Going to see a Healthcare Provider

We recognise that Healthcare Providers play a critical role in helping you improve your health and wellbeing through their expert knowledge. However, we also believe that we have a responsibility to you and our industry to use our experience, expertise and size to help keep private healthcare cover affordable.

This is why we have entered into arrangements with Specialists and GPs – making sure that the amount that you sometimes have to pay out of your own pocket is limited. We do this by paying claims directly to the Healthcare Provider when we have an arrangement with them.

Please click here to find a Specialist or GP Network Provider.

Cover for Specialists and GPs

We pay for Specialist and GP consultations from your Out-of-hospital Benefit. These claims are covered from your Out-of-hospital Benefit at 80% of the contracted/Scheme Rate or the claimed amount, whichever is less. If you are on the Comprehensive Option the balance of the claim is paid from the available funds in your Medical Savings Account (MSA) or we will claim it back from your salary (or debited from your bank account if you are a self paying member). If you are on the Essential Option, the 20% balance is claimed back from your salary (or debited from your bank account if you are a self paying member).

Cover for dentists

Basic dentistry is covered from your Dental Benefit. On the Comprehensive Option, basic dentistry is covered from your Day-to-day limit and advanced dentistry is covered from your Advanced Dental Benefit limit. . On the Essential Option the dental limit is calculated according to the number of dependants on your membership. Advanced dentistry is not covered on the Essential Option

Dentistry claims are covered at 80% at the Scheme Rate or the claimed amount, whichever is less, with the exception of oral and maxillofacial surgery claims, which are covered at 100% of the Scheme Rate on both options. Osseo-integrated implants and orthognathic surgery claims are covered up to 100% of the Scheme Rate from the Advanced Dental Benefit on the Comprehensive Option only.

If you are on the Comprehensive Option the balance of the claim is paid from the available funds in your Medical Savings Account (MSA), or we will claim it back from your salary (or debited from you bank account if you are a self paying member). If you are on the Essential Option, the 20% balance is claimed back from your salary (or debited from your bank account if you are a self paying member). "Click here to view Dental Benefit Guide".

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