Westfund will pay towards your theatre fees, hospital accommodation and prosthetics costs when you are admitted to a contracted hospital for procedures that are included under your policy.
While this isn’t a complete list of the procedures covered under your policy, we recommend you contact us prior to any admissions to hospital or refer to your Policy Summary.
The listed procedures have ‘restricted’ cover if you are admitted to a Private Hospital – meaning we will only pay up to the public hospital shared room accommodation rate.
Significant out of pocket expenses may apply for admissions into a Private Hospital.
No cover is provided for procedures for which Medicare pays no benefit (non-therapeutic cosmetic surgery), if disallowed by the Private Health Insurance Act 2007 or if listed as an exclusion on the policy.
You can still be treated as a Medicare patient in a Public Hospital for these exclusions.
When you switch health funds,
we will
guarantee continuity of cover for the benefits included in your previous cover. This applies only to the benefits
you were entitled to under your previous cover, as long as these benefits are included under your new Westfund
cover.
Benefits are not payable in respect of services provided during a waiting period. The following waiting periods apply to benefits payable for Hospital Treatment.
| Hospital Waiting Periods | |
|---|---|
| Accident-related | 1 Day |
| Psychiatric, Rehabilitation and Palliative Care | 2 Months |
| Obstetric-related services | 12 months |
| Treatment of a pre-existing condition | 12 Months |
| All other services | 2 Months |
The Commonwealth Ombudsman also provides general information about waiting periods.
* A pre-existing condition is an illness or condition for which, in the opinion of a medical practitioner appointed by Westfund, signs or symptoms existed during the 6 months before the date you joined Westfund or upgraded to a higher level of cover. A 12 month waiting period applies to all new Members for hospital costs relating to the treatment of pre-existing conditions.
Westfund has contracts with numerous private hospitals throughout Australia covering theatre fees and hospital accommodation costs for most procedures. Hospital policies do not provide cover for treatment for which Medicare pays no benefit eg. Non-Therapeutic Cosmetic Surgery, or if disallowed by the Private Health Insurance Act 2007.
Where no contract exists with a private hospital, benefits are payable at a default rate determined by the Government. In these cases, out of pocket expenses may be incurred.
We recommend that members check with us prior to admission to hospital to ensure they are covered.
As a private patient in a public hospital, you will receive cover for accommodation and your choice of doctor from doctors with a right to practice at that hospital.
Westfund will pay benefits for surgically implanted prostheses up to the approved benefits in the Government's Prostheses List and in accordance with the requirements of the Act.
Westfund pays benefits for the fees charged by a doctor, surgeon, other specialist services, including pathology and radiology, while you are in hospital. Medicare pays 75% of the Commonwealth Medical Benefits Schedule (CMBS) fee and Westfund pays the additional 25% up to the CMBS fee. Where the fees charged exceed the CMBS fee, Westfund will pay an additional benefit to reduce or eliminate out of pocket expenses where the doctor or specialist participates in our Access Gap Scheme.
Our Access Gap Scheme allows patients with hospital cover to eliminate or reduce out of pocket expenses for medical gap payments for in-patient hospital treatments. Westfund does not pay an amount charged by your doctor above the CMBS fees unless your doctor agrees to participate in the Access Gap Scheme. If a doctor does not use the Access Gap Scheme, patients will be responsible for any additional charges. Doctors are independent of Westfund and each doctor can choose on a case by case basis whether to participate in the Access Gap Scheme.
No benefits are paid for non-therapeutic cosmetic surgery.
Unlimited medically necessary emergency ambulance transport
1 day waiting periodUp to $5,000 per member per calendar year for non-emergency patient transport (eg. Hospital to Hospital transfer)
2 month waiting periodThere's amazing benefits you'll receive because you choose Westfund.
$100 per night per hospitalisation as the result of an accident
Available after 1 day
Member Fees at Westfund Dental Care Centres and Westfund Eye Care Centres.
Available after 2 months
Waiver of premiums up to six months due to forced retrenchment or protected industrial action.
Available after 36 months
