Restriction and Exclusion Rules

Restrictions and exclusion rules

John Connor avatar
Written by John Connor
Updated over a week ago

The following are restrictions and exclusion rules

  • A contributor who is in arrears for a period of up to two months and pays all such arrears before the end of that period is entitled to benefits for services during that period.

  • Fund benefits are not payable where a contributor or dependant has received or established a right to receive a payment by way of compensation or damages (including a payment in settlement of a claim for compensation or damages) under the law that is or was in force in a State or Internal Territory, which, in the opinion of the organisation, includes an amount for expenses equivalent to the fund benefit that would otherwise be payable.

  • Cosmetic surgery benefits are excluded where Medicare does not pay a benefit.

  • Psychology: No Fund benefits are payable for services claimed from Medicare.

  • The fund will not pay for services that are provided by family members or relatives.

  • The fund will not pay for services that fall outside of fund required service provider registrations and associations (specific registrations and associations can be found on the products page alongside the service).

  • The fund will pay limited benefits for surgical podiatry in hospital for recognised podiatric surgeons only.

  • Services provided outside of Australia.

  • For hospital services considered to be restricted, the fund will pay minimum benefits for Private hospital accommodation, theatre fees and labour ward. Members should expect out of pocket expenses.

  • For hospital services considered to be excluded, the fund will pay no benefit.

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