Gold Hospital

What is not covered (non-exhaustive list*)

• Services incurred before waiting periods have been served.
• Treatment for which Medicare does not pay a benefit, including cosmetic surgery. (Some benefits may be payable for hospital treatment following this surgery. Please call us for more details.)
• Services that are provided outside of the Commonwealth of Australia.
• Services where an entitlement exists or may exist under any compensation, sports club or third party insurance.
• A claim for a service that is submitted more than two years after the date of service.
• Outpatient services, unless there is an agreement between Emergency Services Health and the hospital.
• Pharmaceuticals not related to the reason for hospitalisation or not covered under the agreement with the hospital or provided on discharge.
• Exceptional high cost drugs where no or limited benefits are paid.
• Prostheses items that are not included on the Federal Government approved list.
• Charges greater than the benefit defined in the Federal Government’s Prostheses List.
• Personal and take-home items, e.g. newspapers, toiletries, television, hairdressing, manicure, etc.
• Treatment provided to a person in a private hospital emergency department.
• Aged care and accommodation in an aged care facility.
• If you’re in hospital for more than 35 consecutive days and not classified as an acute care patient, your benefits will significantly reduce.
• Benefits for ambulance services covered by a third party arrangement such as a State/Territory transportation scheme.

* This provides a general description of what is not covered. These are not “excluded or restricted” hospital treatments or services. Should you require information about a particular treatment or benefit please call us on 1300 703 703.

Like all private health funds, Emergency Services Health has waiting periods for new members, including people transferring from another insurer when taking out a higher level of cover. Waiting periods also apply to current members upgrading their cover.

Waiting periods are designed to protect the interest of our members. Without them, it would be easy for people to join only at the times when they need cover and to receive benefits. This would lead to higher premiums for all fund members.

At Emergency Services Health the waiting periods are:

Hospital benefits of Gold Hospital and Gold Combined:

• 2 months membership for all benefits, excluding accidents
• 12 months membership for obstetric treatment
• 12 months membership for pre-existing conditions, excluding psychiatric care, rehabilitation or palliative care.
• 12 months membership for travel and accommodation (general treatment) and home nursing. 
• 12 months membership for continuous positive air pressure (CPAP) machines, and goods and services under Non-surgically Implanted Prosthesis and Appliances and other aids and appliances.

Extras benefits for Rolling Extras and Gold Combined:

• 2 months membership for all benefits, excluding accidents
• 12 months membership for major dental (like crowns and dentures) and orthodontics, hearing aids, nebulisers, blood glucose & blood pressure monitors, blood coagulation monitor and for pre-existing conditions
• 12 month membership for Rollover Benefit (2 years Major Dental).

Gold Combined:

• 3 years membership for corrective laser eye surgery.

It is important to note that if you are transferring from another insurer, waiting periods only apply to the level of cover that is greater the previously held.

For instance, if you previously had a top hospital cover with the previous insurer but with an excess, the waiting period only applies to the excess when joining Emergency Services Health.

A government leaflet containing further information is available by clicking here.

Pre-existing conditions

If a new member has a pre-existing condition before joining Emergency Services Health, they may need to serve a 12-month waiting period under the terms of our policy before benefits are payable for the particular condition. This does not apply for psychiatric care, rehabilitation or palliative care.

A pre-existing condition is one where signs or symptoms of your ailment, illness or condition existed at any time during the six months preceding the day on which you purchased your insurance or upgraded to a higher level of cover.

A medical practitioner appointed by Emergency Services Health (not your own doctor) is the only person authorised to decide that a condition is pre-existing. The practitioner must, however, consider any information regarding signs and symptoms provided by your own treating doctor or specialist.

A government leaflet containing further information is available by clicking here

If a new member has a pre-existing condition before joining Emergency Services Health, they may need to serve a 12-month waiting period under the terms of our policy before benefits are payable for the particular condition. This does not apply for psychiatric care, rehabilitation or palliative care.

A pre-existing condition is one where signs or symptoms of your ailment, illness or condition existed at any time during the six months preceding the day on which you purchased your insurance or upgraded to a higher level of cover.

A medical practitioner appointed by Emergency Services Health (not your own doctor) is the only person authorised to decide that a condition is pre-existing. The practitioner must, however, consider any information regarding signs and symptoms provided by your own treating doctor or specialist.

A government leaflet containing further information is available by clicking here

At Emergency Services Health our hospital cover has no benefit limitation periods.

Other funds may apply benefit limitations which pay reduced benefits on one or more services for a set period of time that is no longer than normal waiting periods, then pay full benefits after this period.

Emergency Services Health - Unlimited Ambulance Cover Australia-wide

Did you know that to call an ambulance can cost around $900 depending on your state or territory?

In a medical emergency, the cost of calling an ambulance is not at the top of your mind, but the bill after can be quite a shock if you do not have an ambulance cover. Good news when you are insured with Emergency Services Health all policies include ambulance cover- Australia Wide no matter if you’re in your home state or visiting another part of Australia.  

Comprehensive 100% Ambulance cover for emergency transport, clinically required non-emergency transport and treatment not requiring transport.*

 What's not covered?

Benefits are not payable:

For elective ambulance transport or other non-eligible ambulance service, for example when you pre-book transport between locations such as going from a hospital to a nursing home.

When you’re covered by a third party arrangement**.  For example where you are covered by an ambulance subscription or if you have access to a State/Territory ambulance transportation scheme. 

If you are still serving waiting periods.

*May be subject to waiting periods and other conditions.

**Third Party Arrangements:  Please note Queensland and Tasmanian residents have third-party arrangement ambulance services provided by state government schemes. In some other states, Department of Veterans Affairs Gold Card, pension and healthcare card holders may be exempt from paying for ambulance services.  Under those arrangements, the relevant scheme is responsible for the cost and Emergency Services Health does not pay a benefit. If the benefit for any eligible ambulance treatment costs are not fully covered by an arrangement or scheme, Emergency Services Health will pay a benefit.

Under our Access Gap Cover you may never have to pay a doctor’s bill. Your doctor can forward all accounts to us and we pay them on your behalf.

Top Tip

Before you’re admitted to hospital check with your doctor if they are one of 25,000 doctors Australia wide who has an arrangement with us under the Access Gap Cover scheme.

When doctors bill under this arrangement we can pay higher benefits to eliminate or at least reduce your out of pocket costs.

While all doctors can be involved in Access Gap Cover, it is up to individual doctors to participate on a case by case basis.

Please speak with your doctor or specialist to see if they will participate in Access Gap Cover for any planned private hospital treatment. For a list of providers eligible to participate and who have agreed for their details to be published, please call us or use our online provider search.