Apia Health Insurance

The immediate necessary treatment required as a result of an accident. To be covered for the Accidental Injury Benefit, you must provide documented proof that you have sought treatment at a hospital emergency department or by a medical practitioner within 72 hours of the Accident. The Emergency Department attendance is classed by the Australian Department of Health as an outpatient service, not a hospital admission, and therefore it is not payable by the Fund. The Accidental Injury Benefit covers further treatment in hospital as an admitted patient, where you are re-admitted to a hospital within 90 days of the initial visit.

For example:

• If you were sent home from the Emergency Department before returning within 90 days to be admitted as an inpatient for further treatment relating to the original accident.

Waiting Period: 1 Day

Emergency ambulance transport.

Under all Apia covers, no benefits are payable towards hospital treatment for fertility treatments or procedures.

For example:

• retrieval of eggs or sperm,
• In vitro Fertilisation (IVF), and
• Gamete Intra-fallopian Transfer (GIFT).

Hospital treatment for the investigation and treatment of the back, neck and spinal column, including spinal fusion.

For example:

• sciatica,
• prolapsed or herniated disc, and
• spine curvature disorders such as scoliosis, kyphosis and lordosis.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for the investigation and treatment of diseases, disorders and injuries of the musculoskeletal system.

For example:

• carpal tunnel,
• fractures,
• hand surgery,
• joint fusion,
• bone spurs,
• osteomyelitis and
• bone cancer.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for the investigation and treatment of blood and blood-related conditions.

For example:

• blood clotting disorders and
• bone marrow transplants.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for the investigation and treatment of the brain, brain-related conditions, spinal cord and peripheral nervous system.

For example:

• stroke,
• brain or spinal cord tumours,
• head injuries,
• epilepsy and
• Parkinson’s disease.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for the investigation and treatment of breast disorders and associated lymph nodes, and reconstruction and/or reduction following breast surgery or a preventative mastectomy.

For example:

• breast lesions,
• breast tumours,
• asymmetry due to breast cancer surgery, and
• gynecomastia.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for surgery to remove a cataract and replace with an artificial lens.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for chemotherapy, radiotherapy and immunotherapy for the treatment of cancer or benign tumours. Surgical treatment of cancer is listed separately under each body system.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Under all Apia covers, no benefits are payable towards procedures or hospital costs associated with cosmetic surgery to enhance appearance.

Hospital treatment for surgery to the teeth and gums.

For example:

• surgery to remove wisdom teeth, and
• dental implant surgery.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for the investigation and management of diabetes.

For example:

• stabilisation of hypo- or hyper- glycaemia,
• contour problems due to insulin injections.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for the investigation and treatment of the digestive system, including the oesophagus, stomach, gall bladder, pancreas, spleen, liver and bowel.

For example:

• oesophageal cancer,
• irritable bowel syndrome,
• gall stones and
• haemorrhoids.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for the investigation and treatment of the eye and the contents of the eye socket.

For example:

• retinal detachment,
• tear duct conditions,
• eye infections and
• medically managed trauma to the eye. 

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for the investigation and treatment of the ear, nose, throat, middle ear, thyroid, parathyroid, larynx, lymph nodes and related areas of the head and neck.

For example:

• damaged ear drum,
• sinus surgery,
• removal of foreign bodies,
• stapedectomy and
• throat cancer.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for the diagnosis, investigation and treatment of the internal parts of the gastrointestinal system using an endoscope.

For example:

• colonoscopy,
• gastroscopy,
• endoscopic retrograde cholangiopancreatography (ERCP).

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Waiting Period: 12 months (2 months for ailments / conditions that are not pre-existing)

Medical procedure to examine the oesophagus (throat), stomach and duodenum (first part of the small intestine). Gastroscopies can be used to diagnose and investigate:

• difficult or painful swallowing
• pain in the stomach
• bleeding
• ulcers
• cancers

Hospital treatment for the investigation and treatment of the female reproductive system.

For example:

• endometriosis,
• polycystic ovaries,
• female sterilisation and
• cervical cancer.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for the investigation and treatment of the heart, heart-related conditions and vascular system.

For example:

• heart failure and heart attack,
• monitoring of heart conditions,
• varicose veins and
• removal of plaque from arterial walls.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for the investigation and treatment of a hernia or appendicitis.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment to correct hearing loss, including implantation of a prosthetic hearing device.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Under all Apia covers no benefits are payable towards surgery to investigate a female's fallopian tubes and the condition of uterus and ovaries in relation to infertility. It can also treat conditions effecting fertility such as:

• Endometriosis
• tubal microsurgery
• removal of fibroids
• correction of uterine abnormalities

Hospital treatment for the provision and replacement of insulin pumps for treatment of diabetes.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Waiting Period: 12 months (2 months for ailments / conditions that are not pre-existing)

Surgery to examine the inside of a joint for accurate diagnosis and removal of loose bodies. This may include the investigation of the:

• knee
• shoulder
• elbow
• ankle

Hospital treatment for surgery for joint reconstructions.

For example:

• torn tendons,
• rotator cuff tears and
• damaged ligaments.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for surgery for joint replacements, including revisions, resurfacing, partial replacements and removal of prostheses.

For example:

• replacement of shoulder, wrist, finger, hip, knee, ankle, or toe joint, and
• spinal disc replacement.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for the investigation and treatment of the lungs, lung-related conditions, mediastinum and chest.

For example:

• lung cancer,
• respiratory disorders such as asthma, pneumonia, and
• treatment of trauma to the chest.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for the investigation and treatment of the male reproductive system including the prostate.

For example:

• male sterilisation,
• circumcision and
• prostate cancer.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for surgery that is designed to reduce a person’s weight, remove excess skin due to weight loss and reversal of a bariatric procedure.

For example:

• gastric banding,
• gastric bypass,
• sleeve gastrectomy.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for pain management that does not require the insertion or surgical management of a device.

For example:

• treatment of nerve pain and chest pain due to cancer by injection of a nerve block.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for care where the intent is primarily providing quality of life for a patient with a terminal illness, including treatment to alleviate and manage pain.

Waiting Period: 2 Months

Hospital treatment for the implantation, replacement or other surgical management of a device required for the treatment of pain.

For example:

• treatment of nerve pain, back pain, and pain caused by coronary heart disease with a device (for example an infusion pump or neurostimulator).

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Under all Apia covers, no benefits are payable towards hospital treatment for investigation and treatment of conditions associated with pregnancy and child birth.

Hospital treatment for the treatment and care of patients with psychiatric, mental, addiction or behavioural disorders.

For example:

• psychoses such as schizophrenia,
• mood disorders such as depression,
• eating disorders and
• addiction therapy.

Waiting Period: 2 Months

Hospital treatment for physical rehabilitation for a patient related to surgery or illness.

For example:

• inpatient and admitted day patient rehabilitation, stroke recovery, cardiac rehabilitation.

Waiting Period: 2 Months

Hospital treatment for dialysis treatment for chronic kidney failure.

For example:

• peritoneal dialysis and
• haemodialysis.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Waiting Period: 12 months (2 months for ailments / conditions that are not pre-existing)

Treatment for a stroke. A stroke or CVA is the rapid loss of brain function(s) due to disturbance in the blood supply to the brain. This can be due to lack of blood flow (ischemia) caused by a:

• blockage (thrombosis, arterial embolism)
• haemorrhage

Emergency ambulance transport paid at 100% of the cost.

Waiting period: 1 day.

e.g. fillings, basic extractions, x-rays.

Waiting period: 2 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Includes root canal therapy, crowns, bridges, dentures, oral surgery.

Waiting period: 12 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Includes selected examinations, scale and cleans and fluoride treatments.

Waiting period: 2 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

e.g. prescription glasses and contact lenses

Waiting period: 6 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Waiting period: 2 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Waiting period: 2 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Waiting period: 2 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Waiting period: 2 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Waiting period: 2 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Surgical stockings, CPAP Machine, CPAP parts, pressure garment, walking frame, blood pressure monitor, hip protector, blood coagulation device, erectile dysfunction pump, macular degeneration aid.

Waiting period: 12 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Approved: weight management, quit smoking and health management programs (gym, personal trainer).

Waiting period: 6 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Waiting period: 36 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Waiting Period: 36 months

A hearing aid is a battery-powered, electronic device that makes listening easier for people with hearing loss. Benefits are payable for speech processors (the external component of a cochlear implant) when the processor is replaced as part of an out-patient procedure.

Waiting period: 2 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Hospital treatment for the investigation and treatment of the kidney, adrenal gland and bladder.

For example:

• kidney stones,
• adrenal gland tumour and
• incontinence.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for the investigation and treatment of a miscarriage or for termination of pregnancy.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Remedial massage, acupuncture, Chinese herbalism and myotherapy.

Waiting period: 2 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Remedial massage, acupuncture, Chinese herbalism and myotherapy.

Waiting period: 2 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Waiting period: 2 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Increasing by $100 per calendar year to lifetime limit of $2,600.

Waiting period: 12 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Hospital treatment for care where the intent is primarily providing quality of life for a patient with a terminal illness, including treatment to alleviate and manage pain.

Waiting Period: 2 Months

Benefits only payable for non PBS items. Benefits do not apply to prescriptions dispensed to hospital in-patients.

Waiting period: 2 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Waiting period: 2 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Hospital treatment which is medically necessary for the investigation and treatment of any physical deformity, whether acquired as a result of illness or accident, or congenital.

For example:

• burns requiring a graft,
• cleft palate,
• club foot and
• angioma.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Thin prep, bone density tests, bowel screening.

Waiting period: 6 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Waiting period: 2 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Hospital treatment for the investigation and treatment of skin, skin-related conditions and nails. The removal of foreign bodies is also included. Plastic surgery that is medically necessary and relating to the treatment of a skin-related condition is also included.

For example:

• melanoma,
• minor wound repair and
• abscesses.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for the investigation of sleep patterns and anomalies.

For example:

• sleep apnoea and
• snoring.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for the treatment and care of patients with psychiatric, mental, addiction or behavioural disorders.

For example:

• psychoses such as schizophrenia,
• mood disorders such as depression,
• eating disorders and
• addiction therapy.

Waiting Period: 2 Months

Waiting period: 2 months (Applies if you are new to health insurance or if you have recently increased your level of Extras cover).

Hospital treatment of the tonsils, adenoids and insertion or removal of grommets.

Waiting Period: 12 months (2 Months for ailments / conditions that are not pre-existing)

Hospital treatment for the investigation and treatment of conditions affecting the foot and/or ankle, provided by a registered podiatric surgeon.

Limited to cover for: accommodation; and the cost of a prosthesis as listed in the prostheses list set out in the Private Health Insurance (Prostheses) Rules, as in force from time to time.

Waiting Period: 12 Months (2 Month for ailments / conditions that are not pre-existing)

² Disclaimer: It is important to be aware that Podiatric Surgeon fees for services performed in Hospital besides the hospital treatment for the investigation and treatment of conditions affecting the foot and/or ankle, provided by a registered podiatric surgeon are not Covered. We will not pay benefits for theatre fees and services performed by the Podiatric Surgeon, any medical practitioner, specialist, radiologist, radiographer, sonographer, or pathologist that may be provided during or associated with Podiatric Surgery (provided by a registered podiatric surgeon).