Information for Members

The following information is provided for members and interested persons to provide an outline of conditions, terms and information in regard to Westfund services. Our by-laws which govern our receipt of contributions and payment of benefits are quite large. The fund is able to give a written reply to any request.

Waiting Periods - A twelve-month waiting period exists for pre-existing conditions, obstetric conditions, medical appliances, crowns and bridges, dentures, specialist dental and benefits.

Transferring members - may also be subject to waiting periods with Westfund. Where Westfund's benefit is higher than that which the Member would have received in their previous Health Fund, the lower benefit will be paid until they have served the required waiting period with Westfund. In addition, any excesses or co-payments, which would have applied with the previous fund, will apply for the duration of Westfund's waiting periods. Where Member's benefits were the same or higher at their previous Health Fund, Westfund's benefits will apply and transferring members will be credited for waiting periods already served at their previous fund.

Pre-Existing Conditions - Under the by-laws of Westfund, new applicants and those transferring from another fund are subject to the pre-existing ailments and conditions by-law. A pre-existing ailment or condition is one that presents signs or symptoms which were considered, by Westfund's medical advisor, to be in existence at any time during the 6 months preceding the day on which the member joins or upgrades the level of Westfund cover. This may include signs or symptoms not previously diagnosed by a medical officer. A 12 month waiting period applies (or balance if a waiting period is already being served).

Membership year - For both new and existing members, a membership year commences from the date of joining. The membership year restarts on the anniversary of the date of joining.

Single membership - Covers one member only. Any obstetric claim is payable to the member only and does not include the neonate. Membership should be upgraded to family cover three (3) months prior to expected date of confinement.

Family membership - Covers member's spouse and wholly dependant children under the age of 18.

Child and Student Dependants - Application for registration as an eligible dependant son/daughter of a contributor is available. Eligible dependants are: aged between eighteen and under twenty-five years of age, unmarried, and is a full-time student at school, college or university. They must not derive an income in excess of the minimum taxable income applicable to individuals as specified by the Australian Taxation Office. A form is required annually. Forms are available from any Westfund Branch on or .

Adult Dependant - Application for registration as an eligible dependant son/daughter of a contributor is available. Eligible dependants are: aged at least 18 but under 25 years of age, be an unmarried child of the contributor and earn less than $350 (three hundred and fifty dollars) gross a week or if earnt on a regular basis calculated to be less than $350 per week A form is required annually. Forms are available from any Westfund Branch on or .

Private hospital - Please contact our office with details of the type of operation and name of hospital you are going into so that we can advise you of your benefit entitlements. Toll Free .

Medical Claims - All medical (Medicare) claims can only be submitted after they have been assessed by Medicare and can only be paid after we have received the corresponding Medicare statement. The 25% medical gap is only payable on the receipt of Medicare benefits statements and is not payable until the related hospital account has been received by the fund. Benefit is up to the Government Medical Benefits Schedule Fee (GMBS) only.

Medical gap benefits - Westfund operates under a "No & Known Gap" Scheme. Please contact your nearest branch for information on benefits payable.

Ambulance - Please forward all ambulance accounts to your nearest branch.

Accident - Please notify our office of your accident, so the appropriate form can be forwarded to you to enable you to receive our accident benefit (accidental bodily injury caused solely and directly by external means, you must be hospitalised as a result of an accident to be eligible). A benefit is only payable in respect of the initial admission, following an accident. This is not payable for admission to a rehabilitation facility.

Cancellations - The request to cancel a membership must be in writing. The date of cancellation of the membership will be taken as per the written request except where the request is received after the requested cancellation date. Where this is the case the date of cancellation will be the date that the request was received at a Westfund branch.

Recovery of benefits - Westfund reserves the right to recover benefits paid which, in whole or part, were not lawfully due to the member. Recovery may be offset against and deducted from monies otherwise payable to the member.

Where benefits are not payable - Full particulars of circumstances where benefits are not payable are set out in Westfund by-laws. These include circumstances where the application form contains false or inaccurate information, a member is not financial, or claims involving workers compensation or any service associated with employment conditions.

Claiming benefits - Claims must be made within two years of the date of service.

By-laws concerning contributions - Where contributions are paid yearly and not more than 12 (twelve) months in advance, subsequent rate increases will not affect your membership until the contributions are due again.

Contribution payments - A member must be financial (their contributions must be paid at least a day beyond the service date of the claim) for a claim to be paid. If contributions are not paid within two months of the date on which they fall due, membership shall lapse but may be reinstated, without affecting benefit entitlements, at any time within a further two months by payment of all contributions in arrears.

Conditions - The benefits described in this web site are maximum amounts. Before treatment, please contact Westfund to ascertain your entitlement to benefits.

The benefits described are a summary of by-laws and are payable to recognised members only.

The by-laws of Westfund contain a number of provisions which cannot possibly be detailed here. A written ruling can be obtained in response to a written request.

Westfund Ltd ABN 55 002 080 864. A non-profit registered Health Benefits Organisation, Incorporated in NSW. Trading under Westfund & Westfund Health Assurance. Westfund Holdings Pty Ltd as trustee for the Westfund Unit Trust ABN 43 653 200 942 trading as Classic Eyewear not a registered health benefits organization.

The Private Health Insurance Ombudsman provides an independent service to help consumers with health insurance problems and enquiries.
They can be contacted on 1800 640 695 or at their website http://www.phio.org.au