Is the Medicare Gap claimable under the Personal Accident Policy?
No, the Health Insurance Act (Cth) 1973 does not permit the Insurer to contribute to any charges covered by Medicare (including the Medicare Gap). This means that any charges for treatment from a Doctor, Surgeon, Anaesthetist or Surgeon's Assistant Fees are not covered. It also means charges for X-Ray, some MRI Scans (if Medicare registered) and Public Hospitals are not covered. In addition, there will be no refund in respect of:
Are MRI’s covered under the Personal Accident policy?
MRI scans are generally claimable through Medicare, however sometimes the referrer and/or provider is not registered with Medicare so they deny the claim. In this situation, you can claim through Netball Australia Personal Accident policy.
What is the maximum benefit period for Loss of Income and Non Medicare Medical Claims?
104 weeks for Loss of Income claims and 52 weeks for Non Medicare Medical Claims.
What is the excess / elimination period under the Personal Accident Policy?
There is a $75 excess in respect to making a claim for non-Medicare medical treatment (there is a $25 excess if a member belongs to a Private Health fund). This amount will be deducted from any reimbursements that you are entitled to. If you are making a Loss of Income claim you are subject to a 14 day elimination period which also takes into account any accrued sick leave or other entitlements. This means that any loss of income during this period is not claimable.
Is the cost of Ambulance Transport covered under the Program?
Yes, ambulance transport is a non-Medicare medical expense and as such covered under the Personal Accident section of the program (up to the limits that you are entitled to).
Can I claim on my Private Health insurance as well as the Insurance Scheme for personal injury claims?
You must initially claim on your Private Health insurance and then claim on the Insurance Scheme for any non-Medicare medical costs that exceed the limits of your Private Health insurance.
Do any conditions apply for Loss of Income if I am employed on a part time or casual basis?
Yes. For a claim to be considered, the insured person must be in permanent employment at the time of the injury. Full time employment means being engaged in permanent work in the Insured Person's occupation, for a minimum of 5 hours per week over the 8 week period immediately prior to the injury.
The weekly accident benefit is 100% of your net weekly income up to a maximum of $250 per week($300 per week for Netball WA members,$700 per week for Officials and Voluntary Workers), whichever is the lesser. Please note that your employer needs to complete the Loss of Income section of the claim form.
Can I make more than one claim during the year?
Yes, you can make more than one claim during the year. It is important however, that you obtain a clearance from your treating physician prior to returning to netball activities.
Example of a medical claim payment
Susan is a 14 year student who has injured her leg whilst competing in a sanctioned Netball affiliated club game. She has been advised by her local doctor that she requires an operation to repair tendons and then will be receiving rehabilitation after the surgery. Susan is not covered by Private Health Insurance.
Paying the Claim
The following summarises how an insurance claim is calculated.
(Government legislation does not allow General insurers to cover any costs subject to a Medicare rebate)
|Private practitioner visit (ie. Doctor)||Covered by Medicare *|
|Surgeon||Covered by Medicare *|
|X-Ray/MRI||Covered by Medicare *|
|Anaesthetist||Covered by Medicare *|
|Theatre costs||Covered by Medicare *|
|Private Hospital accommodation||3 days @$500 $1,500.00|
|9 Physiotherapy visits @ $50 per visit||$450.00|
|Benefit Selected 80%||$1,560.00|
|Less $75 excess||$1,485.00|
|Total Claim Payment||$1,485.00|
* In most cases Medicare does not cover 100% of the medical provider’s costs. The difference is known as the “Medicare Gap” and is not covered by the Netball Australia Personal Accident program due to government legislation.