Important Information - About Your Policy - Navy Army Air Force - Navy Health

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Important Information - About Your Policy - Navy Army Air Force - Navy Health
Private Health Insurance

Important Information
    About Your Policy

                 ·       ·
            Navy Army Air Force
Important Information - About Your Policy - Navy Army Air Force - Navy Health
Private Health Insurance • 2


Membership Types                                        4

Membership Information                                  5

Australian Government Private Health Insurance Rebate   6

Lifetime Health Cover Loading                           8

Medicare Levy Surcharge                                 9

Benefit Conditions                                      10

Hospital Benefits and Claiming                          11

Extras Benefits and Claiming                            14

General Information                                     16

Health and Wellness Initiatives                         19

Terms and Conditions                                    20
Important Information - About Your Policy - Navy Army Air Force - Navy Health
Private Health Insurance • 3
Private Health Insurance • 4

Membership Types

Single membership                                   Single parent family                     A dependant can take up membership
Cover is for one adult only.                        Cover is for one adult and dependants.   in their own right at any time after
                                                                                             being ineligible to continue under
Couple membership                                   Dependants only                          their parent’s cover, however some
                                                                                             waiting periods may apply unless
Cover is for the member with a                      Cover is for dependants only. The
                                                                                             membership is taken up within
spouse/partner.                                     adult listed as the member is not
                                                                                             30 days. The new membership
                                                    covered under the policy.
                                                                                             will take effect from the day after
Family membership
                                                                                             they become ineligible on their
Cover is for the member with                        Military memberships
                                                                                             parent’s membership.
a spouse/partner, plus;                             A ‘military family’ is the spouse/
                                                                                             For more information please call
• any unmarried children until they                 partner and/or dependants of the
                                                                                             1300 306 289 or go to
  turn 22 years of age or enter into a              serving person. However, the serving
  de facto relationship.                            person will not be listed or covered
                                                    by the policy.
• any unmarried children between
  the age of 22 and 25 years who are
                                                    Young adult membership
  undertaking a course of study at
  a publicly funded or private                      Young adult membership is for non-
  sector tertiary institution which                 student dependants over 22 years of
  requires a full-time study                        age. They will remain covered under
  workload in Australia.                            the existing family hospital cover (at
                                                    no extra charge) as long as they are
You should advise Navy Health of any                covered on their own extras cover.
unborn children before the expected                 Young adult membership applies
due date (if possible). To ensure no                until the dependant turns 25 years of
waiting periods will apply for newborn              age, marries or enters into a de facto
children, they must be added within                 relationship.
two months of birth (and backdated to               It’s important to note that a non-
date of birth).                                     student dependant must take up
Please note: a dependant who is no longer           any extras cover within 30 days of
eligible for cover under a parent’s membership      being ineligible to continue under a
is able to take out membership in their own         parent’s membership. Continuity of
right. If the new cover is started within 30 days
                                                    hospital cover carried over from a
at an equivalent level, no additional waiting
                                                    parent’s membership will be provided
periods will apply.
                                                    as long as the parent’s membership is
                                                    still current.
Private Health Insurance • 5

Membership Information

When does membership                      When are contributions                           Cooling off period
commence?                                 payable?                                         Members can choose not to proceed
Your membership commences from            Payment of contributions is always in            with their Navy Health cover and
your chosen start date.                   advance. Direct debit payments can               request to have any premiums
                                          be made on a fortnightly, monthly,               reimbursed. This reimbursement is
How can I change my                       quarterly, six monthly or yearly basis.          on the condition that the member
membership?                               Partial payments are not accepted.               expresses their request to the fund
Any changes to the status of                                                               within 30 days of their cover
membership (i.e. level of cover,          Discounts                                        commencing, and that no claims have
adding or removing dependants)            Members choosing to pay half-yearly              been lodged or are pending during the
cannot be undertaken without Navy         will receive a 2% discount and annual            30 day cooling off period.
Health receiving advice from the          payments will receive a 4% discount.
authorised member or person. The                                                           Suspension of membership
                                          If you are an Active Reservist (SERCAT
change cannot be taken as being           3 and above) or hold a current Veteran           Navy Health at its absolute discretion
actioned until the member receives        Gold or White Card, you are eligible             may allow, within a clearly defined
acknowledgement from Navy Health.         for a 10% discount on your policy                limited set of circumstances,
The earliest effective date of any        premiums.*                                       for a member to suspend their
change will be the date notification is                                                    membership for an agreed period.
                                          A serving person’s spouse/partner
received by Navy Health.                                                                   Where the suspension has been
                                          and/or dependants are eligible for
The easiest method of changing                                                             approved in writing by Navy Health,
                                          a 10% discount on their policy
details is via Online Member Services                                                      members will be advised of the
                                          premiums until the serving person
at or call                                                       conditions relating to waiting
                                          discharges from the Australian
us on 1300 306 289.                                                                        periods and pre-existing condition
                                          Defence Force (ADF).
                                                                                           rules which may be applied upon
                                          *Veteran White and Gold Cardholders and
Cover changes                                                                              reinstatement of membership.
                                          Active Reservists (SERCAT 3-5) must be
Transferring to a higher level of cover   covered by the membership for the discount       The agreed suspension period is
will result in the member and any         to apply. Active Reservists and serving ADF      not subject to change without
persons covered having to serve           members must pay via direct debit on selected    written notification to and written
new waiting periods. Whilst these         payment frequencies. Only one discount           confirmation from Navy Health.
                                          can be applied to a membership. Proof of
waiting periods are in force, benefits                                                     ADF personnel can suspend their
                                          eligibility must be provided for discount to
will still be payable at the previous                                                      cover when they are posted overseas.
                                          apply. Discounts will only be applied up to a
level of cover. Higher benefits are not   maximum of 10% across the policy. Please visit   Members who move into continuous
payable for pre-existing ailments or         full time service (CFTS) can also
conditions (regardless of whether         for full terms and conditions.                   suspend their cover for the duration of
or not they have been diagnosed)                                                           the CFTS.
until a waiting period of 12 months       When does membership cease?                      For more information please go to
has been served. This also applies        A membership will cease on a           
to Pregnancy & Birth and Assisted         date advised and paid to by the
Reproductive Services.                    member or automatically when
                                          contribution payments are more than
                                          one month in arrears.
Private Health Insurance • 6

                                          Australian Government
                                          Private Health
                                          Insurance Rebate

Most Australians                            The rebate you are eligible for             • through a reduced premium; or
                                            depends on your age*, is income-            • through your tax return with the
with private health                         tested and applies to all Navy Health         Australian Tax Office (ATO)
insurance currently                         health insurance covers. The rebate
                                                                                        If you choose to receive your rebate
                                            isn’t applicable to the Lifetime Health
receive a rebate                            Cover loading portion of membership         through your insurer, you will be asked
                                                                                        to nominate the tier you expect to fall
from the Australian                         payments.
                                                                                        into in order to avoid a tax liability.
                                            Below are the thresholds set by the
Government to help                          Australian Government. The income           You can nominate your tier by
cover the cost of their                     thresholds will remain at the current       contacting Navy Health.
                                            levels until 1 April 2021.                  More information regarding the
premiums.                                                                               Australian Government Rebate is
                                            The rebate is indexed each year by
                                            the difference between the Consumer         available at
                                            Price Index (CPI) and the industry          knowledge-base-articles/private-
                                            average increase in premiums using a        health-insurance-rebate or by
                                            Government calculated formula.              phoning 1300 306 289.
                                                                                        If you aren’t sure which rebate tier
                                            Claiming the rebate                         you should choose, please contact
                                            If you are eligible for the rebate, there   your tax agent, financial advisor
                                            are two ways you can claim:                 or the ATO at

                                          Federal Government Rebate*

                     Income for rebate purposes                          Under 65           65-69 years 70+ years
                        Single              $90,000 or less
 Base Tier                                                                 24.608%             28.710%            32.812%
                  Couple/Family            $180,000 or less

                        Single           $90,001 – $105,000
    Tier 1                                                                 16.405%             20.507%            24.608%
                  Couple/Family          $180,001 – $210,000

                        Single           $105,001 – $140,000
    Tier 2                                                                  8.202%             12.303%            16.405%
                  Couple/Family         $210,001 – $280,000

                        Single             $140,001 or more
    Tier 3                                                                    0%                  0%                 0%
                  Couple/Family           $280,001 or more

*The rebate is based on the age of the oldest person on your cover.
Private Health
        Health Insurance
                Insurance • 7
Private Health Insurance • 8

                          Lifetime Health
                          Cover Loading

Lifetime Health Cover     If you take out private hospital cover   ADF personnel and Veteran
                          by 1 July after your 31st birthday and   Gold Card holders
(LHC) is a Government     maintain that cover, you will not have   If you are a member of the Australian
initiative that started   to pay LHC.                              Defence Forces (ADF) your medical
                          If you decide to take out hospital       services are provided by the ADF, so
on 1 July 2000. It was    cover at a later date, you’ll pay 2%     you are considered to have hospital
designed to encourage     more for your hospital premiums for      cover. If you joined the ADF prior
                          every year you’re over 30.               to 1 July 2000, your entry age upon
people to take out                                                 discharge will be 30. If you joined the
hospital insurance        Other things to know                     ADF on or after 1 July 2000, your entry
                          about LHC:                               age is that at which you joined the
earlier in life and to                                             ADF, unless you previously had private
                          • the maximum LHC loading you can
maintain their cover.       have is 70% at 65 years old;           health insurance.
                          • people who were born on or before      If you hold a Veterans’ Gold Card you
                            1 July 1934 are exempt from the        are considered to have hospital cover.
                            loading;                               If you have held a Gold Card at any
                          • LHC loadings stay on your cover        time since 1 July 2000, and the card
                            for 10 years. Once you have paid       was subsequently withdrawn by the
                            for 10 continuous years of hospital    DVA, you may claim the period you
                            cover the loading is removed (some     held the card as a period with private
                            conditions apply).                     health insurance.
                                                                   To accommodate small breaks in
                          Lifetime Health Cover                    your cover the Government allows a
                          on discharge                             number of permitted days without
                          Health care costs of serving members     hospital cover. For a full explanation
                          are met by the Commonwealth              of how this works and other LHC
                          until the date of discharge. This is     conditions go to
                          regarded as the equivalent of private
                          health insurance and as such, no
                          Lifetime Health Cover penalty applies
                          to members of the ADF when they
                          separate, providing they take out
                          hospital cover immediately
                          following discharge.
Private Health Insurance • 9

                                           Levy Surcharge

The MLS aims to                             The Medicare Levy Surcharge (MLS)           You may also be subject to the MLS,
                                            is levied on Australian taxpayers who       if your taxable income is over the
encourage individuals                       do not have private hospital cover and      threshold and you have a dependent
to take out private                         earn above a certain income. The            who is not currently covered by an
                                            MLS aims to encourage individuals to        approved health cover.
hospital cover and                          take out private hospital cover and
                                                                                        As an ADF serving member, you would
where possible, to use                      where possible, to use the private
                                                                                        have been exempt from paying the
                                            system to reduce the demand on the
the private system                          public system.
                                                                                        levy if you were single or only paid 1% if
                                                                                        you had a family. Although as an ADF
to reduce the demand                        The MLS covers you and your                 member you may not require health
on the public system.                       dependants. Your dependants include         insurance, if your combined family
                                            your spouse/partner, any of your            income is above $180,000, your family
                                            children who are 21 years of age or         will need to take out private hospital
                                            under, or any of your student children      cover to avoid MLS.
                                            who are under 25 years of age.
                                                                                        If you or your family receive a high
                                            The MLS is calculated at the rate of        income, it is advisable to consider
                                            1% to 1.5% of your income for MLS           private health insurance to avoid
                                            purposes. It is in addition to the          the MLS.
                                            Medicare Levy of 2%, which is paid by
                                                                                        For more information regarding the
                                            most Australian taxpayers.
                                                                                        MLS please go to
                                            Single parents and couples (including       knowledge-base-articles/medicare-
                                            de facto couples) are subjected to          levy or the Australian Taxation Office
                                            family tiers. For families with children,   website at
                                            the thresholds are increased by $1500
                                            for each child after the first.

                                          Income for Rebate Purposes
          No Tier                           Single                      $90,000 or less
 No change to rebate or MLS            Couple/family                   $180,000 or less
                                            Single                   $90,001 – $105,000
            Tier 1                                                                                             1.0%
                                       Couple/family                 $180,001 – $210,000
                                            Single                   $105,001 – $140,000
           Tier 2                                                                                             1.25%
                                       Couple/family                $210,001 – $280,000
                                            Single                     $140,001 or more
           Tier 3                                                                                              1.5%
                                       Couple/family                   $280,001 or more

Medicare Levy Surcharge information correct as of 1 April 2021.
Private Health Insurance • 10

                         Benefit Conditions

For general treatment    Benefit year                              • the procedure does not have an
                         For general treatment (extras) the          assigned Australian Government
(extras) the Navy        Navy Health benefit year is 1 July to       Medicare Benefits Schedule
Health benefit year is   30 June. For hospital products with an      item number;
                         excess, the benefit period is a rolling   • the claim is within a specified
1 July to 30 June. For   12 month period. (i.e. the excess is        waiting or replacement period
hospital products with   payable once per adult, in full, up to      or annual/sub limits have been
                         the family maximum, in any rolling 12       reached;
an excess, the benefit   month period).                            • providers of in hospital services
period is a rolling 12                                               submit medical claims two years
                         When are benefits not payable?
month period.                                                        after the date of service, unless
                         Benefits are not payable when:              approved by Medicare Australia
                         • claims are over two years from the        for benefits;
                           date of service;                        • the services are performed, or
                         • claims for the same service exceed        the products used are purchased,
                           two treatments on the same day;           outside of Australia;

                         • the provider is not recognised in a     • the membership is in a period of
                           private practice;                         suspension or payment arrears;

                         • the provider is not recognised          • the services are considered to be
                           by Australian Health Practitioner         cosmetic surgery (not deemed
                           Regulation Agency (AHPRA);                medically necessary);

                         • for Natural Therapies, the provider     • the extras service provided has an
                           is not recognised by the Australian       assigned Medicare item number;
                           Regional Health Group (ARHG),           • when treatment is provided during
                           or Exercise and Sports Science            an emergency department visit;
                           Australia (ESSA);                       • treatment has been already
                         • if the service forms any part             subsidised by any Government
                           of a payment from Workers’                department.
                           Compensation, Third Party or
                           any other liability provision, Navy     Overseas benefits
                           Health reserves the right to seek       Navy Health will not pay benefits on
                           full reimbursement on any benefits      any services, treatments or products
                           paid in these circumstances from        received outside of Australia or when
                           Workers’ Compensation, Third Party      purchased from a provider without an
                           or any other liability provision;       Australian Business Number (ABN).
Private Health Insurance • 11

                         Hospital Benefits
                         and Claiming

Navy Health aims         When treated as a private patient        Access Gap
                         in a hospital, members may face          Navy Health’s Access Gap scheme aims
to close the gap on      extra costs when the treating doctor     to minimise the difference between the
out of pocket in         charges more than the Medicare           Medicare fee and what your Specialist
                         Benefits Schedule (MBS) allows for the   charges. Specialists can choose to take
hospital expenses.       service provided.                        part in Access Gap on a case-by-case
A gap payment is the                                              basis; if they take part you’ll either have
                         Gap medical                              no gap or be told exactly what your
difference between       The ‘gap’ is defined as the monetary     out-of-pocket costs will be. Even if your
the fee charged by       variation between the MBS fee and the    Specialist elects not to take part, you
                         doctor’s fee.                            are legally entitled to know any out-of-
the hospital or doctor                                            pocket cost before your procedure —
                         If the member receives treatment as
and the benefit paid     a private patient in a hospital from a   ask your Specialist.

by Navy Health           doctor who chooses not to participate
                         in the Access Gap Scheme, Gap Medical
and Medicare.                                                             MBS Fee                  Gap
                         benefits will apply (see below).
                         Under Gap Medical benefits, Medicare
                                                                    Medicare        Fund          Patient
                         will cover 75% of the MBS fee for the
                                                                      75%           25%            100%
                         service that has been provided. The
                         insurer will pay the remaining 25% of
                         the MBS fee.
                         If the doctor charges more than
                         the MBS fee, the member will be
                         responsible for any ‘gap’ payment.
Private Health Insurance • 12

Hospital Benefits
and Claiming

Private and day hospital                  Known Gap Scheme                          Prosthetic appliances
— contracted facilities                   If your chosen Specialist bills with      A prosthesis is an artificial substitute
and services                              a Known Gap through Access Gap,           or replacement body part attached
Prior to admission, please check with     your out-of-pocket expenses relating      or applied to the body to replace a
Navy Health as to whether or not your     to your in-hospital treatment will be     missing part.
treatment or service is contracted.       capped. You won’t be charged any          If you are having surgery to implant or
Contracted services relate to hospital    additional amounts other than what        apply a prosthesis, your private health
fees such as accommodation and            you’ve agreed to in your Informed         insurer must pay a benefit for it if:
theatre.                                  Financial Consent before your in-
                                                                                    • you have the correct cover for the
Navy Health has been able to              hospital treatment.
                                                                                      treatment and the product is on the
negotiate 100% benefits on most                                                       Australian Government Prostheses
treatments and services at over 500       No Gap Scheme
private hospitals and day facilities.     If your chosen Specialist chooses to
                                                                                    • the insurer will pay the recommended
Product excesses still apply.             bill you with no gap, you will not have
                                                                                      minimum benefit as shown on the
Prosthesis items are payable at           any out-of-pocket expenses for their
                                                                                      Prostheses List.
100% of the minimum Government            in-hospital treatment.
                                                                                    • the Prostheses List will have at least
recommended fee. There is at least        The maximum an individual specialist
                                                                                      one no gap prosthesis or device
one prosthesis item available for every   can charge under the Access Gap
                                                                                      item for every in hospital procedure
surgery with no out of pocket expense     scheme is $500, per admission to
                                                                                      covered on the MBS.
to the patient. Drugs prescribed for      hospital, or $800 for obstetrics (as
discharge and drugs not directly          a private patient). Specialists can no    No benefit is payable where the
associated with the reason for            longer charge fees not associated         hospital charges for a prosthetic
admission are excluded from contracts     with the Medicare item number.            appliance or device not listed on the
and are the patient’s responsibility.                                               Prostheses List.
                                          Navy Health’s agreements are
In addition, if a patient chooses to      negotiated by the Australian Health
stay in an executive suite, the patient   Service Alliance (AHSA).
will be required to pay the difference    Please refer to
between the private room benefit          knowledge-base-articles/cover-the-
and the executive suite charge.           gap for further information.
There are 2 ways the Access Gap
scheme can work for you; Known
Gap Scheme or No Gap Scheme.

   MBS Fee                      Gap
                   Gap Fee

Medicare   Fund       Fund      Patient
  75%      25%        100%       100%
Private Health Insurance • 13

Podiatry surgery                          Full ambulance cover
Benefits are available only when          All Navy Health hospital and extras
Podiatric Surgery is performed in a       policies provide full ambulance cover
contracted hospital by an Australian      within Australia, provided that the
Government Accredited Podiatrist.         service is from a State/Territory
For further information call Online       registered ambulance service and
Member Services on 1300 306 289.          deemed medically necessary.
                                          Transport services by Patient
Pharmacy                                  Transport vehicles are not ambulance
Any drugs administered in-hospital        services and are not covered.
that are not on the pharmaceutical
benefits scheme (PBS); may incur out      Hospital claiming
of pocket expenses to be paid by you.     Generally hospitals will invoice
Please ensure the hospital provides       Navy Health directly.
you with informed financial consent.      If you do receive an invoice for
                                          your hospital stay please contact Navy
Exclusions                                Health on 1300 306 289.
Where excluded services are listed on     To search for agreement hospitals and
your policy, no benefits will be paid.    specialists in your area, please go to
Restricted cover
For services that are listed as
restricted on your policy, you can
only be treated as a private patient in
a public hospital. If you are treated
anywhere else such as a private
hospital, you will be significantly out
of pocket.
Private Health Insurance • 14

                           Extras Benefits
                           and Claiming

You can make claims        Preferred optical providers                 CPAP devices
                           If a member uses one of Navy Health’s       CPAP devices cannot be purchased
for most extras services   Preferred Optical Providers, they can       more than once in any rolling three
at your provider at the    receive an additional benefit (subject      year period. The rolling three year
                           to the annual maximum). To view the         replacement period starts from the
time of service.           list of preferred optical providers go to   first date of purchase.
                           The Preferred Optical Provider list is      Pharmacy
                           subject to change without notice.           Your extras policy will only cover
                                                                       pharmacy items that meet the
                           Natural therapies and                       following criteria:
                           recognised providers                        • not supplied or already covered
                           Natural therapies include Acupuncture,        under the Pharmaceutical benefits
                           Chinese Herbal Medicine, Myotherapy,          scheme (PBS);
                           Remedial Massage and Exercise
                                                                       • are fully approved by the
                                                                         Therapeutic goods administration
                           Benefits are not payable on any               (TGA);
                           medications, herbal or dietary
                                                                       • are not experimental drugs or are
                           preparations, or organised weight
                                                                         part of a drug trial;
                           reduction programs.
                                                                       • prescribed by an Australian
                           Medically Prescribed                          registered medical practitioner,
                           Appliances (MPA)                              including dentists and nurses;

                           MPA claims must be accompanied              • supplied by a registered Australian
                           by a referral from a registered               Pharmacist and are schedule 4 or 8
                           practitioner. The following are               medicines only;
                           examples of items that can be               • are not vitamins, weight loss drugs,
                           claimed under the MPA category:               contraceptives, herbal medicines,
                           Nebulisers, Humidifiers, Blood Glucose        over the counter pharmacy or non-
                           Monitors, Heart Rate/Blood Pressure           prescription drugs.
                           Monitors, Support Aids/ Mobility Aids,
                           Compression Garments, Non-cosmetic
                           Prostheses (Premium Extras only), and
                           TENS Machine/ Circulation Boosters.
                           The MPA category covers the
                           purchase, hire and repairs to
                           appliances that are covered under the
                           category up to the annual limit.
Private Health Insurance • 15

Extras Benefits
and Claiming

Electronic claiming                      Making claims by post
All you need is your Navy Health         and email
membership card to use the electronic    A completed Navy Health claim form
claiming system. After a consultation,   must accompany all claims submitted
your card can be swiped through          manually. A copy of receipts forwarded
the electronic claiming facility by      for benefits will be held electronically
the service provider. They will enter    by Navy Health on your behalf.
the claim details and process the        Original receipts will not be returned
transaction on your behalf.              to the member. Claim forms can be
Once the transaction has been            downloaded from
authorised by Navy Health                knowledge-base-articles/forms
electronically you simply pay
the balance amount. (This is the         Benefit payment
difference between the fee charged for   Benefit payments not processed
the treatment and the benefit amount     at time of service can be direct
paid by Navy Health).                    deposited into a nominated bank
                                         account (within Australia and
Online Members Services                  excluding credit cards).
You can claim your extras services
(excluding Orthodontic, MPAs and
Pharmacy) immediately via Online
Member Services.
To register and for more information
go to

Claiming app
Members can claim using our
Navy Health claiming app. This is the
quickest way to submit your claim.
To download go to the App Store or
Google Play Store.
Private Health Insurance • 16


To find out if you are   Waiting periods                            Pre-existing conditions*
                         Waiting periods for the selected level     A pre-existing condition is where
eligible and how to      of cover are detailed in the preceding     signs or symptoms of an ailment,
join Navy Health go      product fact sheet and need to be          illness or condition, in the opinion
                         read carefully.                            of a medical practitioner appointed
to                                               by Navy Health existed at any time
                         If you transfer to a higher level of
eligibility              cover, new waiting periods will be         during the six months preceding the
                         applied. However, benefits at the          day on which you joined the insurer
                         previous level will still be available     or transferred to a higher benefit
                         whilst the new waiting periods are         cover. This is irrespective of whether
                         being served.                              your medical practitioner, you and/or
                                                                    your dependants were aware of the
                         If you transfer to a hospital product
                                                                    condition or ailment.
                         with a lower excess, the previous higher
                         excess will apply for the first two        The pre-existing condition rule also
                         months or if the condition is deemed to    applies when resuming a suspended
                         be pre-existing.                           membership and symptoms or signs
                                                                    developed during the suspension
                         All persons covered under the policy
                         are required to complete waiting
                         periods of the same length                 The pre-existing condition waiting
                         as members.                                period provides protection for existing
                                                                    members against people joining or
                         Transferring from another fund             upgrading cover only when they
                                                                    require treatment. This assists Navy
                         Waiting periods are not applicable if
                                                                    Health in keeping premiums as low as
                         you had an equivalent level of cover
                                                                    possible. Claims and benefits within
                         and completed all waiting periods with
                                                                    the first 12 months of joining the
                         the previous fund.
                                                                    insurer or increasing to a higher level
                         The specified waiting periods will         of cover are subject to the pre-existing
                         apply to those aspects of the Navy         condition rule.
                         Health cover not covered previously
                                                                    *Excludes Psychiatric, Rehabilitation and
                         by your past fund, and for those
                                                                    Palliative care.
                         items specifically nominated within
                         the products as requiring extended
                         waiting periods. Whilst the 2, 6 and
                         12 month waiting periods are being
                         served, benefits are payable at the
                         previous level of cover, including any
                         excesses/co-payments applicable to
                         your previous level of cover.
Private Health Insurance • 17

General Information

Veteran Gold Cardholders                  Feedback and complaint                       Navy Health rules and
Members who are, or become                handling policy                              constitution
Veteran Gold Cardholders have the         If for any reason you are not satisfied      New memberships must be in
option of retaining or cancelling their   with the service you receive from            accordance with the rules and
cover with Navy Health.                   Navy Health or feel that it has failed       constitution of Navy Health Ltd.
Where a member chooses to cancel          to meet your expectations, we                Benefits are also paid in accordance
their coverage, they must advise          would appreciate your feedback.              with these rules.
Navy Health directly. The cover will be   We are committed to resolving your
                                                                                       Members can request a copy of the
cancelled from the date Navy Health       complaints in a fair and efficient
                                                                                       fund rules. All members are bound by
receives notification, not from the       manner and view your feedback as a
                                                                                       the rules of Navy Health Ltd.
date of issue of the card. The person     vital opportunity to improve.
holding the Veteran Gold Card may         Navy Health provides an accessible,
then re-apply for membership to           impartial, free-of-charge complaints
Navy Health without waiting periods       handling procedure for members.
or penalties (excluding pre-existing      This procedure can be viewed at
conditions ), as they are deemed to or by phoning
have continuity of cover.                 1300 306 289.
Any person who has previously held
a Veteran Gold Card is entitled to        Private Health Insurance
join Navy Health from the date their      Ombudsman
Veteran Gold Card is no longer valid      The Private Health Insurance
without serving any waiting periods       Ombudsman (PHIO) was set up by the
(excluding pre-existing conditions).      Government to deal with complaints
Proof of previous Veteran Gold Card       where the member has not been able
status that shows the valid from and      to resolve an issue with their insurer.
to dates is required.                     Whilst we actively encourage all
Where a member chooses to retain          members to discuss any such matters
their coverage, benefits will be          with our office in the first instance, the
paid on costs incurred after the          PHIO will gladly mediate if required.
Department of Veterans’ Affairs           The PHIO can be contacted on
(DVA) payment in line with the level      1300 362 072, by email
of cover held, however the benefit
must not exceed the total charge or       or you can write to:
the Navy Health benefits and annual       Commonwealth Ombudsman
limits and you may still incur an out     GPO Box 442, Canberra ACT 2601
of pocket expense.
Where a member with a Veteran Gold
Card has Premium Gold Hospital
coverage, Navy Health will pay the
supplement (top up) benefit for a
private room in a private hospital, as
DVA already cover the cost of a
shared ward.
Private Health Insurance • 18
Private Health Insurance • 19

                          Health and
                          Wellness Initiatives

Navy Health is            Health + Care program                        Chronic disease
                          The Health + Care program is                 management program
continually seeking new   supported by several service                 We offer a wide range of services to
initiatives to improve    providers. Navy Health is not involved       help manage chronic illnesses such
                          in the assessment of patients’ eligibility   as coronary artery disease, diabetes
your access to quality    to uptake these programs. It is              and mental health. Through our
health services.          important to know that the early             Health + Care program, we can offer
                          discharge and hospital substitute            telephonic or face-to-face support
                          program is NOT available in all              (in the comfort of your own home of
                          hospitals; referrals to the program are      course!) with a qualified registered
                          made by your doctor, hospital staff or       nurse, helping you manage your
                          at the discretion of Navy Health.            health better and avoid the need for
                          We recommend you check with                  a hospital stay.
                          your hospital or contact your provider
                          to discuss what services may be              Broader health cover
                          available to you.                            Broader health cover is supported by
                          Call 1300 306 289 for more                   the Australian Federal Government and
                          information about early hospital             enables private health insurers to pay
                          discharge or hospital substitute             claims for health services that can be
                          programs that may be suitable for            delivered just as effectively at home as
                          your care.                                   they can in hospital.

                          Navy Health is continually seeking new       Health + Care is an example of broader
                          initiatives to improve your access to        health cover at work, assisting our
                          quality health services. For up-to-          members in achieving and maintaining
                          date information regarding our               good health.
                          Health + Care program, please visit          Our integrated program allows for
                                treatment to be provided either in
                                                                       conjunction with hospital care or as
                          Online wellness portal                       a substitute; it may even mean you
                          Want to get healthier? Our online            avoid a hospital stay altogether.
                          wellness portal is here to help. Start       For more information about our
                          with a comprehensive Health Risk             Health + Care program, refer to
                          Assessment to determine where your 
                          health priorities need to be. From here,
                          we’ll help develop a wellness plan and
                          set tasks and goals to work towards
                          better health.
                          You can also upload medical
                          documents and results here to keep
                          all your health information in the
                          one place!
                          To start your wellness journey
                          today, simply visit
Private Health Insurance • 20

Terms and Conditions

Definitions                                 • how you may access your personal       What is personal information?
The term ‘member’ in this booklet             information held by us and correct     “Personal information” is information
refers to a ‘policy holder’ as defined in     that information where it is           or an opinion that identifies you or can
the Navy Health Ltd Rules.                    incorrect;                             be reasonably used to identify you. It
                                            • how you may make a complaint           includes your name, age, gender and
Privacy Policy                                about the way we collect, hold, use    contact details, as well as your “health
Navy Health Ltd ABN 61 092                    or disclose personal information,      information”, such as information or an
229 000 (Navy Health/we/us/                   and how we will deal with privacy      opinion about your health and health
our) are committed to protecting              related complaints;                    services that have been provided
and maintaining the privacy of all          • our contact details;                   to you.
individuals with whom we deal. We           • the consequences of not providing      “Health information” is part of a sub-
are also committed to complying with          personal information; and              set of personal information, known
the Privacy Act 1988 (Cth) (Privacy                                                  as “sensitive information” for the
                                            • how we use your information for
Act), including the Australian Privacy                                               purposes of the Privacy Act. “Health
                                              direct marketing activities.
Principles contained within that Act,                                                information” is specifically regulated
and other State and Territory Laws          It also explains how to contact us if    under the state and territory Health
that regulate health information,           you have any further queries about       Record Laws. In this Privacy Policy, all
such as the Health Records Act 2001         our management of your personal          references to “personal information”
(VIC), Health Records and Information       information.                             includes “sensitive information” and
Privacy Act 2002 (NSW) and Health           This Privacy Policy applies to all       “health information” (unless stated
Records (Privacy and Access) Act            individuals whose personal information   otherwise).
1997 (ACT) (Health Record Laws), to         we have collected or handled,
the extent that they are applicable.        including current and past members,      What kind of personal
                                            service providers, contractors and       information do we collect and
About this Policy?                          prospective employees.                   hold?
This Privacy Policy explains how we         This Privacy Policy was last updated     We only collect personal information
manage the personal information,            in June 2020. Navy Health will make      about you which is reasonably
which we collect, hold, use and             changes to its process and systems       necessary for our functions or
disclose. This includes:                    in relation to how we handle your        activities. The types of personal
• the kinds of personal information         personal information, and this policy    information which we collect and hold
  that we collect and hold about you;       will be updated to reflect those         about you may vary depending on the
                                            changes.                                 nature of our interactions with you.
• how we collect your personal
  information;                              Other terms may also apply to you
• how we hold your personal                 and the information we hold about
  information;                              you. For example, sometimes we
                                            also provide a privacy collection
• the purposes for collecting,
                                            statement at the time we collect
  holding, using and disclosing your
                                            personal information from you, such
  personal information;
                                            as when you first sign up as a member
• whether we will (or are likely to)        for an insurance policy. This privacy
  disclose your personal information        collection statement may include
  to overseas recipients and the            additional terms. If you are employed
  countries where such recipients           with us, you may have specific privacy
  may be located;                           terms in your employment contract
                                            with us.
Private Health Insurance • 21

Members and prospective                      How do we collect your                     While this is not an exhaustive list,
members                                      personal information?                      third parties include:
As an insurance provider, Navy               We only collect personal information       • health providers i.e. hospitals or
Health collects personal information,        about you in a manner that is lawful.        medical practitioners;
including health and sensitive               Wherever it is possible and practical      • other Health Insurers (such as
information. The type of information         to do so, we will collect personal           where you have requested a
we collect about you includes:               information directly from you. For           transfer of your health insurance
• your full name;                            insurance policies that cover more           from another fund to us);
• your gender;                               than one person, such as family or         • authorised persons or persons who
                                             couples policies, we collect personal        act on your behalf;
• your contact details, including
                                             information about all individuals who
  your residential address and email                                                    • another insured person on the
                                             are on the policy from the person who
  address;                                                                                insurance policy;
                                             is taking out the policy. For example,
• your date of birth;                                                                   • government bodies;
                                             where one parent is taking out a
• government related identifiers such        family policy, that parent may provide     • publicly available sources or
  as your Medicare number;                   us with the details of their partner and     networking services (such as
• financial information such as your         children.                                    LinkedIn); and
  bank details;                              We may collect this information:           • recruitment agencies and referees.
• information about your preferences         • in person;                               Unless we are notified otherwise,
  relevant to any marketing activities;      • over the telephone;                      all information, including that of all
• sensitive information such as:                                                        persons covered on the insurance
                                             • by mail;
  - details about your health and                                                       policy, may be disclosed to you or to
                                             • over the internet (including via our
    health services provided to you;                                                    the person authorised by you to have
    and                                                                                 access to your insurance policy.
                                             • by our Navy Health app;
  - historical information such as
                                             • by e-mail or fax; or
    your prior insurance claims.
                                             • by completion of a form (such as
• Prospective employees and
                                               an application form).
                                             We may also collect your personal
We collect personal information when         information from a third party. This
recruiting people to work with us, such      will be limited to circumstances where
as your name, date of birth, gender,         it is impracticable or unreasonable for
contact details, qualifications, and work    us to collect it directly from you or
and study history (including references      you have authorised us to collect
and other information included in a CV       the information from them. The
or cover letter as part of the application   type of third party who might
process).                                    provide information to us will vary
Before offering you a position, we may       depending on the nature of our
collect additional details such as your      interaction with you.
tax file number and superannuation
information and other information
necessary to conduct background
checks to determine your suitability
for certain positions.
Private Health Insurance • 22

For what purposes do we                  Can you deal with Navy Health             • other organisations as required
collect, hold, use and disclose          anonymously?                                or authorized by law, e.g.: in
your personal information?               You may interact with us anonymously        an emergency, investigation of
The purposes for which we may            or by using a pseudonym if the              suspected criminal activity or
collect, hold, use and disclose your     interaction is general in nature.           where we are authorized to by law;
personal information will depend on      However, if the interaction is specific   • contractors and service providers,
our relationship with you. Examples of   to an account or relates to your            such as mailing houses, marketing
some of the purposes are below:          personal information we will need           agencies, information technology
• to manage and administer our           to identify you before we can               service and support providers, data
  products and services including        engage in further discussions and           processing and analytics agencies,
  private health insurance;              correspondence.                             and website maintenance and
                                                                                     development service providers; and
• to perform the functions and
  activities related to our business     Consequences for you if your              • for members admitted to hospital,
  such as assessing your claims and      personal information is not                 our contracted management
  paying your benefits;                  provided to us?                             service — Australian Health
                                         You may decline to give us your             Services Alliance at
• to collect rebate entitlements;
                                         personal information when we request
• to collect installments which are
                                         it. However, we may not be able to        How do we hold your personal
                                         provide you with some or all of the       information?
• to manage our relationship with        products or services that you request     The personal information we collect
  you including by contacting you        of us. If you have any concerns about     about you is kept [on an electronic
  about products or services, news,      the personal information we have          record system in secure databases
  competitions or community events       requested, please let us know.            (including trusted third party storage
  which we think may be of interest                                                providers in Australia). Personal
  to you;                                Who do we disclose your                   information may also be collected
• to research, develop and expand        personal information to?                  in paper-based documents and
  our products and services;             In order to carry out the above-          converted to electronic form for use or
• to identify whether you are suitable   mentioned purposes, we may disclose       storage (with the original paper-based
  for and to contact you about           your personal information to persons      documents either archived or securely
  health management programs and         or organisations, such as:                destroyed).
  services that may be of benefit to     • health service providers;               We understand the importance of
  you;                                                                             protecting the personal information
                                         • professional advisers;
• to recruit employees and                                                         we hold about you. We take
                                         • regulatory bodies;                      reasonable steps to ensure your
  contractors (including volunteers,
  internships and work experience)       • other Health Insurers;                  personal information is free from
  and other third parties that provide   • authorised persons or persons who       misuse, interference, loss, unauthorised
  services to us; and                      act on your behalf;                     access or modification or disclosure,
                                                                                   which include:
• to comply with any applicable laws.    • government agencies, allowing
                                           us to comply with statutory &           • securing all personal information;
We may also use your personal
                                           legislative reporting requirements      • limiting access to personal
information for other purposes
                                           for the collection and submission         information only to those that need
explained at the time of collection
                                           of health related data to                 access; and
or otherwise as set out in this
                                           Commonwealth agencies;                  • protecting our systems with
Privacy Policy.
                                                                                     appropriate technology solutions.
Private Health Insurance • 23

All personal information that is held    A dependent child (who is 16 years or       We may use your personal information
by Navy Health is secured by the         older and in some situations, under the     to contact you (including by phone,
following methods:                       age of 16) may contact Navy Health          text message or email) about products
• securing our premises with alarms      to request that their claims history be     or services which we think may be of
  and 24 hour security monitoring.       kept private from other persons under       interest to you. This may include our
                                         the insurance policy.                       own, our related body corporate’s or a
• ensuring all systems, servers,
                                         Navy Health may, in its discretion,         third party’s products or services with
  computers, databases and
                                         decline to disclose the claims history      whom we have a formal arrangement.
  networks are secured with
  password protection and                of a person insured under the same          In particular, we may contact you
  encryption.                            policy where it cannot be satisfied that    about products and services we
                                         such disclosure reflects the current        think may be of interest to you after
• ensuring various access levels for
                                         intention of the insured person. In that    you cease to hold a private health
  staff to limit access to information
                                         circumstance, the Navy Health may           insurance policy with us. For example,
  and roles.
                                         seek clarification from the insured         we might contact you about renewing
• providing our staff with regular       person.                                     your old policy or taking out a new
  training and feedback pertaining to                                                policy.
                                         It is important to consider the
  the Privacy Act.
                                         privacy settings applicable to your         You consent to us sending these
• In order to satisfy our legal          policy where there are changes in           carefully selected marketing materials
  obligations, we may need to            the relationships amongst persons           to you in this manner.
  retain your information after the      insured under the policy (for example,
  relationship has ended. However,       as children and young people                How can I opt-out of receiving
  we will not retain your identifiable   mature or if partners separate).            marketing material?
  personal information longer than       In that circumstance, you should            You may opt-out of receiving
  is reasonably necessary and            contact us to change the privacy            marketing information from us and our
  permitted under relevant Australian    settings applicable to your policy or       related bodies corporate at any time
  privacy laws. We take reasonable       discuss whether different insurance         by:
  steps to destroy or de-identify        arrangements are appropriate to your
  information that we no longer                                                      • calling us on 1300 306 289;
  require.                                                                           • emailing us at
                                         How can I organise additional       ;
How is personal information              privacy protections as a victim             • ‘ticking the box’ on the relevant
handled for couples and family           of family violence or identity                form when you apply for one of our
health insurance policies?               theft?                                        products or services; or
If you are insured under a health        If you are a victim or family violence or   • using the unsubscribe function on
insurance policy which covers more       identity theft, or have personal safety       various communications.
than one person, such as a ‘family’      concerns relating to the personal
or ‘couples’ policy, you should make                                                 Please allow five working days for your
                                         information we hold about you, we
yourself aware of the privacy settings                                               request to be actioned by us.
                                         may be able to provide further privacy
applicable to your policy. Information   protections for you. Please do not
about the health services received,      hesitate to discuss these options with
claims made and benefits paid (claims    us by:
history) for each person under the
                                         • calling us on 1300 306 289; or
same health insurance policy is
accessible to the other persons under    • emailing us at
the insurance policy.            
Private Health Insurance • 24

How does Navy Health interact               Navy Health may also use information        How can you access and
with you via the internet?                  collected by cookies to display             seek correction of personal
Navy Health’s website, online services,     personalised content and advertising        information held by us?
interactive applications, email             (targeted advertising and online            You are entitled to access the personal
messages and advertisements may             behavioral advertising), based on an        information we hold about you on
use “cookies” and other technologies,       individual’s internet usage, and to         request.
such as Google Analytics.                   send marketing materials that Navy
                                                                                        We do not charge a fee to give you
                                            Health thinks will be of interest to the
Navy Health has the following Google                                                    access to your personal information,
Analytics Advertiser Features enabled:                                                  but you may be charged for the
                                            You can use your settings to disable        reasonable time and expense incurred
• remarketing with Google Analytics
                                            your web browser from accepting             in compiling information, depending
• Google Display Network Impression         cookies. However, in doing so, you may      on the nature and extent of your
  Reporting                                 be unable to access certain features or     request.
• Google Analytics Demographics             content on the Navy Health website.
                                                                                        We will take reasonable steps to
  and Interest Reporting
                                                                                        ensure that the personal information
This enables Google Analytics to            Are we likely to disclose
                                                                                        we collect, use or disclose is accurate,
collect data about Navy Health              your personal information to
                                                                                        complete and up-to-date. You can
Website traffic via Google advertising      overseas recipients?
                                                                                        help us to do this by letting us know
cookies and anonymous identifiers,          We generally hold your information in
                                                                                        if you notice errors or discrepancies
in addition to data collected through       Australia. In certain circumstances, we
                                                                                        in information we hold about you and
a standard Google Analytics                 may transfer your personal information
                                                                                        letting us know if your personal details
implementation.                             outside Australia. Technology allows
Navy Health gathers some information        for services to be provided by
                                                                                        However, if you consider any personal
automatically and stores it in log files.   different service providers including
                                                                                        information we hold about you is
This information includes Internet          some that are located overseas. We
                                                                                        inaccurate, out-of-date, incomplete,
Protocol (IP) addresses, browser            may use overseas service providers
                                                                                        irrelevant or misleading you are
type and language, Internet service         in order to provide our products and
                                                                                        entitled to request correction of the
provider (ISP), referring and exit          services or manage our relationship
pages, operating system, date/time          with you. The countries in which those
                                            third parties are likely to be based are    You can request to access or
stamp and clickstream data. Some of
                                            the United States.                          seek correction of your personal
the information we collect via cookies
                                                                                        information by:
and online technologies is considered       Unless we have your consent, or an
personal information .                      exception under the Privacy Laws            • accessing the Online Member
                                            applies, we will only disclose your           Services portal
Navy Health uses this information to
understand and analyse trends, to           personal information to overseas            • calling us on 1300 306 289;
administer its website, to learn about      recipients where we have taken              • emailing us at
user behavior on the site, to tailor        reasonable steps to ensure the      ; or
email communications and to gather          overseas recipient does not breach the
                                                                                        • by mail at PO Box 172, Box Hill,
demographic information about its           Australian Privacy Principles in relation
                                                                                          Victoria, 3128
user base as a whole. Navy Health may       to your personal information.
use this information in its marketing
and advertising services.
Private Health Insurance • 25

When you contact us to request             We will also endeavor to resolve          Direct debit arrangements
access to and correction of your           any concerns or complaints which          (a) We will, in accordance with
personal information, we may need          you may have to your satisfaction.            the terms of the direct debit
to verify your identity by confirming      However, if you are unhappy with our          request and any other existing
your member number, full name, full        response, you can make a complaint            agreement, periodically debit
address and date of birth.                 to the Office of the Australian               the nominated account for the
We will give you access to your            Information Commissioner (OAIC) in            agreed amount(s).
personal information if practicable,       Australia.
                                                                                     (b) The debits will occur according
and will take reasonable steps to          The contact details for the OAIC:             to the frequency you have
amend any personal information about       The Office of the Australian                  nominated i.e. fortnightly,
you which is inaccurate or out of date.    Information Commissioner                      monthly or as agreed. The
We will take reasonable steps to notify    GPO Box 5218                                  amount debited will vary
you of a decision on the request within    Sydney NSW 2001                               according to the amount
30 days. We may decline your request       Phone: 1300 363 992                           falling due.
to access or correct your personal         Fax: 02 9284 9666                         (c) If any drawing falls due on a
information in certain circumstances       Website:                      non-business day, it will be
permitted by the Privacy Act and           Alternatively, you can contact                debited from the nominated
Health Record Laws. In such a case,        the Victorian Health Complaints               account on the prior business day.
we will provide you with written notice    Commissioner, NSW Privacy
of the reasons for our decision.           Commissioner or ACT Human Rights          Your rights
How can you complain about a breach        Commission.                               (a) You can change your direct
of the Australian Privacy Principles                                                     debit arrangements by calling us
and how will we deal with your             What if I have further                        on 1300 306 289 or log on to
complaint?                                 questions?                                    Online Member Services at
If you have any questions, concerns        If you have any questions about our  at
or complaints about how we collect         Privacy Policy, you may contact our           least five business days prior to
or manage your personal information,       Privacy Officer whose contact details         the next direct debit. Changes
then you may raise that matter with        are listed above. If you have questions       include altering arrangements,
our Privacy Officer. Our Privacy Officer   about the Privacy Act, you may                stopping an individual debit or
can be contacted as follows:               contact the OAIC.                             cancelling a direct debit request
• calling us on 1300 306 289;              Direct debit service agreement                completely.

• emailing us at                           This agreement (“Direct Debit Service     (b) We will give you at least 14 days; or            Agreement”) outlines the terms                notice by telephone or writing
                                           and conditions of the direct debit            (including e-mail) of any change
• by mail at: Attention Privacy
                                           arrangements between the person               to the terms of the direct debit
  Officer, PO Box 172, Box Hill,
                                           signing the direct debit request              arrangements, unless otherwise
  Victoria, 3128.
                                           (“you”) and Navy Health (“us”).               agreed.
We will endeavor to promptly
                                           You agree to be bound by these terms      (c) If you believe we have drawn on
respond to your questions, concerns
                                           and conditions upon your execution of         your account incorrectly, please
or complaints. In most cases we
                                           the Direct Debit Request.                     contact us on
will investigate and response to a
                                                                                         1300 306 289 so the matter can
complaint within 30 days of receipt
                                                                                         be resolved. We will make every
of the complaint. If the matter is more
                                                                                         attempt to resolve the dispute
complex or our investigation may take
                                                                                         within five business days.
longer, we will let you know.
Private Health Insurance • 26

Your obligations                       Code of conduct
(a) You must ensure that:                             Navy Health abides
(i) before completing the direct                      by the Private
    debit request, you check 		                       Health Insurance
    the account details of your                       Code of Conduct.
    nominated account are                             By subscribing to
    accurate (check against a          the code, Navy Health ensures that
    recent statement from your         members receive clear information
    financial institution);            and transparency in their dealings with
                                       Navy Health.
(ii) your nominated account can
     accept direct debits (your 		     The code ensures Navy Health will:
     financial institution can         • continue to improve standards
     confirm this);                      of practice and service;
(iii) your nominated account 		        • provide information to members
      has sufficient clear funds 		      in clear and plain language;
      on the drawing date to allow     • ensure the policy documentation
       payment to be made in 		          is full and complete;
      accordance with the direct
                                       • ensure that Navy Health staff are
      debit request and any other
                                         appropriately trained to provide
      existing agreement between
                                         clear explanations;
      you and us.
                                       • provide members with access
(b) You must advise us immediately
                                         to an internal dispute resolution
    if your nominated account is
                                         procedure and advise members
    not current.
                                         of their rights to take an issue to
(c) If any drawing is returned or        the Private Health Insurance
    dishonoured by your financial        Ombudsman.
    institution, we may, at our
                                       A copy of the code may be provided
    discretion, reprocess the
                                       on request or can be viewed at
    transaction following receipt
    of the notification of return or
    dishonour, or request an
    alternative form of payment
    from you. We may also charge
    any dishonour fees back to you.
Private Health Insurance • 27   PO Box 172, Box Hill, Victoria 3128
                    Navy Health Limited
                    A Registered Private Health Insurer
                    ABN 61 092 229 000
                    T 1300 306 289

                    Information is current as at April 2021 and is
                    subject to change. Defence imagery supplied
                    by Department of Defence.
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