Medicare covers you for 75% of the Medicare Schedule Fee for treatments provided by doctors in hospitals. Your GU Hospital Cover pays the difference – the ‘gap’ – between the Medicare rebate and the Medicare Schedule Fee (in other words, the remaining 25%). Specialists and other healthcare providers do sometimes charge more than the Schedule Fee for different types of services, like surgeons’ and anaesthetists’ fees – which can leave you out of pocket. There are a number of steps we take, including establishing partnerships with certain hospitals and specialists, to help stop this from occurring.

Access Gap Cover
Access Gap reduces or eliminates all out-of-pocket expenses for specialist care you receive in hospital. It’s automatically included with Grand United’s Hospital Cover. It works like this: if your doctor or specialist participates in the scheme, they bill Grand United an agreed amount directly. This means you don’t have to make a claim to either Medicare or Grand United. Ask your doctor about this before you go into hospital. If there are any out-of-pocket expenses involved, you’ll know about them well in advance.

Doctors in partnership with Grand United
Some doctors, like pathologists and radiologists, have an agreement with Grand United which guarantees that you’re covered for 100% of the cost of medical services you receive in hospital.

Hospitals in partnership with Grand United
Most private hospitals and day facilities have an agreement with Grand United, which guarantees that you’re covered for 100% of accommodation and most other services, like Theatre Fees (less any applicable excess).
For a full list of Partner Private Hospitals, call 1800 814 159 or see
www.grandunited.com.au


  When you buy car insurance, you state the value of your car. And when you arrange insurance for your home, you need to list any household valuables. All kinds of insurances have limitations on how much the insurance company will pay. Without limits, any insurance is open to abuse by those few thoughtless people who deliberately exploit the system – and we’d all have to carry the cost through higher contributions.

The health insurance industry also has limits – a cap on how much you can claim for each type of service in a year. They help us manage how much gets paid out in claims each year. Rebate limits are designed to help to keep your health cover fair, comprehensive and reasonably priced.

  HICAPS stands for the Health Industry Claims and Payment Service. It’s a computer system that effectively lets you use your Member Card to ‘pay’ for health service, instead of using your money and then filing a claim. As a Grand United member, you can take advantage of HICAPS on-thespot claims processing using your Member Card. Simply swipe the card through the HICAPS terminal at participating practitioners for instant claim processing. That way, you’ll only have to pay any difference between the treatment fee and the Grand United rebate.

  If you live in NSW or the ACT and decide against taking out Hospital Cover, you really need to consider Ambulance cover, for the cost of transportation and treatment by ambulance – otherwise you’ll need to pay the full amount.
If you’re a resident of another State, you can purchase cover from your State Government Ambulance Scheme.

 
There’s a waiting period between when you join and when you’re able to claim some rebates, listed below:
Accidents (excluding injury subject to Workers Compensation, Third Party or damage claims) 1 day   General services 2 months
Health management services 6 months
Artificial aids / prostheses 12 months   Hearing aids 12 months
Bridges, crowns, dentures and elated services, endodontic, orthodontic, periodontic, inlays, onlays and facings 12 months   Natural therapies 2 months
Optical and repairs 2 months
Cosmetic surgery 12 months   Pre-existing conditions 12 months
Diabetic / hormone implants 12 months   Vitamins and natural
health supplements
6 months

Please note that rebates relating to pre-existing conditions aren’t payable for services received during the 12 months from when you join or increase your level of cover. A ‘pre-existing’ condition is one where the signs or symptoms were in evidence up to six months before you joined or increased your Hospital Cover, regardless of when the condition was diagnosed. Claims related to pre-existing conditions may be referred to Grand United’s consulting doctor prior to being approved for payment. Pre-existing condition restrictions do not apply to Extras Cover.

  If you transfer to Grand United from another registered Australian health fund,
you’re entitled to continuity of membership under the National Health Act, provided you join Grand United within two months of leaving the other fund. So, if you were entitled to certain benefits under your old cover, you’ll be able to claim any equivalent rebates included in your new Grand United plan without waiting. However, when your Grand United plan includes a higher level than your current cover, you’ll have to either wait or pay the difference for non-equivalent rebates. Unfortunately, accrued entitlements are not transferable between funds.

  There are some medical procedures that Grand United doesn’t cover – neither will Medicare. Some cosmetic procedures, for example, are not covered. For more information, please call 1800 814 159.
When rebates aren’t applicable Grand United can’t pay rebates:
• if the service you’re claiming for is not included in your health cover • if the service you’re claiming for was not provided
• if your application form contains false or misleading information in respect of yourself or your dependants
• during a waiting period
• if you’re not a financial member (as defined by Grand United) at the time the services are received
• where hospital or other allied health service charges are claimed or claimable under any Policy of Insurance, Third Party or Workers Compensation
• where a benefit limit has been reached within a calendar/membership year
• for claims made after two years from date of service
• for any claim made for professional services rendered by a provider to members of his/her family or to a partner or partner’s family except for
the wholesale costs involved in providing the services
• for services received or products purchased while overseas
• for services provided by a practitioner who is not a Grand United recognised provider.

  If you’re eligible for Medicare and hold a current Medicare Card, you’re entitled to the Federal Government’s rebate on health insurance. There are 3 rebate levels: 30%, 35% and 40%, depending on your age and other circumstances. For more information call our Member Relations Team on 1800 814 159

  The Private Health Insurance Ombudsman deals with enquiries and complaints about any aspect of private health insurance. Members of private health funds may seek free advice from the Ombudsman if they have a related complaint.

Complaints Hotline: 1800 640 695 free call from anywhere in Australia.
Private Health Insurance Ombudsman
Suite 1201, Level 12, St Martins Tower
31 Market Street, Sydney NSW 2000


  The best way to avoid out-of-pocket expenses is to stay healthy.
That’s why Grand United actively encourages you to take advantage of preventative and complementary therapies through our GALIB Extras Covers. After all, if you take care of yourself now, you’ll need less help later.