Membership rules

Access Gap Cover

TUH aims to close the gap on out-of-pocket in-hospital medical expenses for all members. Access Gap Cover is available with any level of hospital cover. Participation is the personal choice of your medical practitioner, so check this before commencement of treatment. Also ask your specialist to recommend that any assisting specialist/s use Access Gap Cover for the billing of services.

How Access Gap Cover works

As a private inpatient, Medicare will cover 75% of the MBS fee for doctor’s charges. TUH will cover the remaining 25%. If your doctor charges above the MBS fee, this is an out-of-pocket expense. If your doctor uses the Access Gap Cover scheme you will either:

• Have no out-of-pocket expenses; or
• Know your out-of-pocket expenses.

Prior to treatment you can request an estimate of possible costs.
If your doctor participates in this scheme, in most cases you will not receive an account as TUH receives the bill and makes any claims on your behalf from Medicare. Once your account has been settled, you will receive a statement from TUH confirming the amount paid to your doctor.

Accidents

Where a member has been involved in an accident and has received compensation or damages from a third party, benefits cannot be claimed from TUH in relation to this accident. If TUH has made a payment on your behalf for an accident claim all benefits and any associated costs already paid by Teachers’ Union Health must be repaid if you receive compensation.

Active Health Bonus

The Active Health Bonus is a reward available to members who contribute to Ultimate Choice, Easy Choice or Comprehensive General (AN) with any hospital table, when one adult member actively participates in the Health Assessment Program.

• Participation requires the completion and return of 1 questionnaire within 12 consecutive months.
• No benefits are payable for services which were provided whilst not participating in the Health Assessment Program.
• Active Health Bonus is per Calendar Year.
• A six (6) month waiting period applies from fund joining date.

Limits

TUH will pay 70% of the total cost of approved programs, up to the amounts applicable for your nominated level of cover.

Cover	Single	Single Parent/Family
Ultimate Choice
Overall Limit	$150	$300
Sub Limit Gym membership Exercise physiology	$50	$100
Easy Choice
Overall Limit	$100	$200
Sub Limit Gym membership Exercise physiology	$50	$100
Comprehensive General (AN) + any hospital table
Overall Limit	$100	$200
Sub Limit Gym membership Exercise physiology	$50	$100

Benefits claimable under the Active Health Bonus:

• The shortfall for approved claims for out-of-pocket general treatment expenses.
• TUH approved quit smoking programs.
• TUH approved First Aid courses.
• TUH approved membership to illness related associations eg. Diabetes Association, Heart Foundation.
• Customised orthotics requested by a podiatrist (not applicable to Easy Choice).
• Orthotics custom made or customised requested by a chiropractor or physiotherapist (not applicable to Easy Choice).
• Health management programs that have been recommended by a qualified medical practitioner*:
  • Gym memberships
  • Exercise physiology
  • Weight management

The following are not claimable under the Active Health Bonus:

• Casual gym visits, membership to aquatic centres or personal trainers.
• Co-payments for PBS prescriptions.
• Any difference between the Medicare Benefits Schedule fee and the doctor’s charge for medical expenses.
• Any medical expense precluded by law from being paid.
• Hospital excesses.

Benefits attracted through the Active Health Bonus are transferable between certain levels of cover provided that both levels of cover include the Active Health Bonus.
For further information on our Active Health Bonus, please call our Customer Contact Centre on 1300 360 701.

*Please contact TUH on 1300 360 701 or visit our website for a Health Management Program Application Form to submit to your medical practitioner for completion.

Acute Care

All inpatient hospitalisation is paid in accordance with each individual hospital contract. An Acute Care certificate must be issued by the treating doctor after 35 days of continuous inpatient hospitalisation.

Calendar Year

A 12 month period commencing 1 January and ending 31 December.

Claims information

Original accounts and receipts must accompany all claims if accounts have been paid. For inpatient Medical Gap Cover treatment the Medicare statement of benefits is required to process your entitlements. All documents are retained unless otherwise instructed. The refund cheque will be issued to the policy holder if services have already been paid. Benefits are not payable for services which took place two years or more prior to the date of lodgement of the claim.
Benefits are not payable for:

• Telephone consultations or letters of advice by providers.
• Treatment by a provider to one of their family members including partner and dependants.

Cooling Off Period

A policy holder has the right to terminate during a 30 day Cooling Off Period. The membership must be financial and no claims made during the 30 day Cooling Off Period. The 30 day period commences from the effective date joining the fund or the date the level of cover increases or decreases (in the case of the latter cover reverts back to the previous level of cover).

Cosmetic/Elective surgery

When medically necessary and when Medicare benefits are payable, Contracted Hospital rates apply. Where there is no Medicare entitlement, a benefit equal to the basic Default benefit is payable, with no theatre fee benefit.

Default benefit

This benefit is determined by the Federal Government and is the minimum amount funds must pay for accommodation costs in public hospitals. Default benefits do not provide any benefit for labour ward or theatre fees and other hospital charges. Significant out-of- pocket costs may result if the treatment can only be claimed at the Default benefit rates.

Dental prosthetists

Benefits are paid for treatment by registered dental prosthetists. Benefits are paid for certain dental items at 75% of the refund which would be payable for treatment provided by registered dentists.

General cover membership year

All limits apply per person and unless otherwise stated, relate to the period January to December each year, with the exception of orthodontic treatment, which is subject to a lifetime limit, hearing aids, CPAP machines and anti snore devices where a benefit is paid every three years from date of previous supply.

General cover upgrade

New/existing members, who upgrade their cover, will commence membership on the higher table at the oneyear level of annual limits. Waiting periods may apply.

General dental

General dental includes the surgical removal of teeth (including wisdom teeth). No benefit is payable under General cover basic Y for the surgical extraction of teeth (including wisdom teeth). Mouthguards are also covered under this category of benefits with a limit of one per person per calendar year.

Hospital excess – Calendar Year

An excess is the agreed amount per person which must be paid for all hospital treatment charges (including same day surgery and Prosthesis) in a Calendar Year. For single parent/family cover you pay the excess at the single rate for each admission until the full family amount has been reached for that Calendar Year. The excess must be fully paid before any TUH benefits are payable. Once the excess limit has been reached for the membership the excess will not apply to further treatments in the same Calendar Year. From 1 January 2010 the hospital excess is not payable for dependent children aged under 18 (17 years and 364 days) on Easy Choice and Total Care Hospital plus excess (HX & HE). Hospital excess is still payable for dependants on Active Choice and Young Choice. Note: Reducing your excess is considered to be "upgrading" your membership.

Increasing your level of cover

All waiting periods will apply to any increased level of cover. Existing TUH members with AN cover who transfer to the Ultimate or Easy Choice packages will be automatically accredited with all waiting periods served as well as years of membership accrued with TUH for all general treatments. The previous level of cover will apply until all appropriate waiting periods have been met. Please contact our Customer Contact Centre on 1300 360 701 to discuss your individual circumstances.

Major dental

Major dental includes all dental services relating to dentures, crowns, bridges, inlays, onlays, facings, dental implants, endodontia, periodontia, anti snore devices and orthodontia. Entitlements are based on a maximum of 3 years continuous orthodontic treatment where benefits have not been claimed for previous orthodontic treatment during the patient’s lifetime. All orthodontic treatment plans must be submitted to TUH before benefits will be paid. (Major dental does not apply to Basic General Y cover).

Medical Gap Cover

The Medical Gap represents the difference between the Medicare refund and the Medical Benefits Schedule fee for inpatient medical services. However, should a doctor charge over the MBS fee, there may be out-of-pocket expenses. Paediatric services provided in hospital are not payable unless an inpatient charge is raised by the hospital for your baby. Refer to Access Gap Cover on page 30.

Membership eligibility

The eligibility criteria set out below must be met in order to qualify for membership of Teachers Union Health.

• Current or former member of one of the following unions: Queensland Teachers’ Union (QTU), Queensland Independent Education Union (QIEU), Queensland Public Service Union (QPSU), Australian services Union (ASU), Community Public Services Union (CPSU).
• Any person who is or has been employed by a school, university or other tertiary, further education or training institution (other than as a teacher) and is or has been a member of a union or who’s occupation had no union coverage.
• Any person who is or has been an employee of QTU, QIEU or TUH.
• A family member (see below) of a person who is eligible to join TUH.* Parent, partner or former partner, dependent child, adult child (incl. their partner), grandchild, brother or sister (incl. their partner and dependent children)

*Providing that a policy holder’s partner was insured by TUH on 12 October 2007, then that partner’s relatives (as covered by the above relationships) are also eligible to join TUH.

Please contact TUH if you are in doubt about your eligibility.

Single membership covers:

• The policy holder only.

To ensure your baby is covered from birth, members on
single cover must transfer to family membership at least
two months prior to the date of the birth of your child.

Single Parent membership covers:

• The policy holder.
• Dependent children as defined below.

Family membership covers:

• The policy holder.
• The policy holder’s partner.
• A natural child, stepchild, legally adopted child or child to whom the policy holder is the legal guardian or who is in the policy holders legal custody.
  The policy holder’s unmarried children, who are not married or in a defacto relationship and who are under 18 years of age for all levels of cover, except Ultimate Choice and Easy Choice where the age is extended to under 21 years.

A policy holder’s student dependent child who is:

• Unmarried and not in a de facto relationship.
• A full time student at a recognised education facility for the whole of the scholastic semester.
• Under age 25 (only applies to Ultimate Choice and Early Choice).
• Not in receipt of a taxable income above an amount determined, from time to time by the Board.

A policy holder must complete a Student Registration form at the start of each academic year. Students are not covered if they cease or defer study during the year.

Pre-existing Ailment rule

Refers to an ailment, condition or illness, the signs or symptoms of which (in the opinion of a medical practitioner appointed by TUH) existed at any time during the six months preceding the day on which the policy holder began contributions to the fund or upgraded to a higher level of benefits.

All hospital claims in the first 12 months for new members or members transferring/upgrading to a higher level of hospital cover are subject to the Preexisting Ailment rule. Our appointed medical practitioner is the only person authorised to deem a hospital claim to be pre-existing.

Policy holder

The policy holder is the person in whose name the membership is held and the person who holds the legal responsibility for the membership. The policy holder is the only person who can terminate the membership.

Overseas travel

TUH does not provide benefits for medical/hospital/ general treatment received while travelling overseas. Teachers’ Union Health recommends travel insurance for all overseas travel. Contact our Teachers’ Insurance representative at Union Shopper on 1300 301 461 for details of competitive pricing options.

Rate protection

Members may pay their membership for up to 12 months in advance of the date they make their payment. The financial date of a member who is paid up to 12 months in advance will not change if a rate increase comes into effect after their payment is made. Rate protection will cease if a member changes his/her table of cover or suspends membership; any amount paid in advance of the date of the cover change or suspension will be applied at the rate that is current at that time.

Registered/recognised practitioners

Benefits are paid for treatment by registered practitioners in private practice and recognised Natural Therapists, approved by the Australian Regional Health Group (ARHG) and acknowledged by Teachers’ Union Health.

Single Parent

Single parent family annual limits are the same as the limits identified for a family membership.

Spouse/partner authority

A policy holder can request that their spouse/partner be treated as authorised to operate the policy on the same level as the policy holder (excluding joining/terminating membership and removal of dependants). This can be done by calling our Customer Contact Centre on 1300 360 701 or by downloading the Spouse/Partner Authority form. The authority provided by the policy holder may be withdrawn by the policy holder at any time by notification to the fund, in writing or over the phone.

Subscription arrears

Contributions are payable in advance. An unfinancial member shall be excluded from payment of benefits or facilities in respect of services rendered after the date to which the membership was financial. Membership of Teachers’ Union Health will automatically cease for any member whose contributions are more than two months in arrears.

Members experiencing difficulty in making regular payments should contact our Customer Contact Centre on 1300 360 701 to discuss payment options.

Suspension of cover

A policy holder who has been a financial member of TUH for at least 12 months is entitled to suspend their membership. The minimum period allowed between consecutive financial hardship suspensions is 12 months and nine months for overseas suspensions.

Suspension due to financial hardship

A policy holder who has been a financial member of TUH for at least 12 months is entitled to suspend their membership due to financial hardship. The minimum period allowed between consecutive suspensions is 12 months. A member who is experiencing financial difficulties may apply to have their membership suspended for a minimum period of one month to a maximum period of six months. Multiple suspensions are allowed; however 12 months must be served between consecutive suspensions. The application must be submitted on an Application for Hardship Suspension form, which is available from TUH on request. This form must be accompanied by a letter explaining the situation and a document from Centrelink verifying the member has been in receipt of sickness or unemployment benefits since the beginning of the proposed period of suspension. All suspensions must be approved by TUH.

Suspension due to overseas travel

A policy holder may suspend their membership due to overseas travel for a minimum period of two calendar months to a maximum period of three years. One month's contribution must be paid in advance of the suspension date. Two suspensions are allowed per calendar year. The second suspension can commence after the member has resumed the policy for a period equal to the length of their previous absence or 9 months, whichever is the shorter. Please telephone our Customer Contact Centre on 1300 360 701 to request an Application for Suspension of Membership form, or download the form. Documentation to verify departure and return dates will be required upon resumption of membership.
Application to suspend membership must be made prior to the date of overseas departure. Members suspending their cover should refer to the conditions that apply to suspension of membership. These are listed on the Application for Suspension of Membership form and the accompanying information sheet. NOTE: The remainder of any waiting period not completed prior to departure will continue when membership is resumed.

Transferring from another fund (hospital cover)

From time to time, members covered by health insurance products see a need to vary their existing product to take account of their changing needs. The PHI Act provides protection for members should they wish to transfer to a different level of cover in their own fund, or transfer to another registered health fund. It also identifies the effect of waiting periods applicable to transferring members. The overriding principle, which underpins the portability provisions, is that any member transferring from one product to another, either within a fund or between funds, will not be disadvantaged over a member entering that product for the first time. To assist members to understand the portability of benefits, the Private Health Insurance Ombudsman, in conjunction with the health insurance industry, has produced a brochure “The Right To Change” which is available from TUH.

Transferring from another health fund (general)

New members transferring to an equivalent level of cover with TUH will be entitled to the annual basic limit (year one benefits and limits) with TUH for all services, provided all waiting periods have been served with the previous fund.

Credit will be given for waiting periods partially served with your previous fund. If you transfer to a TUH level of cover that provides services not covered by your previous fund, then all relevant waiting periods for these services must be served with TUH. TUH may accrue any benefits paid by your previous fund towards the TUH limits within the first 12 months of membership where members have claimed benefit limits with their previous fund. Continuity of membership for equivalent levels of cover and waiting periods already served will only be taken into account if you join TUH within two months of ceasing membership with your previous registered health fund. Please request a Transfer Certificate from your previous fund or complete and return the Transfer Certificate with your TUH application form. It is the transferring member’s responsibility to contact their paymaster to cease payroll deductions.

Waiting periods

2 years

• Laser eye surgery

12 months

• Obstetric related conditions
• Hearing aids
• Pre-existing conditions
• Major dental
• Orthodontia
• Prostheses (non implanted)
• Mechanical/Health appliances
• Cosmetic/Elective surgery (only if medically necessary)

6 months

• Active Health Bonus
• Optical (for Young Choice and Active Choice)
• Midwife services for home births

2 months

• All other services (unless specified otherwise)
• Palliative Care
• Psychiatric
• Rehabilitation

Immediate cover

• Accidents

WorkCover

Claims for work related injuries must be submitted directly to WorkCover. In the event that WorkCover deny your claim, payment relevant to your level of cover may be made by TUH on submission of fully itemised accounts/receipts with a copy of WorkCover’s letter stating that you are not entitled to WorkCover benefits.

Common terms

• Access Gap Cover. For inpatient medical services with participating doctors, you will have either nothing to pay, or in most cases you will know your out-of-pocket expense before treatment begins.
• Benefit. The amount you receive from a health fund.
• Contracted Hospital. At TUH Contracted Hospitals there is 100% cover for hospital accommodation and theatre fee charges for members with Total Care Hospital.
• Co-payment. An amount you pay towards your treatment expenses after you have received your entitled benefit from the health fund. The amount still owing is called a co-payment.
• Excess. An amount you agree to pay towards your hospital treatment. Once you have paid this amount in a Calendar Year, no further excess will apply for that year. The higher the excess, the lower your premium.
• General. Provides benefits for services such as physiotherapy, dental, and optical treatment.
• HICAPS. On the spot claims using your Teachers’ Union Health card at participating service providers.
• Lifetime Health Cover. A Federal Government initiative designed to encourage people to join
  a health fund before the age of 31 and maintain membership throughout life.
• Limit. The maximum amount payable per Calendar Year for a general benefit. The annual limit is renewed on 1 January each year.
• Non-Contracted Hospital. Hospital’s without a contract with Teachers’ Union Health, reduced benefits will apply.
• Out-of-pocket expenses. Amount you owe after all benefits have been received. This varies depending upon the Government’s schedule fees for the medical services you receive, the practitioner you see, the particular treatment you have, and if applicable, the hospital you go to.
• Sub-limit. A limit which is applied annually (or another specified period of time) on the benefit paid for a particular item or service within an overall annual limit.

Code of Conduct

TUH is accredited under the Private Health Insurance Code of Conduct. This Industry Code represents a new standard of service to promote communication and understanding between private health insurers and their members.

The code ensures TUH:

• Continually works towards improving the standards of service we offer to our members;
• Provides information in plain language about our products and services;
• Provides easy access to our internal dispute resolution procedures; and
• Keeps your information confidential in accordance with privacy principles.

Accreditation is a significant achievement and confirms TUH’s commitment to excellence in delivering quality products and services to our members.

Internal Dispute Resolution

Teachers' Union Health ensures that concerns raised by members are dealt with in a timely, professional and consistent manner and will resolve them to the mutual satisfaction of both the member and the fund where possible. The final recourse for unresolved issues is the Private Health Insurance Ombudsman (see below). For further enquires please contact our Customer Contact Centre on 1300 360 701.

Private Health Insurance Ombudsman

The Private Health Insurance Ombudsman has been established to assist with enquiries and complaints about any aspect of private health insurance. The Ombudsman is independent of the private health funds, private and public hospitals and the Government. An annual report called ‘The State of the Health Funds’ is available on their website www.phio.org.au. Any information or complaints about health insurance may be lodged by telephoning the Ombudsman’s office toll-free on 1800 640 695.