This is the “fine print” page with necessary legal information. If any point is unclear, please call us for a human explanation.

1. Waiting periods

MONTHS CLAIM CATEGORY
NIL Ambulance subscription
NIL Accidents
NIL *Transfers from another fund or Phoenix Health Fund membership where ALL of the following occurs: Previous level of cover is identical or higher; Membership is currently financial with the previous cover; and The relevant Phoenix Health Fund waiting period has been served with the previous cover.
2 Excess – Waiting periods apply when upgrading cover to a nil excess policy. This applies for existing Phoenix members or a new member transferring from another fund.
2 All Hospital and Extras Cover items other than the items listed below in this table
2 General Dental and Endodontic Dental procedures
12 Major Dental, Orthodontic Dental procedures and Hearing Aids
6 Optical
12 *Obstetrics and Assisted Reproductive Services
12 Pre-Existing Conditions: In respect of an ailment, condition or illness, the signs or symptoms
of which existed at any time during the 6 months preceding the day of joining or upgrading tables. This is in the opinion of a medical practitioner appointed by the fund. When transferring from another fund OR transferring to a higher level of cover within the fund, waiting periods already served by a member are retained through continuity of cover.
2 Psychiatric, Rehabilitation and Palliative Care

*Transferring Members: For transferring members who have used all or part of their annual limits under their previous cover, the member will only receive the difference between the Phoenix Health Fund limit for their level of cover and the amount already claimed in this calendar year. Members transferring from another cover that has lower limits or benefit exclusions compared to the chosen Phoenix Health Fund cover must serve the waiting periods listed above before they can claim more than the previous cover’s benefits or limits. Claims are unable to be paid for transferring members until Phoenix has received confirmation of served waiting periods through an interfund transfer certificate generated by the previous health fund.

*Obstetrics: The fund advises that to accommodate for a premature birth, members will need to purchase the correct level of cover at the appropriate time so that the fund can provide benefit payments for obstetrics.

2. Continuation of membership
Members leaving the employ of any of our associated companies are encouraged to retain their membership. Refer to Payment of Contributions for alternative payment options.

3. Suspension of membership
Members can opt to suspend their membership while travelling overseas. This is available for a minimum of 3 months, and must be applied through the fund (with proof of travel – this includes boarding passes, travel itineraries, or record of movement) prior to departure. Suspension can only be made if the membership is financial on the proposed date of suspension. Members must notify the fund within 1 month of returning to Australia to reactivate their policy. Where a Policy is not re-activated by the relevant date, waiting periods may be applied upon activating. In some cases, Phoenix may terminate the Policy if it is not reactivated within the specified time.
If you are having travelling overseas, members can opt to suspend their membership while out of the country.

4. Making a complaint
If you have a complaint concerning your membership, contact the Fund in the first instance so that it can be resolved as quickly as possible. Your complaint will be dealt with in accordance with our Complaints Policy. Call our office to discuss your matter on 1800 028 817.

If you are unable to resolve your complaint with the Fund, the independent Private Health Insurance Ombudsman has been established to assist with inquiries and complaints about any aspect of private health insurance. Complaints can be lodged with the Ombudsman website, www.ombudsman.gov.au, by emailing phio.info@ombudsman.gov.au or by telephone on 1300 362 072.

5. Dependants
Dependants may remain in the fund in their own right after reaching the age of twenty-one (21) years. Members who have children who wish to join the fund should contact our office for further information. Sons and daughters will still be covered as student dependants under their parents’ membership provided the following conditions are met:

  • Unmarried
  • A full time student at a school, college or university which is recognised for income tax purposes
  • Is under the age of 25 years
  • Is in receipt of an annual income not in excess of that which is recognised as the maximum annual income a person may derive before taxation becomes payable, and
  • A Student Declaration form is submitted.

6. International travel & purchases
The Fund does not pay benefits for services provided outside the Commonwealth of Australia. Members should consider Travel Insurance for the period of overseas travel. The Fund does not pay a benefit for any items purchased outside of the Commonwealth of Australia.

7. Nursing Home Type Patients   
Unless a doctor certifies otherwise, patients in hospital for in excess of 35 days continuously are regarded as Nursing Home Type Patients.  Nursing Home Type Patients are required by legislation to pay part of the daily accommodation charge as approved by the federal Minister of Health.

8. Restriction 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.

9. Payment of contributions

  • By Direct Debit through either a:
    • Bank Account, Building society or Credit union debit account. – Frequency options of weekly, fortnightly, monthly or quarterly OR;
    • Credit Card (Visa & MasterCard) – Frequency options of weekly, fortnightly, monthly or quarterly.
  • By quarterly payments in advance.  Pay your account off using our Online Payment Facility, Bpay or over the phone.  The Fund forwards accounts to your postal address detailing contributions owing to the end of the next applicable quarterly period (i.e. periods ending 31 March, 30 June, 30 September and 31 December).

10. Payment of Benefits

The maximum payment from each table will be as stated or the amount of the account, whichever is the lesser. Initial consultation benefits are paid only once per person per calendar year.

11. Limitation of benefits

All limits are per person. In all cases where benefit payments are limited to a calendar year the period will be from 1st January to 31st December.  Please also note that product pages do not include the full detail of all services covered, and that sublimits apply for some services.  It is recommended that you contact the fund before your treatment to check exactly what you are covered for.

12. Submission of claims

Members must ensure that all claims are submitted for processing within two (2) years from the date of service.

13. Alternative Therapies

Payment of benefits is limited to Approved Therapies and Accredited Associations. The respective lists are available here, or by contacting the office of the Fund.

14. Lifetime Health Cover

People over the age of 30 who have not had continuous private patient hospital cover since 1st July 2000 may be subject to Lifetime Health Cover loadings. Contribution rates included with this brochure may be adjusted in accordance with Lifetime Health Cover Legislation. Contact our office for further information, or visit the Federal Government’s information site.

15. Medicare Levy Surcharge

Individuals and families on incomes above the Medicare Levy Surcharge thresholds, who do not have private patient hospital cover, may have to pay the Medicare Levy Surcharge. Income thresholds for the Medicare Levy Surcharge can be obtained from the Australian Taxation Office.   All Phoenix Health Fund products that include hospital cover exempt members from the Medicare Levy Surcharge.

16. Privacy Statement

Members are encouraged to peruse the Privacy Statement of the fund.

17. ‘Cooling Off’ Period

We will allow any member who has not yet made a claim to cancel their policy and receive a full refund of any premiums paid within a period of 30 days from the commencement date of their policy.

18. Additional Information

Individuals wishing to join the fund or current members who require any additional information should contact our office. This web site provides a summary of available benefits and should be read in conjunction with the registered rules.