This is the “fine print” page with necessary legal information. If you still have questions or would prefer to chat, give us a call; we’re happy to help.
Hospital Cover Waiting Periods
Excluding Hospital Psychiatric services, Rehabilitation and Palliative Care
|Pregnancy and birth||12 months|
|Hospital Psychiatric services, Rehabilitation and Palliative Care
Regardless of whether they are pre-existing or not
|All other conditions requiring a hospital admission, that are not considered pre-existing||2 months|
|Hospital Care programs||2 months|
|Hospital treatment as a result of an accident||No waiting period|
*A pre-existing condition is any condition in which signs or symptoms existed (in the opinion of an independent Medical Practitioner appointed by Phoenix Health) in the 6 months prior to taking out Private Health Cover, or upgrading hospital cover.
If hospitalisation is required within waiting periods, Phoenix Health will require forms to be completed by both the member’s treating GP and Specialist, which will then be assessed by an external independent Doctor appointed by the Fund, who will determine whether the condition is considered re-existing or not.
Extras Cover Waiting Periods
|Major Dental||12 months|
|Hearing Aids||12 months|
|Aids to Recovery||12 months|
|All other Extras services||2 months|
*An accident is any unplanned or unforeseen event that results in an injury that requires immediate treatment after joining Phoenix Health. This does not include unforeseen episodes that can be related or affiliated to a medical condition.
Psychiatric Hospital Upgrade Waiver
To improve access to mental health treatment in Australia, the Government have introduced mandatory Psychiatric Hospital upgrade waiver rules.
Where a member holds a cover that has restrictions on hospital psychiatric services, and has served their 2 month waiting periods, the member may elect to upgrade to a cover that provides full access to psychiatric services without having to serve any waiting periods for that service. This waiver does not extend to the waiving of any upgrades in Excess (and or co-payments) that apply.
The psychiatric waiver is only available once per person per insured lifetime, and is transferrable between health funds.
*Transferring Members: For transferring members who have used all or part of their annual limits under their previous cover, the member will only receive the difference between the Phoenix Health Fund limit for their level of cover and the amount already claimed in this calendar year. Members transferring from another cover that has lower limits or benefit exclusions compared to the chosen Phoenix Health Fund cover must serve the waiting periods listed above before they can claim more than the previous cover’s benefits or limits. Claims are unable to be paid for transferring members until Phoenix has received confirmation of served waiting periods through an interfund transfer certificate generated by the previous health fund.
*Obstetrics: The fund advises that to accommodate for a premature birth, members will need to purchase the correct level of cover at the appropriate time so that the fund can provide benefit payments for obstetrics.
Continuation of membership
Members leaving the employ of any of our associated companies are encouraged to retain their membership. Refer to Payment of Contributions for alternative payment options.
Suspension of membership
Members may suspend their membership when they are travelling overseas for a minimum of 21 days, up to a maximum of 2 years, by submitting an Overseas Travel Temporary Suspension of Membership Application form prior to their departure and agreeing to the terms and conditions of suspension.
Members must provide their proof of travel within 30 days of their return to Australia, by supplying us with their e-tickets or boarding passes for all members on their policy, showing their exit and re-entry into Australia for their membership to be re-activated and their suspension to be honoured. Where a membership is not re-activated within the required time, or the member fails to meet the requirements of suspension, Phoenix Health may cancel the suspension, or in some cases terminate the policy, and waiting periods may apply on re-joining.
A membership must be active and financial for a minimum period of 6 months before a suspension will be approved, and suspensions are not available to Extras only memberships. Benefits are not claimable during a period of suspension. As you do not hold hospital cover during a suspension period, in some cases the Medicare Levy Surcharge may apply.
For full eligibility criteria and terms and conditions, please contact the Phoenix Health Team, or check out the Overseas Travel Temporary Suspension of Membership Application form.
Making a complaint or providing feedback
Happy members make us happy, and as such we are focused on providing you with the best, most personal health insurance experience possible. If you would ever like to provide feedback, or if you would like to make a complaint about your membership, please reach out to us as, so that we can address your concerns and come to a resolution for you as quickly as possible.
Step One: Contact Us
We appreciate and take your feedback seriously and any complaints will be dealt with in accordance with our Dispute Resolution Policy.
Call us: 1800 028 817
Email us: firstname.lastname@example.org
Write to us: PO Box 156 Newcastle NSW 2300
Step Two: Escalation
Once you have contacted us as above, if you are not happy with the outcome the matter can be escalated internally to the Member Service Manager, and if required the Chief Executive Officer and/or Board of Directors.
Step Three: External Review
If, after our best efforts, you are still not satisfied with our review and result of your concern, you can escalate your issue to the Commonwealth Ombudsman for Private Health Insurance.
Phone: 1300 362 072
For a copy of the Phoenix Health Dispute Resolution Policy, click here.
Dependants may remain in the fund in their own right after reaching the age of twenty-one (21) years as student dependants or up to the age of 25 on an Extended Family membership. Dependant children can still be covered asunder their parents’ membership provided the following conditions are met:
- A full time student at a school, college or university which is recognised for income tax purposes
- Is under the age of 25 years
- Is in receipt of an annual income not in excess of that which is recognised as the maximum annual income a person may derive before taxation becomes payable, and
- A Student Declaration form is submitted.
Please call or email our Member Service Team to learn more about Extended Family cover and for a personalised quote.
International travel & purchases
The Fund does not pay benefits for services provided outside of Australia and we recommend members consider Travel Insurance when travelling overseas and for some cruises when travelling off the coast of Australia. The Fund does not pay a benefit for any items purchased while outside of Australia.
Nursing Home Type Patients
Unless a doctor certifies otherwise, patients in hospital for in excess of 35 days continuously are regarded as Nursing Home Type Patients. Nursing Home Type Patients are required by legislation to pay part of the daily accommodation charge as approved by the federal Minister of Health.
Restriction and Exclusion Rules
- A contributor who is in arrears for a period of up to two months and pays all such arrears before the end of that period is entitled to benefits for services during that period.
- Fund benefits are not payable where a contributor or dependant has received or established a right to receive a payment by way of compensation or damages (including a payment in settlement of a claim for compensation or damages) under the law that is or was in force in a State or Internal Territory, which, in the opinion of the organisation, includes an amount for expenses equivalent to the fund benefit that would otherwise be payable.
- Cosmetic surgery benefits are excluded where Medicare does not pay a benefit.
- Psychology: No Fund benefits are payable for services claimed from Medicare.
- The fund will not pay for services that are provided by family members or relatives.
- The fund will not pay for services that fall outside of fund required service provider registrations and associations (specific registrations and associations can be found on the products page alongside the service).
- The fund will pay limited benefits for surgical podiatry in hospital for recognised podiatric surgeons only.
- Services provided outside of Australia.
- For hospital services considered to be restricted, the fund will pay minimum benefits for Private hospital accommodation, theatre fees and labour ward. Members should expect out of pocket expenses.
- For hospital services considered to be excluded, the fund will pay no benefit.
Payment of contributions
- Direct Debit through either a:
- Bank Account, Building society or Credit union debit account – frequency options of weekly, fortnightly, monthly or quarterly OR;
- Credit Card (Visa & MasterCard) – frequency options of weekly, fortnightly, monthly or quarterly.
- By quarterly payments in advance. Pay your account off using our Online Payment Facility, Bpay or over the phone. The Fund forwards accounts to your postal address detailing contributions owing to the end of the next applicable quarterly period (i.e. periods ending 31 March, 30 June, 30 September and 31 December).
Payment of Benefits
The maximum payment from each table will be as stated or the amount of the account, whichever is the lesser. Initial consultation benefits are paid only once per person per calendar year.
Limitation of benefits
All limits are per person. In all cases where benefit payments are limited to a calendar year the period will be from 1st January to 31st December. Please also note that product pages do not include the full detail of all services covered, and that sub-limits apply for some services. It is recommended that you contact the fund before your treatment to check exactly what you are covered for.
Submission of claims
Members must ensure that all claims are submitted for processing within two (2) years from the date of service.
Government Surcharges and Incentives
Please see our Understanding Private Health Insurance page to learn more about the following
- Rebate on Private Health Insurance
- Medicare Levy Surcharge (MLS)
- Lifetime Health Cover (LHC)
- Age-based discount
30-day Cooling Off Period
Changed your mind? You have a 30-day cooling off period from the commencement date of your cover to change your mind or your cover choice. This allows you to review your cover and be sure you have made the right decision.
If you cancel your membership during the 30-day cooling off period, you will receive a full refund of any premiums you have paid as long as we haven’t processed and paid any claims during that period. If Phoenix Health have paid you a claim, premiums will only be refunded from the day after the date of service.
If you’re already a member and change your level of cover, then change your mind, you can revert back to the previous cover level held within the 30-day cooling off period.