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Many of the terms used on this website, in our brochures and Fund Rules have a specific meaning. This Glossary outlines some of the key terms we use in relation to your health cover.

You should refer to our Fund Rules for a full listing of key terms relating to your health cover. Please note that our Fund Rules, and the terms used below, may change from time to time.

Before joining any Bupa health cover, you should carefully read our Fund Rules, the information on the website and any brochures or Standard Information Statement available to you, and you should retain this information for future guidance.

Download a copy of our Fund Rules (PDF), or alternatively visit any Bupa Centre to view a copy.

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  • Accidents

    An accident is an unforeseen event, occurring by chance and caused by an unintentional and external force or object resulting in involuntary hurt or damage to the body, which requires immediate (within 72 hours) medical advice or treatment from a registered practitioner other than the policyholder.

  • Adjusted taxable income

    Generally your adjusted taxable income includes your:

    - taxable income
    - adjusted fringe benefits amount (total reportable fringe benefit amounts x 0.535)
    - tax-free pensions or benefits
    - target foreign income (includes any income earned from overseas that is not already in your taxable income or received in the form of a fringe benefit)
    - reportable super contributions (includes both reportable employer super contributions and deductible personal super contributions)
    - total net investment loss (includes both net financial investment loss and net rental property loss) less
    - deductible child maintenance expenditure (child support you paid)

    Annual maximums and service limits

    An annual maximum is the maximum amount you can claim in a service category per person and per calendar year (unless otherwise stated). For certain services, annual maximums also apply on the number of times that benefits are payable for the same service (e.g. initial consultations). These maximums apply from the date of service or purchase. Some services also have lifetime limits or periodic annual maximums (e.g. orthodontics). Per person annual maximums are not transferable to any other member on your policy.


  • Bupa Medical Gap Scheme

    This refers to the difference between what your doctor charges and the amount Medicare pays for inpatient procedures. If your doctor charges up to the Medicare Benefits Schedule (MBS) fee or is participating in the Bupa Medical Gap Scheme, in most cases you will have no medical gap costs to pay.

    For doctors who are not participating in our Medical Gap Scheme and are charging above the MBS fee, we will pay the difference between the Medicare benefit and the MBS fee. Any amount above the MBS fee will be the amount you are required to pay and this is referred to as the 'Medical Gap'.


  • Calendar year

    A calendar year is 1 January to 31 December.


  • Emergency admissions

    In an emergency, we may not have time to determine if you are affected by the pre-existing condition rule before your admission. Consequently, if you have been a Bupa member for less than 12 months you might have to pay for some or all of the hospital and medical charges if:

    • you are admitted to hospital and you choose to be treated as a private patient, and we later determine that your condition was pre-existing.
  • Excess or co-payment

    To lower the cost of your hospital cover, on selected covers you can choose to include an excess or co-payment. Excesses or co-payments are only payable on overnight and same-day inpatient hospital admissions in any hospital.

    • An excess is a set amount you pay upfront before your benefit is paid. The excess is paid each time a person on your membership is admitted into hospital, to a maximum of once per person and twice on the entire membership each calendar year unless otherwise specified.
    • A co-payment is an amount you agree to pay towards the cost of your daily hospital bill. A co-payment is charged per day and capped after five days for each hospital admission.
    • No excess or co-payment applies to your children on certain hospital covers. Please contact us for further details.
  • Exclusions

    If you require treatment for a specific procedure or service that is excluded under your level of cover you will not receive any benefits towards your hospital and medical costs and you may have significant out-ofpocket costs.

    If a service is not covered by Medicare there will be no benefit payable from your hospital cover so you should always check with us to see if you’re covered before receiving treatment.


  • Health aids and appliances

    To receive benefits for health aids andappliances you'll need to visit one of our recognised providers. You'll also need to meet the eligibility criteria, provide proof of purchase and a clinical referral where required. It is important to note that benefits are not payable when a prescribed treatment is not fully custom made (e.g. orthotics). Visit our website or contact us to find out more.

    Benefits for hire, repair and maintenance of health aids and appliances are not payable in the first 12 months after purchasing an item; within 12 months following a repair; or on items where hire and repair are deemed inappropriate.

  • Home nursing

    Benefits are payable towards some home nursing services that do not need to take place in a hospital and are provided in the home. Please contact us to find out more.


  • Living Well Programs

    Our Living Well Programs help cover healthrelated programs from approved, recognised providers. You can visit our website for a list of our recognised providers. A Living Well Programs approval form must be completed by your doctor for gym memberships, yoga and Pilates to confirm that the program is medically necessary. Other benefit and recognition criteria apply. Visit our website or contact us to find out more.


  • Out-of-pocket expenses

    You are likely to experience out-of-pocket expenses when you are not fully covered for services and benefits, or when a set benefit applies. You should refer to what is and isn't covered for your relevant level of cover to determine when an out-of-pocket expense may occur. You should also refer to our Fund Rules for any additional information on benefits payable. A copy of our Fund Rules can be found on our website or in our retail centres.

    It is important to ensure when being admitted to hospital that Informed Financial Consent is provided to you for a pre-booked admission to allow you to understand any out-of-pocket expenses upfront. If you have received any out-of-pocket expenses and require clarification, please contact us directly.


  • Pre-existing conditions

    A pre-existing condition is any condition, ailment or illness that you had signs or symptoms of during the six months before you joined or upgraded to a higher level of cover with us. It is not necessary that you or your doctor knew what your condition was or that the condition had been diagnosed.

    A condition can still be classed as preexisting even if you hadn't seen your doctor about it before joining or upgrading to a higher level of cover.

    If you knew you weren't well, or had signs of a condition that a doctor would have detected (if you had seen one) during the six months prior to joining or upgrading, then the condition would be classed as pre-existing.

    A doctor appointed by us decides whether your condition is pre-existing, not you or your doctor. The appointed doctor must consider your treating doctors' opinions on the signs and symptoms of your condition, but is not bound to agree with them.

  • Premium and benefits

    You must pay the premium and the Lifetime Health Cover Loading that applies to you. Premiums differ from state to state due to different state charges. If you move to another state your premium will change too. Therefore you must let us know about any change of address.

    To receive the benefits available on your cover, you need to:

    • fully complete the application process and pay your premiums one month in advance. Or, if you're on a corporate plan, it's up to you to make sure payments are made during times of unpaid leave or if your employment ends
    • ensure that newborns are enrolled onto a family membership within two months of their birth to avoid any waiting periods for your baby
    • enrol your adult children under their own names within 60 days after they no longer qualify under your cover (to avoid a break in their cover)
    • provide proof of purchase of what you have spent before we can reimburse you for any services received
    • submit your claims within two years of when the service was given (we don't pay benefits for any claims that are older than this).
  • Proof of identity and/or age

    Bupa may require you to provide proof of identity and/or age when joining, changing your level of cover or in relation to any other transaction with us.


  • Restricted cover/benefits

    For restricted services there will be full cover in a shared room with your choice of doctor in a public hospital and restricted/default benefits in a private hospital which would not be adequate to cover all hospital costs and are likely to result in large out-of pocket expenses.


  • Special Benefits

    If you're on a cover that provides Special Benefits cover, you could receive benefits for accommodation and meal costs if your partner, immediate family member, carer or next of kin is required to stay at hospital with you or a person on your membership. They will be covered for $60 per night for accommodation in hospital and up to $30 a day for hospital meals. Hospital meals are covered when provided at a hospital cafeteria, kiosk or patient meal menu. A $1,000 per person, per calendar year annual maximum applies to Special Benefits.

  • Surgically implanted prostheses

    You will be covered up to the benefit set out in the Government's Prostheses List for a listed prosthesis which is surgically implanted as part of your hospital treatment. The Prostheses List includes: pacemakers, defibrillators, cardiac stents, joint replacements, intraocular lenses and other devices. If a hospital proposes to charge you a 'gap' for your prosthesis, they need your informed financial consent. Please contact us for further details.

  • Suspension rules

    A membership may be suspended when travelling overseas for work or leisure. If you are travelling overseas, you may choose to suspend your membership during this period of time. You can suspend your cover for the following period of time:

    • a minimum period of two months travel; and
    • a maximum period of two years per suspension. You can only suspend your policy twice per calendar year. Your membership will be cancelled if not resumed. One month contributions are required between each suspension period.To be eligible to suspend your cover you must:
      • have been a financial member for at least 12 months
      • apply for suspension prior to thedeparture date
      • provide overseas travel documentation showing your departure and return dates
      • notify us of your return to Australia within 30 days of your arrival; and
      • complete an overseas travel suspension form.


  • Travel and accommodation

    On select levels of extras cover, if you're travelling for essential medical or hospital treatment because treatment you need cannot be provided by your own doctor, we will help cover the cost when the total return distance is 300 kilometres or more from your normal place of residence.

    We also give a benefit towards your overnight accommodation outside of hospital for you and a caregiver. Check your extras cover to determine if you are covered for these benefits.


  • Waiting periods

    A waiting period is the time between when you joined us and when you are covered for a service or treatment. If you receive a service or treatment during this time, you are not eligible to receive a benefit payment from us, regardless of when you submit the claim. Different waiting periods apply for different services.