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 program 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 but 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.
A tailored business package Insurance solution to help protect your clubs’ assets from fire, theft, damage and more.
A sporting club specific insurance solution that can help you prevent, detect and respond to cyber risks.
Cover is not 24/7.
Cover will only apply to official and sanctioned club activities and events.
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, the personal injury policy does cover ambulance transportation subject to the policy sub-limits.
Yes, the two policies will work together. You need to lodge a claim with your private health insurer first, then submit your claim . Costs that exceed your private health cover may be insured via the Darts Australia policy.
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 to competing.
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. 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 26/1918
