Private Health Insurance Act 2007

CHAPTER 3 - COMPLYING HEALTH INSURANCE PRODUCTS

PART 3-3 - REQUIREMENTS FOR COMPLYING HEALTH INSURANCE PRODUCTS

Division 72 - Benefit requirements for policies that cover hospital treatment

SECTION 72-1 BENEFIT REQUIREMENTS

72-1(1)
An insurance policy that ^[*]

To find definitions of asterisked terms, see the Dictionary in Schedule 1 .

covers ^[*]

To find definitions of asterisked terms, see the Dictionary in Schedule 1 .

hospital treatment meets the benefit requirements in this Division if:

(a) the policy meets the requirements in the table in subsection (2) ; and

(b) the policy meets any requirements specified in the Private Health Insurance (Complying Product) Rules to be benefit requirements; and

(c) the policy does not provide benefits for:

(i) the cost of care and accommodation in an aged care service (within the meaning of the Aged Care Act 1997 ); or

(ii) a charge for a pharmaceutical benefit supplied under Part VII of the National Health Act 1953 , unless the circumstances of the charge are covered by section 92B of that Act; or

(iii) any other treatment specified in the Private Health Insurance (Complying Product) Rules as a treatment for which benefits must not be provided; and

(d) the ^[*]

To find definitions of asterisked terms, see the Dictionary in Schedule 1 .

rules of the private health insurer that issues the policy meet the rules requirement in section 72-5 .

72-1(2)
These are the requirements that a policy must meet for the purposes of paragraph (1)(a) :

Requirements that a policy that ^[] To find definitions of asterisked terms, see the Dictionary in Schedule 1 . covers ^[] To find definitions of asterisked terms, see the Dictionary in Schedule 1 . hospital treatment must meet
Item	There must be a benefit for ...	The amount of the benefit must be ...
1	any part of ^[*] To find definitions of asterisked terms, see the Dictionary in Schedule 1 . hospital treatment that is one or more of the following:	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.
	(a)		psychiatric care;
	(b)		rehabilitation;
	(c)		palliative care;
	if the treatment is provided in a ^[] To find definitions of asterisked terms, see the Dictionary in Schedule 1 . hospital and no ^[] To find definitions of asterisked terms, see the Dictionary in Schedule 1 . medicare benefit is payable for that part of the treatment.
2	^[] To find definitions of asterisked terms, see the Dictionary in Schedule 1 . hospital treatment ^[] To find definitions of asterisked terms, see the Dictionary in Schedule 1 . covered under the policy for which a ^[*] To find definitions of asterisked terms, see the Dictionary in Schedule 1 . medicare benefit is payable.	(a)	if the charge for the treatment is less than the ^[*] To find definitions of asterisked terms, see the Dictionary in Schedule 1 . 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 schedule fee for the treatment.
3	if the policy ^[] To find definitions of asterisked terms, see the Dictionary in Schedule 1 . covers ^[] To find definitions of asterisked terms, see the Dictionary in Schedule 1 . hospital-substitute treatment - hospital-substitute treatment covered under the policy for which a ^[*] To find definitions of asterisked terms, see the Dictionary in Schedule 1 . medicare benefit is payable.	(a)	if the charge for the treatment is less than the ^[*] To find definitions of asterisked terms, see the Dictionary in Schedule 1 . 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 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.
4	(a)	^[] To find definitions of asterisked terms, see the Dictionary in Schedule 1 . hospital treatment ^[] To find definitions of asterisked terms, see the Dictionary in Schedule 1 . covered under the policy; and	(a)	at least the amount set out, or worked out using the method set out, in the Private Health Insurance (Medical Devices and Human Tissue Products) Rules as the minimum benefit, or method for working out the minimum benefit, for the medical device or human tissue product; and
	(b)	if the policy covers ^[*] To find definitions of asterisked terms, see the Dictionary in Schedule 1 . hospital-substitute treatment - hospital-substitute treatment covered under the policy;	(a)
	that is the provision of a medical device or human tissue product, of a kind listed in the Private Health Insurance (Medical Devices and Human Tissue Products) Rules, as described in either of the following paragraphs:	(b)	if the Private Health Insurance (Medical Devices and Human Tissue Products) 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 medical device or human tissue product - no more than that amount or the amount worked out using that method.
	(c)	the medical device or human tissue product is provided in circumstances in which a ^[*] To find definitions of asterisked terms, see the Dictionary in Schedule 1 . medicare benefit is payable, and, if those Rules set out conditions that must be satisfied in relation to the provision of the medical device or human tissue product in those circumstances, those conditions are satisfied;
	(d)	the medical device or human tissue product is provided in other circumstances set out in those Rules, and, if those Rules set out conditions that must be satisfied in relation to the provision of the medical device or human tissue product in those circumstances, those conditions are satisfied.
5	any treatment for which the Private Health Insurance (Benefit Requirements) Rules specify there must be a benefit.	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.

Note:

If a private health insurer provides an insured person with, or arranges for an insured person to be provided with, treatment, it is treated as a benefit for the purposes of this Division (see subsection 69-5(3) ).

View history note

History

S 72-1(2) amended by No 8 of 2023, s 3 and Sch 1 items 2 - 7, by substituting " a *medical device or *human tissue product, of a kind listed in the Private Health Insurance (Medical Devices and Human Tissue Products) Rules " for " a prosthesis, of a kind listed in the Private Health Insurance (Prostheses) Rules " in table item 4, column headed " There must be a benefit for … " , " medical device or human tissue product " for " prosthesis " (wherever occurring) in table item 4, column headed " There must be a benefit for … " , para (c) and (d), " Private Health Insurance (Medical Devices and Human Tissue Products) Rules " for " Private Health Insurance (Prostheses) Rules " in table item 4, column headed " The amount of the benefit must be … " , para (a), " the medical device or human tissue product " for " the prosthesis " in table item 4, column headed " The amount of the benefit must be … " , para (a), " Private Health Insurance (Medical Devices and Human Tissue Products) Rules " for " Private Health Insurance (Prostheses) Rules " in table item 4, column headed " The amount of the benefit must be … " , para (b) and " the medical device or human tissue product " for " the prosthesis " in table item 4, column headed " The amount of the benefit must be … " , para (b), effective 1 July 2023. For application and transitional provisions, see note under s 72-11 .

S 72-1(2) amended by No 40 of 2010, s 3 and Sch 1 item 1, by substituting " that is the provision of a prosthesis, of a kind listed in the Private Health Insurance (Prostheses) Rules, as described in either of the following paragraphs: (c) the prosthesis is provided in circumstances in which a *medicare benefit is payable, and, if those Rules set out conditions that must be satisfied in relation to the provision of the prosthesis in those circumstances, those conditions are satisfied; (d) the prosthesis is provided in other circumstances set out in those Rules, and, if those Rules set out conditions that must be satisfied in relation to the provision of the prosthesis in those circumstances, those conditions are satisfied. " for all the words from and including " that is the provision of a prosthesis " in table item 4, column headed " There must be a benefit for ... " , effective 13 April 2010.

Disclaimer and notice of copyright applicable to materials provided by CCH Australia Limited

CCH Australia Limited ("CCH") believes that all information which it has provided in this site is accurate and reliable, but gives no warranty of accuracy or reliability of such information to the reader or any third party. The information provided by CCH is not legal or professional advice. To the extent permitted by law, no responsibility for damages or loss arising in any way out of or in connection with or incidental to any errors or omissions in any information provided is accepted by CCH or by persons involved in the preparation and provision of the information, whether arising from negligence or otherwise, from the use of or results obtained from information supplied by CCH.

The information provided by CCH includes history notes and other value-added features which are subject to CCH copyright. No CCH material may be copied, reproduced, republished, uploaded, posted, transmitted, or distributed in any way, except that you may download one copy for your personal use only, provided you keep intact all copyright and other proprietary notices. In particular, the reproduction of any part of the information for sale or incorporation in any product intended for sale is prohibited without CCH's prior consent.