Claims and payments FAQs

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.

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 can I make a payment?

You can make a payment through our My Membership app or in our online member services or call 13 14 39 during the following hours:

Mon–Fri: 8am–8pm (AEST/AEDT)
Sat: 9am–5pm (AEST/AEDT).

You can also set up direct debit or make a one-off payment.

The different ways to make a payment are:

Direct debit and direct credit

How can I set up direct debit?
You can set up direct debit for your premium payments in the My Membership app or in online member services. Just go to ’Payments’ then ‘Update payment details’.

If you can’t do this online, to set up direct debit to pay your premiums, or to change your current direct debit payment details, please call 13 14 39 during the following hours:

Mon–Fri: 8am–8pm (AEST/AEDT)
Sat: 9am–5pm (AEST/AEDT).

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

Why doesn’t my first direct debit match my quoted premium?

Your first direct debit can differ from your quoted premium for a number of reasons, including Lifetime Health Cover loading, rebate tiers, rate changes or your level of cover.

Your first direct debit may also include an additional 1-day premium, which is a one-off charge on top of your first payment.

Your membership commences at 12am on your join date. Your first direct debit covers your chosen frequency (weekly, fortnightly, monthly, quarterly, half-yearly or yearly) and any additional days if you’ve chosen a direct debit date after your join date.

Your first payment may also include an additional 1-day premium to cover your chosen frequency plus the direct debit date itself. This is to ensure that your direct debit date is also covered for on-the-spot claiming. The direct debit date only needs to be covered once in the first payment, which is why your first payment may look different to subsequent payments.

For example, your membership commences on 1 January and your payment frequency is weekly. Your direct debit date is also 1 January. Your first payment covers you from 1 January to 8 January inclusive, which is 8 days of premium. Your next payment on 8 January covers you from 9 January to 15 January inclusive, which is 7 days of premium. The first payment had an additional 1-day premium to ensure the direct debit date was also covered for on-the-spot claiming.

As long as no other changes apply to your membership, the subsequent direct debits will match your quoted premium.

If you have any further questions, please call 13 13 34.

At what frequency can I make a payment?
You can pay your payments yearly, half yearly, quarterly, monthly, fortnightly or weekly, depending on your cover, but keep in mind we don't allow direct debit dates from 28–31 of each month.

What are the advantages of direct debit?
You can save time and hassle by setting up an automatic direct debit to pay your premiums.

Who can change direct debit and direct credit payment details?
When using our online member services or the My Membership app, only the policyholder can update these details.

Can I edit these payment details at any time?
Yes, once it's set up you can edit your direct debit and direct credit payment details at any time. If you can’t do this online, to set up direct debit to pay your premiums, or to change your current direct debit payment details, please call 13 14 39.

Can I get my claims paid to my credit card?
Unfortunately, we can't pay your claims to a credit card, only a bank account.

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.

Making a payment online

If you have a health and/or life insurance policy with us, you can make a secure payment in the My Membership app or in online member services under ’Payments’ then ‘Make a payment’.

You can pay up to 18 months in advance, depending on your cover. We accept credit cards (MasterCard, Visa, Amex) for payments.

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.

Please keep in mind, if you have one of our Recover Cover products, you can’t use payroll deduction.

If you're unsure whether your company has a scheme, ask your Human Resources or Payroll team, or call us on 13 14 39.

Phone

We accept American Express, MasterCard and VISA. Just call 13 14 39.

BPAY

With BPAY, you can make payments for your health and Recover Cover life insurance policies any time online or over the phone on 13 14 39.

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 5 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-5pm 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-5pm AEST/AEDT) or visit your local branch. Learn more about our complaints process.

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