Membership Conditions

1. Waiting Periods

A waiting period is the length of time you have to wait before you become eligible for benefits. For more information on waiting periods, click here. 

2. Pre-existing condition

A pre-existing condition is an ailment, illness or condition the signs or symptoms of which, in the opinion of a medical practitioner appointed by Astute Simplicity Health, existed at any time in the period of 6 months ending on the day on which the person became insured under the policy. A 12-month waiting period applies to all pre-existing conditions. 

3. Accidents

Hospital treatment that results from an accident which occurred after joining, is covered immediately on hospital cover, providing there is no right to claim compensation and damages from another source. An accident is an event or occurrence which is unforeseen and unintended, which results in physical hurt or damage to the body and requires immediate treatment. An accident does not include an obstetric related condition, or an unforeseen ailment, illness or condition brought on by medical causes. 

4. Restricted service

Benefits for a restricted service are limited to a shared room benefit in a public hospital should you elect to be treated as a private patient. There is very limited cover in a private hospital meaning you will have significant out-of-pocket costs if you use a private hospital for a restricted service. These costs include accommodation fees and theatre fees charged by the private hospital. You are entitled to Medicare Benefit Schedule rates for any medical services and therefore you may also have out-of-pocket cost from your doctors.

Your prosthesis costs will be in accordance with normal fund rules.

5. Excluded service

Benefits for excluded services are not payable therefore there is no cover as a private patient in a public hospital or a private hospital meaning that you will have significant out-of-pocket costs if you opt to be treated as a private patient in a public hospital or a private hospital for an excluded service. These costs include accommodation fees and theatre fees charged by the hospital. You are entitled to Medicare Benefit Schedule rates for any medical services and therefore you may also have out of pocket costs from your doctors. 

6. Cosmetic Surgery and surgical procedures not covered by Medicare

No benefit is payable on any hospital cover for treatment relating to cosmetic surgery or other surgical treatment that does not meet the eligibility criteria for the payment of Medicare benefits, or is not listed in the Medicare Benefits Schedule (with the exceptions of membership conditions 8 and 9). 

7. Obstetric Related Services

A 12-month waiting period applies to obstetric related conditions. After the 12-month waiting period has been served, the mother’s hospitalisation will be covered on a single policy and both the mother and baby will be covered on a family policy. However, the baby will not be covered on a single policy if it requires hospitalisation in its own right after birth. To ensure coverage of a newborn child, a single policy must be upgraded to a family cover from the child’s date of birth, providing the change occurs within 90 days of the child’s birth. A newborn child should also be added to a family cover within 90 days of the child’s birth to ensure that no waiting periods apply to the child. Premature births or complications arising from a pregnancy where a medical practitioner confirms the baby’s expected date of birth is after the 12-month waiting period, will be covered.

8. Sterilisation/Vasectomy or reversal of

Sterilisation, vasectomies and reversals of, are only covered on our hospital covers when they attract a Medicare benefit. Benefit is not payable for procedures not covered by Medicare. Where Medicare benefit is payable, a 12-month waiting period will apply under the pre-existing rule. 

9. Podiatric Surgery

Astute Simplicity Health will pay hospital accommodation benefits on its Gold and Silver products for surgical procedures performed by a registered podiatric surgeon. Surgical procedures performed by a Podiatric Surgeon do not attract Medicare benefit and therefore no medical benefit will be paid towards the charges raised by a Podiatric Surgeon.

10. Overseas Treatment

No benefit is payable for services or treatment rendered or appliances purchased outside Australia. 

11. Who is covered?

A single membership covers the individual only. 

A couple membership covers the member and their partner/spouse. 

A family membership covers the member, partner/spouse and child dependants. 

A dependant extension membership covers the member, partner/spouse and child dependants including non-student child dependants who are not married or living in a defacto relationship.

On a family membership, child dependants include children under 23 years of age and full students under 25 years of age who are not married or living in a defacto relationship and if totally dependent on their parents.

Dependants will receive immediate cover for equivalent benefits providing they join their own membership within 60 days of ceasing to qualify as a child dependant or non-student child dependant and providing all waiting periods have been served under their parent’s policy.

12. Transferring to higher cover

When changing to higher levels of cover, waiting periods and the pre-existing condition rule will apply for the additional benefit payable on the higher cover, with the exception of benefits for psychiatric treatment where a one-off lifetime waiting period exemption may apply. In the interim, your previous level of cover applies provided you have served the waiting periods on your previous level of cover. 

13. Transferring from other insurers

Members who transfer from another Australian registered private health insurer within 60 days of ceasing financial membership of the previous insurer, may do so without waiting periods providing the benefits are common to both insurers, the transfer is to equivalent or lower levels of cover and all waiting periods have been served with the previous insurer. If a break in Hospital cover does occur on transfer, the days without hospital cover will be counted as a period of absence for Lifetime Health Cover. Should the transfer be to a higher level of cover or a higher benefit than the previous insurer then all waiting periods, including the pre-existing condition waiting period will apply for the additional benefit, with the exception of benefits for psychiatric treatment where a one-off lifetime waiting period exemption may apply. When transferring from another insurer, your original age at joining Hospital cover with your previous insurer will be taken into consideration for the calculation of any premium loading payable under Lifetime Health Cover.

14. Direct Debit Request Service Agreement

Debiting your account

By signing a Direct Debit Request or by providing Astute Simplicity Health with a valid instruction, you have authorised Astute Simplicity Health to arrange for funds to be debited from your account. We will only arrange for funds to be debited from your account as authorised in the Direct Debit Request. If the debit day falls on a weekend or public holiday, we may direct your financial institution to debit your account on the following banking day. Monthly, quarterly, half-yearly and yearly direct debits are deducted on the day of the month that you nominate or within two business days after that day. Weekly and fortnightly are deducted on the day of the week that you nominate or within two business days after that day. An adjustment may be taken with your first direct debit payment to bring your payments in line with your chosen direct debit cycle.

Amendments by us

Astute Simplicity Health may vary any details of this Agreement or a Direct Debit Request at any time by giving you at least 14 days written notice. 

Amendments by you

You may change or defer a debit payment, or terminate this Agreement by providing us with at least 7 days notification in writing. 

Your obligations

It is your responsibility to ensure that there are sufficient clear funds available in your account to allow a debit payment to be made in accordance with the Direct Debit Request. If there are insufficient clear funds in your account to meet a debit payment you may be charged a fee and/or interest by your financial institution or you may also incur fees or charges imposed or incurred by us. You must arrange for the debit payment to be made by another method or contact us to arrange an alternative date that we can process the debit payment. If a scheduled debit payment fails then we will notify you and re-attempt the transaction after 14 calendar days. You must contact us to make alternative arrangement if you do not want this to occur. You should check your account statement to verify that the amounts debited from your account are correct. 

Dispute

If you believe that there has been an error in debiting your account, you should notify Astute Simplicity Health as soon as possible either by phone, by email or by contacting us via one of the methods listed on the back of this brochure. Alternatively you can take it up with your financial institution directly.

If Astute Simplicity Health concludes as a result of our investigation that your account has been incorrectly debited we will advise you of our findings and arrange for your financial institution to apply a correction and will notify you of the details of the adjustment.

Accounts

You should check with your financial institution whether direct debiting is available from your account as direct debiting is not available on all accounts offered by financial institutions. 

You should also check that your account details, which you have provided to us, are correct by checking them against a recent account statement and you should check with your financial institution before completing the Direct Debit Request if you have any queries about how to complete the Direct Debit Request. 

Confidentiality

Astute Simplicity Health will keep information (including your account details) in your Direct Debit Request confidential. We will make reasonable efforts to keep any such information that we have about you secure and to ensure that any of our employees or agents who have access to information about you do not make any unauthorised use, modification, reproduction or disclosure of that information. 

Astute Simplicity Health will only disclose information that we have about you to the extent specifically required by law, or for the purposes of this Agreement (including disclosing information in connection with any query or claim). 

Notice

If you wish to notify us in writing about anything relating to this Agreement, you should write to us at the Head Office or email the address on the back page of this brochure. Astute Simplicity Health will notify you by sending a notice in the ordinary post to the address you have given us in the Direct Debit Request. Any notice will be deemed to have been received on the third banking day (other than a Saturday, Sunday or public holiday listed throughout Australia) after posting. 

15. Overdue payments

If contributions are in arrears, payments will not automatically be accepted. It may be necessary to re-serve waiting periods from the date of payment of the arrears and entitlement to benefit for services rendered while in an unfinancial period may be lost.

If premiums fall more than two months in arrears, the policy will be subject to cancellation and all waiting periods may have to be re-served. 

16. Claims lodgement

Benefits are not payable where a claim is lodged more than two years after the date of service. 

17. Payment of benefit

Benefits are payable for face-to-face consultations and telehealth consultations where services are deemed appropriate by St.LukesHealth and where treatment is provided by a recognised provider.

18. Compensation from other sources

Benefits are not payable for any condition for which members or dependants have the right to recover costs from any other source, including third party, workers compensation or persons liable at law. 

19. Approved providers

Benefits are only payable when rendered by a practitioner in private practice who has been approved and registered with this Fund.

The approval and registration by St.LukesHealth of a Provider, Medical Practitioner, Hospital or Day Hospital Facility (as defined in the Rules and By-Laws of St.LukesHealth) for the payment of benefits does not constitute a representation or recommendation by St.LukesHealth or any of its agents that any particular Provider, Medical Practitioner, Hospital or Day Hospital Facility or any service, product or treatment recommended or provided by that Provider, Medical Practitioner, Hospital or Day Hospital Facility, will or may be of benefit to St.LukesHealth members. St.LukesHealth thus accepts no responsibility for the outcome of any advice, service, product or treatment given to members by a Provider, Medical Practitioner, Hospital or Day Hospital Facility registered with this Fund.

20. Hospital claims

Benefits are payable at the insured rate for 365 days for all persons covered in any one year (subject to conditions 1, 2, 4, 6, 8, 9, 15 and 20). For hospitalisation that extends beyond 35 continuous days, benefits will be reduced unless a medical certificate for ongoing Acute Care is provided by the patient’s doctor and approved by Astute Simplicity Health. 

21. Benefit limited to fee charged

Benefits shall be limited to the fee charged or the insured amount whichever is the lesser. 

22. Medicare Benefits Schedule fee

The Medicare Benefit Schedule fee is set for the purpose of paying Medicare Benefits.

It does not necessarily indicate the amount that the doctor will charge but forms the basis from which the Medicare and ‘medical gap’ benefit is determined. 

23. Periods of absence from hospital cover

Under Lifetime Health Cover, if you cease your hospital membership for 3 years or more over your lifetime, an additional premium loading may apply when you rejoin. Click here or contact the Astute Simplicity Health team on 1300 090 960 for more information.

24. Policy suspension

Members may suspend their policy in certain circumstances on application to Astute Simplicity Health. Astute Simplicity Health will consider suspension for periods of extended overseas travel, for periods of unemployment and in special cases of financial hardship. 

A suspension application will need to be completed. An additional Medicare Levy Surcharge may apply to high income earners during any period of policy suspension. Click here for further details on the Medicare Levy Surcharge. 

25. Privacy policy

Astute Simplicity Health is committed to respecting your right to privacy and protecting your personal and sensitive information. We are bound by the Australian Privacy Principles in the Privacy Act 1988 (Commonwealth), as amended, which regulates how we collect and manage your personal information. Our staff are trained to respect your privacy in accordance with our standards, policies and procedures. Our underwriters Privacy Policy outlines how we manage your personal and sensitive information.

It also describes in general terms the type of personal and sensitive information held, for what purposes, and how that information is collected, stored, used and disclosed. Our underwriters Privacy Policy applies to all your dealings with us whether at one of our customer care centres, via our website or with one of our customer care or business development consultants. To view our privacy statement, click here.

26. Private Health Insurance Code of Conduct

Our underwriter, St.LukesHealth supports the Private Health Insurance (PHI) Code of Conduct. The PHI Code of Conduct is an industry self-regulatory code which aims to promote informed relationships between private health insurers, consumers, agents and brokers. To view a copy of our code, click here.

27. Private Health Insurance Ombudsman

If you are unable to resolve a complaint with us to your satisfaction, you have the right to address your complaint to the Private Health Insurance Ombudsman (PHIO). These services are free to members.

To make a complaint, contact the Commonwealth Ombudsman at www.ombudsman.gov.au

For general information about private health insurance, see www.privatehealth.gov.au

The contact details for the Private Health Insurance Ombudsman are:

Private Health Insurance Ombudsman
GPO Box 442
Canberra ACT 2601
Phone: 1300 362 072 

Notation

The Membership Conditions is a summary of Astute Simplicity Health Fund Rules. The complete Fund Rules are available to all members for examination on request at Astute Simplicity Health. The information contained in this brochure cancels and supersedes all previously published material. The Fund Rules may be amended from time to time. If they are, then by signing the declaration on our membership application you agree to be bound by any amendments which are made.