11FCoverage of treatments for insurance policies that cover hospital treatment

11F Coverage of treatments for insurance policies that cover hospital treatment

Application of rule (1) For paragraph 63‑10 (g) of the Act, this rule applies to an insurance policy that covers hospital treatment (whether or not the policy also covers general treatment). Treatments that must be covered by policy (2) The policy must cover: (a) all hospital treatments that are within the scope of cover that is identified, in Schedule 5, for each clinical category in relation to which the policy provides cover (see subrules (5) and (6)); and (b) all hospital treatments that are not within the scope of cover of such a clinical category, but that are: (i) associated treatments for complications (see subrule (7)); or (ii) associated unplanned treatments (see subrule (8)). (3) However, the policy is not required to cover cosmetic surgery that is not medically necessary. Treatments that may be covered by policy (4) The policy may also provide either or both of the following: (a) accident cover; (b) benefits for travel or accommodation relating to a treatment referred to in subrule (2) or paragraph (a). Interpretation (5) For paragraph (2) (a), the scope of cover of a particular clinical category includes, but is not limited to: (a) all hospital treatments involving the provision of an MBS item listed in Schedule 5 against that clinical category; and (b) all hospital treatments: (i) that are provided in relation to a treatment of a kind referred to in paragraph (2) (a) or (5) (a); and (ii) involving the provision of an MBS item listed in: (A) the common treatments list in Schedule 6; or (B) the support treatments list in Schedule 7. (6) Paragraph (5) (b) does not apply in relation to the clinical category “Podiatric surgery (provided by a registered podiatric surgeon)”. (7) For subparagraph (2) (b) (i), a hospital treatment is an associated treatment for complications if it is: (a) provided during an episode in which hospital treatment of a kind described in paragraph (2) (a) is being provided; and (b) provided for a complication that arises during that episode. (8) For subparagraph (2) (b) (ii), a hospital treatment is an associated unplanned treatment if it is: (a) provided during an episode in which hospital treatment of a kind described in paragraph (2) (a) is being provided; and (b) an unplanned treatment that: (i) is provided as part of planned surgery performed during that episode; and (ii) is, in the view of the medical practitioner who provides the unplanned treatment, medically necessary and urgent.