PHI 75/18 Circumstances where multiple procedures (including non-clinically necessary treatments) are provided in a single episode of care

Page last updated: 20 December 2018

PHI 75/18 Circumstances where multiple procedures (including non-clinically necessary treatments) are provided in a single episode of care (PDF 47 KB)

This circular provides guidance to insurers about the statutory requirement for the payment of hospital benefits in circumstances where an insured person receives both treatment that is covered under their policy and treatment that is not covered (including cosmetic treatment) in the course of a single episode of care.

Under the Private Health Insurance Act 2007 (the Act) and the associated Rules, each treatment is to be considered separately for the purpose of determining the payable benefit.

There are no provisions in the Act or Rules which expressly allow for multiple hospital treatments to be combined into a single ‘episode of care’ and for benefits to be calculated on this basis. The Act contemplates benefits for individual ‘episodes of hospital treatment’, not ‘episodes of care’.

A patient would still be entitled to the minimum benefit in respect of the covered treatment, provided all other relevant requirements are met.

Insurers would be in contravention of the Act if they adopt a practice where the provision of a non-clinically necessary treatment ‘invalidates’ the claim for the covered hospital treatment under the Act and the Rules.

If you have any questions regarding this Circular please contact the Department at PHI@health.gov.au.