pharmaceutical Benefits Scheme (PBS) script items. You are required to pay, per script item, an amount equal to the current Government PBS fee. All pharmacy accounts must be paid before claiming Benefit from HIF. A refund will be paid on items that are only available on prescription. The prescription must be issued by a registered medical or Dental Practitioner. Benefits 100% of balance to a maximum of $80.00 per script item Annual Limits Up to 3 years: $ Over 3 years: $400.00

119 If you are issued with a prescription for an item that is available for purchase without a prescription then Benefit will not be paid. No Benefit will be paid for contraceptives. Contraceptive drugs may be claimed if being prescribed only for the treatment of acne. A letter to that effect must be supplied by your doctor before a Benefit will be paid. The payment of a Benefit for prescriptions for the treatment of acne is limited to six months supply. Drugs purchased outside of Australia are not claimable. I1 10 Podiatry Benefits Annual limit Per person: $ Treatment must be carried out by a registered Podiatrist who is approved by HIF. First visit Subsequent visit Non podiatry practice visit $32.00 $25.00 $12.00 Note: Benefit is not payable for any surgery or treatment provided by an Approved Podiatrist in a hospital or approved hospital facility

120 I1 11 Psychology and Counselling Benefits Annual limit A Benefit is paid only if the Psychologist is a Fund Member of the Australian Psychological Society or the Association of Counselling Psychologists. The Health Care Provider must also be Registered with HIF. First visit Subsequent visit Groups, couples and family therapy $ $55.00 $30.00 per person with a Treatment must be carried out by a Health Care Provider in respect of their registered practice premises. You should contact HIF before treatment is commenced to ensure that you are eligible for treatment. maximum $75.00 per session Per person: $1,000 A maximum of 2 treatment sessions will be paid on the same date, with a minimum of 2 hours between sessions. I1 12 Alternative Therapies I1 13 Natural Therapies Benefits Annual limits A Benefit is paid towards the cost, of Myotherapy, Naturopathy, Homoeopathy, Acupuncture, Massage Therapy, Traditional Chinese Medicine, Aromatherapy, Deep Tissue Massage, Swedish Massage and Sports Massage. The treatment must be provided by a practitioner who is registered with HIF in the speciality for which the charge is raised. Visit 1-6 Over 6 visits $25.00 $17.00 Up to 3 years: $ Over 3 years: $ Benefits are not payable for natural medicines.

121 I1 14 Speech Therapy Benefits Annual limits Benefits are paid on items carried out by a registered speech therapist, approved by HIF First visit Subsequent visit $75.00 $45.00 Per person: Up to 5 years: $1,200 Over 5 years: $1,500 Note: Combined limit for Occupational Therapy, Orthoptics, Physiotherapy and Speech Therapy I1 15 Orthotics Benefits Annual Limit per person A Benefit on replacement Orthotics will be paid after 2 years from date of supply or each Calendar Year if the Fund Member or Dependent has physically outgrown the Orthotics. 75% $ The Orthotics must be supplied by a registered podiatrist, orthotics provider or surgical boot maker. A Benefit for testing, analysis and fitting of Orthotics and / or surgical shoes is included in the Orthotics maximum. I1 16 Dietetics Benefits Annual limit Benefits are payable only for treatment carried out by a registered Dietician approved by HIF in respect of their registered practice premises. First visit Subsequent visit Group visit $40.00 $20.00 $12.00 Per person: $324.00

122 I1 17 Occupational Therapy Benefits Annual limits Benefits are paid only for treatment medically necessary for physical rehabilitation. Fund Members may be asked to supply documentation with the initial claim outlining details of the proposed course of treatment. First visit Subsequent visit Group therapy $60.00 $25.00 $10.00 Per person: Up to 5 years: $1,200 Over 5 years: $1,500 Note: Combined limit for Occupational Therapy, Orthoptics, Physiotherapy and Speech Therapy I1 18 Naturopathy I1 19 Acupuncture I1 20 Other Therapies 1 st visit $ nd to 10 th visit $ th and subsequent visits $18.00 per person annual limits Up to 3 years: $650 Over 3 years: $750 per Fund Membership annual limits Up to 3 years: $1,300 Over 3 years: $1,500

123 Note: Combined limit for Osteopathy and Chiropractic I1 21 Non Surgically Implanted Prostheses and Appliances Benefit Annual limit A Benefit is paid on external prostheses Refer to HIF $1,500 I1 22 Hearing Aids Benefits Annual limits A Benefit is paid for the purchase of one hearing aid per person. Fund Members who have contributed to the HIF table continuously for more than five years may claim for one appliance for each ear. Up to 5 years 5 to 10 years Over 10 years $ $ $ Up to 5 years: 1 Over 5 years: 1 per ear A Benefit is paid on replacement hearing aids after five years. I1 23 Prevention Health Management Benefits up to Annual limit Approved health management program, weight loss program, health assessments, skin cancer screening 100% of fee $125 per person

124 (where Medicare rebate not available), quit smoking program and exercise physiology. $250 per couple, family or single parent Membership I1 24 Ambulance Transportation A Benefit payable for emergency transport and/or medical attention (Priority 1 and 2) is 100% of the charge. A co-payment of $50.00 applies to all non-emergency call-outs and transport (Priority 3), except where a pensioner receives the 50% discount from St John Ambulance. This discount is mentioned on Accounts or in Fund Membership comments on HAMBS. Benefits are not payable for inter-hospital transport except in cases of emergency or new illness where approved on a case by case basis by HIF at its absolute discretion. I1 25 Accident Cover I1 26 Accidental Death Funeral Expenses I1 27 Other Special Benefits Annual Limits Asthmatic Spacers Benefit paid on an Asthmatic Spacer. $18.00 Maximum 2 per person Blood Glucose Monitor/Blood Pressure Monitor You may claim for a replacement monitor after three years. 75% of cost to $ of either Diabetics Education Initial visit $ visits Subsequent visit $18.00

125 Benefits Annual Limits A Benefit is paid towards fees charged for diabetes education by providers Registered with HIF. Nebuliser /Humidifier Benefit is paid on a replacement nebuliser after three years. 75% of cost to $ per person Peak Flow Meter $ per person A Benefit is paid on a peak flow meter. Orthoptics (Eye Therapy) Initial visit Subsequent visit $50.00 $25.00 Up to 5 years: $1,200 Over 5 years: $1,500 Combined limit for Occupational Therapy, Orthoptics, Physiotherapy and Speech Therapy

126 Benefits Annual Limits Auxiliary Home Nursing: A Benefit is payable where the Fund Member receives nursing treatment in excess of 30 minutes per day for a medical condition. It does not include domestic services. The service MUST be ordered by a medical practitioner. Each visit over 30 minutes per day One visit only payable per day $ I2 SCHEDULE GENERAL TREATMENT TABLES I2 1 Table Name or Group of Table Names Super Options (A) I2 2 Eligibility I2 3 General Conditions I2 4 Loyalty Bonuses

127 I2 5 Dental Item Number Annual Limits Year 1 Year 2 Year 3 Year 4 Year 5 After 5 Years General - Unlimited No Limit No Limit No Limit No Limit No Limit No Limit General - Limited $1,150 $1,350 $1,550 $1,750 $2,050 $2,350 Inlay/Onlay $700 $800 $900 $1,000 $1,100 $1,200 Denture, Crown, Bridge $900 $1,000 $1,100 $1,200 $1,300 $1,400 Periodontic & Endodontic $500 $600 $700 $800 $900 $1,000 Orthodontic $1,300 $1,500 $1,700 $1,900 $2,200 $2,500 Annual Limit per Person $1,300 $1,500 $1,700 $1,900 $2,200 $2,500 HIF calculates dental rebates by applying a percentage (%) to (a) (b) the actual fee charged by the dentist and then compares this value (i.e. % of dentist s fee) with; the maximum Benefit (refer Schedule M1 1 Dental Schedule). The rebate Benefit payable by HIF is the lower of the calculated value at (a) and the value at (b) above. The value at (b) above is the set maximum rebate Benefit payable. The orthodontic Annual Limit is also the lifetime limit for these dental items.

128 HIF s dental rebate Benefits are based on the Australian Dental Association Schedule (item numbers). HIF recommends that Fund Members contact the Fund prior to commencing treatment to obtain an estimate of the rebate Benefit entitlement for each relevant item number. HIF may restrict or not pay dental rebate Benefits in any of the following circumstances: (a) (b) (c) (d) (e) (f) (g) for replacement dentures and partial dentures within 3 years of a previous supply of replacement or partial dentures; a charge from a Dental Prosthetist for an item that they are not registered or authorised to perform or supply; an item from the Australian Dental Association Schedule that is not included in the HIF schedule of Benefits; an item is performed or supplied in conjunction with another item as part of the same course of treatment; where the relevant Annual Limit has been reached; where the relevant Waiting Period has not been served; where the Fund Membership is unfinancial at the date of service. I2 6 Optical Item Description Quantity Item No Spectacle Frames 110 Repairs to Frame 120 Spectacle lenses Single Vision Stock Lens Single 211 Pair 212 Single Vision specially Single 221 worked Lens Pair 222 Single 311 Bifocal Spectacle Lens Pair 312 Trifocal Spectacle Lens Single 411 Pair 412 Progressive Spectacle Single 511 Lens Pair 512 Contact lens items Rigid Spherical Lens Single 811 Pair 812 Rigid Toric Lens Single 821 Pair 822 Single 831 Soft Spherical Lens Pair 832 Single 841 Soft Toric Lens Pair 842 Frequent Replacement Single 851 Spherical Lens Pair 852 Benefit up to 5 yrs 100% of charge up to Annual Limit Change applies as of 1 st June 2015 Benefit over 5 yrs 100% of charge up to Annual Limit Change applies as of 1 st June 2015

129 Frequent Replacement Single 853 Toric Lens Pair 854 Single 861 Bifocal contact Lens Pair 862 Single 871 Other Contact Lens Pair 872 Annual Limits $ $ HIF Benefits are payable: (a) on glasses and contact lenses that are necessary to correct, remedy or relieve any optical defect of sight; (b) on glasses or contact lenses that are supplied by a registered optometrist or optical dispenser; (c) Fund Members or Fund Contributors who have been covered by HIF Super Options continuously for more than 5 years are entitled to a higher Annual Limit as specified above. HIF Benefits are not payable on: (a) (b) non-prescription safety glasses, protective glasses, sunglasses, cosmetic glasses or cosmetic contact lenses; for the component where a Fund Member or Fund Contributor is eligible for pensioner subsidy claim from any state, territory or federal government. I2 7 Physiotherapy 1 st visit $ nd to 10 th visit $ th and subsequent visits $20.00 Hydrotherapy $13.00 Antenatal $13.00 Group $13.00 per person annual limits Up to 5 years: $ Over 5 years: $1,100 per person group sub-limit $500.00

130 Note: Combined limit for Orthoptics, Physiotherapy, Occupational and Speech Therapy I2 8 Chiropractic 1 st visit $ nd to 10 th visit $ th and subsequent visits $14.00 per person annual limits Up to 3 years: $ Over 3 years: $ per Fund Membership annual limits Up to 3 years $1,100 Over 3years $1,300 X-ray $85.00 annual limit 1 X-ray per person Note: Combined limit for Osteopathy and Chiropractic I2 9 Non PBS Pharmaceuticals Benefit is payable only on non-government Pharmaceutical Benefits Scheme script items. You are required to pay, per script item, an amount equal to the current Government PBS fee. Benefits up Annual Limits to Per Person 100% of Up to 3 balance to a years: maximum of

131 All pharmacy accounts must be paid before claiming Benefit from the Fund. A refund will be paid on items that are only available on prescription. The prescription must be issued by a registered medical or Dental Practitioner. Benefits up Annual Limits to Per Person $80.00 per Over 3 script item years: $ If you are issued with a prescription for an item that is available for purchase without a prescription then Benefit will not be paid. No Benefit will be paid for contraceptives. Contraceptive drugs may be claimed if being prescribed only for the treatment of Acne. A letter to that effect must be supplied by your doctor every 12 months before Benefit will be paid. Drugs purchased outside of Australia are not claimable. The payment of Benefit for prescriptions related to the treatment of acne is limited to 6 months supply. I2 10 Podiatry Treatment must be carried out by a registered Podiatrist who is approved by the Fund. First visit Subsequent visit Benefits up to $32.00 $23.00 Annual limit Non podiatry practice visit $12.00 Note: Benefit is not payable for any surgery or treatment provided by an Approved Podiatrist in a hospital or approved hospital facility Per person: $382.00

132 I2 11 Psychology and Counselling Benefits up to Annual limit per person A Benefit is paid only if the Psychologist is a Fund Member of the Australian Psychological Society or the Association of Counselling Psychologists. First visit Subsequent visit $75.00 $55.00 $ The Health Care Provider must also be Registered with HIF. Treatment must be carried out by a Health Care Provider in respect of their registered practice premises. You should contact HIF before treatment is commenced to ensure that you are eligible for treatment. Groups, Couples and Family therapy $25.00 per person with a maximum $75.00 per session A maximum of 2 treatment sessions will be paid on the same date, with a minimum of 2 hours between sessions. I2 12 Alternative Therapies I2 13 Natural Therapies Benefits Annual limits A Benefit is paid towards the cost, of Naturopathy Homoeopathy, Acupuncture, Massage Therapy, Traditional Chinese Medicine, Aromatherapy, Deep Tissue Massage, Swedish Massage and Sports Massage. Visit 1-6 Over 6 visits $20.00 $13.00 Up to 3 years: $ Over 3 years: $ The treatment must be provided by a practitioner who is registered with HIF in the speciality for which the charge is raised. Benefits are not payable for natural medicines. Fund Membership Annual Limit: $700.00

133 I2 14 Speech Therapy Benefits Annual limits Benefits are paid on items carried out by a registered speech therapist, approved by HIF. First visit Subsequent visit $75.00 $45.00 Per person: Up to 5 years: $ Over 5 years: $1,100 Note: Combined limit for Occupational Therapy, Orthoptics, Physiotherapy and Speech Therapy I2 15 Orthotics A Benefit on replacement Orthotics will be paid after 2 years from date of supply or each calendar year if the member or Dependent has physically outgrown the Orthotics. Benefits up Annual limits to Per Person 75% $ The Orthotics must be supplied by a registered podiatrist, orthotics provider or surgical boot maker. Benefit paid for testing, analysis and fitting of Orthotics and/or surgical shoes is included in the Orthotics maximum. I2 16 Dietetics Benefits are payable only for treatment carried out by a registered Dietician approved by the Fund in their registered practice premises. First visit Subsequent visit Group visit Benefits up to $36.00 $18.00 $10.00 Annual limit Per person: $324.00

134 I2 17 Occupational Therapy Benefits are paid only for treatment medically necessary for physical rehabilitation. First visit Subsequent visit Benefits up to $45.00 $25.00 Annual limits Per person: Up to 5 years: Fund Members may be asked to supply documentation with the initial claim outlining details of the proposed course of treatment. Group Therapy $10.00 $ Over 5 years: $1,100 Note: Combined limit for Occupational Therapy, Orthoptics, Physiotherapy and Speech Therapy I2 18 Naturopathy I2 19 Acupuncture I2 20 Other Therapies 1 st visit $ nd to 10 th visit $ th and subsequent visits $17.00 per person annual limits Up to 3 years: $ Over 3 years: $650.00

135 per Fund Membership annual limits Up to 3 years: $1,100 Over 3 years: $1,300 Note: Combined limit for Osteopathy and Chiropractic I2 21 Non Surgically Implanted Prostheses and Appliances Benefits up to Annual limit Per Person A Benefit is paid on external prostheses. Refer to fund $1,500 I2 22 Hearing Aids Benefit is paid for the purchase of one hearing aid per person. Fund Members who have contributed to the HIF table continuously for more than five years may claim for one appliance for each ear. Up to 5 years 5 to 10 years Over 10 years Benefits up to $ $ $ Annual limits Per Person Up to 5 years: 1 Over 5 years: 1 per ear Benefit is paid on replacement hearing aids after five years. I2 23 Prevention Health Management Approved health management program, weight loss program, health assessments, skin cancer screening (where Medicare rebate not available), quit smoking program and exercise physiology. Benefits up to Annual limit 100% of fee $100 per person $200 per couple, family or single parent Membership

136 I2 24 Ambulance Transportation 100% Benefit payable for emergency transport and/or medical attention (Priorities 1 and 2). A co-payment of $50.00 applies to all non emergency call outs and transport (Priority 3), except where a pensioner receives the 50% discount from St. John Ambulance. This discount is mentioned on Accounts or in Fund Membership comments on HAMBS. Benefits are not payable for inter hospital transport except in cases of emergency or new illness where approved on a case by case basis by HIF. I2 25 Accident Cover I2 26 Accidental Death Funeral Expenses I2 27 Other Special Asthmatic Spacers Benefit paid on an Asthmatic Spacer. Benefits up to Annual Limits $18.00 Maximum 2 per person Blood Glucose Monitor/Blood Pressure Monitor You may claim for a replacement monitor after three years. Diabetics Education A Benefit is paid towards fees charged for diabetes education by providers registered with the Fund. Initial visit Subsequ ent visit 75% of cost to $ $36.00 $ of either per person 6 visits per person Nebuliser /Humidifier Benefit is paid on a replacement nebuliser after three years. 75% of cost to $ per person

137 Peak Flow Meter Benefits up Annual Limits to $ per person A Benefit is paid on a peak flow meter. Orthoptics (Eye Therapy) Initial Visit Subsequent visit $50.00 $25.00 Up to 5 years: $ Over 5 years: $1,100 Combined limit for Occupational Therapy, Orthoptics, Physiotherapy and Speech Therapy Auxiliary Home Nursing Benefit is payable where the Fund Member receives nursing treatment in excess of 30 minutes per day for a medical condition. It does not include domestic services. The service MUST be ordered by a medical practitioner. Each visit over 30 minutes per day. One visit only payable per day. $75.00 $1,800 per person I3 SCHEDULE GENERAL TREATMENT TABLES I3 1 Table Name or Group of Table Names Special Options I3 2 Eligibility

138 I3 3 General Conditions I3 4 Loyalty Bonuses I3 5 Dental Annual Limits Item After 5 Year 1 Year 2 Year 3 Year 4 Year 5 Number Years General - No No No No No No Limit Unlimited Limit Limit Limit Limit Limit General Limited $800 $950 $1,150 $1,350 $1,550 $1,750 Inlay/Onlay $500 $600 $700 $800 $900 $1,000 Denture, Crown, Bridge $600 $700 $800 $900 $1,000 $1,100 Periodontic & Endodontic $300 $400 $500 $600 $700 $800 Orthodontic $1,000 $1,200 $1,400 $1,600 $1,800 $2,000 Annual Limit per Person $1,000 $1,200 $1,400 $1,600 $1,800 $2,000 HIF calculates dental rebates by applying a percentage (%) to: (a) (b) the actual fee charged by the dentist and then compares this value (i.e. % of dentist s fee) with; the maximum Benefit (refer Schedule M1 1 Dental Schedule). The rebate Benefit payable by HIF is the lower of the calculated value at (a) and the value at (b) above. The value at (b) above is the set maximum rebate Benefit payable. The orthodontic Annual Limit is also the lifetime limit for these dental items. HIF s dental rebate Benefits are based on the Australian Dental Association Schedule (item numbers). HIF recommends that Fund Members contact the Fund prior to commencing treatment to obtain an estimate of the rebate Benefit entitlement for each relevant item number.

139 HIF may restrict or not pay dental rebate Benefits in any of the following circumstances: (a) (b) (c) (d) (e) (f) (g) for replacement dentures and partial dentures within 3 years of a previous supply of replacement or partial dentures; a charge from a Dental Prosthetist for an item that they are not registered or authorised to perform or supply; an item from the Australian Dental Association Schedule that is not included in the HIF schedule of Benefits; an item is performed or supplied in conjunction with another item as part of the same course of treatment; where the relevant Annual Limit has been reached; where the relevant Waiting Period has not been served; where the Fund Membership is unfinancial at the date of service. I3 6 Optical Quantity Item Item Description No Spectacle Frames 110 Repairs to Frame 120 Spectacle lenses Single 211 Single Vision Stock Lens Pair 212 Single Vision specially Single 221 worked Lens Pair 222 Single 311 Bifocal Spectacle Lens Pair 312 Single 411 Trifocal Spectacle Lens Pair 412 Progressive Spectacle Single 511 Lens Pair 512 Contact lens items Single 811 Rigid Spherical Lens Pair 812 Single 821 Rigid Toric Lens Pair 822 Single 831 Soft Spherical Lens Pair 832 Single 841 Soft Toric Lens Pair 842 Single 851 Benefit up to 5 yrs 100% of charge up to Annual Limit Change applies as of 1 st June 2015 Benefit over 5 yrs 100% of charge up to Annual Limit Change applies as of 1 st June 2015

140 Frequent Replacement Spherical Lens Frequent Replacement Toric Lens Bifocal contact Lens Other Contact Lens Pair 852 Single 853 Pair 854 Single 861 Pair 862 Single 871 Pair 872 Annual Limits $ $ HIF Benefits are payable: (a) on glasses and contact lenses that are necessary to correct, remedy or relieve any optical defect of sight; (b) on glasses or contact lenses that are supplied by a registered optometrist or optical dispenser; (c) Fund Members or Fund Contributors who have been covered by HIF Special Options continuously for more than 5 years are entitled to a higher Annual Limit as specified above. HIF Benefits are not payable on: (a) non-prescription safety glasses, protective glasses, sunglasses, cosmetic glasses or cosmetic contact lenses; (b) for the component where a Fund Member or Fund Contributor is eligible for pensioner subsidy claim from any state, territory or federal government. I3 7 Physiotherapy 1 st visit $ nd to 10 th visit $ th and subsequent visits $19.00 Hydrotherapy, Group and/or Antenatal $13.00 per person annual limit $ per Fund Membership annual limit $ per person group sub-limit $400.00

141 Note: Combined Complementary Therapies, Chiropractic, Osteopathy, Physiotherapy and podiatry I3 8 Chiropractic 1 st visit $ nd to 10 th visit $ th and subsequent visits $10.00 per person annual limit $ per Fund Membership annual limit $ X-ray $70.00 annual limit 1 X-ray per person Note: Combined Complementary Therapies, Chiropractic, Osteopathy, Physiotherapy and Podiatry I3 9 Non PBS Pharmaceuticals Pharmacy: A Benefit is payable only on non-government Pharmaceutical Benefits Scheme script items. You are required to pay, per script item, an amount equal to the current Government PBS fee. Benefits up to. 100% of balance to a maximum of $80.00 per script item. Annual Limits $200.00

142 Benefits up to. Annual Limits All pharmacy accounts must be paid before claiming Benefit from the Fund. A refund will be paid on items that are only available on prescription. The prescription must be issued by a registered medical or Dental Practitioner. If you are issued with a prescription for an item that is available for purchase without a prescription then Benefit will not be paid. No Benefit will be paid for contraceptives, or drugs in relation to erectile dysfunction disorder. Contraceptive drugs may be claimed if being prescribed only for the treatment of Acne. A letter to that effect must be supplied by your doctor before Benefit will be paid. Drugs purchased outside of Australia are not claimable. The payment of Benefit for prescriptions related to the treatment of acne is limited to 6 months supply I3 10 Podiatry (Consultations only) The provider must be registered with the Fund. First visit Subsequent Surgery visit Benefits up to $32.00 $23.00 Annual limits Per person: $ Non podiatry practice visit $12.00 Per Fund Membership Note: Benefit is not payable for any surgery or treatment provided by an Approved Podiatrist in a hospital or approved hospital facility $ Note: Combined limit for Complementary Therapies, Chiropractic,

143 Benefits up to Annual limits Osteopathic, Physiotherapy and Podiatry I3 11 Psychology and Counselling I3 12 Alternative Therapies I3 13 Natural Therapies Benefits Annual limits A Benefit is paid towards the cost, of Myotherapy, Naturopathy, Homoeopathy, Acupuncture, Massage Therapy, Traditional Chinese Medicine, Aromatherapy, Deep Tissue Massage, Swedish Massage and Sports Massage. Visit 1-6 Over 6 visits $16.00 $11.00 Up to 3 years: $ Over 3 years: $ The treatment must be provided by a practitioner who is registered with HIF in the speciality for which the charge is raised. Benefits are not payable for natural medicines. Note: Benefits also subject to combined overall person limit $450 and membership limit $900 for complementary therapies, chiro (incl. 1 x-ray per person per year), osteo, physio and podiatry. Fund Membership Annual Limit: $ I3 14 Speech Therapy I3 15 Orthotics

144 I3 16 Dietetics Benefits up to Annual limit Benefits are payable only for treatment carried out by a registered Dietician approved by the Fund in their registered practice premises. First visit Subsequent visit Group visit $36.00 $18.00 $10.00 Per person: $ I3 17 Occupational Therapy This section intentionally left blank I3 18 Naturopathy I3 19 Acupuncture I3 20 Other Therapies I3 21 Non Surgically Implanted Prostheses and Appliances I3 22 Hearing Aids I3 23 Prevention Health Management Approved health management program, weight loss program, health assessments, skin cancer screening (where Medicare rebate not available), quit smoking program and exercise physiology. Benefits up to Annual limit 100% of fee $75 per person $150 per couple, family or single parent Membership

145 I3 24 Ambulance Transportation 100% Benefit payable for emergency transport and/or medical attention (Priority 1 and 2). A Patient co-payment of $50.00 applies to all non emergency call outs and transport (Priority 3), except where a pensioner receives the 50% discount from St. John s Ambulance. This discount is mentioned on Accounts or in Fund Membership comments on HAMBS. Benefits are not payable for inter hospital transport except in cases of emergency or new illness where approved on a case by case basis in advance by HIF. I3 25 Accident Cover I3 26 Accidental Death Funeral Expenses I3 27 Other Special I5 SCHEDULE GENERAL TREATMENT TABLES I5 1 Table Name or Group of Table Names Saver Options (A2) I5 2 Eligibility I5 3 General Conditions I5 4 Loyalty Bonuses

146 I5 5 Dental General - Unlimited General - Limited Item Number Inlay/Onlay Denture, Crown, Bridge Periodontic & Endodontic Orthodontic Annual Limit per Person Annual Limits Year 1 Year 2 Year 3 Year 4 Year 5 After 5 Years No Limit No Limit No Limit No Limit No Limit No Limit $750 $850 $950 $1,050 $1,150 $1,250 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $750 $850 $950 $1,050 $1,150 $1,250 HIF calculates dental rebates by applying a percentage (%) to: (a) (b) the actual fee charged by the dentist and then compares this value (i.e. % of dentist s fee) with; the maximum Benefit (refer Schedule M1 1 Dental Schedule). The rebate Benefit payable by HIF is the lower of the calculated value at (a) and the value at (b) above. The value at (b) above is the set maximum rebate Benefit payable. HIF s dental rebate Benefits are based on the Australian Dental Association Schedule (item numbers). HIF recommends that Fund Members contact the Fund prior to commencing treatment to obtain an estimate of the rebate Benefit entitlement for each relevant item number. HIF may restrict or not pay dental rebate Benefits in any of the following circumstances: (a) (b) (c) for replacement dentures and partial dentures within 3 years of a previous supply of replacement or partial dentures; a charge from a Dental Prosthetist for an item that they are not registered or authorised to perform or supply; an item from the Australian Dental Association Schedule that is not included in the HIF schedule of Benefits;

147 (d) (e) (f) (g) an item is performed or supplied in conjunction with another item as part of the same course of treatment; where the relevant Annual Limit has been reached; where the relevant Waiting Period has not been served; where the Fund Membership is unfinancial at the date of service. I5 6 Optical Item Description Quantity Item No Spectacle Frames 110 Repairs to Frame 120 Spectacle lenses Single 211 Single Vision Stock Lens Pair 212 Single Vision specially Single 221 worked Lens Pair 222 Single 311 Bifocal Spectacle Lens Pair 312 Single 411 Trifocal Spectacle Lens Pair 412 Progressive Spectacle Single 511 Lens Pair 512 Contact lens items Single 811 Rigid Spherical Lens Pair 812 Single 821 Rigid Toric Lens Pair 822 Single 831 Soft Spherical Lens Pair 832 Single 841 Soft Toric Lens Pair 842 Frequent Replacement Single 851 Spherical Lens Pair 852 Frequent Replacement Single 853 Toric Lens Pair 854 Single 861 Bifocal contact Lens Pair 862 Single 871 Other Contact Lens Pair 872 Benefit up to 5 yrs 100% of charge up to Annual Limit Change applies as of 1 st June 2015 Benefit over 5 yrs 100% of charge up to Annual Limit Change applies as of 1 st June 2015 Annual Limits $ $ HIF Benefits are payable

148 (a) on glasses and contact lenses that are necessary to correct, remedy or relieve any optical defect of sight; (b) on glasses or contact lenses that are supplied by a registered optometrist or optical dispenser; (c) Fund Members or Fund Contributors who have been covered by HIF Saver Options continuously for more than 5 years are entitled to a higher Annual Limit as specified above. HIF Benefits are not payable on: (a) (b) non-prescription safety glasses, protective glasses, sunglasses, cosmetic glasses or cosmetic contact lenses; for the component where a Fund Member or Fund Contributor is eligible for pensioner subsidy claim from any state, territory or federal government. I5 7 Physiotherapy 1 st visit $ nd to 10 th visit $ th and subsequent visits $19.00 Hydrotherapy, Group and/or Antenatal $13.00 per person annual limit $ per Fund Membership annual limit $ per person group sub-limit $ Note: Combined Complementary Therapies, Chiropractic, Healthy Lifestyle, Osteopathy, Pharmacy, Physiotherapy, Dietetics and Podiatry. I5 8 Chiropractic 1 st visit $ nd to 10 th visit $ th and subsequent visits $10.00 per person annual limit $350.00

149 per Fund Membership annual limit $ X-ray $65.00 annual limit 1 X-ray per person Note: Combined Complementary Therapies, Chiropractic, Healthy Lifestyle, Osteopathy, Pharmacy, Physiotherapy, Dietetics and Podiatry I5 9 Non PBS Pharmaceuticals A Benefit is payable only on non-government Pharmaceutical Benefits Scheme script items. You are required to pay, per script item, an amount equal to the current Government PBS fee. All pharmacy accounts must be paid before claiming Benefit from the Fund. A refund will be paid on items that are only available on prescription. The prescription must be issued by a registered medical or dental practitioner. If you are issued with a prescription for an item that is available for purchase without a prescription then Benefit will not be paid. No Benefit will be paid for contraceptives. Contraceptive drugs may be claimed if being prescribed only for the treatment of Acne. A letter to that effect must be supplied by your doctor before Benefit will be paid every 12 months. Drugs purchased outside of Australia are not claimable. The payment of Benefit for prescriptions related to the treatment of acne is limited to 6 months supply. Benefits up to Annual limits 100% of balance to a maximum of $80.00 per script item Single: $350 Family: $700 Combined limit for Complementar y Therapies, Physiotherapy, Chiropractic, Healthy Lifestyle, Osteopathy, Dietetic and Podiatry

150 I5 10 Podiatry (Consultations only) The provider must be registered with the Fund. First visit Subsequent Surgery visit Non podiatry practice visit Benefits up to $32.00 $23.00 $12.00 Annual limits Per person: $350 Per Fund Membership: Note: Benefit is not payable for any surgery or treatment provided by an Approved Podiatrist in a hospital or approved hospital facility $700 Note: Combined limit for Complementary Therapies, Physiotherapy, Chiropractic, Healthy Lifestyle, Osteopathy, Dietetic and Pharmacy I5 11 Psychology and Counselling I5 12 Alternative Therapies I5 13 Natural Therapies A Benefit is paid towards the cost, of Naturopathy Homoeopathy, Acupuncture, Massage Therapy, Traditional Chinese Medicine, Aromatherapy, Deep Tissue Massage, Swedish Massage and Sports Massage. The treatment must be provided by a practitioner who is registered with HIF in the speciality for which the charge is raised. Benefits are not payable for natural medicines. Visit 1-6 Over 6 visits Benefits $15.00 $10.00 Annual Limits Up to 3 years: $50.00 Over 3 years: $100.00

151 Benefits Annual Limits Note: Benefits also subject to combined overall person limit $350 and Fund Membership limit $700 for complementary therapies, chiro (incl. 1 x-ray per person per year), dietetics, healthy lifestyle, pharmacy, osteo, physio and podiatry. Fund Membership Annual Limit: $ I5 14 Speech Therapy I5 15 Orthotics I5 16 Dietetics Benefits are payable only for treatment carried out by a registered Dietician approved by the Fund in their registered practice premises. First visit Subsequent visit Group visit Benefits up to $36.00 $18.00 $10.00 Annual limits Per Person: $350 Per Fund Membership: $700 Note: Combined limit for Complementary Therapies, Physiotherapy, Chiropractic, Healthy Lifestyle, Osteopathy, Podiatry and Pharmacy I5 17 Occupational Therapy I5 18 Naturopathy I5 19 Acupuncture

152 I5 20 Other Therapies I5 21 Non Surgically Implanted Prostheses and Appliances I5 22 Hearing Aids I5 23 Prevention Health Management Approved health management program, weight loss program, health assessments, skin cancer screening (where Medicare rebate not available), quit smoking program and exercise physiology. Benefits up Annual limit to 100% of fee $50 per person $100 per couple, family or single parent Membership I5 24 Ambulance Transportation 100% Benefit payable for emergency transport and/or medical attention (Priority 1 and 2). A Patient co-payment of $50.00 applies to all non-emergency call outs and transport (Priority 3), except where a pensioner receives the 50% discount from St. John s Ambulance. This discount is mentioned on Accounts or in Fund Membership comments on HAMBS. Benefits are not payable for inter-hospital transport except in cases of emergency or new illness where approved on a case by case basis in advance by HIF. I5 25 Accident Cover I5 26 Accidental Death Funeral Expenses I5 27 Other Special

153 I6 SCHEDULE GENERAL TREATMENT TABLES I6 1 Table Name or Group of Table Names Vital Options I6 2 Eligibility This product is available to single adult and two adult insured groups, commencing 1st February I6 3 General Conditions I6 4 Loyalty Bonuses I6 5 Dental Services included Benefit Annual Limit General Dental Item numbers , 022, , , , , Periodontic & Endodontic Item Numbers , % $800 per person* *Combined with and inclusive of rebates payable toward all other services covered under this policy HIF calculates dental rebates for this cover by applying fifty percent (50%) to the actual fee charged by the dentist. HIF may restrict or not pay dental rebate Benefits in any of the following circumstances: (h) an item claimed is not included in the HIF schedule of Benefits; (i) an item is performed or supplied in conjunction with another item as part of the same course of treatment; (j) where the Annual Limit has been reached; (k) where the relevant Waiting Period has not been served; (l) where the Fund Membership is unfinancial at the date of service.

154 I6 6 Optical I6 7 Physiotherapy Services included Benefit Annual Limit Physiotherapy visits and/or group therapy 50% $800 per person* *Combined with and inclusive of rebates payable toward all other services covered under this policy I6 8 Chiropractic Services included Benefit Annual Limit Chiropractic and Osteopathy visits and/or group therapy 50% $800 per person* *Combined with and inclusive of rebates payable toward all other services covered under this policy Chiropractic X-ray 50% $800 per person* *Combined with and inclusive of rebates payable toward all other services covered under this policy I6 9 Non PBS Pharmaceuticals I6 10 Podiatry I6 11 Psychology and Counselling

155 I6 12 Alternative Therapies I6 13 Natural Therapies I6 14 Speech Therapy I6 15 Orthotics I6 16 Dietetics I6 17 Occupational Therapy I6 18 Naturopathy I6 19 Acupuncture I6 20 Other Therapies I6 21 Non Surgically Implanted Prostheses and Appliances I6 22 Hearing Aids

156 I6 23 Prevention Health Management I6 24 Ambulance Transportation Services included Benefit Annual Limit Benefit is paid on charges raised for approved ambulance services i.e. emergency transport where a patient is transported and admitted to an emergency department of a hospital or emergency medical attention where the ambulance responds to an emergency call-out and the patient is treated but does not require immediate transportation to hospital. Benefits are not payable for inter-hospital transfers or non urgent transport or services. 50% $800 per person* *Combined with and inclusive of rebates payable toward all other services covered under this policy I6 25 Accident Cover I6 26 Accidental Death Funeral Expenses I6 27 Other Special

157 J2 SCHEDULE COMBINED HOSPITAL TREATMENT and GENERAL TREATMENT TABLES J2 1 Table Name or Group of Table Names HealthMax Saver Plus 100/200 J2 2 Eligibility J2 3 General Conditions J2 4 Hospital Treatment Payments 1. Contracted Hospitals Benefits will be paid at the Contracted Hospital Purchaser Provider Agreement rate agreed between the Hospital and Australian Health Service Alliance, and in accordance with the following table. Subject to any excess or co-payment listed below. Service Shared Accommodation including: Day patient, neo-natal, ICU, HDU Private Accommodation including: Day patient, neo-natal, ICU, HDU Theatre and labour ward fees Prostheses Procedure room fees Outpatient fees All episodic items Inpatient Pharmaceutical drugs Benefit up to: In accordance with HPPA In accordance with HPPA. The Fund Member will pay an out of pocket cost which may vary depending on the Hospital In accordance with HPPA In accordance with the PHI (Prostheses) Rules (Cth) 2007 In accordance with HPPA In accordance with HPPA In accordance with HPPA In accordance with HPPA 2. Non-contracted Hospitals and Public Hospitals

158 Where an HPPA does not exist between the Fund and the Health Care Provider Benefits will be paid in accordance with the Minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 (Cth) and in accordance with the Minimum Benefit requirements in section 72-1 of the PHI Act Miscellaneous Benefits shall be payable for 365 days per year on all Hospital covers subject to acceptance of an Acute Care Certificate after 35 days Patients admitted to a Private Hospital that does not have the facilities to treat surgical patients shall be limited to 52 days supplementary Benefit in any 12 month period. J2 5 Medical Services Payments while admitted Benefits are payable up to 25% of the Medicare Benefits Schedule Fee where Benefits are payable by Medicare Australia. Where the medical practitioner meets the requirements of the Access Gap Scheme Benefits are payable to the agreed rate under that scheme. J2 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals Where the cost of a non-pbs item is less than the Pharmaceutical co-payment (as determined by the Commonwealth department of health and ageing) these drugs will not be covered. J2 7 Non PBS Pharmaceuticals The cost of approved pharmaceuticals is included in the charges agreed between the Hospital and HIF. J2 8 Surgically Implanted Prostheses Benefits will be paid in accordance with the PHI (Prostheses) Rules J2 9 Nursing Home Type Patients HIF will pay Benefits towards Nursing Home Type Patients in accordance with the minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 and in accordance with the minimum Benefit requirements in section 72-1 of the PHI Act J2 10 Co Payments J2 11 Excesses The Fund Benefits payable under this table shall be reduced by the amounts detailed below. The excess will apply to the first amount of Hospital Benefit otherwise payable in any Calendar Year.

159 The excess will not apply to Hospital charges associated with same-day or outpatient treatment. HealthMax Saver Plus - Single - Family Code YICS Excess per Person per year $100 $100 Maximum Excess per Insurance Product per year $100 $200 J2 12 Benefit Limitation Periods Benefit Limitation Periods do not apply. J2 13 Restricted Benefits Benefits are payable for the services as specified below in accordance with the Minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007(Cth) and in accordance with the Minimum Benefit requirements in section 72-1 of the PHI Act 2007 Assisted Reproductive Services Heart (Cardiac) procedures including medical treatment or surgical procedures for cardiac conditions such as, arrhythmias, artery bypass grafts, coronary angioplasty, congenital defects, heart disease, heart transplants, pacemakers and defibrillators, stent insertion Psychiatric care and attention Joint Replacement Eye surgery (e.g. cataracts, intraocular lenses) Obstetric and related procedures J2 14 Exclusions Cosmetic Surgery: Patients who undergo cosmetic surgery where a Benefit is not payable by Medicare Australia will not be eligible for payment of Benefits under this Hospital table. Gastric banding and obesity surgery: is not eligible for Benefits on this cover. Other: Hospital Treatment for which Medicare does not pay a benefit will be ineligible for Benefits on this cover. J2 15 Loyalty Bonuses

160 J2 16 Other Special Hospital Treatment J2 17 Dental Annual Limits Item Numbers Year 1 Year 2 Year 3 Year 4 Year 5 After 5 Years General - Limited $750 $850 $950 $1,050 $1,150 $1, Inlay/Onlay No No No No No No Denture, Crown and Bridge Periodontic & Endodontic Orthodontic Annual Limit per person Benefit No Benefit No Benefit No Benefit Benefit No Benefit No Benefit No Benefit HIF calculates dental rebates by applying a percentage (%) to: Benefit No Benefit No Benefit No Benefit Benefit No Benefit No Benefit No Benefit Benefit No Benefit No Benefit No Benefit Benefit No Benefit No Benefit No Benefit $750 $850 $950 $1,050 $1,150 $1,250 (a) (b) the actual fee charged by the dentist; and then compares this value (i.e. % of dentist s fee) with; the maximum benefit (refer Schedule M1 1 Dental Schedule). The rebate benefit payable by HIF is the lower of the calculated value at (a) and the value at (b) above. The value at (b) above is the set maximum rebate Benefit payable. HIF Dental Benefits are based on the Australian Dental Association Schedule (item numbers) and HIF recommend contacting the Fund prior to commencing treatment for benefit entitlements. HIF may restrict or not pay Dental Benefits for any of the following reasons: (a) (b) for replacement dentures and partial dentures are not paid within three years of previous supply. Where a Dental Prosthetist raises a charge for an item that they are not registered to perform eg: partial dentures

161 (c) (d) (e) (f) (g) Where an item is provided in the Australian Dental Association schedule but is not included in the HIF schedule for benefit eg: home bleaching kit Where an item is supplied/performed in conjunction with another item as part of the same course of treatment Where an applicable Annual maximum has been reached Where the relevant Waiting Period has not been served Where the Fund Membership is un-financial at the date of service J2 18 Optical Item Description Quantity Item No Spectacle Frames 110 Repairs to Frame 120 Spectacle lenses Single Vision Stock Lens Single 211 Pair 212 Single Vision specially Single 221 worked Lens Pair 222 Bifocal Spectacle Lens Single 311 Pair 312 Trifocal Spectacle Lens Single 411 Pair 412 Progressive Spectacle Single 511 Lens Pair 512 Contact lens items Rigid Spherical Lens Single 811 Pair 812 Rigid Toric Lens Single 821 Pair 822 Soft Spherical Lens Single 831 Pair 832 Soft Toric Lens Single 841 Pair 842 Frequent Replacement Single 851 Spherical Lens Pair 852 Frequent Replacement Single 853 Toric Lens Pair 854 Single 861 Bifocal contact Lens Pair 862 Benefit up to 5 yrs 100% of charge up to Annual Limit Change applies as of 1 st June 2015 Benefit over 5 yrs 100% of charge up to Annual Limit Change applies as of 1 st June 2015 Other Contact Lens Single 871 Pair 872

162 Annual Limits $ $ HIF Benefits are payable: (a) (b) (c) on glasses and contact lenses that are necessary to correct, remedy or relieve any optical defect of sight; on glasses or contact lenses that are supplied by a registered optometrist or optical dispenser; Fund Members or Fund Contributors who have been covered by HIF Saver Options continuously for more than 5 years are entitled to a higher Annual Limit as specified above. HIF Benefits are not payable on: (a) (b) non-prescription safety glasses, protective glasses, sunglasses, cosmetic glasses or cosmetic contact lenses; for the component where a Fund Member or Fund Contributor is eligible for pensioner subsidy claim from any state, territory or federal government. J2 19 Physiotherapy 1 st visit $ nd to 10 th visit $ th and subsequent visits $19.00 Hydrotherapy, Group and/or Antenatal $13.00 per person annual limit $ per Fund Membership annual limit $ per person group sub-limit $ Note: Combined Complementary Therapies, Chiropractic, Healthy Lifestyle, Osteopathy, Pharmacy, Physiotherapy, Dietetics and Podiatry. J2 20 Chiropractic 1 st visit $ nd to 10 th visit $ th and subsequent visits $10.00

163 per person annual limit $ per Fund Membership annual limit $ X-ray $65.00 annual limit 1 X-ray per person Note: Combined Complementary Therapies, Chiropractic, Healthy Lifestyle, Osteopathy, Pharmacy, Physiotherapy, Dietetics and Podiatry J2 21 Non PBS Pharmaceuticals Benefits up to Annual Limits Pharmacy: A Benefit is payable only on non-government Pharmaceutical Benefits Scheme script items. You are required to pay, per script item, an amount equal to the current Government PBS fee. All pharmacy accounts must be paid before claiming Benefit from the Fund. A refund will be paid on items that are only available on prescription. The prescription must be issued by a registered medical or Dental Practitioner. If you are issued with a prescription for an item that is available for purchase without a prescription then Benefit will not be paid. No Benefit will be paid for contraceptives. Contraceptive drugs may be claimed if being prescribed only for the treatment of Acne. A letter to that effect must be supplied by your doctor before Benefit will be paid every 12 months. Drugs purchased outside of Australia are not claimable. The payment of Benefit for prescriptions related to the treatment of acne is limited to 6 months supply 100% of balance to a maximum of $80.00 per script item Single: $ Family: $ Combined limit for Physiotherapy, Chiropractic, Healthy Lifestyle, Osteopathy, Dietetics and Podiatry

164 J2 22 Podiatry (Consultations only) The provider must be registered with the Fund. First visit Subsequent Surgery visit Non podiatry practice visit Note: Benefit is not payable for any surgery or treatment provided by an Approved Podiatrist in a hospital or approved hospital facility. Benefits up to $32.00 $23.00 $12.00 Annual limits Per person: $350 Per Fund Membership: $700 Note: Combined limit for Complementary Therapies, Physiotherapy, Chiropractic, Healthy Lifestyle, Osteopathy, Dietetic and Pharmacy J2 23 Psychology and Counselling J2 24 Alternative Therapies J2 25 Natural Therapies J2 26 Speech Therapy J2 27 Orthotics

165 J2 28 Dietetics Benefits are payable only for treatment carried out by a registered Dietician approved by the Fund in their registered practice premises. First visit Subsequent visit Group visit Benefits up to $36.00 $18.00 $10.00 Annual limits Per Person: $350 Per Fund Membership: $700 Note: Combined limit for Complementary Therapies, Physiotherapy, Chiropractic, Healthy Lifestyle, Osteopathy, Podiatry and Pharmacy J2 29 Occupational Therapy J2 30 Naturopathy J2 31 Acupuncture J2 32 Other Therapies J2 33 Non Surgically Implanted Prostheses and Appliances J2 34 Hearing Aids

166 J2 35 Prevention Health Management Approved health management program, weight loss program, health assessments, skin cancer screening (where Medicare rebate not available), quit smoking program and exercise physiology. Benefits up to 100% of fee Sub-limit: $50 per person $100 Membership Annual limit But subject to combined Healthy Lifestyle, Chiropractic, Osteopathy, Physiotherapy, Dietetics, Podiatry and Pharmacy annual limit of: $350 per person $700 per couple, family or single parent Membership J2 36 Ambulance Transportation Ambulance Rebate 100% Benefit payable for emergency transport and/or medical attention (Priority 1 and 2) A Patient co-payment of $50.00 applies to all non emergency call outs and transport (Priority 3), except where a pensioner receives the 50% discount from St. John s Ambulance. This discount is mentioned on Accounts or in Fund Membership comments on HAMBS. Benefits are not payable for inter Hospital transport except in cases of emergency or new illness where approved on a case by case basis in advance by HIF. Annual limit No Limit J2 37 Accident Cover J2 38 Accidental Death Funeral Expenses J2 39 Other Special General Treatment

167 J2 40 Hospital-Substitute Treatment J10 SCHEDULE COMBINED HOSPITAL TREATMENT and GENERAL TREATMENT TABLES J10 1 Table Name or Group of Table Names No Maternity Hospital with Mid Extras Combo J10 2 Eligibility This product is available to single adult and two adult insured groups only, commencing 6 th December J10 3 General Conditions J10 4 Hospital Treatment Payments 1. Contracted Hospitals Benefits will be paid at the Contracted Hospital Purchaser Provider Agreement rate agreed between the Hospital and Australian Health Service Alliance and in accordance with the following table. Subject to any excess or co-payment listed below. Service Shared Accommodation including: Day patient, ICU, CCU, HDU Private Accommodation including: Day patient, ICU, CCU, HDU Theatre fees Prostheses Procedure room fees Outpatient theatre fees All episodic items Inpatient Pharmaceutical drugs Benefit In accordance with HPPA The agreed shared room fee. The Fund Member will pay an out of pocket cost which may vary depending on the Hospital. In accordance with HPPA In accordance with the PHI (Prostheses) Rules 2007 (Cth) In accordance with HPPA In accordance with HPPA In accordance with HPPA In accordance with HPPA 2. Non-contracted Hospitals and public Hospitals

168 Where an HPPA does not exist between the Fund and the Health Care Provider Benefits will be paid in accordance with the Minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 (Cth) and in accordance with the Minimum benefit requirements in section 72-1 of the PHI Act Miscellaneous Benefits shall be payable for 365 days per year on all Hospital covers subject to acceptance of an Acute Care Certificate after 35 days. J10 5 Medical Services Payments while admitted Benefits are payable up to 25% of the Medicare Benefits Schedule Fee where Benefits are payable by Medicare. Where the medical practitioner meets the requirements of the Access Gap Scheme Benefits are payable to the agreed rate under that scheme. Limited benefits will be paid toward the cost of services provided in an approved hospital facility by HIF recognised podiatric surgeons J10 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals Where the cost of a non-pbs item is less than the Pharmaceutical co-payment (as determined by the Commonwealth department of health and ageing) these drugs will not be covered. J10 7 Non PBS Pharmaceuticals The cost of approved pharmaceuticals is included in the charges agreed between the hospital and HIF. J10 8 Surgically Implanted Prostheses Benefits will be paid in accordance with the PHI (Prostheses) Rules J10 9 Nursing Home Type Patients HIF will pay Benefits towards Nursing Home Type Patients in accordance with the minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 and in accordance with the minimum Benefit requirements in section 72-1 of the PHI Act J10 10 Co Payments Private overnight ward accommodation shall attract a co-payment as follows: 1. Contracted hospitals Equitable payment model [ EPM ] payments

169 For private ward accommodation in respect of hospitals which have a Hospital Purchaser Provider Agreement [ HPPA ] with Australian Health Services Alliance [ AHSA ] using the AHSA s DRG [i.e. Diagnostic Related Group] based payment model [or EPM ], the copayment shall be the difference between the amount charged by the hospital for a shared room and the amount charged by that hospital for a private room, per overnight stay for the total number of overnight stays. Per diem payments For private ward accommodation in respect of hospitals which have a HPPA with AHSA using the AHSA s per diem based payment model or other Non-EPM payment model, the copayment rate per each overnight stay shall be the difference between the per diem or other private room accommodation charge and the per diem or other shared room accommodation charge and shall apply to the total number of overnight stays. 2. Non-contracted hospitals For private ward accommodation, the co-payment rate per each overnight stay shall be the difference between the per diem or other private room accommodation charge and the per diem or other shared room accommodation charge and shall apply to the total number of overnight stays J10 11 Excesses The Fund Benefits payable under this table shall be reduced by the amounts detailed below. The excess will apply to overnight accommodation. The excess will not apply to Hospital charges associated with same-day or outpatient. No Maternity Hospital cover Single Couples Excess per person per year $500 $500 Maximum excess per policy per year $500 $1,000 J10 12 Benefit Limitation Periods Benefit Limitation Periods do not apply.

170 J10 13 Restricted Benefits Benefits are payable for the services as specified below in accordance with the Minimum Benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007(Cth) and in accordance with the Minimum Benefit requirements in section 72-1 of the PHI Act Psychiatric care and treatment J10 14 Exclusions Assisted Reproductive Services (IVF) Pregnancy and birth related services Gastric banding and obesity surgery J10 15 Loyalty Bonuses J10 16 Other Special Hospital Treatment J10 17 Dental Services included General Dental Periodontic & Endodontic Item Number Benefit Annual Limit , 121, , , , Inlay/Onlay % $600 per person* *The limits detailed are subject to a combined overall person limit of $1,000. Denture, Crown, Bridge This limit includes the following services dental, chiro, physio & podiatry, complementary therapies Healthy lifestyle services

171 Orthodontic No benefits payable for this service HIF calculates dental rebates for this cover by applying sixty percent (60%) to the actual fee charged by the dentist. HIF may restrict or not pay dental rebate Benefits in any of the following circumstances: (a) an item claimed is not included in the HIF schedule of Benefits; (b) an item is performed or supplied in conjunction with another item as part of the same course of treatment; (c) for replacement dentures and partial dentures are not paid within three years of previous supply. (d) Where a Dental Prosthetist raises a charge for an item that they are not registered to perform eg: partial dentures (e) where the Annual Limit has been reached; (f) where the relevant Waiting Period has not been served; (g) where the Fund Membership is unfinancial at the date of service. J10 18 Optical Item Description Quantity Item No Benefit / Limit for Optical Spectacle Frames Spectacle Frames 110 Repairs to Frame % of charge up to $150 optical Annual Limit Spectacle lenses Single Vision Stock Lens Single Vision specially worked Lens Bifocal Spectacle Lens Single 211 Pair 212 Single 221 Pair 222 Single 311 Pair 312 The following services have a combined annual limit of $1,000 per person, and you can claim 60% back until your annual limit has been reached: Dental Chiro, physio & podiatry Complementary therapies Healthy lifestyle services Trifocal Spectacle Lens Single 411

172 Item Description Quantity Item No Benefit / Limit for Optical Pair 412 Progressive Spectacle Lens Single 511 Pair 512 Contact lens items Single 811 Rigid Spherical Lens Pair 812 Single 821 Rigid Toric Lens Pair 822 Single 831 Soft Spherical Lens Pair 832 Single 841 Soft Toric Lens Frequent Replacement Spherical Lens Frequent Replacement Toric Lens Pair 842 Single 851 Pair 852 Single 853 Pair 854 Single 861 Bifocal contact Lens Pair 862 Single 871 Other Contact Lens Pair 872 HIF Benefits are payable: (a) For glasses and contact lenses that are necessary to correct, remedy or relieve any optical defect of sight;

173 (b) For glasses or contact lenses that are supplied by a registered optometrist or optical dispenser; HIF Benefits are not payable on: (a) (b) Non-prescription safety glasses, protective glasses, sunglasses, cosmetic glasses or cosmetic contact lenses; For the component where a Fund Member or Fund Contributor is eligible for pensioner subsidy claim from any state, territory or federal government. J10 19 Physiotherapy Service Benefit Annual Limit Physiotherapy visits and /or group therapy All group sessions must be fully supervised by a registered physiotherapist. 60% of the charge Sublimit $500 combined with Physio/ Chiro/ Podiatry $1000 combined limit with and inclusive of rebates payable towards the following services; Dental Chiro, physio & podiatry Complementary therapies Healthy lifestyle services J10 20 Chiropractic Service Benefit Annual Limit Chiropractic visits and Chiropractic X-ray Chiropractic visits are only payable for Spinal Adjustments or Spinal Manipulations 60% of the charge Sublimit $500 limit combined with Physio/ Chiro/ Podiatry $1000 combined limit with and inclusive of rebates payable towards the following services; Dental Chiro, physio & podiatry Complementary therapies Healthy lifestyle services

174 J10 21 Non PBS Pharmaceuticals Benefits up to Annual Limits Per Person Benefit is payable only on non-government Pharmaceutical Benefits Scheme script items. You are required to pay, per script item, an amount equal to the current Government PBS fee. All pharmacy accounts must be paid before claiming Benefit from the Fund. Refund will be paid on items that are only available on prescription. The prescription must be issued by a registered medical or Dental Practitioner. Benefits will not be paid in the following circumstances; If you are issued with a prescription for an item that is available for purchase over the counter, without a prescription For contraceptives drugs. Contraceptive drugs may be claimed if being prescribed only for the treatment of Acne. A letter to that effect must be supplied by your doctor every 12 months before Benefit will be paid The payment of Benefit for prescriptions related to the treatment of acne is limited to 6 months supply Drugs purchased outside of Australia are not claimable J10 22 Podiatry Member pays PBS contribution. The benefit is 100% of balance to a maximum of $60.00 per script item Single: $ Couple: $ Service Benefit Annual Limit Podiatry consultations only. 60% of the charge Sublimit $500 limit combined with Physio/ Chiro/ Podiatry

175 Note: Benefit is not payable for any surgery or treatment provided by an Approved Podiatrist in a hospital or approved hospital facility The provider must be registered with the fund. $1000 combined limit with and inclusive of rebates payable towards the following services; Dental Chiro, physio & podiatry Complementary therapies Healthy lifestyle services J10 23 Psychology and Counselling No benefits are payable for this service. J10 24 Alternative Therapies J10 25 Natural Therapies Service Benefit Annual limit A Benefit is paid towards the cost, of Myotherapy, Naturopathy, Homoeopathy, Acupuncture, Massage Therapy, Traditional Chinese Medicine, Aromatherapy, Deep Tissue Massage, Swedish Massage and Sports Massage. The treatment must be provided by a practitioner who is registered with HIF in the speciality for which the charge is raised. Benefits are not payable for natural medicines. 60% of the charge Complementary therapy sublimit of $150 $1000 combined limit with and inclusive of rebates payable towards the following services; Dental Chiro, physio & podiatry Complementary therapies Healthy lifestyle services J10 26 Speech Therapy No benefits are payable for this service. J10 27 Orthotics No benefits are payable for this service. J10 28 Dietetics No benefits are payable for this service.

176 J10 29 Occupational Therapy No benefits are payable for this service. J10 30 Naturopathy J10 31 Acupuncture J10 32 Other Therapies J10 33 Non Surgically Implanted Prostheses and Appliances No benefits are payable for this service. J10 34 Hearing Aids No benefits are payable for this service. J10 35 Prevention Health Management Services Benefit Annual limit Approved health management program, weight loss program, health assessments, skin cancer screening (where Medicare rebate not available), quit smoking program and exercise physiology. Benefits are payable for HIF approved programs delivered by registered providers only. 60% of the charge Healthy Lifestyle sublimit of $150 $1000 combined limit with and inclusive of rebates payable towards the following services; Dental Chiro, physio & podiatry Complementary therapies Healthy lifestyle services J10 36 Ambulance Transportation Rebate Annual limit Ambulance 100% Benefit payable for emergency transport and/or medical attention (Priority 1 and 2) A Patient co-payment of $50.00 applies to all non emergency call outs and transport (Priority 3), except No Limit

177 J10 37 Accident Cover where a pensioner receives the 50% discount from St. John s Ambulance. Benefits are not payable for following; - Inter Hospital transport except in cases of emergency or new illness where approved on a case by case basis in advance by HIF - Transportation from a hospital to your home, nursing home or other hospital - Transportation for ongoing medical treatment - Off road or air ambulance J10 38 Accidental Death Funeral Expenses J10 39 Other Special General Treatment J10 40 Hospital-Substitute Treatment This section is left blank intentionally.

178 K SCHEDULE CONTRIBUTION RATE K1 Contribution Rate The following are the weekly (total cost of policy) premiums payable for each HIF product, by state, effective 1 st April, These premiums do not include any government rebate, Lifetime Health Cover loading or HIF approved discounts. WA Monthly HOSPITAL NT Monthly FAMILY SINGLE FAMILY SINGLE Product Name Top with Private Room Top with Private Room GoldStar No Excess FH3 $ SH3 $ FH3 $ SH3 $ GoldStar Excess $200/ FR3 $ SR3 $ FR3 $ SR3 $ GoldStar Excess $400/$800 FR4 $ SR4 $ FR4 $ SR4 $ GoldStar Excess $500/ FR5 $ SR5 $ FR5 $ SR5 $ Top with Shared Room Top with Shared Room Gold No Excess FH2 $ SH2 $ FH2 $ SH2 $ Gold Excess $100/$200 FR2 $ SR2 $ FR2 $ SR2 $ Gold Excess $200/$400 FR6 $ SR6 $ FR6 $ SR6 $ Gold Excess $400/$800 FR7 $ SR7 $ FR7 $ SR7 $ Intermediate with Shared Room Intermediate with Shared Room GoldSaver Excess FGS $ SGS $ FGS $ SGS $ Basic with Shared Room Basic with Shared Room GoldStarter Excess FGR $ SGR $94.40 FGR $ SGR $79.20 Economy with Shared Room Economy with Shared Room GoldVital CGV $ SGV $70.55 CGV $ SGV $51.35 Basic Hospital FB $ SB $ FB $ SB $ EXTRAS Premium Options FA5 $ SA5 $ FA5 $ SA5 $ Super Options FA $ SA $79.15 FA $ SA $79.15 Special Options FA1 $ SA1 $50.55 FA1 $ SA1 $50.55 Saver Options FA2 $63.25 SA2 $31.65 FA2 $63.25 SA2 $31.65 Vital Options CA4 $55.25 SA4 $27.60 CA4 $55.25 SA4 $27.60 COMBINED COVER HealthMax Saver CYICS $ SYICS $ CYICS $ SYICS $ No Maternity with Mid Level Extras CNM $ SNM $ CNM $ SNM $163.35

179 HOSPITAL ACT NSW Monthly Monthly FAMILY SINGLE FAMILY SINGLE Product Name Top with Private Room Top with Private Room GoldStar No Excess FH3 $ SH3 $ FH3 $ SH3 $ GoldStar Excess $200/ $400 FR3 $ SR3 $ FR3 $ SR3 $ GoldStar Excess $400/$800 FR4 $ SR4 $ FR4 $ SR4 $ GoldStar Excess $500/ FR5 $ SR5 $ FR5 $ SR5 $ Top with Shared Room Top with Shared Room Gold No Excess FH2 $ SH2 $ FH2 $ SH2 $ Gold Excess $100/$200 FR2 $ SR2 $ FR2 $ SR2 $ Gold Excess $200/$400 FR6 $ SR6 $ FR6 $ SR6 $ Gold Excess $400/$800 FR7 $ SR7 $ FR7 $ SR7 $ Intermediate with Shared Room Intermediate with Shared Room GoldSaver Excess FGS $ SGS $ FGS $ SGS $ Basic with Shared Room Basic with Shared Room GoldStarter Excess FGR $ SGR $ FGR $ SGR $ Economy with Shared Room Economy with Shared Room GoldVital CGV $ SGV $94.50 CGV $ SGV $94.50 Basic Hospital FB $ SB $ FB $ SB $ EXTRAS Premium Options FA5 $ SA5 $ FA5 $ SA5 $ Super Options FA $ SA $86.20 FA $ SA $86.20 Special Options FA1 $ SA1 $53.40 FA1 $ SA1 $53.40 Saver Options FA2 $65.30 SA2 $32.65 FA2 $65.30 SA2 $32.65 Vital Options CA4 $59.80 SA4 $29.85 CA4 $59.80 SA4 $29.85 COMBINED COVER HealthMax Saver CYICS $ SYICS $ CYICS $ SYICS $ No Maternity with Mid Level CNM $ SNM $ CNM $ SNM $248.75

180 SA Monthly HOSPITAL QLD Monthly FAMILY SINGLE FAMILY SINGLE Product Name Top with Private Room Top with Private Room GoldStar No Excess FH3 $ SH3 $ FH3 $ SH3 $ GoldStar Excess $200/ FR3 $ SR3 $ FR3 $ SR3 $ GoldStar Excess $400/$800 FR4 $ SR4 $ FR4 $ SR4 $ GoldStar Excess $500/ FR5 $ SR5 $ FR5 $ SR5 $ Top with Shared Room Top with Shared Room Gold No Excess FH2 $ SH2 $ FH2 $ SH2 $ Gold Excess $100/$200 FR2 $ SR2 $ FR2 $ SR2 $ Gold Excess $200/$400 FR6 $ SR6 $ FR6 $ SR6 $ Gold Excess $400/$800 FR7 $ SR7 $ FR7 $ SR7 $ Intermediate with Shared Room Intermediate with Shared Room GoldSaver Excess FGS $ SGS $ FGS $ SGS $ Basic with Shared Room Basic with Shared Room GoldStarter Excess FGR $ SGR $ FGR $ SGR $ Economy with Shared Room Economy with Shared Room GoldVital CGV $ SGV $92.60 CGV $ SGV $94.50 Basic Hospital FB $ SB $ FB $ SB $ EXTRAS Premium Options FA5 $ SA5 $ FA5 $ SA5 $ Super Options FA $ SA $79.15 FA $ SA $79.15 Special Options FA1 $ SA1 $50.55 FA1 $ SA1 $51.50 Saver Options FA2 $63.25 SA2 $31.65 FA2 $63.25 SA2 $31.65 Vital Options CA4 $55.25 SA4 $27.60 CA4 $55.25 SA4 $27.60 COMBINED COVER HealthMax Saver CYICS $ SYICS $ CYICS $ SYICS $ No Maternity with Mid Level Extras CNM $ SNM $ CNM $ SNM $253.35

181 TAS Monthly HOSPITAL VIC Monthly FAMILY SINGLE FAMILY SINGLE Product Name Top with Private Room Top with Private Room GoldStar No Excess FH3 $ SH3 $ FH3 $ SH3 $ GoldStar Excess $200/ FR3 $ SR3 $ FR3 $ SR3 $ GoldStar Excess $400/$800 FR4 $ SR4 $ FR4 $ SR4 $ GoldStar Excess $500/ FR5 $ SR5 $ FR5 $ SR5 $ Top with Shared Room Top with Shared Room Gold No Excess FH2 $ SH2 $ FH2 $ SH2 $ Gold Excess $100/$200 FR2 $ SR2 $ FR2 $ SR2 $ Gold Excess $200/$400 FR6 $ SR6 $ FR6 $ SR6 $ Gold Excess $400/$800 FR7 $ SR7 $ FR7 $ SR7 $ Intermediate with Shared Room Intermediate with Shared Room GoldSaver Excess FGS $ SGS $ FGS $ SGS $ Basic with Shared Room Basic with Shared Room GoldStarter Excess FGR $ SGR $ FGR $ SGR $ Economy with Shared Room Economy with Shared Room GoldVital CGV $ SGV $94.50 CGV $ SGV $92.15 Basic Hospital FB $ SB $ FB $ SB $ EXTRAS Premium Options FA5 $ SA5 $ FA5 $ SA5 $ Super Options FA $ SA $79.15 FA $ SA $79.15 Special Options FA1 $ SA1 $50.55 FA1 $ SA1 $50.55 Saver Options FA2 $63.25 SA2 $31.65 FA2 $63.25 SA2 $31.65 Vital Options CA4 $55.25 SA4 $27.60 CA4 $55.25 SA4 $27.60 COMBINED COVER HealthMax Saver CYICS $ SYICS $ CYICS $ SYICS $ No Maternity with Mid Level Extras CNM $ SNM $ CNM $ SNM $253.35

182 OVERSEAS COVER ALL STATES Monthly FAMILY SINGLE Comprehensive Working Visa FO $ SO $ Comprehensive Working Visa $500/$1,000 FOE $ SOE $ Intermediate Working Visa FOI $ SOI $ Essential Working Visa FOB $ SOB $95.55 Basic Working Visa $500/ $1,000 FOD $ SOD $71.60 Visitor Advantage $200/ $400 FOS $ SOS $ Visitor Value FOC $ SOC $ Visitor Saver FOA $ SOA $93.05 L SCHEDULE OVERSEAS L1 Overseas L1.1 Table Name/Group of Table Names Comprehensive Working Visa Cover Comprehensive Working Visa $500/$1,000 Excess Cover Intermediate Working Visa Cover Essentials Working Visa Cover Basic Working Visa Cover Visitor Advantage Cover Visitor Value Cover Visitor Saver Cover L1.2 Eligibility Comprehensive, Intermediate, Essentials, and Basic Working Visa covers are available to any non resident of Australia who is permitted to live and work temporarily within Australia under an Australian Government Department of Immigration and Border Protection approved "Working Visa", and is less than 65 years of age. Visitor Advantage cover is available to any non resident of Australia who is temporarily residing in Australia. Visitor Value and Visitor Saver covers are available to any non resident of Australia who is temporarily residing in Australia, and is less than 65 years of age.

183 L1. 3 General Conditions 1. Non refundable minimum period of cover A non refundable two month minimum cover duration will apply for all products in this table. 2. Cancellation of application Administration Fee Where a future dated new membership application has been accepted but is cancelled prior to the commencement date, HIF may charge the applicant a $50 administration fee. L1.4 Hospital Treatment Payments 3. Contracted Hospitals In the case of: Shared and /or Private Room (see product exclusions below) Accommodation including Day patient, neo-natal, ICU, CCU, HDU Theatre and Labour ward fees Procedure room fees Outpatient fees All episodic items Inpatient Pharmaceutical drugs For Visitor Advantage cover, Comprehensive Working Visa and Comprehensive Working Visa Excess $500/$1,000 covers - Private hospital accommodation, benefits will be paid at the Contracted Hospital Purchaser Provider Agreement ( HPPA ) rate(s) agreed between the relevant Hospital and Australian Health Service Alliance ( AHSA ), and in accordance with the table Hospital Services Covered, subject to any excess or co-payment listed below. Accommodation benefits will be paid for a shared or private room. For public hospital accommodation, benefits will be paid at the relevant State and territory health authority gazetted rates for ineligible patients. For Intermediate Working Visa and Visitor Value cover Hospital and Medical private hospital accommodation, benefits will be paid at the Contracted Hospital Purchaser Provider Agreement ( HPPA ) rate(s) agreed between the relevant Hospital and Australian Health Service Alliance ( AHSA ), and in accordance with the table Hospital Services Covered, subject to any excess or co-payment listed below. A fund member may elect to take a private room in a private hospital however Benefit will be paid to the equivalent of a shared room only according to that HPPA. For public hospital accommodation, benefits will be paid at the relevant state and territory health authority gazetted rates for ineligible patients.

184 For Basic Working Visa, Essentials Working Visa, and Visitor Saver covers - Hospital benefits will be paid in accordance with the table Hospital Services Covered, and benefits will be paid at the relevant State and territory health authority gazetted rates for ineligible patients. In the case of prostheses, benefits will be paid for all Overseas Visitor Cover products in accordance with the PHI (Prostheses) Rules 2007 (cth). The Table entitled Hospital Services Covered located at the end of this Product Group section identifies those services which are eligible for benefits under each of the Overseas Visitors products. 4. Ambulance A benefit will be paid for 100% of the Ambulance charge, that is not otherwise covered by third party arrangements, for transport by Ambulance provided by, or under an arrangement with, a government approved ambulance service when medically necessary for admission to hospital, emergency treatment on site, or inter-hospital transfer for emergency treatment. 5. Medical Rebate Outpatient services Outpatient services are not eligible for benefit for persons covered under Basic Working Visa, Essentials Working Visa or Visitor Saver covers. Outpatient services benefits will be paid for all other Working Visa or Visitor cover products in accordance with the Medicare Benefit Scheduled Fee and/or Access Gap Benefits where eligible, up to a maximum amount per person per calendar year. The benefit will be at least 100% of the charge up to the Medicare Benefit Scheduled Fee applicable to that service but subject to any annual cover limitation which may apply. The annual maximum amount per calendar year per person is: Comprehensive Working Visa and Comprehensive Working Visa $500/$1,000 Excess cover: No Maximum. Intermediate Working Visa and Visitor Value Covers: Maximum of $500. Visitor Advantage Cover: an annual maximum of $1,500 will apply per person, per calendar year. However this limit will not apply to persons covered prior to April 2013, until 1 st July Non-contracted Hospitals and Public Hospitals Where an HPPA does not exist between the Fund and the provider, benefits will be paid in accordance with the minimum benefit requirements as specified in the PHI (Benefit Requirements) Rules (Cth) and in accordance with the Minimum Benefit Requirements in section 72-1 of the PHI Act 2007.

185 L1 5 Medical Services Payments while admitted Benefits of at least 100% of the Medicare Benefits Schedule Fee are payable where benefits for the service(s) received are payable by Medicare. Where the medical practitioner meets the requirements of the Access Gap Scheme, benefits are payable at the agreed rate under that scheme for all Working Visa and Visitor covers, with the exception of Intermediate, Essentials, Basic Working Visa covers and Visitor Value and Visitor Saver covers. Basic Working Visa cover: The annual maximum amount per calendar year per person is $1,000,000 L1 6 Pharmaceutical Benefits Scheme PBS Pharmaceuticals For all Pharmaceutical Benefits Schedule (PBS) listed drugs that are prescribed according to the PBS approved indications, that are administered during and form part of an admitted episode of care a Benefit will be paid equal to the PBS listed price in excess of the patient contribution. L1 7 Non PBS Pharmaceuticals The cost of HIF approved pharmaceuticals is included in the charges agreed between the hospital and HIF. L1 8 Surgically Implanted Prostheses Benefits will be paid in accordance with the PHI (Prostheses) Rules L1 9 Nursing Home Type Patients HIF will pay benefits towards Nursing Home Type patients in accordance with the minimum benefit requirements as specified in the PHI (Benefit Requirements) Rules 2007 and in accordance with the minimum benefit requirements in section 72-1 of the PHI Act L1 10 Co Payments Co payments are not payable on any level of Working Visa or Visitor covers for the services for which each product is eligible to be covered. L1.11 Excesses Fund Members on Working Visa and Visitors Cover products which include an excess will be required to forego the applicable excess portion of benefit otherwise payable for services provided to them whilst they are a patient admitted to a hospital as an overnight patient (i.e. Inpatient). The excess will apply once per person covered under the relevant cover to a maximum of two

186 excesses in any calendar year for a family membership, with the exception of Basic Working Visa cover. An excess will not apply to services provided out of the hospital. Product Excess per Patient per Episode of Hospitalisation Maximum Excess Payable per Insurance Product per Year Comprehensive Working Visa Cover Single $0 $0 Family $0 $0 Comprehensive Working Visa $500/ $1,000 Excess Cover Single $500 $500 Family $500 $1,000 Intermediate Working Visa Cover Single $0 $0 Family $0 $0 Essentials Working Visa Cover Single $0 $0 Family $0 $0 Basic Working Visa Cover Single $500 No person or family cap on excess Family $500 No person or family cap on excess Visitor Advantage Cover Single $200 $200 Family $200 $400 Visitor Value Cover Single $250 $250 Family $250 $500 Visitor Saver Cover Single $250 $250 Family $250 $500 L1 12 Benefit Limitation Periods This section intentionally left blank L1 13 Restricted Benefits Fund Members on Basic Working Visa cover are eligible for basic benefits payable at shared room public hospital rates for the following services: Pregnancy and birth related services Psychiatric care and treatment Palliative care Gastric banding and obesity surgery

187 Benefits are payable up to the rate determined by the relevant gazetted state and territory health authority. L1.14 Excluded services Fund Members on all HIF Working Visa and Visitor Cover products will not be covered for medical or hospital treatment if: Provided en-route to and from Australia; Provided outside of Australia; Arranged prior to coming to Australia; Covered by any entitlement to Compensation or damages; A benefit is claimable or payable from another source; For any cosmetic reasons; For any service for which Australian residents would not be covered under the Australian Medicare scheme. Fund Members on Basic Working Visa, Essentials Working Visa, and Intermediate Working Visa Covers and Visitor Value Cover are also ineligible for benefits for: Artificial reproductive techniques or investigation of treatment relating to infertility; Bone marrow and Organ transplant. Fund Members on Visitor Advantage cover are also ineligible for Benefit for: Artificial reproductive techniques or investigation of treatment relating to infertility. Fund Members on Visitor Saver Cover are also ineligible for Benefit for: Heart (Cardiac) procedures including medical treatment or surgical procedures for cardiac conditions such as, arrhythmias, artery bypass grafts, coronary angioplasty, congenital defects, heart disease, heart transplants, pacemakers and defibrillators, stent insertion; Eye surgery (any procedure on the surface or within the structures of the eye); Gastric banding and obesity services; Joint replacement; Obstetrics or any maternity related services; Palliative care; Psychiatric; Rehabilitation; Renal dialysis; Bone marrow and organ transplant; Artificial reproductive techniques, investigation or treatment relating to infertility. L1 15 Loyalty Bonuses

188 L1.16 Other Special Persons covered by HIF Working Visa policies may be eligible to receive a benefit toward the cost of their repatriation to their home country (prior to temporary residence in Australia). For eligible policy holders and any other eligible person(s) covered under the policy who have to be repatriated to their home country because they are terminally ill or suffer from a substantial life-altering illness or injury, HIF will pay a contribution towards the cost of that person s return travel with one other family member and one other person qualified to give that person medical supervision, provided that a benefit, up to a maximum limit, is only payable after that person s treating medical practitioner and HIF agree that they are terminally ill or suffer from a substantially life-altering illness or injury. In the event of death, the deceased person s mortal remains and those any other person, or any other person covered by that deceased person s policy may be repatriated to their home country if legally permissible. The repatriation benefit amounts listed below are maximum amounts, payable once per person per lifetime of their policy. Repatriation Benefit Benefit Eligibility Maximum benefit per person per lifetime Basic Working Visa Cover Essentials Working Visa Cover Intermediate Working Visa Cover Comprehen sive Working Visa Covers Visitor Covers (Advantage, Value and Saver) Yes Yes Yes Yes Not eligible $4,000 $4,000 $6,000 $8,000 Nil Table: Hospital and Admitted Patient Services Covered Working Visa Covers: Services covered Shared Room in Public Hospital Shared Room in Private Hospital Private Room in Public Hospital Private Room in a Private Hospital Basic Working Visa Cover Essentials Working Visa Cover Intermediate Working Visa Cover Comprehensiv e Working Visa Covers Yes Yes Yes Yes Not covered Not covered Yes Yes Not covered Not covered Yes Yes Not covered Not covered Not covered Yes

189 Services covered Basic Working Visa Cover Essentials Working Visa Cover Intermediate Working Visa Cover Comprehensiv e Working Visa Covers Emergency Ambulance Yes Yes Yes Yes Access Gap Cover Not covered Not covered Not covered Yes Intensive care Yes Yes Yes Yes Private Hospital theatre charges 365 day per year cover, subject to approved certification after 35- days Same day accommodation and theatre charges In-hospital procedure room fees Artificial appliances and prostheses during surgery (e.g. joints, heart valves) Cardiac surgery and procedures Pregnancy and birth related procedures Eye surgery (e.g. cataracts, lens transplant, pterygium removal) Gastric banding and obesity services Joint replacement surgery (e.g. hip, knee) Renal, Sterilisation, Sleep disorders, Psychiatric treatment, Psychiatric treatment Bone Marrow & Organ Transplant Assisted Reproductive Technology Not covered Not covered Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Restricted Yes Yes Yes Yes Yes Yes Yes Restricted Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Restricted Yes Yes Yes Not covered Not covered Not covered Yes Not covered Not covered Not covered Yes

190 Services covered Basic Working Visa Cover Essentials Working Visa Cover Intermediate Working Visa Cover Comprehensiv e Working Visa Covers In patient pharmacy Yes Yes Yes Yes Non Working Visa Covers Services covered Visitor Saver Cover Visitor Value Cover Visitor Advantage Cover Shared Room in Public Hospital Yes Yes Yes Shared Room in Private Hospital Not covered Yes Yes Private Room in Public Hospital Not covered Yes Yes Private Room in a Private Hospital Not covered Not covered Yes Emergency Ambulance Yes Yes Yes Access Gap Cover Not covered Not covered Yes Intensive care Yes Yes Yes Private Hospital theatre charges No Yes Yes 365 day per year cover, subject to approved certification after 35-days Yes Yes Yes Same day accommodation and theatre charges Yes Yes Yes In-hospital procedure room fees Yes Yes Yes Artificial appliances and prostheses during surgery for covered procedures Yes Yes Yes Cardiac surgery and procedures Not covered Yes Yes Pregnancy and birth related procedures Not covered Yes Yes Eye surgery (e.g. cataracts, lens transplant, pterygium removal) Not covered Yes Yes Gastric banding and obesity services Not covered Yes Yes Joint replacement surgery (e.g. hip, knee) Not covered Yes Yes Renal, Sterilisation, Sleep disorders, Not covered Yes Yes Psychiatric treatment Not covered Yes Yes Bone Marrow & Organ Transplant Not covered Not covered Yes Assisted Reproductive Technology Not covered Not covered Not covered In patient pharmacy Yes Yes Yes