Basic Accident Only Hospital

At AIA Health, we believe health insurance should help people live healthier, longer, better lives. That’s why we offer our policyholders (and partner where applicable) access to AIA Vitality, the science-backed health and wellbeing program that rewards you for getting to know your health and taking steps to improve it.

Depending on your cover, you’ll get access to AIA Vitality or AIA Vitality Starter.

Under this product, you have access to AIA Vitality Starter, the introductory program with similar benefits and rewards to AIA Vitality. Find out more about the features of AIA Vitality Starter.

As an AIA Vitality member, you start your journey to better health at Bronze Status, with the opportunity to work your way up to Silver, Gold and Platinum by completing points earning activities. The more points you earn, the higher your AIA Vitality Status and the greater the rewards. For more information regarding AIA Vitality please refer to the AIA Health Member Guide.

Excess

Your excess is the amount that you must contribute towards the cost of any hospital treatment during any calendar year. Basic Accident Only Hospital cover has a $500 or $750 excess. No excess is payable for any dependants covered under a family or single parent policy.

	$500 excess	$750 excess
Maximum annual excess, per person	$500	$750
Dependant excess waiver	Yes	Yes

Each person on the policy (other than dependents) only needs to pay one excess per calendar year irrespective of how many hospital admissions that person has in the calendar year.

How do I get a refund on my hospital excess?

AIA Health includes access to AIA Vitality, the science-backed health and wellbeing program that rewards you for looking after your health. If, at the time you are admitted into hospital, you have held an AIA Health policy for a minimum of six months and have an AIA Vitality Status of Silver or above, we will refund part of your excess. The maximum Excess Refund benefit payable is $250 (if you have a $500 Excess) or $500 (if you have a $750 Excess). Simply submit a claim, including your receipt to get the excess refunded.

Please note that AIA Health must wait for the hospital to process your account before we are able to provide your refund. This can take anywhere between 1–8 weeks depending on the hospital.

When Excess Refund is not available

Where applicable, Excess Refund is not available when claiming on the following clinical categories: cataracts, joint replacements, dialysis for chronic kidney failure, pregnancy and birth, assisted reproductive services, insulin pumps, pain management (with device) and sleep studies. Consult the Fact Sheet for further information.

Basic Accident Only Hospital – Hospital treatment list

Hospital treatments	Included, Restricted or Excluded	Waiting periods
Rehabilitation	R	We will recognise waiting periods already served for equivalent services with your previous insurer when you switch to AIA Health. If you are new to private health insurance, you will need to serve any applicable waiting periods. Waiting periods may also apply if you have upgraded your cover or have not fully served your waiting periods for those services with your previous insurer. The following waiting periods apply for: 2 months Rehabilitation Hospital psychiatric services Palliative care. 1 day Accidents and emergency ambulance.
Hospital psychiatric services	R
Palliative care	R
Accidental injury	✔
Emergency ambulance	✔


R Restricted service	✔ Included	Minimum required to be covered under Basic cover

For further information including waiting periods, travel & accommodation, accidental injury, emergency ambulance treatment, preexisting conditions, restricted & excluded services and pharmacy benefits, please review the current Basic Accident Only Hospital Fact Sheet.

General things you should know about this Hospital Cover

Please consult the provided Member Guide and Hospital Fact Sheets for the most up-to-date product details before purchasing.

How we communicate with you
- As our primary method of communication is email, it is important that your contact details are kept up to date with your current email address to ensure you’re able to receive any correspondence.
Going to hospital, out-of-pocket expenses and Access Gap Cover
- Being admitted to hospital can be a stressful experience. You should contact AIA Health as soon as you know you need to go to hospital. We can help make the experience easier and help to ensure any out-of-pocket expenses you incur are minimized and to avoid any unexpected surprises.
  Detailed information regarding going to hospital is included in the Member Guide and found in the FAQs at aia.com.au/health
  The Federal Government sets a schedule of fees for eligible services provided by doctors to inpatients in hospital. Medicare pays 75% of these scheduled fees and health funds like AIA Health pay the remaining 25%.
  
  Doctors and providers are not restricted to charging the scheduled fee and are able to set their own fees, which can be higher than the scheduled fee. If your doctor chooses to charge a higher fee there will be a gap between what the Government and AIA Health will pay, and the total amount owed to the doctor. This is the ‘Gap’ that can leave you with significant out-of-pocket expenses.
AIA Health’s Access GAP Cover
- If your doctor participates in AIA Health’s Access Gap Cover we’ll pay even more than the 25% of the scheduled fee – leaving you with reduced, or even eliminated, out-of-pocket expenses. The best way to find out if your doctor is registered for AIA Health’s Access Gap Cover is to ask them. Every doctor is different, and some will opt in or out on a patient-by-patient basis. If your doctor participates in AIA Health Insurance’s Access Gap Cover they can either choose to participate as a ‘no gap’ or a ‘known gap’ charge as follows:
  1. ‘No Gap’ – Your doctor participates in Gap Cover and does not charge you an out-of-pocket fee for the treatment you receive as an inpatient, or
  2. ‘Known Gap’ – Your doctor participates in Gap Cover and charges you a reduced out-of-pocket fee for the treatment you receive as an inpatient. You should be aware of the costs before surgery.
  Just remember to check your out-of-pocket fees with your doctor before agreeing to any treatment.
Inpatient vs outpatient
- For AIA Health to pay benefits towards 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 diagnostic 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.
Participating hospitals
- AIA Health has agreements with most private hospitals and day surgeries across Australia. When treated for an included service as a private patient in one of our participating hospitals, we’ll generally pay benefits towards all hospital accommodation charges as part of our agreement with that hospital. This means your out-of-pocket expenses will be limited to your excess, any expenses related to your medical provider’s fee, any gap for a medical device/human tissue product, high cost drugs and inpatient pathology/imaging.
  To find out if your treating hospital has an agreement with AIA Health, please contact our Member Services team via contact us.
Private patient in a public hospital
- AIA Health will only pay for same day or overnight accommodation in a public hospital shared room or ward up to the minimum rate as set by the Australian government. As a private patient you could be charged extra for private room accommodation in a public hospital if being treated as a private patient and the member will be required to pay any difference between the benefit AIA pays and the amount the hospital charges (in addition to private room accommodation and any applicable excess and/or co-payment).
Waiting Periods
- Waiting periods are the period of time during which a member is not entitled to the benefits of the policy. Waiting periods can apply when changing your cover to include new or upgraded services. If you’re switching to AIA Health from another equivalent policy, you won’t need to re-serve waiting periods already served with your previous health insurer. Waiting periods may apply if you have upgraded your cover with AIA Health. 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 served. However, if you are adding to or upgrading your hospital cover, you do need to serve waiting periods for the new or upgraded services.
  A newborn, adopted child, step child or fostered child can be added to a family/single parent membership without waiting periods provided that the policyholder has held the policy for more than two months, and that child is added within six months of birth/adoption/fostering, or within six months of the step child’s biological parent being added as a partner under the main policyholder’s policy. The join date will be effective as at the newborn’s date of birth. The join date for adopted, fostered or step children will be the date they are added to the membership.
  Other child dependents added to a policy will be subject to new waiting periods. This includes children added more than six months after birth, adopted children, foster children and step children. Normal portability rules will apply in the case where a child is transferring from another health insurer.
Accidental Injury
- All AIA Health products include cover to be treated in an agreement private hospital or as a private patient in a public hospital for injuries sustained through an accident. An accident is an unforeseen event – occurring by change and caused by an external force or object – which results in involuntary injury to the body requiring immediate treatment. The accident must occur after the time of joining or upgrading your cover. An accident does not include any unforeseen conditions, the onset of which are due to medical causes nor does it include pre-existing conditions, falling pregnant or accidents arising from surgical procedures. For AIA Health to pay benefits towards an accident, treatment must be sought through a Doctor or an Emergency Department within 48 hours of sustaining the injury.
Emergency ambulance treatment
- AIA health will pay benefits towards clinically necessary emergency ambulance services where you are transported directly to a hospital in Australia or require on-site treatment only. AIA Health does not pay benefits towards transfers between hospitals (including in an emergency).
  Emergency ambulance services requiring on-site treatment only is limited to two call outs per calendar year, per insured person.
  Emergencies are circumstances when immediate hospital treatment is required for a serious and acute injury or condition where the viability of function of an organ or body part is threatened.
  Note: Tasmania and Queensland have State schemes to cover ambulance services for residents of those States. AIA Health will not pay benefits towards ambulance services where it is provided by the State.
  We recommend members purchase state-based ambulance membership where applicable to ensure they are fully protected against the cost of ambulance transport and treatment by paramedics. This is not required for Queensland and Tasmanian residents where ambulance services are provided under State schemes. It may also not be required for New South Wales and Australian Capital Territory residents as when members have Hospital cover in those States, they pay a government-imposed ambulance levy as part of their health insurance premium.
  Check with your state Ambulance authority to ensure you have the right level of cover for emergency treatment and non-emergency ambulance transport by paramedics within Australia. Without the right level of cover, members may face significant out-of-pocket costs for ambulance transport.
What is a pre-existing condition?
- 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 (not your own doctor), existed at any time during the six months preceding the day on which you purchased or upgraded your hospital cover.
Restricted Services
- Restricted services are hospital claims which are limited to a minimum (default) benefit. This is a minimum dollar amount set by the Federal Government for accommodation as a private patient in a shared room of a public hospital.
  A restricted service does not pay any money towards the costs of intensive and cost of intensive and coronary care, or theatre fees in a private hospital or private day centre. The minimum default benefit is unlikely to cover other costs such as the cost of accommodation in a private hospital. Therefore you may incur a large out-of-pocket expense if you receive a restricted service in a private hospital, private day centre or private room in a public hospital.
Excluded Services
- If a service is excluded, this means that AIA health does not pay any benefits towards the hospital, medical or other costs relating to that service.
  This also excludes hospital treatments for which Medicare pays no benefit – such as cosmetic surgery.
Pharmacy Benefits
- Provided a hospital admission is not related to an excluded treatment, AIA health will pay benefits towards certain pharmaceuticals administered while admitted to a participating private hospital. This includes both Pharmaceutical Benefits Scheme (PBS) and non-PBS items. Medications dispensed upon being discharged from hospital, high-cost medications and experimental drugs are excluded. Please contact AIA Health prior to the provision of any high-cost medications or experimental drugs to understand what your potential out-of-pocket costs are likely to be.

AIA Health may make changes to this cover from time to time, including adding or reducing the benefits or services available to you, and notice of such changes will be provided via email in accordance with the PHI Act, Code of Conduct and Australian Consumer Law. The information provided here is a guide and you should always consult your provided member guide and up-to-date fact sheets at the point of purchase and claiming or call us on 1800 333 004.

Choose the right cover

When considering a private health insurance policy, you should review your current and future medical needs, budget, and healthcare priorities. Having a good understanding of these will help you decide if a cover is appropriate for your personal circumstances.

Before selecting a Hospital Policy, you should review:

What services are covered
What waiting periods apply
What exclusions apply
What excess and/or co-payment you would be subject to on your hospital policy

What makes AIA Health different?

At AIA Health, we believe that health insurance should benefit you every day and not just when things go wrong. That’s why our cover comes with access to AIA Vitality, our science-backed health and wellbeing program designed to support you at every stage of your health journey.