Health Insurance

Waiting Period: 1 day

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 within 24 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

If you need immediate medical attention and your condition means that you cannot be transported in another way, you are covered for:

• Emergency Ambulance transport to hospital provided by a State or Territory Ambulance service anywhere in Australia
• Emergency Ambulance call out fees (where the customer is treated at the scene by paramedics and it is determinded that transport to hospital is not required)
• Transport between hospitals when the transfer is required as a result of the existing hospital not specialising in the treatment required

Disclaimer: Emergency Ambulance transport is paid at 100% of the cost. No hospital excess is applicable for this service.

Under all Apia covers no benefits are payable towards Inpatient services relating to egg retrieval and implantation.

This includes:

• IVF
• GIFT

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

Surgery to treat back abnormality or injury. This includes:

• spinal fusion
• discectomy (surgical removal of a herniated disc)

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

Surgery to treat conditions of the brain or skull. This may include:

• removing a brain tumour
• bleeding (haemorrhage) in the brain
• blood clots (hematomas) in the brain
• weaknesses in blood vessels (brain aneurysm repair)
• craniotomy

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

Surgery to diagnose or remove cancer and in-hospital cancer treatments which are approved under the Pharmaceutical Benefits Scheme for the specific type of cancer being treated. This may include:

• surgery
• radiation (radiotherapy)
• chemotherapy

Disclaimer: You will not be covered for cancer surgery and in-hospital cancer treatment if it relates to an excluded service on your hospital cover. For example, if eye treatment & surgery is excluded on your hospital cover then cancer of the eye would also not be covered.

Cancer treatment in hospital: It is important to be aware that health insurance will only cover the portion of costs that relate to an admission to hospital. Specialist fees outside of hospital or other outpatient fees in relation to chemotherapy or radiotherapy aren’t covered.

High cost drugs are sometimes requested for the Treatment of some cancers. Typically high-cost drugs are for newer Treatments that are not recognised by the Pharmaceutical Benefit Scheme (PBS) because the PBS considers them to be still under clinical trial and therefore experimental Treatments. Health insurance will not Cover high cost drugs for the same reasons (or may only Cover a small portion of the cost). It is the responsibility of the treating doctor, and Hospital, to inform Patients about the potential for large out-of-pockets as a result of high cost drugs.

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

Medical procedure to examine the large intestine (colon) and/or to diagnose and investigate:

• cancer of the colon (bowel cancer)
• colon polyps)
• unexplained abdominal pain

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

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

Teeth extractions where a hospital admission is required for a general anaesthetic. This may include:

• surgical removal of impacted wisdom teeth

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

Surgery and treatment relating to the eye. This may include:

• cataract removal
• lens-related services

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

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

Procedures dealing with the health of the female reproductive system (uterus, vagina and ovaries) where not related to infertility. This may include:

• abdominal or vaginal hysterectomy
• endometriosis

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

The medical treatment or surgical procedure for cardiac conditions such as heart disease, arrhythmias, congenital defects. This may include:

• surgical insertion of pacemakers and defibrillators
• stent insertion
• coronary angioplasty and artery bypass grafts
• heart transplants
• operations for congenital defects and heart valve defects

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

Surgery to repair a hernia. A hernia is the protrusion of organs, such as intestines, through a weakened section of the abdominal wall. The most common sites are:

• in the groin
• abdominal areas such as the navel

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

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

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

Surgery to reconstruct damaged ligaments. This may include the reconstruction of the:

• knee
• shoulder

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

Surgery to replace a joint in the body with an artificial prosthesis. This can be the replacement of the entire joint or a component of it. This may include the replacement of the:

• hip
• knee
• shoulder

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

Surgery to reduce the capacity of the stomach as a treatment for morbid obesity. This may include:

• gastric banding surgery
• stomach bypass

Waiting Period: 2 months

The care of patients with serious illness to relieve pain. Palliative Care:

• provides relief from pain and other distressing symptoms
• does not hasten or postpone death
• supports people to live as actively as possible until death

Under all Apia covers no benefits are payable towards childbirth or complications during pregnancy. This may include:

• child birth
• early labour
• pregnancy induced diabetes
• hypertension

Waiting Period: 2 months (MBP)

Treatment of mental illness or addiction in a psychiatric facility. This may include treatment for:

• depression
• eating disorders
• drug and alcohol rehabilitation

*Minimum Benefits Payable (MBP) means that we will pay the minimum amount of benefits that we are required to pay under the Private Health Insurance Act, to or on behalf of a customer for hospital treatment under a Hospital cover. If you’re attending a Private Hospital for these services, there will be significant out-of-pocket costs. If a treatment important to you is listed as MBP, we recommend you consider a higher level of cover.

Waiting Period: 2 months

Physical therapy and exercise treatment at a rehabilitation facility following an inpatient admission. This may include:

• stroke recovery
• strengthening of joints and limbs
• cardiac rehabilitation

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

Treatment to replace the function of the kidneys. Primarily used by people with temporary or permanent renal failure.

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

Waiting Period: 1 day

If you need immediate medical attention and your condition means that you cannot be transported in another way, you are covered for:

• Emergency Ambulance transport to hospital provided by a State or Territory Ambulance service anywhere in Australia
• Emergency Ambulance call out fees (where the customer is treated at the scene by paramedics and it is determinded that transport to hospital is not required)
• Transport between hospitals when the transfer is required as a result of the existing hospital not specialising in the treatment required

Disclaimer: Emergency Ambulance transport is paid at 100% of the cost. No annual limit is applicable for this service.

Waiting Period: 2 months

Diagnostic and other preventative procedures (not covered under Preventative dental) completed to help you keep on top of your oral health. This is routine dental that includes:

• fillings
• basic extractions (excluding wisdom teeth)
• x-rays

Disclaimer: Doesn't include more complex treatments or procedures such as orthodontic work, endodontic treatment (root canal therapy), crowns or bridges. See Dental (Major).

Waiting Period: 12 months

Complex dentistry procedures such as:

• crowns and bridges
• root canal therapy
• removal of wisdom teeth
• dentures
• implants

Waiting Period: 2 months

Preventative dental treatment to help you maintain your oral health with no annual limits. This includes selected:

• examinations
• scale and clean
• fluoride treatments

Disclaimer: No annual limit is applicable for this service. For more diagnostic and preventative dental procedures see Dental (General).

Waiting Period: 6 months

Correction of visual impairment such as long or short sightedness. Examples of treatment include:

• prescription glasses
• contact lenses

Waiting Period: 2 months

Treatment by a physiotherapist which uses physical means to relieve pain, regain range of movement, restore muscle strength and return patients to normal activities of daily living.

Disclaimer: Benefits are only payable for consultations with a physiotherapist.

Waiting Period: 2 months

Chiropractic treatment involves manipulation based therapy to treat conditions related to the nerves, skeleton and muscles. Ostepathic treatment includes manipulation of the body to promote mobility and balance. Chiropractors and osteopaths are useful for:

• back and neck pain
• sciatica
• frequent headaches
• joint pains and muscle strains
• work-related, repetitive strain and sports-related injuries

Disclaimer: Benefits are only payable for consultations with a chiropractor or osteopath.

Waiting Period: 2 months

Dietitians and Nutritionists educate people on appropriate diet, menu planning and preparation of food to enhance and maintain optimum health.

Disclaimer: Benefits are only payable for consultations with a dietitian or nutritionist. Food items are not covered.

Waiting Period: 2 months

The use of exercise (as prescribed by an Exercise Physiologist) as a treatment strategy in the physical rehabilitation of a patient. Exercise physiologists assist with:

• disease prevention
• injury rehabilitation
• establishing and maintaining functional independence

Disclaimer: Benefits are only payable for consultations with an exercise physiologist.

Waiting Period: 2 months

Eye therapy involves detecting, assessing, diagnosing and performing non-surgical (and non-medical) management of eye movement disorders and abnormalities. Orthoptists exclusively specialise in treating conditions such as:

• lazy or turned eyes
• double vision
• vision impairments caused by trauma

Disclaimer: Benefits are only payable for consultations with an orthoptist.

Waiting Period: 12 months

A range of artificial and health aids that may assist in everyday living. Examples include:

• blood pressure monitor and coagulation checks (blood clots)
• hip, knee, ankle, foot and ankle-foot orthoses finger, hand, arm & elbow orthoses/splints nebuliser and spacers (asthma)

Waiting Period: 6 months

This benefit is designed to allow you to claim on items that assist your health and wellbeing as prescribed by your GP or nib recognised provider. Benefits are payable for the following services:

• gym memberships
• yoga and pilates classes
• personal training
• weight management programs (Jenny Craig, Weight Watchers)

Disclaimer: To claim on health management items, you'll need your GP or nib registered provider to sign a Health Management Program Supporting Evidence form. This cover is for consultations only (food or supplementary items are not covered).

Waiting Period: 36 months

A battery powered, electronic device that makes listening easier for people with hearing loss.

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

Services provided by a registered nurse in private practice for the treatment of illness, disease, incapacity or disability. This service includes:

• wound management
• removal of sutures
• pain management

Disclaimer: Benefits are not payable for services such as a nurse-housekeeper during recovery after illness.

Waiting Period: 2 months

Treatments that work on the physical and emotional body to relieve pain and improve health and wellbeing. Services include:

• remedial massage
• acupuncture
• naturopathy
• herbalism
• myotherapy and shiatsu

Disclaimer: Benefits are only payable for consultations with your natural therapy practitioner.

Waiting Period: 2 months

Therapy which assists people to overcome limitations caused by injury or illness, emotional or psychological difficulties, developmental delay or the effects of aging. This can include:

• rehabilitation in skills of self care
• physical rehabilitation
• cognitive and memory assessment
• stress management and relaxation

Disclaimer: Benefits are only payable for consultations with an occupational therapist.

Waiting Period: 12 months

A form of specialty dentistry focusing on realigning teeth and bites. Examples include:

• braces
• plates

Disclaimer: The annual limit on this service starts at $800 and increases by $100 per calendar year to $2,600 lifetime limit.

Waiting Period: 2 months

This benefit only covers nib approved items that are not part of the Pharmaceutical Benefits Scheme.

Waiting Period: 2 months

Podiatrists specialise in the prevention, diagnosis and treatment of disorders and conditions of the feet and lower limbs. Orthotics are devices prescribed by a podiatrist that are placed into the shoe to control or correct abnormal lower limb motions and alignment. Conditions treated by a podiatrist include:

• complications with arthritis affecting the legs and feet
• skin and nail disorders
• corns and calluses
• ingrown toenails

Disclaimer: This cover is for podiatrist consultations and prescribed devices only. Benefits are not payable for surgery in a doctor's or podiatrist's rooms.

Waiting Period: 6 months

Screening tests to help with the early detection of health conditions. These tests can include:

• thin prep (additional testing following a pap smear)
• bowel screening
• bone density testing

Waiting Period: 2 months

Group or individual consultations with a psychologist. Psychology services are commonly sought for:

• marital, family or relationship problems
• stress or pain
• fears, phobias, anxiety and panic attacks
• sexual difficulties
• eating and weight control problems

Disclaimer: A benefit is not payable for tests (e.g. psychometric testing).

Waiting Period: 2 months

The diagnosis, management and treatment of people who are unable to effectively communicate or who have difficulty with feeding and swallowing. Speech pathologists help a range of people, including:

• kids who have difficulty making themselves understood verbally
• those who stutter
• stroke sufferers

Disclaimer: Benefits are only payable for consultations with a speech pathologist.