All Australian Unity sales require a disclaimer to be read in full. This is found at the bottom of the application page.

A welcome call is made by the fund within 7 days of the application date. If the member does not answer after three attempts a welcome email is sent instead.

After the application process has been completed the member will receive an activation link to guide them to their Online Member Portal.

A welcome pack will be sent within 10 business days of the application date.

• Weight loss - $100 upfront, another $100 when you reach your goal weight. Another $150 if you stay within 5kg of goal weight for 12 months!
• Quit Smoking - $120 per calendar year to complete an approved quit smoking course (Smokenders, Allan Carr Easyway, Quit Foundation)
• Doctor Health Checks – Up to $150 pp pcy towards consultations not covered by Medicare

• Personal Health Coach - $45 toward a health coaching consult (dietician, psychologist)
• Diabetes Australia Membership – 80% of the cost of a Diabetes Aust membership
• Bone Density Scanning – 70% of the cost of a DEXA scan up to $70 pp payable every 5 years if not eligible through Medicare or the free federally funded screening program for Australian aged 70+

• Lift for Life - $50 on each stage of the 3-stage program completed

• Mammogram Screening – 70% of screening costs not covered by BreastScreen , up to $100
• Cervical Cancer Vaccinations-100% of cost up to $200 payable on three-vaccine treatment

Accident means an unplanned and unforeseen event, occurring by chance, and leading to bodily injuries caused solely and directly by an external force or object requiring treatment from a Medical Practitioner (defined here as a medical doctor who is not the member or a relative of the Member) within 7 days of the event, but excludes injuries arising out of: surgical procedures; unforeseen illness; pregnancy; drug use; and aggravation of an underlying condition or injury.

Accident override
If you need hospital treatment for an injury sustained during an Accident that occurred after joining this cover, and the hospital treatment is within a Clinical Category that is listed as Restricted or Not Covered, that hospital treatment will be treated as Covered.

Single Policy at time of birth

• Upgrade to a Family or Single Parent Family cover; and
• Add your child to the policy. You may also be able to add your Partner to your membership effective your child’s date of birth, or adoption/ fostering date

We recognise waiting periods which have been served with the customer's previous fund, if that fund is an Australian OVC policy. If a customer switched across without waiting periods being served, they would not be recognised with us. If the customer switches to AU OVC from an Overseas OVC, we don’t recognise WPs.

Once granted PR, the member can join a CHIP cover, however we don’t recognise the waiting periods already served. All waiting periods would be re-served. An OV customer can take a CHIP policy of it is for MLS purposes, however they cannot claim rebate, and must be made clear they cannot use the policy for medical purposes, that it is for taxation purposes only.

Any MBS item number is covered up to the scheduled fee, unless otherwise excluded or restricted on the policy. Australian Unity are aware of the issue with Medibank Private and their knowledge was that they don’t have this issue.

Covered treatments means your hospital cover will pay benefits towards:

• Except for the Clinical Category Podiatric Surgery (Provided by a Registered Podiatric Surgeon):
• Medication in hospital approved by the Pharmaceutical Benefits Scheme (PBS) (excluding medication you take home)
• Dressings and other consumables while admitted. Excludes robotic surgery consumables unless otherwise covered for your treatment by the agreement between Australian Unity and the hospital. Please contact your hospital about any out-of-pocket costs
• Most diagnostic tests during your admission e.g. pathology and radiology
• The cost of a prosthesis as listed in the prostheses list set out in the Private Health Insurance (Prostheses) Rules, as in force from time to time.

Chemotherapy

Preventative Dental
No waiting periods on dental items 011 – 171, (excluding 051, 059, 074, 075, 116, 131, 141 and 142). This means customers can join Australian Unity and book in for a dental check-up straight away! Waiting periods apply to other dental services.

No Gap Dental
No Gap Dental is available on all Extras except and all Combo’s except Simple Saver & Care & Repair 

• Initial Examination
• Scale & Clean
• X-rays 
• Topical fluoride treatment 
• Preventative examinations 
• Custom mouthguard  

Service Limits

There are service limits that apply to dental claims, refer to the individual Extras PDF. 

Wisdom Teeth Removal

Teeth Whitening

Located under Major Dental with Endodontics or Root Canal

Orthodontics (Braces)
Orthodontic benefits are payable on a year by year basis, not upfront, payable on each year of active treatment.
If a member pays upfront for their orthodontic treatment, each calendar year of treatment they are required to re-submit their treatment plan so that further benefits for that calendar year can be made.
Claims are only payable for benefits on services which occur after waiting periods have been served. In the example, if they commenced treatment prior to joining the fund, or an eligible table, benefits would be payable on any payments made for treatment after the waiting period has been served.

AU allow a member to switch mid-treatment, however they require a copy of the initial treatment plan from the Orthodontist, almost as if they were starting a new treatment as such, to be provided by the customer, before the first claim will be paid.

• Insulin Pumps are on the Prosthesis List even though they are not surgically implanted.
• Insulin Pumps are listed under Schedule C of the Prostheses List.
• Benefits are paid under the member’s hospital cover; this is not an Extras benefits.
• The Fund is required to pay for a specific insulin pump where the pump is provided as part of an episode of hospital or hospital-substitute treatment during a professional attendance by a consultant physician for which a Medicare benefit is payable. (A certified Type C procedure)
• Members generally may not require admission to hospital to be fitted with an insulin pump.
• Pumps fitted in a clinic (out of hospital) are considered part of general treatment therefore the Fund is not required to pay the minimum benefit for the pump.
• Members who have served waiting periods e.g. 12mths pre-existing, on an eligible level of cover are able to apply of an insulin pump out of Hospital. Note: Members on Basic (Public Hospital) Covers are not eligible for benefits out of hospital.
• Approval for benefits is required when an insulin pump is being replaced.
• Any requests for a replacement insulin pump should in the form of a written request from the member’s Endocrinologist, specialist clinician or a Credentialed Diabetes Educator – Registered Nurse.
• The request must include evidence supporting the clinical need for the device to be replaced.
• The need for a replacement must be due to a clinical need, the avg replacement period should be 4-5 years. We will not pay benefits for replacements due to no longer being under warranty. All requests must be sent to the Claims Review Manager for approval

Cochlear devices are not hearing aids, they are listed prostheses on the government prostheses list. Hospital and implant benefits are payable by the Fund when the member has an appropriate level of cover. There is a 12 month waiting period for Pre-existing condition Benefits for Upgrade/replacement speech processors require pre-approval.

Replacements/Upgrades
AHSA have created a processor Replacement/Upgrade application form which must be completed by the provider and submitted to the health fund for approval. Completion of the warranty period is not a valid reason for replacement of a processor. To be considered for funding a clinical reason for the upgrade or evidence that the device is no longer functioning, repairable or able to be supported must be provided. The availability of improved technology is not sufficient reason for an upgrading of a processor. All requests must be sent to the Clinical Approvals team for consideration. Note: Upgrades and replacements will not be considered whilst the processor is still under warranty.

• All Artificial Aids/Appliances have a 12-month waiting period
• Most Artificial Aids and appliances have a 2 year Benefit Replacement Period .
• A letter of recommendation may be required for these purchases. 

• It should state the condition the aid will alleviate and the referring  doctor/health practitioner.
• The letter must be no more than 6 months old at the time of claiming
• A letter is required for the purchase of the first device only. If member requires a replacement device (after the BRP is served, if relevant), no letter will be required.​

Benefit is subject to a 12-month waiting period. Benefits for orthotics are payable on referral from a recognised podiatrist, chiropractor, physiotherapist or medical practitioner in private practice. Medical practitioners and podiatrists do not need to be registered with the specialty code 900. Orthotics must be an approved external appliance supplied by a recognised provider in private practice.

Modifications or adjustments do attract a benefit if the purchase of a replacement can be avoided. Modifications on orthotics are only payable if they are performed more than 3 months after the purchase. If there is a charge raised before this time, it possibly should have been included as part of the fitting of the original product or payable under the product’s warranty. We wish to protect our members against over-charging.

A benefit is paid on the actual orthotic only. Any other treatments and/or consultations relating to the purchase of the orthotics should be paid under the podiatry or relevant provider’s ‘consultation’ benefit.

Benefits under this modality are primarily for orthotics; when orthotics are not appropriate for the given medical condition, benefits are payable for custom-made or off-the-shelf shoes on referral from a recognised Podiatrist or Medical Practitioner in private practice. Benefits are not payable for a combination of shoes and orthotics; where a charge for both is raised only the orthotic would attract a benefit.

Benefits are not payable towards the cost of custom made or off the shelf shoes that are bought to fit orthotics.

Please note: Top Choice covers podiatry but not Orthotics. Ask the customer how they use podiatry, whether it’s just podiatry consults (for feet check ups) or whether they need orthotics. If so, do they buy off-the-shelf orthotics (not covered) or custom-made orthotics. If just podiatry consults, or if they buy off-the-shelf orthotics, then Top Choice is suitable; if they need custom-made orthotics, they need to look at a mix n match extras product

Benefit is subject to a two-month waiting period. Claims are processed using the generic provider number 0555555P

No as Ozempic is a PBS item for its intended purpose

Script numbers and prescribing doctor’s name must be indicated on the account. Each script must be assessed on a single line, bulking is NOT permitted. However, if there are multiples of the one pharmaceutical on the one script then the benefit is payable on the total charge of the script.

Hormone supplements and allergy serums are payable if they have been supplied by a medical practitioner in private practice. Vitamins, minerals and health supplements do not attract a benefit

Medical Cannabis

While Commonwealth, state, and territory governments have laws in place to allow the prescribing and dispensing of medicinal cannabis products, as well as cannabis cultivation and manufacture for medicinal purposes, there are currently only two medicinal cannabis medications, Sativex and Epidyolex, that are TGA approved in limited circumstances. These 2 drugs would be payable under a Member’s Extras pharmacy benefits, but only if they meet the fund criteria for payment, advised under section” To claim benefits” above

While TGA can sometimes grant medical practitioners authority to prescribe the specified unapproved medicinal cannabis product for a single patient on a case-by-case basis (through the Authorised Prescriber Scheme or Special Access Scheme-B), the fund does not pay for benefits as these circumstances do not meet the above fund criteria. 

Australian Unity does not cover this.

The da Vinci Robotic System allows surgery via a keyhole approach which is computer aided through a dual camera system. Most surgeries that are performed robotically, at this time, are for Urology, Colorectal, Cardiac and Gynecology treatments.

The cost involves fees for the use of the robotic system, including facility fees charged to the user (doctor) of the robotic technology together with disposable/consumable items specifically related to this surgery

• Australian Unity and benefits payable for robotic surgery:
• Australian Unity members are covered for robotic surgery procedures.
• Whether AU pays any benefits towards the cost of the disposables/consumables used for the related procedure, this depends on the terms of the agreement that Australian Unity has with the relevant Agreement Private Hospital. Depending on this Agreement, Australian Unity may pay part or the full cost of the disposables/consumables, or no payment at all. Members must contact their hospital and find out about their out of pocket expenses.
• The facility fee (rental of the robot) is not payable by the Fund. This is a charge for the surgeon to use the robotic technology and an additional out of pocket for the member can be anywhere from $2,500 up to $5,000.
• Assuming the member is covered for the procedure, Australian Unity will also pay the MBS raised by the doctors, theatre fees and bed fees in Private Agreement Hospital. Members will have to pay any excess/ co-payment (if applicable). Check Fact Sheets for coverage

• Patients can incur significant out-of-pocket costs for robotic consumables as well as the facility fees.
• It is important to advise any members to enquire with their doctor and the hospital about all out-of-pocket expenses and they should request for Informed Financial consent from both hospital and doctors before they agree to have the procedure.

Australian Unity does not cover cosmetic surgery if it is not medically nessessary.

Gender Reassignment Surgery (GRS) (also referred to as “Sex Reassignment Surgery”) is a combination of multiple surgeries that changes a person’s physical characteristics to bring them into alignment with their gender identity, for example, a person that was born female but identifies as a male.

Patients considering GRS must first undertake psychiatric counselling, which generally occurs at the same time as the patient commencing Hormone Replacement Therapy (HRT) with an endocrinologist. Once a psychiatrist and endocrinologist are satisfied that the patient has met the criteria for GRS, they are given approval to proceed with surgery.

Gender reassignment describes several treatments used to manage the condition Gender Dysmorphia

Australian Unity and benefits payable for Gender Reassignment Surgery
Private health insurance is not required to pay for gender reassignment surgery as a set package from beginning to end, as gender reassignment is not a medical diagnosis in itself. 

Mental Health Waiver
The Mental Health Waiver allows members who have served their two-month Waiting Period for Restricted Hospital psychiatric services to upgrade to a cover with Included Hospital psychiatric services and elect to have the two-month Waiting Period for those higher benefits waived. 

While your membership is suspended, we will not pay on any claims for services or treatments that occur during that period. Any remaining waiting periods must be served on reactivation of your membership. 

Overseas Trip
If you’re travelling overseas, you can suspend your membership for a minimum of two months and up to two years. You need to have at least a hospital cover and your membership must have been active for at least one continuous month prior to your application request and you must be paid up to or in advance of the requested suspension date. Your application must be submitted to us before your departure. A minimum of 12 months must have elapsed since your last suspension.

Financial Hardship
If you have been a Member with hospital cover for at least 12 continuous months and face financial hardship, you may apply to suspend your membership. Your membership must be paid up to the requested suspension date and the maximum period you can suspend is three months. A minimum of 12 months must have elapsed since your last suspension and only three periods of financial hardship suspension will be allowed in a lifetime.

Tax Implications
If you hold hospital cover, suspending your cover may mean you’re subject to the Medicare Levy Surcharge for the period you’re suspended. This is because you’re not considered by the Australian Taxation Office (ATO) to hold appropriate private hospital cover for the period. Contact your Accountant, Financial Advisor or call the ATO on 13 28 61 for more details.

In determining whether a device is eligible for payment we consider that it is intended for repeated use, can alleviate or assist a medical condition and is not useful where no illness or injury exists. An appliance must be supplied by a reputable supplier, who has a registered Australian Business Number (ABN), and authorised by the attending doctor or allied health professional. For a benefit to be paid on some aids and devices, a letter is required (no more than 6 months old) from your treating doctor or health practitioner indicating the medical condition for which the item is required.

For artificial aids or devices: such as Hearing Aids or Blood Pressure Monitor, your cover may specify a longer period of time over which the yearly dollar limit applies for that particular aid or device (noting the yearly limit still applies for groups of aids/ devices). For example on some covers, the maximum dollar limit only resets every two calendar years for devices like blood pressure monitors. During this time you can still claim benefits towards another blood pressure monitor up to the remaining set limit, which resets every two calendar years. Where there is a combined limit for a group of devices or aids, benefits are subject to the remaining limits of the combined group. Where this applies, your product Fact Sheet says, for example, “Benefit for each item is payable every 2 calendar years”.

No information is available at this stage

Australian Unity does not differentiate between physio modalities – this means we pay a physio session based on the provider’s registration, not the service.

For example, if the provider is a registered physio provider, we pay the session as physio, rather than the specifics of the treatment,ie, physio,vpilates, hydrotherapy etc.so if the provider is a registered physio, and is using clinical pilates to treat the member, the session will be paid as physio.