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Health Fund Checklist - Obstetrics



Sometimes it can feel like speaking with your Health fund about your policy requires an Interpreter or foreign correspondent just to clarify the basics.

It can also be the same for choosing a health fund and the type of cover you need for the future.

But fear not! you are not alone....

According to the Australian Medical Association (AMA, 2016) health insurance report card, the two most commonly misunderstood aspects of private health insurance policies are;

1. Not all policies cover every medical treatment

and there is a big difference between what is covered under a top and basic levels of cover;

2. Patients will sometimes have out-of-pocket costs even when their policy covers the medical treatment they need.

It is especially important to remember that even though you might have the highest level of cover, you will have other out of pocket costs as a private patient.

These can include;

- hospital excess

- incidental hospital fees,

- inpatient pathology & radiology

- other specialist’s fees i.e Paediatrician and Anaesthetist.

Planning for a Pregnancy in the future:

It’s really important to get your insurance sorted for Obstetrics well before you actually fall pregnant.

This is because all private health funds have a 12 month waiting period for obstetrics (pregnancy) services.

This simply means you will need to have held that appropriate level of care for at least 12 months before your hospital admission. (Including the delivery of your baby).

For individuals with insurance this might mean for example;

-you need actually take out private hospital cover

- you might need to upgrade your existing policy to now include pregnancy or family cover.

***Please note***

With most health funds you can change you cover level anytime but it may mean you need to restart the waiting periods if you have downgraded in the past and wish to upgrade you level of cover.

I can't stress enough how important it is to 100% sure before you remove your obstetrics cover from your policy.

If you remove obstetric cover too soon and fall pregnant in that time, you will often not be covered and another 12 month waiting list will apply

Always read the fine print:

Take care when choosing which health insurance policy to buy – many of the lower cost policies don’t cover obstetrics, or pay restricted benefits that will only cover you as a private patient in a public hospital.

For Patients of our practice this is not the end of the world, we can certainly deliver your baby in a public hospital as a private patient of Dr Saj Rathnayake,

which simply means your care would be managed soley by Dr Saj and we would simply be delivering your baby in a public hospital.

If you want to have your baby delivered in a private hospital, you will need to have a policy that covers you for a private hospital as a private patient.

Making Sure Your Baby is Included on Your Policy

In order to cover your baby from birth, without waiting periods, you must check that your hospital policy will cover dependent children as well as yourself.


A single hospital policy covers you – but it won’t cover your baby.***

It’s important to ensure your baby is covered from birth in case he or she requires hospital care immediately.

This could occur in cases of premature birth where a baby is admitted to a Special Care Nursery or Intensive Care Unit. This type of admission is very costly and can rise into the tens of thousands of dollars.

Every fund has different rules about covering newborn babies. We advise as apart of our health fund check list that you check this early on.

Most private health funds will require you to upgrade your policy to a ‘family’ level one to three months prior to the baby’s birth.

However, some funds may require you to upgrade your policy to a ‘family’ level as early as 12 months prior to birth in order to cover your baby for possible congenital conditions.

What’s Not Covered....

Private hospital cover gives you the choice of a private obstetrician and private hospital, and will cover a portion of your medical fees. won’t cover all the costs associated with your pregnancy.

Some of the out-of-pocket expenses you may incur include;

Medical services incurred outside of hospital;

- Specialist consultations

- Ultrasounds

-Genetic screening test

- Blood tests.

All of these costs are Medicare claimable and our practice manager will talk to you about claiming at your first visit.

- Some Specialists will charge a ‘gap’ on medical services incurred while admitted to hospital, Dr Saj Does not currently charge a out of pocket gap for Obstetrics.

- Excesses and co-payments. Some health insurance policies require you to pay an Excess or co-payment for admissions to hospital. This is one of the questions on the check list and based on you cover level.

- Before you and your baby can go home, a paediatrician will check on his or her progress.

If your baby has not been admitted as a patient to hospital, as is the case with most births without complications, the fee for the paediatrician’s visit cannot be claimed on your private health insurance policy.

However...this cost can only be claimed via Medicare and usually a gap is payable, depending on how much the paediatrician charges above the Medicare Scheduled fee & If you have reached your Medicare threshold for that calendar year.

At your first visit with Dr Saj we will provide you with a fee outline from Geelong Paediatric Group to help you plan your budget.

Now Breath, the heavy stuff is out of the way… now for the check list!!!

We advise all of our Obstetrics patients

to take the phone their health fund

and run through the following check list...

Health fund Check List:

- Does your policy cover “Private cover in private hospital for Delivery at St John of God Hospital Geelong”?

- Obstetric cover; does you cover include Obstetric cover?

- Confirm you Expected Due date with the Fund to ensure you will be covered at the time of delivery and have you have served all of you waiting periods in relation to this?

- When to add you baby onto you membership? Will baby have an excess?

- If need be will you baby be covered for special care nursery admission?

- Do you have a hospital excess? This amount will be paid to St John of God Hospital?

For our patients if you still have questions please call our practice anytime and our practice manager can help with any questions you have Ph: 5222 8858

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