Making a claim

To be covered for treatment under your hospital cover, you’ll need to be treated as a private inpatient. An inpatient is someone who has been admitted into hospital for a medical service.

Outpatient services are medical services provided without a hospital admission, such as a consultation with a Specialist, Surgeon, General Practitioner (GP) or visits to an Emergency Department. Pathology and dialogistic imaging are also considered outpatient services where there is no admission.

Health funds are unable to provide cover for outpatient services; however, you may be eligible to receive a benefit from Medicare. 

For Extras claims, your claim will be assessed within five business days from the date your claim is received.

AIA Health Insurance is partnered with the Australian Health Service Alliance Ltd (AHSA), which provides our members with access to most Private Hospitals and Day Surgeries in Australia. When you are treated for a service included under your policy in an agreement hospital, we will cover the associated hospital costs less any excesses.

All AIA Health Insurance products have a $500 or $750 excess, however, you may be eligible to have your full excess refunded if you hold an AIA Vitality status of Silver or above. There are no excesses for dependents.

AIA Health Insurance rewards its members for taking an active role in their health and wellbeing. If you have held an eligible product for a minimum of six months and have an AIA Vitality status of Silver or above on the day you’re admitted into hospital, we will refund your excess.
 

Excess Refund is not available when claiming on services within the following clinical categories: Cataracts, Joint replacements, Dialysis for chronic kidney disease, Pregnancy and birth, Assisted reproductive services, Weight loss surgery, Insulin pumps, Pain management and Sleep Studies.

To understand what you’re covered for and any associated out of pocket costs, please contact our Member Services team on 1800 333 004.

If your doctor participates in Access Gap, they’ll agree to either remove (No Gap) or reduce (Known Gap) your out-of-pocket medical expenses. Where a Known Gap has been agreed, you will be made aware of your costs as part of your Informed Financial Consent.
 

Doctors can choose to opt in or out on a patient-by-patient basis so it’s important to ask them upfront.

All AIA Health Insurance products include cover for accidents. An accident is an unforeseen event – occurring by chance and caused by an external force or object – which results in involuntary injury to the body requiring immediate treatment. An accident does not include any unforeseen conditions the onset of which is due to medical causes nor does it include pre-existing conditions, falling pregnant or accidents arising from surgical procedures. For an accident to be covered, treatment must be sought through a Doctor or an Emergency Department within 48 hours of sustaining the injury.

A pre-existing condition (PEC) is one where signs or symptoms of your ailment, illness or condition, in the opinion of a medical practitioner appointed by AIA Health Insurance (not your own doctor), existed at any time during the six months preceding the day on which you commenced cover for the relevant service.
 

If you have transferred from another health insurer without a break in cover, you do not need to re-serve hospital waiting periods you have previously completed. However, if you are adding or upgrading your hospital cover, you do need to complete waiting periods for the new or upgraded items. This includes reducing a hospital excess.
 

Pre-existing conditions related to palliative care, psychiatric and rehabilitation services will serve a two month waiting period. If you have less than 12 months membership on your current hospital cover, you’ll need to contact us by phone or email before being admitted so we can determine whether the waiting period for pre-existing conditions applies. It can take up to five working days to complete this assessment, so make sure you factor this in when you book your stay. If you go ahead with your admission without confirming your entitlements and we subsequently determine your condition to be pre-existing, you’ll have to pay all outstanding hospital and medical charges not covered by Medicare.