How to claim on medical expenses

Depending on your level of cover, you may be able to claim back some—or all—of the medical costs for your hospital stay or day surgery procedure. Examples of medical costs include pathology, radiology and doctor/specialist fees that arise during a hospital admission.

The way you claim on these costs will depend on whether your doctor is participating in Australian Unity’s Gap Cover Scheme.

Gap Cover claims

If your policy includes Gap Cover—and your doctor agrees to participate in the scheme for your procedure—they should deal directly with Medicare and Australian Unity. You should only receive an invoice from them if there are out-of-pocket costs (which can still arise, depending on how much your doctor charges).

If, for some reason, you do receive a bill for all your medical expenses, you’ll need to complete a health cover claim form and submit to Australian Unity via post or email. You won’t be able to complete a Gap Cover claim on your online account or over the phone. Of course, if you have any questions, please call us on 13 29 39.

Non Gap Cover claims

If your doctor isn’t participating in Gap Cover, you’ll receive an invoice from them. You’ll then need to:

1. Submit your paperwork to Medicare. You’ll receive a cheque, or some other form of payment, for your doctor and a statement of Medicare benefits for Australian Unity.
2. Hold onto the payment from Medicare. Then log into your Australian Unity health app, or Online Member Services (online account).
3. Head to ‘Make a claim’ and select ‘Medical services’. Complete the online form. Make sure to include your statement of Medicare benefits and any other documents relevant to your claim.
4. Once we’ve processed your claim, we’ll make a payment into your nominated bank or credit union account.
5. Pass the payment from Australian Unity, and the Medicare payment, onto your doctor. If there’s any amount outstanding, you’ll also need to pay this.

If your doctor asks you to pay upfront, you can follow the same process above. Just make sure to show Medicare your proof of payment. Medicare will then pay you directly. Medicare will still issue you a statement of Medicare benefits and you’ll need to include this in your Australian Unity claim.

What about accommodation and theatre fees?

You shouldn’t be charged for accommodation or theatre fees (or prosthesis, if needed) if you’re “Covered” for your procedure at that hospital (your Fact Sheet will tell you which treatments are “Covered” and at which type of hospital); and you’ve completed any applicable waiting periods.

In most cases, the hospital will bill Australian Unity directly. You’ll only receive an invoice if an excess or co-payment applies to your cover (and you haven’t already paid it). If you do happen to receive an invoice for the full amount, please call us on 13 29 39.

If your procedure is “Covered” but is in a “non-agreement” private hospital or a private room of a public hospital, you may incur large out-of-pocket costs. This may include theatre fees, intensive or coronary care costs and accommodation. If your cover provides for “Restricted” benefits, Australian Unity will only pay the basic default benefit[1] for your accommodation and prosthesis (if needed). You will not be covered for any other accommodation and theatre fee costs relating to your procedure, and may incur large out-of-pocket costs.

For any charges not covered by Australian Unity, you will need to contact the hospital and confirm how to pay.

How to claim on ambulance

If you’re covered for emergency ambulance transportation or ambulance attendance—and need to claim—log into your account and head to Make a claim. Select ‘Extras services’ or ‘Other services’ and follow the steps. Once we’ve processed your claim, we’ll make a payment directly to the ambulance provider. If there’s any amount outstanding, you’ll need to pay this.