Doctors & hospital fees
When you go into any hospital (private or public) as a private patient, your doctor will charge you for their services. Medicare sets a recommended 'scheduled fee' for every single procedure performable by a doctor.
Frank will cover you for 100% of the Medicare Scheduled Fee.
If your doctor charges more than what Frank covers, then you will have to pay the difference. That difference is commonly known as your out of pocket or gap cost.
Listing all the possible doctors' fees here isn't practical as there are over 10,000 procedures in Medicare's scheduled fee list. Usually you'd get the fee information from your doctor/specialist in something called Informed Financial Consent.
Outpatient Procedures.
Outpatient Consultations unless covered by your policy.
Treatment received outside Australia.
Treatment arranged before you arrived in Australia.
Services and treatment covered by compensation of any kind.
Dental bills, even if you are an inpatient in hospital. In this case, the hospital account will be covered but the dentist bills will be an out of pocket.
Treatment you had over 1 year ago.
If you can claim damages or compensation from someone else, you can't claim it from Frank.
You can't claim on stuff that isn't covered by your membership.
If you're not paying us, we won't pay you. So, if you suspend your membership or don't pay your fees you can't claim on treatment you receive during that time.
You're not covered for any treatment you have overseas.
If you have not served the appropriate waiting period for that service.
We won't pay at all for drugs purchased outside of the hospital (like from a chemist).
You can only claim on face to face services. This means services delivered remotely (like over the phone) aren’t covered by Frank.
The person treating you needs to be working in a private practice, for a registered hospital or for an organisation recognised by Frank. If not, your claim won't be covered.
Hiring of equipment.
Benefits are only payable on original, itemised accounts. Accounts which have been altered in any way won’t be accepted.
You can't claim on treatment you can get free from the government.
If the person who treated you is a family member you can't claim for that treatment. We also won’t pay if you are treated by your business partner, or the business partner of a family member. If you’re unsure who qualifies as ‘family’ check with us.
If you're given drugs in hospital, there are limits on how much we will pay for them.
Understanding waiting periods
A waiting period is the length of time you have to wait before being eligible for health insurance benefits.
Waiting periods exist to protect members from claims made by those who join Frank or increase their level of cover because they have a condition or illness that may require treatment.
New members (previously uninsured);
Additions to a membership (unless the addition/s has already served all waiting periods with Frank or another fund) except newborns and adopted or permanent foster children where the family membership has been in existence for at least 2 months.
Existing Frank memberships, and transfers to Frank from another insurer where:
the level of cover and/or benefit entitlement is upgraded or increased;
any hospital service was not covered by the previous insurer and/or;
the waiting periods have not been completed;
where there has been a gap in cover between the old fund and Frank of more than 30 days.
12 months - pre-existing conditions (other than for psychiatric, rehabilitation or palliative care).
12 months – pregnancy (childbirth) and related services.
2 months - psychiatric, rehabilitation or palliative care (regardless of whether or not the condition is pre-existing).
0 days - Emergency Ambulance, Outpatient Services (where covered on your product) and all other services.
If you have an ailment, illness or condition it is considered pre-existing if in the opinion of a medical practitioner (appointed by Frank OVHC) the signs or symptoms of the ailment, illness or condition existed at any time in the 6 months leading up to the day you became insured. This is not dependent on whether you saw a medical practitioner during the 6 months prior to joining Frank OVHC.
For treatment that was covered under the old policy (at the same or higher level than the new policy) waiting periods are limited to the balance of any waiting periods that have not been served by the person under the policy.
For treatment that was covered under the old policy but at a lower level, the member is entitled to the lower benefits equivalent to their old cover during the waiting period.
Existing members with at least 12 months membership in total across their old and new cover are entitled to the lower benefits on their old cover during the waiting period.
Understanding extras
Whatever the provider charges, Frank pays 65% up to your annual limits. That means if you are charged $100 for a treatment your benefit will be $65 as long as you have served your waiting periods and have available limits.
Yes. Frank believes in freedom of choice, so we pay the same benefits to any registered provider. This means you can use your regular dentist, optometrist or physio and still claim.
Yes, on most services you will have to serve a waiting period if you’re new to health insurance. With Frank (and most health insurers) you have to wait a specific amount of time between signing up and making your first claim. This is called a waiting period.
Mid Workers Plus Bundle services have the following waiting periods:
2 months for included extras (except for Optical)
6 months for Optical
The good news is that waiting periods may not apply if you’re coming to Frank from another fund.
Benefits are only payable on original, itemised accounts. Accounts which have been altered in any way won’t be accepted.
Services/treatment that you have a right to claim damages or compensation from any other person or body. For example, if you can claim from WorkCover, you can’t claim from Frank too.
Treatment where the member and/or dependant is eligible for free treatment under any Commonwealth or State Government Act.
Services/treatment you had more than 12 months prior to the date you’re claiming.
Services/treatment which is not covered by your membership and/or is rendered while the membership is in arrears or is suspended.
Services/treatment rendered by a practitioner not in a private practice and/or not recognised by bodies approved by Frank.
If the person who treated you is a family member you can't claim for that treatment. We also won’t pay if you are treated by your business partner, or the business partner of a family member. If you’re unsure who qualifies as ‘family’ check with us.
Hiring of equipment (unless otherwise stated).
You can only claim on face to face services. This means services delivered remotely (like over the phone) aren’t covered by Frank.
You can’t claim benefits for lifestyle services that primarily take the form of sport, recreation or entertainment.
You can’t make a profit from your insurance, so we won’t pay more than you were charged for a treatment.
Benefits for services on treatment received overseas.
Claims if you’ve reached your limits for the calendar year.
Claims if you have transferred to a Frank Extras cover from another fund’s Extras cover and have previously claimed for the service/treatment.
Claims if the service is subject to a waiting period or other limit which has not been served/met.
Dental procedures carried out and charged direct to the member/dependant by a dental mechanic, other than an advanced dental technician.
A range of dental procedures when provided on the same day. For example if your bill says you had a tooth filled and removed on the same day, we won’t pay for the filling.
There’s a limit to the number of times you can have certain dental procedures. If you exceed those limits we won’t pay.
Tooth identification numbers (ID) must be supplied by the provider, or we won’t pay.