HCi Factsheet – cover limits and caps
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Extras health cover limits explained
April 2024
A limit or cap is the maximum you can claim for a service, or a specified group of services, on your extras cover. Each group limit may also contain sub limits. Most cover limits apply on a calendar year basis and reset every 1 January.
Having limits and caps helps keep member premiums down and maintain services at a sustainable level.
Various cover limits apply to all HCi extras policies. Waiting periods and eligibility terms also apply.
The what and why of cover limits and caps
For most extras services, you can claim up to an annual limit which is the maximum amount HCi will pay per calendar year for that service. Limits generally apply per person covered for a specific service or group of services.
However, there is a combined limit applied across a calendar year for some groups of services (eg general dental). You can use one service a number of times or a number of services once each – the limit applies to the total claimed across that group of services.
Each cover limit may contain sub limits for specific services. You can’t claim beyond the sub limit for that service type in a calendar year, but other services can be claimed up to the group limit. For example, a group of dental services may have a limit of $1,000 and include a sub-limit of $500 for fillings. In this case, you can claim only $500 for fillings along with up to $500 on other services such as cleans and x-rays.
In some instances, a policy cap may also apply. This is the maximum amount HCi will pay for a particular service or group of services for a policy in a calendar year. For a single policy, the annual limit and policy cap are the same.
What cover limits apply?
Limits are usually specific to each service and each type of cover. You can see the limits for various services, and groups of services, in the relevant product summary or by logging into OMS (Online Member Services).
Annual limit
This is the maximum you can claim in a calendar year for a specific service or group of services. We do not pay claims above that limit until the limit is reset on 1 January.
Annual sub-limit
Each limit may contain sub limits for specific services, or groups of services. You can’t claim beyond the sub limit for that service type/group in a calendar year, but other services may be claimable up to the group limit. For example, a group of dental services may have a limit of $1,000 and include a sub-limit of $500 for fillings.
Lifetime limit
Some services have a lifetime limit, which is the maximum amount you can claim for that service across your lifetime.
Note that this may apply across different health funds.
Per person limit
Annual limits, sub limits and lifetime limits generally apply per person on the policy, so each person is covered up to that limit for a particular service. One person reaching their limit on a service does not usually impact on claims for the same service for other people on the policy.
Policy cap
Some services, or groups of services, have a maximum annual limit to the policy as a whole. This is often a multiple of the per person limit and is indicated on your product summary if applicable.
Service limit
Certain services are limited to a particular frequency of use, for instance some dental services impose limits on the number of times each year you can claim against a particular service
Reasonability rules
Reasonability rules restrict claims to reasonable use. So, certain claims cannot be made for services that would not usually be used together clinically (especially for dental services). Thus ensuring providers do not seek to charge you for multiple services for the same item on the same day, or to over use them beyond reasonable clinical need.
Are my annual limits different if I switch to HCi from another fund?
The claim limit for any particular service or group of services may be reduced by any claims paid by your previous funds. So, if you used $300 of physiotherapy with your old fund, your new limit will be reduced by $300 for the same calendar year.
Within OMS, you can see how much of a specific limit is still available for claiming in the current calendar year.
What happens when a limit is reached?
Claims for services in a calendar year above any relevant limits or sub limits will not be paid in that year.
// CLAIMING EXTRAS
OMS
- the HCi member portal
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When it's time to claim, simply take a photo of the receipt(s) or upload a pdf then submit! Easy!
