When it comes to reimbursement of personal injury claims, some people get confused about Medicare, the Medicare gap and what is covered through the risk protection program.
Medicare is a Commonwealth Government programme that provides eligible Australian residents with free or low-cost medical and hospital care.
Medicare provides access to:
The medical benefits schedule (MBS) lists all treatments and associated MBR relating to Medicare.
You can access the MBS at any time by Medicare’s website. Items commonly used by sports participants that are Medicare listed can include general practitioners, surgeons and anaesthetists.
The MBS lists a rebate amount for each Medicare Item.
Example: A short consultation with a Doctor = Medicare rebate of $15.36
However, doctors or specialists may charge more than the listed MBS amount.
The difference between what is charged and the MBS rebate is called the “Medicare Gap”
The Health Insurance Act 1973 (Cth) strictly prohibits any general insurer from insuring any item that is listed on the Medicare Benefits Schedule.
This also means that regardless of your out of pocket expenses, it is against the law for the insurer to cover the Medicare Gap.
So what does that mean?
If your medical or other treatment has a Medicare Item number, such as the doctor fee above, it is claimable on Medicare by is uninsurable and you may not claim for reimbursement.
In the example you cannot claim the $29.65.
If your medical or other treatment does not have a Medicare Item Number, you may claim for reimbursement through Marsh. For specific insurance and risk protection information please visit the making a claim section of this website.
No, insurers are unable to pay claims already covered under Medicare, including the Medicare gap in accordance with the Health Insurance Act (Cth) 1973.
Personal accident insurance provides coverage for injuries sustained whilst participating in an activity under the following circumstances:
Yes.
Yes, the two policies will work together. You need to lodge a claim with your private health insurer first, then submit your claim via Sports cover. Costs that exceed your private health cover may be insured via the Skate Australia policy. We suggest you contact Sports cover on 1300 134 956 for further details.
Subject to the policy limits and sub-limits you can make more than one claim during the policy period. It is important however, that you obtain a clearance from your treating physician prior to returning.
If your business is not deemed to be a safe environment caused by deliberate neglect, then your policy may become void. In this instance, you are personally liable for the financial burden of the liability claim. Often an excess will be in place. This excess is not covered by the insurance policy.
Marsh Advantage Insurance Pty Ltd (ABN 31 081 358 303, AFSL 238369) (“Marsh”) arranges the general insurance (i.e. not the Discretionary Trust Arrangement) and is not the insurer.
This page contains general information and does not take into account your individual objectives, financial situation or needs. For full details of the terms, conditions and limitations of the covers, refer to the specific policy wordings and/or Product Disclosure Statements available from Marsh on request. Marsh makes no representation or warranty concerning the application of policy wordings or the financial condition or solvency of insurers or re-insurers. Marsh makes no assurances regarding the availability, cost, or terms of insurance coverage. Any statements concerning actuarial, tax, accounting, or legal matters are based solely on our experience as insurance brokers and risk consultants and are not to be relied upon as actuarial, accounting, tax, or legal advice, for which you should consult your own professional advisors. Any modelling, analytics, or projections are subject to inherent uncertainty, and the Marsh Analysis could be materially affected if any underlying assumptions, conditions, information, or factors are inaccurate or incomplete or should change. This publication is not intended to be taken as advice regarding any individual situation and should not be relied upon as such. The information contained herein is based on sources we believe reliable, but we make no representation or warranty as to its accuracy. Marsh shall have no obligation to update this publication and shall have no liability to you or any other party arising out of this publication or any matter contained herein.
The Discretionary Trust Arrangement is issued by the Trustee, JLT Group Services Pty Ltd (ABN 26 004 485 214, AFSL 417964) (“JGS”). Any advice or dealing in relation to the Discretionary Trust Arrangement is provided by JLT Risk Solutions Pty Ltd (ABN 69 009 098 864, AFSL 226 827) (“JLT”). JGS and JLT are businesses of Marsh McLennan. The cover provided by the Discretionary Trust Arrangement is subject to the Trustee’s discretion and/or the relevant policy terms, conditions and exclusions.
LCPA 24/556
