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Non-Medicare medical expenses
This cover reimburses expenses that are not standard Medicare items (up to a maximum of $5,000 as per terms and conditions of the policy) and incurred within twelve (12) calendar months of you sustaining an injury, and are paid by you for treatment certified necessary by a legally qualified medical physician. This cover includes the cost of medical supplies and ambulance hire.
What are the benefits payable?
The table of benefits below must be read in conjunction with the policy wording.
Benefit |
Description |
Cover |
Non Medicare medical |
Reimbursement of non-Medicare medical expenses incurred within 12 calendar months. Can include Private Hospital Accommodation, Ambulance transport costs, Chiropractic, dental services, Ancillary Medical procedures, Theatre Fees in Private Hospital where Medicare fee doesn’t apply, Orthotics, splints and prostheses. Subject to the percentage and maximum sum insured. |
- 75% reimbursement |
Physiotherapy Benefits
|
If an insured person suffers bodily injury that results in physiotherapy treatment required and provided by a suitably qualified physiotherapist. |
- 1-5 visits 95% reimbursement - $50 excess per claim |
Domestic home help |
Reimbursement of actual costs of domestic home help. |
- 75% reimbursement |
Student allowance |
Reimbursement of actual costs incurred for home tutorial expenses. |
- 75% reimbursement |
Bed care patient |
Weekly payment to an insured person who is confined to a bed after a bodily injury for a period of not less than 7 days. |
- 100% reimbursement |
Parent Allowance |
For everyday a child under 20 years old spends in hospital |
- $50 per day |
Rehabilitation |
Reimbursement of all reasonable costs incurred for the rehabilitation of a bodily injury including but not limited to a gymnasium, pilates studio or physical trainer. |
- up to $500 maximum per claim |
Home / vehicle modification |
Reimbursement of costs incurred for home / vehicle renovations required as a direct result of bodily injury which is claimable under events 2 - 7 of Capital Benefits including but not limited to ramps, guide rails etc. |
- up to $3,500 maximum per claim |
Funeral expenses |
Reimbursement of costs as a result of event 1 of Capital Benefits |
- $5,000 maximum per claim |
Medicare vs Personal Injury Coverage
When it comes to reimbursement of Personal Injury claims, some people get confused about Medicare, the Medicare Gap and what is covered through the National Club Risk Protection Programme.
The Health Insurance Act (Cth) 1973 does not permit the trustee or insurer to contribute to any charges covered by Medicare (including the Medicare Gap).
This means that any charges for treatment from a doctor, surgeon, anesthetist or surgeon's assistant 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:
1. any expenses recoverable by you from any other insurance scheme or plan providing medical or similar coverage, or from any other source except for the excess of the amount recoverable from such other policies/plans.
2. any expense to which the National Health Act (Cth) 1953 or any of the regulations made there under apply.
What is Medicare?
Medicare is a Commonwealth Government programme that provides eligible Australian residents with free or low-cost medical and hospital care.
Medicare provides access to:
- Free treatment as a public (Medicare) patient in a public hospital.
- Free or subsidised treatment by practitioners such as Doctors and specialists.
What’s covered by Medicare?
The Medicare Benefits Schedule (MBS) lists all treatments and associated rebates relating to Medicare. You can access the MBS at any time via Medicare’s web site. Items commonly used by sports participants that are Medicare listed include general practitioners, surgeons and anesthetists.
What is the Medicare Gap?
The MBS lists a rebate amount for each Medicare Item.
Example: A short consultation with a Doctor = Medicare rebate of $15.35
However, doctors or specialists may charge more than the listed MBS amount.
The difference between what is charged and the MBS rebate is called the “Medicare Gap”.
- The Doctor charges $45.00.
- Medicare provides a rebate of $15.35.
- Medicare Gap = $29.65 (out of pocket expense).
What’s the difference between Medicare and our National Club Risk Protection Programme?
The Health Insurance Act 1973 (Cth) strictly prohibits any general insurer from insuring any item that is listed on the Medicare Benefits Schedule.
This also means that regardless of your out of pocket expenses, it is against the law for the Insurer to cover the Medicare Gap.
So what does that mean?
If your medical or other treatment has a Medicare Item Number, such as the doctor fee above, it is claimable on Medicare but is uninsurable and you may not claim for reimbursement through Sportscover. In the example you cannot claim the $29.65.
If your medical or other treatment does not have a Medicare Item Number, you may claim for reimbursement through Marsh Advantage Insurance.
Please refer to the policy wording for a complete list of policy conditions and exclusions or by calling Marsh Advantage Insurance on 1300 130 373.