Complaints hit a new high – but disputes remain low

Assisted Reproductive Services
and Private Health Insurance

Infertility and Assisted Reproductive Services
Waiting Periods
Infertility is defined as the inability to conceive after one year of regular, As infertility is generally defined as the inability to conceive after one year, unprotected intercourse. Infertility can be caused by many factors, including assisted reproductive services wil usual y be subject to the twelve month genetic, medical, surgical, or trauma related causes in either the male or waiting period for pre-existing conditions. This means you need to complete female or both. Equally, there is a range of assisted reproductive treatments twelve months of membership on an appropriate hospital policy prior to the available to assist in treating the condition. commencement of IVF treatment in order to be eligible for benefits. In Vitro Fertilisation (IVF) treatment and Gamete Intra Fallopian Transfer If you do need treatment within the first twelve months of taking out or (GIFT) are two of the procedures for treating infertility which are most upgrading your policy, your fund will assess whether your condition is a pre- commonly covered by private health funds. existing condition and therefore, whether benefits are payable. You will need to ask your treating doctors to complete a medical certificate supplied by Choosing a Hospital Policy
your fund to assist the fund’s medical adviser in determining whether your condition is a pre-existing condition or not. Assisted reproductive services are not covered by al health insurance policies. Always check with your fund before proceeding with IVF or similar It’s important to note that it is the fund’s medical adviser that makes this treatments to confirm whether you are covered for these services, whether decision and not your treating doctors. The fund medical adviser will take there are services you wil be required to pay for yourself, and whether you account of information provided by your treating doctors in making his or her have completed any required waiting periods. If your current policy doesn’t decision. You should ensure this assessment has been completed before you include Assisted Reproductive Services, you will need to upgrade your policy. are admitted to hospital for treatment. Otherwise, you may be liable for the cost of the admission if benefits are denied by your fund on the basis of the pre-existing conditions rule. For more information about waiting periods, see Waiting periods apply when you take out or upgrade your hospital policy. PHIO’s “Waiting Periods” brochure. Australian funds apply the following maximum waiting periods: Some funds also include Benefit Limitation Periods as a feature of some of • a two month waiting period for any benefits; their hospital policies. These are initial periods of membership during which • a twelve month waiting period for benefits for pre-existing only a minimal benefit is paid for some types of treatment. These Benefit Limitation Periods may be from one to three years, depending on the policy. • a twelve month waiting period for benefits for obstetrics (maternity) Check with your fund for more information. Issued by The Private Health Insurance Ombudsman
March 2011
Assisted Reproductive Services
and Private Health Insurance

What’s covered by private hospital insurance?
What isn’t covered by private health insurance?
It’s important to know that that for IVF treatment, like most other medical There are many components to IVF treatment and some of the associated treatments, only in-patient services (where you are formally admitted as a services occur outside of a hospital admission (out-patient services). These private patient to the hospital) that have a valid Medicare item number will services include consultations with your clinic and doctor, scans, ultrasounds, attract a benefit from your health fund. some diagnostic procedures and pathology services. Some of these services may be claimable through Medicare and some wil be at your own expense. This means that if there is no Medicare item number for the service or There are also additional costs associated with egg transportation, testing and treatment, your fund may not pay any benefits towards the cost of the freezing that may be at your own expense. procedure. The hospital should advise you prior to admission about any costs you wil incur for the procedure and obtain your informed consent to IVF treatment also includes the use of IVF drugs. Not all drugs will attract a benefit from Medicare. Drugs that are not covered by Medicare include, but are not limited to, Lucrin, Provera, Synarel, Orgalutran and progesterone Generally, the main surgical procedure in an IVF cycle is the egg collection. pessaries. Your health fund may provide a benefit toward the cost of some of This procedure is also referred to as egg pick-up, oocyte pick-up, OPU, and the IVF related drugs. It’s important that you contact your health fund to sometimes egg harvesting. As this procedure is carried out in an operating discuss what benefits are payable toward the IVF drugs specific to your theatre, you will be admitted as an in-patient to hospital. If your policy covers Assisted Reproductive Services, then the hospital accommodation and theatre fees will be covered by your health fund. Your fund will also provide a More Information
benefit towards your anaesthetist and treating doctors’ fees. You may have to pay part of the medical fees yourself (the portion charged above the To help determine what you wil be covered for, we strongly recommend you Medicare Benefits Schedule fee, known as the ‘gap fee’) – check with your ask your IVF clinic for a detailed quote of your expected treatment plan, including all medical item numbers. Take this information to your fund – having this quote will assist your fund in being able to accurately advise you In some cases, you may also be admitted as an in-patient for the embryo about how you are covered and what costs you are likely to incur. transfer procedure. If this is the case, the same benefits as described above For more information on private health insurance, contact our office: Websitesan
Phone: 1300 737 299
Issued by The Private Health Insurance Ombudsman
March 2011


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