Emergency

Topic 1: Coverage and Waiting Periods (New Members in Emergency)

If the customer asks about coverage for an emergency/accident, especially if they are a new member (<12 months):

• Fact 1: General Waiting Period: For standard hospital treatments, Saint Luke's requires a 2-month waiting period.

• Fact 2: Pre-existing Conditions (P-E-C): A 12-month waiting period applies for pre-existing conditions.

• Fact 3: The Accident Exception: If the injury is due to a genuine accident (a sudden, unforeseen event), the 12-month P-E-C waiting period does not apply.

• Agent Guidance: If the member has completed the 2-month waiting period and the injury is an accident, their hospital treatment is generally covered under their policy.

Topic 2: Policy Excess and Out-of-Pocket Expenses

Saint Luke's Gold Hospital 300 is a comprehensive hospital policy designed to offer extensive coverage for all 38 clinical categories recognized by Australian health insurance standards. This policy is classified as "Gold," meaning it provides the highest level of coverage available.

Here is a breakdown of what Gold Hospital 300 covers, including details on the excess, inclusions, and other important features.

Comprehensive Coverage
The Gold Hospital 300 policy covers a wide range of services, including those typically restricted or excluded on lower-tier policies. This plan offers peace of mind, covering all hospital treatments, including:

Pregnancy and Birth: Includes assisted reproductive services.

Cataracts and Eye Surgeries

Joint Replacements

Weight Loss Surgery

Psychiatric Services (Note: A 2-month waiting period applies even for pre-existing conditions)

Palliative Care and Rehabilitation

Sleep Studies

Heart and Vascular System treatments

Understanding the Excess
The "300" in the policy name refers to the maximum excess amount per person, per year. An excess is the amount you pay toward your hospital treatment when admitted.

Maximum Excess: $300 per person, up to a maximum of $600 per policy per year.

Same-Day Surgery: For adults, a "half excess" applies to same-day hospitalizations, up to the maximum product excess.

Child Dependents: A significant benefit of Gold Hospital 300 is that the excess does not apply to hospital admissions for child dependents.

Waiting Periods
Standard waiting periods apply to new members or those upgrading their cover:

2 Months: For general hospital treatments and services (including palliative care, rehabilitation, and psychiatric treatments, even if pre-existing).

12 Months: For pre-existing conditions and pregnancy and birth (obstetrics).

Additional Features and Benefits
Medical Gap Scheme Cover: Saint Luke's Gold Hospital 300 provides 'no gap' or 'known gap' cover for medical bills, which helps minimize or eliminate out-of-pocket expenses for doctor and specialist fees.

Ambulance Cover: The policy includes emergency ambulance cover.

Key Details on Injury Coverage

Comprehensive Hospital Coverage:

The Gold Hospital 300 policy covers the investigation and treatment of injuries, including:

• Bone, Joint, and Muscle: This includes coverage for fractures, surgery for musculoskeletal injuries, joint reconstructions, and conditions like carpal tunnel.

• Back, Neck, and Spine: Coverage for investigations and treatments related to back, neck, and spinal injuries.

• Brain and Nervous System: Treatment for injuries affecting the brain, spinal cord, and peripheral nervous system.

• Plastic and Reconstructive Surgery: Medically necessary procedures for physical deformities resulting from injury or illness.

Waiting Periods for Injuries:

• General Waiting Period (2 months): For injuries resulting from accidents, the standard waiting period for general hospital services is 2 months. Once this period is served, the member is covered.

• Pre-existing Conditions (12 months): If the injury relates to a pre-existing condition, a 12-month waiting period applies. However, as noted above, if the injury is the result of a genuine accident, the 12-month waiting period for pre-existing conditions does not apply.

Excess and Benefits:

• Excess: As detailed previously, Gold Hospital 300 includes an excess of $300 per person per year, which applies to hospital admissions. A half-excess typically applies to same-day surgeries.

• Benefits: The policy provides benefits for hospital accommodation, theatre fees, and intensive care in contracted private hospitals. It also offers coverage for approved surgically implanted prostheses related to the injury treatment.

Medical Gap Cover for Injuries:

The policy offers "no gap" or "known gap" cover for medical bills related to in-hospital services, helping to reduce or eliminate out-of-pocket costs for doctor and specialist fees associated with the injury treatment.