What do the Benefits cover?

Each benefit is carefully planned to cover a set of medical expenses for members and their dependants. This table gives a general idea of what may be covered by each benefit. You must read the full member guide to find out what is and is not covered.

Name of benefit Examples of what may be covered under the benefit
Major Medical BenefitHas no overall yearly limit, but there are limits and restrictions for particular treatments. Emergency treatment in hospitals or casualtyHospital stays and most treatment in hospitalSome treatments and procedures at day clinics and in doctor’s rooms

Female contraception

Some treatment after a hospital visit (30 day benefit)

Doctor appointments with network GPs (when a member’s Out-of-Hospital Expenses Benefit has run out)

Oncology treatment

Screening benefit

Threshold Benefit when a member’s day-to-day expenses have added up to his/her threshold level

Chronic Disease BenefitMay have an overall yearly limit and only provides cover if a member’s condition is one of the conditions covered on their option.There may be restrictions for particular medicines and treatment. Conditions that are covered include the 25 Prescribed Minimum Benefit conditions as well as an additional 26 conditions, depending on the option.The medicine for the treatment of these conditions that meet the criteria as set by the scheme will be covered by this benefit
Day-to-day BenefitsMembers’ day-to-day expenses are covered from:

  1. Savings Account
  2. Out-of-Hospital Expenses Benefit
  3. Carry over Savings or self-payment
  4. Threshold Benefit
Visits to doctors or specialistsPrescribed medicine for illness (for example, the flu)Over-the-counter medicine

Other day-to-day medical expenses. Common examples are dentistry, optometry, blood tests and physiotherapy