Ways to claim on your health insurance

• On the spot: You can use your or digital or physical membership card to claim on the spot at selected extras providers^*. You'll need to pay any difference that's owing. 
• Online: You can upload your extras or ambulance claim with our My Membership app or online in member services in a couple of easy steps.
• In a branch: Drop into your local HCF branch with your membership card and your original receipts and we’ll take care of the rest.
• By post: Send your completed claim form and original receipts to HCF, GPO Box 4242, Sydney NSW 2001.

Your health cover claims checklist

To make a claim you can log in to our My Membership app or online member services. Before claiming, make sure you:

• have given us your bank details so we can pay your claims. Go to ‘Payments’ and then ’Update payment details’.
• are covered for that treatment or service and have served any relevant waiting periods. Go to 'My cover' and then 'Cover details'
• have already had the treatment or service (you can’t claim in advance) and are claiming within 2 years of receiving the treatment or service you’re claiming for
• have read and agreed to HCF’s Privacy Policy and ticked the declaration.

Please keep in mind, we may ask you for some extra information to help with the claim.

Claiming on your hospital cover

If you're having hospital treatment, there'll be different aspects of your claim. The hospital will usually take care of claiming for things like accommodation, the theatre room hire and prostheses. 

You’ll be given a claim form to complete and sign, and the hospital will then send the bill to us. If there’s an excess, or any other out-of-pocket expenses, you’ll usually pay the hospital directly.

But there are also medical costs, like surgeons and anaesthetists, not handled by the hospital. Your doctor and anaesthetist will create their own invoice and you’ll need to first claim through Medicare who’ll give you a Medicare Benefit Statement.

We’ll need this Medicare Benefit Statement so we can process our portion of the claim. Sometimes your doctor and anaesthetist will lodge your claim to Medicare and HCF on your behalf, so ask your practitioner about their billing so you know what to do next.

Claiming on your extras cover

If you have a supported Apple or Android mobile device^*, you can use your digital membership card to claim on the spot at selected providers.

Otherwise, you can claim for your extras with the HCF My Membership app, online in member services, in a branch or by post. To claim online, go to 'Claims' and then 'Make a claim'.

Claiming on your ambulance cover

If you need to make an ambulance claim, you can you do it through:

• our My Membership app
• online in member services 
• in a branch 
• or by post.

Ambulance cover will vary from state to state:

NSW & ACT members
If you live in New South Wales or Australian Capital Territory, a levy is included in the hospital component of your private health cover. This entitles you to free ambulance transport under the state government ambulance transport schemes.

If you're sent an invoice for ambulance transport, send it to us and we'll settle it. If you have pension or social security entitlements in NSW or the ACT complete that section on the back of the invoice and return it to the ambulance service.

If you fall outside the state-based arrangement for ambulance services and aren’t otherwise covered, you can claim under your HCF cover for state government-provided emergency ambulance services.

QLD & TAS members
If you live in Queensland or Tasmania, you’re covered under your state ambulance service scheme.

If you fall outside your state-based arrangement and aren’t otherwise covered for emergency ambulance services, you can claim under your HCF cover for state government-provided emergency ambulance services.

VIC, SA, NT & WA members
If you live in Victoria, South Australia, the Northern Territory or Western Australia and don’t have an ambulance subscription with your state ambulance service and aren’t otherwise covered (including under another state-based arrangement) you can claim under your HCF cover for state government-provided emergency ambulance services.

How long does it take for a claim to be processed?

Claims are usually processed and paid within 7 working days. If you have your physical or digital membership card with you, you can claim on the spot at your appointment with selected extras providers^*. You’ll need to pay any difference that’s owing.

How will I be paid for my claim?

When you claim online, you’ll need to confirm what bank account you’d like to use. If you haven’t linked a bank account to your claim, our team will contact you directly.

How to claim extras on the spot using your Android device

If you have a supported Android mobile device*, you can use your digital membership card to claim on the spot at selected providers. You can use either tap-and-go or the QR code.

You’ll need:

• your Android mobile device
• the most recent version of the My Membership app. Download it from Google Play
• an internet connection.

Tap-and-go

Use it at extras providers with a HICAPS VX, HICAPS Trinity or CommBank Smart Health payment terminal.

1. Make sure you’re connected to the internet. Go to your device settings, search for NFC, and make sure it’s switched on.
2. Open your My Membership app and tap the card icon in the top right corner. Your digital card will appear on-screen.
3. To claim, hold your device near the terminal at your provider. You’ll hear a beep.
4. Your claim will be processed. The provider will let you know if your claim has been approved. You’ll need to pay any difference that’s owing.

QR code

Use it at extras providers with a HICAPS Trinity payment terminal.

1. Make sure you’re connected to the internet.
2. Open your My Membership app and tap the card icon in the top right corner. Your digital card will appear on-screen. Select ‘Show QR code’.
3. To claim, scan the QR code by holding it in front of the terminal camera. You’ll hear a beep.
4. Your claim will be processed. The provider will let you know if your claim has been approved. You’ll need to pay any difference that’s owing.

If you’re having trouble accessing or finding your digital card, try reinstalling the My Membership app.

If you’re still experiencing issues, call us on 13 13 34 or email service@myhcf.com.au and we’ll look into it.

How to claim extras on the spot using your Apple device

If you have a supported Apple mobile device*, you can use the QR code on your digital membership card to claim on the spot at selected providers. 

You’ll need:

• your Apple mobile device
• the most recent version of the My Membership app. Download it from the App Store
• an internet connection.

Use it at extras providers with a HICAPS Trinity payment terminal.

1. Make sure you’re connected to the internet.
2. Open your My Membership app and tap the card icon in the top right corner. Your digital card will appear on-screen.
3. To claim, scan the QR code by holding it in front of the terminal camera. You’ll hear a beep.
4. Your claim will be processed. The provider will let you know if your claim has been approved. You’ll need to pay any difference that’s owing.

If you’re having trouble accessing or finding your digital card, try reinstalling the My Membership app.

If you’re still experiencing issues, call us on 13 13 34 or email service@myhcf.com.au and we’ll look into it.

How can I make a payment?

Direct debit

You can choose your direct debit date (apart from the 28th, 29th, 30th or 31st of the month). You can pay your premiums yearly, half yearly, quarterly or monthly.

We'll advise you if your payment isn't made, and what you need to do to keep your membership up to date. Please note: If your account becomes overdrawn, some financial institutions may charge you a fee.

We guarantee to abide by the Direct Debit Customer Service Agreement so we can maintain a trusting relationship with you.

Bank account

You can pay your premiums through direct debit from a bank, building society or credit union account. Complete and submit a payment authority form.

Credit card

To set up automatic payments by direct debit from your credit card, complete and submit a payment authority form.

If you want to change your bank or credit card details, log into online member services, go to 'your details', then change billing details, or call us on 1800 649 422.

To change your details for direct credits, please call us on 1800 649 422.

Payroll deduction

Payroll deduction is an automatic payment from your wages or salary. If your employer participates under an HCF Payroll Scheme, you can arrange to have your contributions paid directly from your salary or wages.

If you're unsure whether your company has a scheme, ask your Human Resource or Payroll team, or call us on 1800 649 422.

Online

You can make a secure payment with your credit card online. Just log in to online member services and go to 'make a payment'.

Phone

We accept American Express, MasterCard and VISA. Just call 1800 649 422.

Mail

You can mail a cheque to us at: HCF, GPO BOX 4242, Sydney, NSW, 2001.

Please write your membership number on the back of your cheque. We can't accept cash through the mail.

BPAY

With BPAY, you can make your payments any time online or over the phone on 1800 649 422.

What are waiting periods?

Waiting periods must be served before you can claim for a service. They apply to:

• members that are new to private health insurance
  
• existing HCF members who upgrade to a higher level of cover or reduce excess payable (you need to serve the necessary waiting period for the higher entitlement)
• members who switch from another fund who haven't already completed the required waiting period for equivalent benefits
• new dependants, unless they switch from another fund where they've completed the required waiting period for equivalent benefits
• treatment of a pre-existing ailment or condition
• members who cancel their policy for a period of time and then rejoin HCF without having cover with another insurer during the gap period.

Why do private health funds have waiting periods?

Waiting periods are common to all private health insurers and protect regular fee-paying members against inheriting the cost of large medical bills from people with serious conditions who might join, receive treatment, then quickly leave the fund.

How long are waiting periods? 

The maximum waiting periods that a private health insurer can impose for hospital treatment or hospital-substitute treatment are set by the Australian Government:

• 12-months for treatment of pre-existing conditions. ‘Pre-existing’ means any condition, illness, or ailment you had signs or symptoms of in the 6 months before you took out hospital cover or upgraded your hospital cover – even if it wasn’t officially diagnosed. This doesn't apply to psychiatric care, rehabilitation or palliative care which has a 2 month waiting period for pre-existing and new conditions.
• 12-months for pregnancy and birth-related services.
• 2-months for psychiatric care, rehabilitation and palliative care, plus all other hospital treatment.

The waiting periods for extras cover differ to hospital cover and vary between 2 and 12 months. Ambulance waiting periods also vary between 1 day and 12 months.

Hospital waiting periods:

• Palliative care: 2 months 
• Hospital Psychiatric Services: 2 months
• Rehabilitation: 2 months 
• Pre-existing ailments or conditions: 12 months 
• Pregnancy & birth: 12 months 
• All other hospital services, including treatments under Accident Safeguard: 2 months.

Extras waiting periods:

• Health management programs: 2 months 
• Artificial appliances (e.g. CPAP machine, blood glucose monitors): 12 months 
• Dental bleaching, bridges and crowns: 12 months 
• Dentures: 12 months 
• Endodontics: 12 months 
• Hearing aids: 12 months 
• Occlusal therapy: 12 months 
• Oral surgery: 12 months 
• Orthodontics: 12 months 
• Periodontics: 12 months 
• Pre-existing ailments & conditions: 12 months 
• Prosthodontics: 12 months 
• Veneers: 12 months 
• School accident benefit: 2 to 12 months 
• All other extras services: 2 months.

Ambulance waiting periods:

• Emergency ambulance (where not for pre-existing ailments): 1 day
• Medically necessary non-emergency ambulance (where not for pre-existing ailments): 2 months
• Pre-existing ailments: 12 months.

If you joined during an HCF waiver offer, waiting periods are only waived for extras with waiting periods equal to or less than the waiver. All other waiting periods in excess of the waiver apply.

Waivers are only available to new members taking both hospital and extras cover. All hospital services (including the same day excess) and ambulance services are excluded from the waiver offer.

Does a waiting period apply to me if I joined during a waiver period?  

A waiting period waiver does not apply to all waiting periods. The waiver only applies to extras with waiting periods equal to or less than the waiver period. Services with waiting periods longer than the waiver period are not included.

Waivers are only available to new members taking both hospital and extras cover. All hospital services and ambulance services are excluded from the waiver offer.

Pre-existing Conditions

What is a pre-existing condition?

A pre-existing condition is an ailment, illness or condition that you had at any time in the 6 months before a health insurance policy started. The condition may not have been diagnosed by a doctor or specialist and you may not have been aware of the condition, but if signs and symptoms were present in those 6 months, the condition will likely be considered ‘pre-existing’.

This applies if you’re upgrading to a higher level of health cover, adding a dependant or child to your policy, or if you’re new to private health insurance or had a gap in cover.

A waiting period of 12 months will be applied for treatment of a pre-existing condition if:

• if the treatment wasn’t covered under your previous cover; or
• you did not have health cover before.

What are signs and symptoms?

A symptom is an indication of the existence of a condition or ailment. A doctor may find signs of a condition even if you have no symptoms, so you may have a pre-existing condition without realising it. It’s important to note that a diagnosis doesn’t have to be made for a condition to be pre-existing.

What is a pre-existing condition assessment?

If your condition or illness falls within the first 12 months of joining HCF or upgrading your cover, then we’ll request that you complete a pre-existing condition assessment. If you join HCF within 30 days of leaving another fund, and you have already served the 12-month waiting period for the required service, you won’t need to complete a pre-existing condition assessment.

The pre-existing condition assessment involves HCF having a medical professional look at information from your doctor and specialists, as well as any other relevant medical or claim details. The decision of whether you had signs or symptoms of your condition in the 6 months before your cover started is in the hands of our fund-appointed medical professional, not your own doctor, and takes about 10 days to complete once all required information is received.

The above definition of a pre-existing condition is set out under government legislation which also requires the assessment to be made by a medical practitioner appointed by HCF.

I’m already an HCF member. Do I need to complete the pre-existing condition assessment?

If you’re an existing HCF member and you recently upgraded your level of hospital cover, you’ll need to serve the 12-month waiting period for new services added to your hospital cover that weren’t covered before your upgrade and for services that have a higher level of benefits. You will not have to re-serve waiting periods for benefits previously covered under your old level of cover.

New people added to your policy will need to serve their 12-month waiting period for a service if they haven’t already served their waiting periods for that service with another fund (at the same level of benefits) and joined HCF within 30 days of leaving.

I already served my waiting periods with my previous fund. Do I need to complete the pre-existing condition assessment?

If you’ve served 12 months or more for a service with a previous fund and you join us within 30 days of leaving the other fund on the same level of cover, then you’ll have continuity and won’t need to complete the pre-existing condition assessment. You won’t need to serve waiting periods again at HCF and you can claim instantly for the same benefits you were entitled to with your previous fund.

If your treatment wasn’t covered by your previous fund at the same level or you weren’t covered for a full 12 months, your condition may be pre-existing and you may need to serve the 12-month waiting period or the remaining period of time.

Whenever there is a potential treatment or service you would like to claim for, it’s always best to contact us first so we can check your cover and provide guidance on waiting periods and how to prepare for your treatment. You can send a message, call us on 13 13 34 (Mon-Fri: 8am-8pm, Sat: 9am-1pm AEST/AEDT) or visit your local branch.

How do you determine if my condition is pre-existing or not?

Your medical practitioner will need to complete a Certificate of Attendant (COA) form available on our website.

We may also ask for documentation like:

• doctors’ notes
• referral letters from your doctor to a specialist
• medical certificates signed by a doctor
• emergency department notes if you were treated in an emergency department.

In order to carry out a full assessment, we may require you to provide us with your medical records from your doctor(s). You have a right to gain access to all the information held about you. We, as a third party, are bound by the Privacy Act, which means we’re unable to request this documentation directly without your consent.

My condition is considered pre-existing. What does this mean for me?

If your condition has been deemed as pre-existing by our medical practitioner, you’ll need to serve the 12-month waiting period (or the remaining part of the period if you have served some of it with your previous fund) before you can claim for the service or treatment. We won’t pay benefits if you decide to go ahead with the service or treatment before the waiting period has been served. This also means that you cannot lodge a claim after the waiting period has ended for a service that was provided within the waiting period.

If you do not agree with our medical practitioner's assessment, you can request a second review to take place. There must be a valid reason and we’ll require additional relevant clinical documentation that was not previously supplied in the first review to be provided. If you would like to enquire about a second review, please contact our Clinical Review team at clinicalreviewemail@hcf.com.au or 02 9290 0256 (Mon-Fri: 8.30am – 5pm AEST/AEDT).

We know illnesses and conditions aren’t planned and while we uphold waiting periods in the fairness of all members, you can also access treatment through the public system. However, you may need to join the public wait list for your treatment in the public system.

HCF's medical practitioner has determined that my condition is pre-existing, however, my doctor disagrees. What should I do?

You can request a second review to take place. There must be a valid reason and we’ll require additional relevant clinical documentation that was not previously supplied in the first review to be provided. If you would like to enquire about a second review, please contact our Clinical Review team at clinicalreviewemail@hcf.com.au or 02 9290 0256 (Mon-Fri: 8.30am – 5pm AEST/AEDT).

We’re always looking for ways to improve our products, services and the overall experience for our members. If you’re unhappy with the outcome of the second review, or would like to provide feedback, you can contact our Feedback and Resolutions team at complaints@hcf.com.au or 13 13 34 (Mon-Fri: 8am-8pm, Sat: 9am-1pm AEST/AEDT) or visit your local branch. Learn more about our complaints process.

What is restricted cover?

Restricted cover is where certain services are specified as being restricted services under a hospital product and where minimum benefits are applicable.

• In a private hospital: These benefits wouldn't cover all hospital costs and are likely to result in large out-of-pocket expenses.
• In a public hospital: If the minimum benefits are less than what your chosen public hospital charges, you may have out-of-pocket expenses to pay.

What's an exclusion?

If you need treatment for any procedures listed as an exclusion on your hospital cover, you won't receive any benefits from us and may have significant out-of-pocket expenses.

Ensure you've reviewed the exclusions list before buying your cover.

* To use the digital card, you'll need an Apple or Android device and the My Membership app. Supported Apple devices run at least iOS 13. Supported Android devices run at least Android 8. Eligible extras providers have HICAPS VX, HICAPS Trinity or CommBank Smart Health payment terminals.

^{^} Members who have held a hospital cover for at least 2 months and upgrade to receive hospital benefits (or a higher level of hospital benefits) for hospital psychiatric services may elect to be exempted from the 2 month waiting period for hospital psychiatric services that usually applies to members when they upgrade their hospital cover. Members who have held a hospital cover for less than 2 months may elect to serve a reduced waiting period of 2 months minus the length of time that the member held hospital cover. This exemption or reduction can only be accessed once in a member’s lifetime.

** dependent on no other changes being applied on the policy