Your A to Z membership guide

Your RT Health membership

Joining RT Health

Here’s what you need to know about joining and transferring to RT Health, including our 30-day cooling off period.

Who can join?

If you’re an Australian resident (and you have full access to Medicare), we can welcome you into the RT Health family. If you aren’t eligible, or partly eligible, for Medicare you aren’t able to take up private health insurance in Australia. You’ll need to take out Overseas Visitor cover.

Since we merged with HCF in 2021, we’re an open fund. This means we’re not restricted by your employment or other interest groups. While we’re committed to the rail, transport and energy industries, we’re open to all Aussie residents from all walks of life.

Switching from another fund?

We’d be pleased to welcome you!

It’s an important part of our private health cover system that you’re able to switch insurers as you like without re-serving waiting periods. We’ve make it easy for you by outlining these below.

- Continuity of cover. It’s part of the legislation of private health insurance that you can transfer between Australian health funds with ‘portability’ or ‘continuity of cover’. This means you won’t have to re-serve any waiting periods already served with a previous fund. When you join RT Health, we’ll recognise any waiting periods (or part of a waiting period) if you join us within two months of leaving another fund.

- Levels of cover and your waiting periods. The level of cover you’ve selected is important when it comes to knowing if you’ll need to serve a waiting period once you join RT Health. If you’ve joined us on a higher level of cover than you were on with your previous fund, you’ll still need to serve the waiting period for the higher cover with us.

- Your excess. Transferring from a cover with a higher excess to one with a lower excess (for example, from a $700 excess to a $350 excess) works the same as an upgrade to your cover. You may have to pay your previous higher excess until you’ve served the waiting period for the new, lower excess.

- Your Extras. We’ll also look at some of the Extras claims you’ve made with your previous fund when working out your annual limits and entitlements. Sometimes, within your first 12 months of membership with us, the amounts you’ve already claimed with your previous fund may be deducted from your annual limits. But don’t worry, our annual limits refresh on 1 January each year. It’s important you know that if you’ve already claimed on ‘lifetime limit’ with your previous fund, this amount will be permanently deducted from any lifetime limit available under your new RT Health cover.

- Private health cover overseas. We’re not able to recognise any health cover held overseas, or any ‘overseas visitor’ or ‘overseas visitor’ cover provided by another Australian fund when providing continuity of your cover. If you’re just starting out with health cover in Australia for the first time, or after a period of being overseas without having an Australian health cover, all waiting periods will apply.

We make switching easy - transfer certificates

A transfer certificate (also known as a clearance certificate) is a document provided when you move from one Australian health fund to another. It contains all the information we need about your previous membership, including the length of your membership, your level of cover, any Lifetime Health Cover loading as well as claims information.

When you join RT Health, you’ll authorise for us to contact your previous fund to cancel your cover with them.

While transfer certificates should be provided within 14 days, there are sometimes administrative delays. This can mean we’re not able to recognise waiting periods already served, and that we are unable to establish whether a Lifetime Health Cover (LHC) loading applies to your membership.

Sometimes it can be quicker and easier for you to contact your previous fund to ask for a transfer certificate. This will also help make sure that your previous fund doesn’t take any further payments on your membership.

Until we receive a transfer certificate, we can’t process any claims on your new RT Health membership.

We’ll use the information provided in your transfer certificate to confirm your membership details – including advice on the Lifetime Health Cover loading and anything that may not have been mentioned in your application to join.

Do you have an excess? What you need to know

An excess is the pre-set amount you pay if you're admitted to hospital for planned treatment. Generally, the higher your excess, the lower your premiums will be, and vice versa.

Your RT Health Hospital cover may include an excess.

If you’re admitted to hospital, you’ll be asked by the hospital before or at the time you go in to be treated and you’ll make the payment directly to the hospital.

About your excess:

- With most hospital covers you’ll only need to pay one hospital excess amount per person per calendar year. 

- You won’t pay hospital excess for dependent children (under the age of 22).

- Depending on your level of cover, you won’t pay an excess, or you’ll only pay a reduced excess, on same-day hospital admission (when you don’t stay overnight at hospital).

- If your Hospital cover does have day admission excess, and you have multiple day admissions in a calendar year, you’ll only pay up to the maximum of the full hospital excess amount, no matter how many admissions you have.

Changed your mind? Our 30-day cooling off period

We want you to be happy at RT Health. That’s why we offer a risk-free 30-day cooling off period. If we’re not the fund for you, and as long as you haven’t made a claim, we’ll refund your premiums.

All of the usual waiting periods (outlined above) apply during your cooling off period.

back to top

 

Your new RT Health membership

There are a few things it’s good to know about when you become part of the RT Health family – from your new membership card(s) and keeping your details up to date through to authority on your membership . 

We’ve outlined them here for you.

Your membership card

When you join RT Health, we’ll send you your membership card (and one for every adult on the membership).

Your membership card displays your RT Health membership number and will list the people covered. You should check this when you first receive it (and whenever you receive a replacement card), to ensure your details are correct and that everyone you want covered is listed.

Your RT Health card lets you to make on-the-spot claims through HICAPS and iSOFT, and you’ll be asked to show it if you’re admitted to hospital.

Keep your card safe! You don’t want anyone else making claims. If your card is lost or stolen, let us know as soon as you can so we can cancel it and issue a new one for you.

Principal member

When you complete your application, we’ll ask you to nominate one person and the ‘principal member.’ They will be the person responsible for the membership and who we will communicate with about all membership information.

If you’re the principal member, you’re responsible for:

- ensuring that all information included on your application is true and correct           

- ensuring your membership payments are made and up to date

- abiding by all fund rules

- letting us know about any change of contact details or circumstances that affect any of the people covered by your membership.

Authorities

You’re able to organise for other people to have authority on your membership.

Partner authority: Initially, the principal member is the only person who can change your membership, submit claims and receive benefit payments. We make it easy for you to extend this authority to your partner. By completing a simple ‘partner authority, you’re can make sure your partner or spouse (as long as they’re listed on your membership) ifs able to access and administer our membership.

You can organise your ‘partner authority’ when you or at any time contacting our member care team, or by simply ticking the ‘partner authority’ box on the membership in your online Member Services portal.

To set up your partner authority online, or check if you already have one in place, visit our online Member Services portal.

Legal authority: We recognise the authority of a third party to make claims and changes to a membership where a general or enduring power of attorney is in place.

However, we don’t recognise a ‘guardianship’ as authority to deal with someone else’s membership. (While guardianship allows the guardian to make many decisions about someone’s living arrangements and medical treatment, it does not usually extend to making financial decisions).

Third party authority: The principal member can nominate someone who is not covered by the membership to make changes, ask about claims and generally manage the membership on his or her behalf by completing a ‘third party authority’ form.

Making changes to your membership 

Changes in life happen all the time. We get it. But, it’s important that you keep us in the loop when it comes to some of life’s bigger moments. That way we can make sure we’re doing everything we can to help you make the most out of your RT Health cover..

We’ve outlined a few for you here.

Changes in membership: If there’s a change to the people covered by your membership, please just let us know. That way, we can make sure your cover remains valid for everyone on your membership.

Changing your contact details: Keeping you informed about your cover and other great things across the RT Heath community is important to us. Just let us know if you’ve changed your address, phone number or email address. That way, we’ll be able to get important information to you when you need it. And, we’ll be able to make sure your claim payments find their way to you quickly and easily.

Moving interstate?: The price of your cover varies between states, so an interstate move can either increase or decrease the cost of your health cover. Ambulance cover arrangements also differ significantly between states, so it’s important you give us a heads up if you’re on the move.

When we make a change: From time to time, we make changes to our covers. We do this to ensure all members are getting great value from their cover with RT Health. If there’s a change to legislation, or a change to our Fund Rules or to your cover we’ll let you know in writing (you’ll get an email or letter from us).

Saying goodbye to RT Health?: If you’re looking to cancel your membership, we’d be sad to see you go.Membership cancellations must be requested by the principal member, and specify the date of cancellation. We can’t backdate a cancellation, so we’ll make them from the date we receive them. (This doesn’t apply during your cooling off period). Because membership contributions are paid in advance, we’ll refund you any amount you’ve paid ahead of the date you cancel your cover.

Any adult or dependent child who is 18 or older can remove themselves from the membership without approval from the principal member. They can’t suspend themselves from the membership.

Can we cancel your membership?: There are some situations when we’ll need to cancel your membership. These include:

- when your payments are 90 days behind

- if you provide false or misleading information in any correspondence or claims (you’ve engaged in fraudulent activity)

- if you’ve acted in a manner detrimental to the fund

- if you’ve received, obtained, or attempted to receive or obtain, any advantage you’re not entitled to under our Fund Rules, or

- if you’ve obtained your membership by misrepresentation or mistake

back to top

 

Claiming on your membership

We’ve put together this short guide with some things you need to know about claiming benefits on your RT Health membership.

There’s also some great info about ways to submit your claim here: rt health | Managing Your Cover | Make a Claim (rthealthfund.com.au)

There are a few rules around what we’ll pay benefits for, how long you have to submit your claims and when we’re not able to pay your claims.

We’ve outlined them for you here.

Overseas products and services: Your RT Health cover doesn’t include benefits for products, services or treatments purchased from or provided outside of Australia (this applies whether you buy them in person, by mail or online).

There’s a time limit for submitting claims: You have up to two years from the date of purchase, service or treatment to submit your claim. We’re not able to pay benefits if you submit your claim after two years.

Waiting periods: We’re not able to pay benefits on products, services or treatments you receive or purchase during any waiting periods.

Compensation claims: We can’t pay benefits for products, services or treatments you need as a result of an incident for which you are entitled to claim compensation or damages from a third party.

Sometimes, you’re able to submit an ex-gratia payment, which may help you to cover the upfront costs. If granted, we pay the initial costs and you agree to repay the sum once the third party claim is resolved.

In this situation, it is possible to ask us to pay the claims to cover the upfront costs provided you provide us with all information to enable us to recover these costs from the third party. If we’re not able to recover these costs from the third party, we’ll look to recover them directly from you.

Incorrect payments: If we pay a benefit by mistake, we’ll work with you to recover any amount mistakenly paid.

Fraudulent claims: It’s important to us that our approach to member benefits is fair – for everyone. That’s why we’re serious about our approach to fraudulent claims. When we evaluate our products and pricing each year, we take many things into account, but the volume and cost of claims are among the key drivers of how much your health cover costs. Fraudulent claiming drives the cost of health cover up for all members.

Fraudulent claims can come from many different sources, including health service providers and members. If you become aware of (or suspect that you may have been exposed to) fraudulent claiming, please let us know.

back to top

 

Paying your membership

Keeping your payments up to date

When we welcomed you into the RT Health family, we let you know that your membership payments should always be paid in advance. This helps us ensure that you’re covered, no matter what happens (especially when you’re admitted to hospital).

It also helps you be sure that you’re able to claim on the spot at providers at offer HICAPS and iSOFT payments.

For example, if you pay monthly you’ll pay a month’s premium ahead on each payment date. The same with weekly and fortnightly payments.

The only exception is members who pay via salary deduction.

If your payments fall behind, we’re not able to pay benefits for any product, service or treatment received until you’re back up to date again.

If your membership remains unpaid after 90 days, we’ll end your membership with us and you won’t be covered any longer.

Ways of paying your membership

There are plenty of options available when it comes to making your membership payments.

Direct debit: Direct debit is the simple and easy way to make sure you make your payments to us. You can pay your membership via direct debit from a bank account, or with your credit card. If you choose to pay by direct debit, there are a few things to remember:

- You can choose to pay weekly, fortnightly, monthly, quarterly, half-yearly or yearly payment frequencies.

- Weekly payments are deducted each Friday.

- Fortnightly payments are deducted on alternate Fridays (depending on which fortnight you choose).

- We offer Direct Debit Any Day for monthly direct debit payments. You can choose which day you’d like your payment to be taken. You can read  more about it here: rt health | Direct Debit Any Day (rthealthfund.com.au)

- If you’re paying by credit card and your card is lost or stolen, please let us know immediately, so we can stop payments and set up a new debit with your replacement card for you.

- If the credit card you’re paying with expires, payments will fail and you’ll generally get a dishonour fee from your bank.

- If you’d like to change or cancel a direct debit, we’ll need to know at least 7 business days before your next debit is due to occur. This gives us time to process your request.

Paying online: 

We make it easy for you to pay online- 24/7 when it suits you. You can make your payments via your online Member Services portal. It’s quick and easy.

back to top

 

Suspending your membership

 

No one wants to be paying for something they’re not able to use. Likewise, we know that when things get tough, you need some time to get back on your feet.

That’s why we offer our members two opportunities to suspend their RT Health membership.

Your memberships can be suspended for two reasons:

1. If you’re travelling overseas (for work or a holiday)

2. If you’re experiencing financial hardship.

You can suspend your RT Health cover for up to two years (maximum) when travelling overseas. The minimum period of suspension is 28 days.

Suspended Hospital cover does not count toward your number of ‘absent days’ for Lifetime Health Cover (LHC) purposes, but it may result in you being liable to pay the Medicare Levy Surcharge (MLS).

We recommend that you speak to your accountant, tax agent or the Australian Taxation Office if you need further advice about how suspending your membership may impact you.

The following apply all membership suspensions:

- The principal member is the only person with authority to request a membership suspension.

- If you’re travelling overseas on holidays, your health cover can be suspended for any period from a minimum of 28 days to a maximum of two years.

- You must be overseas for the entire duration of your membership suspension. (For example, it is not possible to suspend your membership for 28 days if you are going to be overseas for any period less than 28 days).

- A membership suspension applies to the entire membership and each person covered. This means you aren’t able to suspend one person’s cover while continuing cover for other people named on the membership and you’re not able to suspend your membership if all people covered by it are not travelling overseas.

- You aren’t able to suspend just the Hospital or just the Extras part of your membership;

- You must have held your RT Health membership at least 12 months before requesting a suspension.

- Your membership must be paid up to the date of your departure before we’re able to suspend it.

- Any contributions you’ve paid in advance of the date of your departure will be credited to your membership once it’s reactivated.

- Suspension requests should be submitted at least two weeks before you leave Australia (we’re not able to backdate a membership suspension).

- There must be a minimum of six months between the end of one period of suspension and the beginning of another. The ‘beginning’ of any period of suspension is the first full day you are out of the country.

Reactivating your membership:

So we can reactivate your membership and get you back on track, we ask you provide proof of travel for each person covered by the membership (within 30 days of returning to Australia):

- If you travelled for less than three months, you can provide boarding passes for flights out of and into Australia, or a stamped passport showing dates of departure and return. We’ll reinstate your cover from the date of your return to Australia.

- If you travelled for three months or more, we ask you provide us with a Certificate of Movement from the Department of Immigration and Citizenship.

- Members travelling by sea for any length of time can provide copies of cruise boarding cards and cruise itinerary.

We’re not able to accept travel itineraries or e-tickets as proof of travel.

If you can’t provide proof of travel for each person covered, we’ll need to reassess your suspension and you may need to pay any outstanding contributions for the period of suspension.

- Following a period of suspension, your membership will become active again when the membership has been reactivated and contribution payments have recommenced. Where contributions have been made in advance, your membership must still be reactivated before claims can be made. Your cover will be reinstated from the date of your return to Australia.

- You may need to pay the Medicare Levy Surcharge (MLS) while your membership is suspended if your income exceeds the Medicare Levy Surcharge thresholds. You should discuss this with your accountant or tax advisor.

back to top

 

Getting to know your health cover - Hospital cover

Hospital cover excesses 

Your excess applies to the first overnight hospitalisation or day admission in any calendar year. Once the full excess amount has been paid, you won’t need to pay it again if you’re admitted to hospital in the same year.

Your dependants covered by your membership (under the age of 22) won’t be charged any excess for any hospitalisation.

Depending on your level of cover you may pay either no excess, or a reduced excess on day admissions (this is when you’re admitted to hospital and discharged within the same day).

If your cover has an excess for same-day admissions, and you have multiple same-day admissions in a calendar year, you’ll pay the day surgery excess only until your total excess amount has been reached.

What's included in my Hospital cover

Your Hospital cover pays benefits on six types of costs:

- Accommodation in the private or public hospital of your choice

Depending on which one of our Hospital covers you have, you’re covered for up to 100% of all hospital costs when you’re treated in any public hospital, or a private hospital that RT Health has a contract with, including day surgery facilities.

The hospital’s costs relate to the use of its facilities, and include fees for your accommodation, use of the operating theatre, specialist wards, medical equipment, meals, nursing staff, and so on. We have contracts with most private hospitals and day surgeries in Australia and you’re covered anywhere in the country, even if you’re going into hospital outside of your home state.

You can see which private hospitals RT Health has a contract with here: https://rthealthfund.com.au/health-services/find-a-hospital/

If you choose to go to a private hospital that we don’t have a contract with, you’ll have substantial out-of-pocket costs.

If you have cover for treatment in a private hospital, a private room is dependent on the hospital having one available for you. If the hospital does not have a private room available, you may be accommodated in a shared room.

- Doctors of your choice

When you’re treated as an inpatient in hospital, each of the doctors who treats you will charge a fee for services. Responsibility for paying these fees is split between Medicare, your private hospital cover (RT Health) and you.

Medicare reimburses you for 75% of the MBS (Medicare Benefits Schedule) fee and your Hospital cover pays the remaining 25%. Out-of-pocket costs can arise when doctors charge higher than the MBS fee. Any amount your doctor charges above the MBS fee is an amount you’re responsible for paying – and out-of-pocket cost.

RT Health offers members the Medicover program. Medicover can help to reduce or eliminate your out-of-pocket costs by making arrangements with your doctors before you go into hospital.

The way it works:

- Ask your doctors if they will participate in RT Health’s Medicover program at the time you’re arranging your hospital stay.

- If your doctors agree, they are willing to accept a set fee for their services (it’s more than the MBS fee, but less than what they might otherwise charge).

- This means your Hospital cover will pay a benefit higher than the standard 25% of the MBS fee. This means you’ll have lower out-of-pocket costs (and sometimes, none at all).

You can research doctors who have participated in our Medicover program on our website here – rt health | Find a Doctor (rthealthfund.com.au)

Remember doctors are able to choose who they treat under Medicover on a case by case basis. You’re free to ask any doctor who is going to treat you if they’re willing to participate.

- Implanted prostheses and in-hospital pharmaceuticals

Prostheses include things like artificial hip or knee joints, cardiac devices such as pacemakers or defibrillators and so on – you can think of them as being any ‘artificial body parts’. Pharmaceuticals are any type of medication, whether it is anaesthesia, pain reduction medication or other specialist medication related to the treatment of your condition.

While generally most prostheses and pharmaceuticals are fully covered, there are a few restrictions on the types of products we’re able to pay for. These restrictions generally apply to items that are not covered by the federal government’s Prostheses List or Pharmaceutical Benefits Scheme (PBS). For those few items that are not fully covered, you’ll need to pay out-of-pocket costs.

If you need a prosthesis fitted, ask your doctor to provide the prosthesis item number. That way, we’ll be able to tell you if you should expect any out-of-pocket costs.

In the case of medications, you can ask your doctor in advance if they plan to prescribe anything to you that is not covered by the PBS. You can ask us for advice on whether it will be claimable.

Each of our Hospital covers pays prostheses and pharmaceutical fees in the same way. However, you’re not covered for any prostheses or pharmaceutical costs if you’re being treated for any exclusions of your chosen cover.

- Ambulance attendance and transportation

Your level of ambulance cover is based on the State or Territory where you hold your policy (the address we have on file for your membership).

If you or any of the people listed on your membership live in a different State or Territory to the residential address listed on your membership, please contact us to check what level of cover you have.

For more information, look at our Private Health Insurance Explained. 

- Travel and accommodation expenses

Travel benefit: Our travel benefit helps members with travel costs when they need to make a trip to get care. You can claim a travel benefit on return journeys of more than 200 kilometres when you’re travelling to get specialist medical, dental or hospital treatment. This helps members who live in areas where they don’t have access to the treatments they need closer to home, rather than for people who are travelling to receive treatment by choice.

Any travel benefit claims should be submitted with a letter from your referring doctor.

Individual limits apply. 

Accommodation: Our accommodation benefit helps with the costs involved when a parent or carer needs to stay away from home overnight to help you receive inpatient hospital care. The benefit is only available where the member receiving treatment is staying in hospital and the carer needs to pay for accommodation. The costs of food and other items associated with the accommodation are not included.

We’ll be able to pay your accommodation benefits after we’ve received a claim for the hospital treatment.

Individual limits apply. 

What isn't covered by your Hospital cover? 

Getting the Hospital cover that’s right for you and your family is important.

Just as we’ve outlined the six main costs covered by your Hospital cover, it’s only fair we outline the items, services or products we aren’t able to pay a claim on. Generally, we can’t pay claims because there’s legislation restricting what we’re able to pay for.

Here’s a list of items not covered by your Hospital cover:

Treatments and procedures not covered by Medicare: Your Hospital cover will pay full benefits for treatments that are recognised and subsidised by Medicare. If the treatment or procedure you’re having can’t be claimed under Medicare, we can’t cover it either. You’ll generally have substantial out-of-pocket costs for these procedures.

Non-medically necessary elective cosmetic surgery and laser eye surgery are examples of procedures that can’t generally be claimed under Medicare. If you’re having one of these procedures, we can only pay a ‘default benefit’ toward the cost of your hospital accommodation, and you’ll have large out-of-pocket costs.

Admission to a non-contracted private hospital: If you’re treated in a private hospital that RT Health does not have a contract with, we’ll only be able to pay a ‘default benefit’ toward the cost of your accommodation, but no other benefits are payable. You’ll have large out-of-pocket costs.

Hospital or medical costs for outpatient treatment: We can only pay benefits for treatment you receive as an inpatient (that’s when you’re admitted as a patient into hospital). Legislation stops us from covering claims for outpatient medical services. This includes things like GP and specialist consultations, as well as any treatment you receive in hospital as an outpatient or in an emergency department.

They only way you can claim outpatient medical care is through Medicare. Medicare will pay 85% of the MBS fee and the remaining 15% (plus anything your doctor charges above that) is an out-of-pocket cost that you’ll need to pay.

Private hospital emergency department fees: When you’re treated in an emergency department, you are an outpatient (you have not yet been admitted to the hospital). We’re not able to pay any benefits for outpatient treatment.

Most public hospital emergency departments will treat you as a public patient at no cost. Some private hospitals also have emergency departments, and if you attend one of these, we’re not able to cover these costs for you.

Discharge pharmaceuticals: These are items prescribed for you to take home after you are discharged from hospital. No benefits are payable for these under your Hospital cover, but you may be able to claim under your Extras cover.

Other non-contracted fees, benefits and services: Your Hospital cover does not pay benefits for additional products or services, such as television hire, internet access, phone calls, purchase of newspapers, purchase of medication not related to the reason for your admission, and fees above the contracted or default amount.

Treatment provided in non-hospital facilities: Your Hospital cover does not pay benefits for nursing home, aged care, respite care or palliative care facilities.

Sometimes, a person may remain in hospital following a treatment or procedure while waiting for a position in a nursing home to become available. These people are referred to as ‘nursing home-type patients.’ The benefit we pay toward the care of nursing home-type patients does not fully cover the amount that will be charged by the hospital. If you are in this situation, the hospital will advise you of the anticipated cost of this service.

back to top

 

Recovering your way - Hospital at home

Our Hospital at Home programs are available to members with all RT Health members who hold hospital cover. You’ll just need to be sure you’ve served your relevant waiting periods.

Our Hospital at Home program can help you get home from hospital sooner, or avoid a hospitalisation altogether, by providing you with ‘hospital equivalent’ treatment and follow-up care in your own home.

Hospital at Home is available for all kinds of treatments and post-procedure support. If it is possible to provide the treatments you need in your home (and if you, your doctor and the hospital agree that it is appropriate for you) then we can help.

We’re committed to bringing the hospital to you, so you can concentrate on your recovery in the comfort and privacy of your own home.

Here’s how it works:

If your treating doctor agrees that hospital treatment at home is right for you, then we’ll work in consultation with your doctor and hospital, arranging for you to receive all the services you need. All the people involved in your home treatment and recovery planning will be experienced health service providers with specialist knowledge of home-based hospital care.

You can read more information about Hospital At Home here: https://rthealthfund.com.au/health-services/hospital-at-home/

back to top

 

Getting to know your health cover - Extras cover

Having Extras helps you make the most of your private cover. It’s a great way to curb the ongoing costs of maintaining your general health and wellbeing. Kids’ dental appointments, annual optometrist appointments. They all add up. But, if you have good Extras cover you’re one step ahead.

You’ll get a benefit each time you’re treated by a registered provider or purchase an item that helps improve your health.

Each cover guides provides detailed information about what you’re covered for, and how much you can expect to get back when you make your claim. If you need a hand, just reach out to our Member Care team on 1300 886 123 and we’ll help you.

How Extras cover works

There are a few things you should know about how your Extras cover works. We’ve listed the main ones here for you.

Benefits: A ‘benefit’ is the amount we pay to you for the services you’ve received. In other words, it’s the money you get back from RT Health when you make a claim for something that you’re covered for.

Benefit limits: Your Cover Guide will show a range of benefit limits. A benefit limit is the maximum amount you can claim either:

- per person

- per family

- per service

- or within a specified period of time.

There are a couple of other types of benefit limits. We’ve defined them for you here.

Annual limit: This is the maximum amount you can claim for a specific service in a calendar year (remember, most benefit limits re-set on 1 January each year). You can’t ‘roll over’ unclaimed annual limits into the following year.

Person limit: This is the maximum amount each person covered by the membership can claim for a specific service each calendar year. Per person limits may be restricted where there is an overriding family limit, sub-limit or lifetime limit. You can’t transfer unused ‘per person’ limits between the people covered by your membership.

Family limit: This is the maximum amount that can be claimed collectively by everyone covered by the membership for a specific service each calendar year. Per person limits may still apply.

Sub-limit: This is a limit within a limit. Here’s an example: Our Top Extras cover has an annual limit of $1,600 for health aids; however, a sub-limit of 80% of the cost up to $600 applies to each individual aid. Sub-limits also apply for other services in this category.

Lifetime limit: This is a limit for the lifetime of your membership with RT Health. The only lifetime limit we have is $3,000 per person for orthodontic treatment under our Top Extras cover. Once this limit has been reached, no further benefits can be claimed for that person for the remainder of their membership, even if they leave and return at some stage in the future.

Registered providers

Unlike doctors and hospitals, there is no one group that ensures only qualified, skilled and experienced practitioners provide the types of treatments covered by Extras cover. By only paying benefits on services received from registered providers, we help to ensure that our members are receiving quality care from properly qualified people.

Generally, we will pay benefits for health care services provided by:

- dentists registered with AHPRA (Australian Health Practitioner Regulation Agency)

- registered optometrists or ophthalmologists

- natural therapists registered with the Australian Regional Health Group (ARHG)

The ARHG ensures that providers:

- have full and proper qualifications

- undertake ongoing professional development

- have current first aid and insurance certification

- belong to an accredited industry association.

Consultations

There’s a couple of things to know about how we pay benefits for consultations with providers. We’ve outlined them below:

- Each member is covered for one ‘initial consultation’ benefit per person, per therapy, per provider, each calendar year. If you receive a second ‘initial consultation’ from the same provider (in the same calendar year), you’ll receive the benefit that applies to ‘subsequent consultations.’

- We’re not able to pay a benefit for fees you may receive for cancelled or missed appointments or consultations.

Products, services or treatments purchased in Australia

As an Aussie private health insurer, we’re only able to pay benefits where the transaction for your product, service or treatment takes place in Australia. If you purchase something overseas, order it online and the transaction takes place overseas, or have a treatment or procedure overseas, we won’t be able to pay your claim.

Waiting periods

When you first take out Extras cover, if you re-join after letting your cover go, or when you upgrade to a higher level of cover, you’ll need to serve waiting periods. For each person covered, the waiting period starts on the first day the person is insured under the policy and ends at the time specified by the policy.

During a waiting period, you’re not covered for the applicable services.

back to top

 

Important documents 

Our fund rules 

Understanding what private health insurance covers can be confusing. Each health insurer has a set of Fund Rules which set out guidelines for your membership, your premiums and the payment of benefits. You’ll find ours here:  https://rthealthfund.com.au/managing-your-cover/managing-your-cover/#UsefulForms

Every transaction we make is governed by our fund rules and policies.

As an RT Health member, you’ve agreed to act in line with our fund rules, which can change from time to time.

If we make a change to the Fund Rules that will have a detrimental effect on your benefit entitlements, we’ll let you know you in writing before we make the change.

We also take steps to protect members when we’re making changes, especially to your Hospital cover. For instance, we provide a transition period for every change to Hospital cover. This means you’re protected from a detrimental change if you’re booked in for an admission at the time the change is communicated to members.

We also make things easy for you and will chat you through any transitional arrangements and how we can help. (conditions may apply)

The Private Health Insurance Code of Conduct 

RT Health, as a division of HCF, HCF, is a signatory to the industry’s voluntary code of conduct. The code is designed to help health fund members by ensuring that funds provide clear information and transparency. It covers four main areas:

1. Ensuring you receive the correct information from appropriately trained staff.
2. Ensuring you are aware of the internal and external dispute resolution procedures available in the event that you have a dispute with the fund.
3. Ensuring policy documentation contains all the information you require to make a fully informed decision about your purchase, and that all communications between you and the fund are conducted in such a way that the appropriate information flows between the parties. This includes staff, agents and brokers.
4. Ensuring that all information between you and the fund is protected in accordance with national and state privacy principles.

As a signatory to the code, we’re committed to:

- working towards improving our standards of practice and service

- providing information to you in plain language

- Promoting better informed decisions about our private health insurance products and services by:

•      ensuring that our policy documentation is full and complete;
  • providing you with clear explanations of the contents of policy documentation when asked;
  • ensuring that the people providing you with information on health insurance are appropriately trained.
  • ensuring information exchanged between you and us is protected in accordance with privacy principles;
  • providing information to you on your rights and obligations in your relationship with us, including information on this code of conduct;
  • providing you with easy access to our internal dispute resolution procedure, and advise you of your rights to take an issue to an external body such as the Commonwealth Ombudsman.

If you’re interested in reading more about the code of conduct, visit privatehealthcareaustralia.org.au/codeofconduct

Privacy policy 

We are committed to handling all personal information we collect in accordance with the Privacy Act 1988 (Cth), and to making sure that the information we hold for members is handled in a responsible manner and that your privacy is protected.

A full copy of our privacy policy is available on our website, and we will update it as required so you are always aware of the type of information we collect, how it may be used, and under what circumstances it may be disclosed by us.

If you are interested in reading our privacy policy, it can be found on our website footer, at the bottom of any page. You can find it here: https://rthealthfund.com.au/privacy-policy/

Your privacy is important to us! That’s why we take steps every day to protect your privacy, your information and you.

We’ve outlined a couple of the ways we do this for you below.

Verification procedures: Whenever you contact us by phone, we will ask you a few questions to establish your identity and make sure that we’re talking to the principal member or an authorised partner. Even if you’re a regular caller, we’ll go through this quick verification process before we can start discussing your membership with you. If you’re not able or unwilling to provide us with this information, we won’t be able to assist you.

Authorities: If you have a couples or family membership, you were asked to nominate one person to be the ‘principal member’ at the time you joined (that is the person in whose name the membership is held). The principal member is the only person with an automatic entitlement to manage the membership – that includes signing claim forms, asking questions about claims, making changes to the membership and so on. The principal member can grant an authority to his or her spouse/partner if that person is named on the membership or to a third party who is not named on the membership. This authority provides the nominated person approval to interact with us in the same way as the principal member can (with the exception of being able to suspend or cancel the membership).

Without authority, no one else covered by the membership is able to sign claim forms, make enquiries about the membership or make changes to the membership.

Regulatory bodies 

Private health insurance in Australia is a highly-regulated industry. Among the key groups that supervise the operations of health funds (and that exist to help consumers) are the Commonwealth Ombudsman, the Australian Prudential Regulation Authority (APRA) and the Australian Government Department of Health.

Commonwealth Ombudsman

The Commonwealth Ombudsman is an independent government agency that:

- helps consumers deal with health insurance issues and enquiries

- provides advice to the health insurance industry, government and consumers, and

- publishes independent information about private health insurance and the performance of health funds.

Any member of a health fund is able to contact the Ombudsman about any private health insurance-related matter - whether it is about the health fund, an insurance broker, a hospital, a medical practitioner, a dentist or other practitioner.

- To make a complaint, you can contact the Commonwealth Ombudsman at www.ombudsman.gov.au or by phone on 1300 362 072

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

There are a number of consumer resources available from the Ombudsman. They include:

- the annual State of the Health Funds Report – comparing the performance and service delivery of all Australian health funds

- individual health fund report cards

- annual reports and quarterly bulletins

- a variety of information brochures.

All of these materials are available at no cost on the Ombudsman’s website (ombudsman.gov.au).

The Ombudsman also manages the consumer website privatehealth.gov.au. This site provides information to enables people to more easily compare health insurance products between health funds. It provides information on every product from every health fund in a consistent format. It also provides a wealth of additional material on private health insurance in Australia.

You can visit the website for more information, privatehealth.gov.au

Australian Prudential Regulation Authority (APRA)

The Australian Prudential Regulation Authority (APRA) is the regulator of the Australian financial services industry. It oversees banks, credit unions, building societies, general insurance and reinsurance companies, life insurance, private health insurance, friendly societies, and most of the superannuation industry. Established in July 1998, APRA is funded largely by the industries that it supervises.

You can visit the APRA website for a great range of useful consumer information and publications at apra.gov.au

Department of Health of Aged Care

Private health insurance policy is set down by the Department of Health. The health.gov.au website has a wealth of information about the government’s key health programs and services, and useful resources to help people make more informed decisions about their health and wellbeing.

back to top

 

What to do if you have a complaint

 

We try to be, but we’re not perfect.  We’re committed to providing you with the best possible service, but we know there’ll be times when we make a mistake or when you might have reason to let us know you’re less than happy.

We use feedback from our members as a tool to improve. We want to help you get everything you need and value from your health cover. And we love hearing from you.

We take our complaints process seriously, and we’ll do everything we can to come to a solution that works for you.

For more information, please see 'Complaints and Feedback’, which can be accessed through the website footer, at the bottom of every page. You’ll find it here: https://rthealthfund.com.au/about-us/governance-and-structure/complaints-and-feedback

back to top