pageheroimage

Claims related to Health Insurance

For claims related to health insurance

1800 333 004 
Between 8am and 6pm (AEST) Monday to Friday. 
Or follow the steps below for health insurance extras, hospital and medical claims. 

Health insurance extras claims

As a health insurance member you can claim by using one of the methods listed below:
 
  • Using your HICAPs card at your registered provider
  • Online, by logging in to our Online Member Services portal. 
  • Email, by completing our health insurance claim form and sending to Health.Claims@aia.com.au
  • Post, by completing our claim form and posting to:
          AIA Health Insurance
          Att: Health Insurance Claims
          PO Box 7302
          Melbourne VIC 3004
Our health insurance claim form is available here. A copy of your paid invoice is required to process your claim.

Hospital claims

Hospital treatments included in your policy are covered in all agreed private hospitals and/or day facilities with AIA Health.
 
In most instances your hospital will ask you to complete a claim form on admission, which they’ll send to AIA Health directly. The only upfront cost will be your excess that applies to your cover, this is paid on the day of your hospital admission to the hospital.
 
For full details about your cover, please refer to your Product Fact Sheet by logging onto your Online Member Portal. 

Medical claims

You can claim medical costs charged by specialists involved in your hospital treatment, like surgeons and anaesthetists.
 
Your medical benefits vary dependent on whether your specialist participates in the Access Gap Cover. If your specialists participate in the Access Gap Cover, it will help you to reduce or remove out of pocket costs related to your procedure.
 
Doctors can choose to opt in and out of the Access Gap Cover on a patient-by-patient basis, so it’s important to ask them upfront.

Participating Doctors

If your doctor has agreed to participate in the Access Gap Cover, following the medical procedure, they will send your bill to Medicare and AIA Health for payment. Once this has been processed, if there are any remaining costs, this is considered as your  out-of-pocket expense. Before you receive any treatment, please consult with your doctor on how much your treatment would cost, including any extra money you may have to pay out of your own pocket.

Non- Participating Doctors

If your doctor doesn’t participate in any level of gap cover, you’ll need to pay the total costs charged over the standard MBS fee.
 
You can complete this by following these easy steps:
 
  1. Take your medical invoices (paid or unpaid) directly to Medicare where they will request a Medical Claim Form and a Medicare Two-way claim form to be filled out.
  2. Medicare will cover the MBS portion of the procedure and issue a Statement of Benefits form as confirmation that the invoice has been completed.
  3. Once your Statement of Benefits is issued from Medicare, they will forward it on to AIA Health to complete the Private Health Insurance portion owing.
  4. If there are any outstanding costs after this arrangement, this is considered an out-of-pocket expense for the member.
Note: Some doctors request full payment up front where the process described above also applies. Simply provide proof of payment for Medicare to reimburse accordingly. 

Frequently asked questions


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.

We make claims easy

We have one of the largest and most experienced claims teams in Australia and we will guide you through the claim process in a quick and simple manner.

Our claims philosophy is simple – helping you when you need it most, making sure every claim that should be paid is paid promptly and that we always treat you with empathy, compassion and respect.
 
We also understand that everyone has different needs and your health and wellbeing goes beyond payments. That’s why we offer supported return to work, work-readiness and wellness programs that are evidence backed and results driven, at the right time for you.