72‑1 Benefit requirements72‑1 Benefit requirements

72‑1 Benefit requirements (1) An insurance policy that *covers *hospital treatment meets the benefit requirements in this Division if: (a) the policy meets the requirements in the table in subsection (2); and (b) the policy meets any requirements specified in the Private Health Insurance (Complying Product) Rules to be benefit requirements; and (c) the policy does not provide benefits for: (i) the cost of funded aged care services (within the meaning of the Aged Care Act 2024); or (ii) a charge for a pharmaceutical benefit supplied under Part VII of the National Health Act 1953, unless the circumstances of the charge are covered by section 92B of that Act; or (iii) any other treatment specified in the Private Health Insurance (Complying Product) Rules as a treatment for which benefits must not be provided; and (d) the *rules of the private health insurer that issues the policy meet the rules requirement in section 72‑5. (2) These are the requirements that a policy must meet for the purposes of paragraph (1)(a): - Requirements that a policy that *covers *hospital treatment must meet - Item There must be a benefit for ... The amount of the benefit must be ... - 1 any part of *hospital treatment that is one or more of the following:(a) psychiatric care;(b) rehabilitation;(c) palliative care;if the treatment is provided in a *hospital and no *medicare benefit is payable for that part of the treatment. at least the amount set out, or worked out using the method set out, in the Private Health Insurance (Benefit Requirements) Rules as the minimum benefit, or method for working out the minimum benefit, for that treatment. - 2 *hospital treatment *covered under the policy for which a *medicare benefit is payable. (a) if the charge for the treatment is less than the *schedule fee for the treatment—so much of the charge (if any) as exceeds 75% of the schedule fee; and(b) otherwise—at least 25% of the schedule fee for the treatment. - 3 if the policy *covers *hospital‑substitute treatment—hospital‑substitute treatment covered under the policy for which a *medicare benefit is payable. (a) if the charge for the treatment is less than the *schedule fee for the treatment—so much of the charge (if any) as exceeds 75% of the schedule fee; and(b) otherwise—at least 25% of the schedule fee for the treatment;but the benefit must not be provided if a medicare benefit of an amount that is at least 85% of the schedule fee is claimed for the treatment (or could be claimed for the treatment but for section 19AD of the Health Insurance Act 1973). - 4 (a) *hospital treatment *covered under the policy; and(b) if the policy covers *hospital‑substitute treatment—hospital‑substitute treatment covered under the policy;that is the provision of a *medical device or *human tissue product, of a kind listed in the Private Health Insurance (Medical Devices and Human Tissue Products) Rules, as described in either of the following paragraphs:(c) the medical device or human tissue product is provided in circumstances in which a *medicare benefit is payable, and, if those Rules set out conditions that must be satisfied in relation to the provision of the medical device or human tissue product in those circumstances, those conditions are satisfied;(d) the medical device or human tissue product is provided in other circumstances set out in those Rules, and, if those Rules set out conditions that must be satisfied in relation to the provision of the medical device or human tissue product in those circumstances, those conditions are satisfied. (a) at least the amount set out, or worked out using the method set out, in the Private Health Insurance (Medical Devices and Human Tissue Products) Rules as the minimum benefit, or method for working out the minimum benefit, for the medical device or human tissue product; and(b) if the Private Health Insurance (Medical Devices and Human Tissue Products) Rules set out an amount, or a method for working out an amount, as the maximum benefit, or method for working out the maximum benefit, for the medical device or human tissue product—no more than that amount or the amount worked out using that method. - 5 any treatment for which the Private Health Insurance (Benefit Requirements) Rules specify there must be a benefit. at least the amount set out, or worked out using the method set out, in the Private Health Insurance (Benefit Requirements) Rules as the minimum benefit, or method for working out the minimum benefit, for that treatment. Note: If a private health insurer provides an insured person with, or arranges for an insured person to be provided with, treatment, it is treated as a benefit for the purposes of this Division (see subsection 69‑5(3)). (3) For the purposes of this section, disregard section 19AD of the Health Insurance Act 1973 when determining whether medicare benefit is payable. (4) If an amount of a benefit payable under an insurance policy does not meet the requirements in the table in subsection (2) merely because of the operation of subsection 10(4) of the Health Insurance Act 1973 (which rounds the calculation of a *medicare benefit), the amount of the benefit payable is taken to meet the requirements in the table in subsection (2).