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At certain times in your life, you may face health issues that require the type of attention and treatment that only a specialist doctor can provide. In these cases, you’ll be referred to one usually by your GP or other medical professional.

Sometimes you may claim a portion of these costs under Medicare. At other times, under particular conditions, your health fund may cover these costs.

In order for your health fund to cover the cost of consultations with a specialist doctor, your treatment must meet specific criteria.

1. Treatment must be in-hospital

In order for your specialist doctors’ fees to to be covered, your consultation or treatment must take place after you’ve been admitted to hospital as an in-patient.

If you’re seeing a specialist doctor without being admitted to hospital (as an outpatient), your costs will not be covered, even if you see them in their rooms within the hospital. This includes obstetrician and gynaecologist consultations prior to giving birth.

By law, health funds cannot provide benefits for consultations and diagnostic services that do not normally require hospital treatment.

2. You must be treated at an agreement private hospital

To have your specialist doctors’ fees covered by your health fund after admission to hospital, you must be admitted to an agreement private hospital. That is, one that has an agreement with your health fund to eliminate or reduce out-of-pocket costs.

3. Your treatment or procedure must be covered under your policy

If you see a specialist doctor after being admitted into hospital, the treatment you’re receiving must be covered under your hospital cover in order for your health fund to pay their fees.

Not all health insurance policies cover all procedures, so make sure you know what features you’re covered for.

Be sure to read the policy description carefully and fully understand what you’re covered for before seeking treatment with a specialist.

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