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Assisted Reproductive Services and Private Health Insurance
Infertility and Assisted Reproductive Services Waiting Periods
Infertility is defined as the inability to conceive after one year of regular,
As infertility is generally defined as the inability to conceive after one year,
unprotected intercourse. Infertility can be caused by many factors, including
assisted reproductive services wil usual y be subject to the twelve month
genetic, medical, surgical, or trauma related causes in either the male or
waiting period for pre-existing conditions. This means you need to complete
female or both. Equally, there is a range of assisted reproductive treatments
twelve months of membership on an appropriate hospital policy prior to the
available to assist in treating the condition.
commencement of IVF treatment in order to be eligible for benefits.
In Vitro Fertilisation (IVF) treatment and Gamete Intra Fallopian Transfer
If you do need treatment within the first twelve months of taking out or
(GIFT) are two of the procedures for treating infertility which are most
upgrading your policy, your fund will assess whether your condition is a pre-
commonly covered by private health funds.
existing condition and therefore, whether benefits are payable. You will need
to ask your treating doctors to complete a medical certificate supplied by
Choosing a Hospital Policy
your fund to assist the fund’s medical adviser in determining whether your
condition is a pre-existing condition or not.
Assisted reproductive services are not covered by al health insurance
policies. Always check with your fund before proceeding with IVF or similar
It’s important to note that it is the fund’s medical adviser that makes this
treatments to confirm whether you are covered for these services, whether
decision and not your treating doctors. The fund medical adviser will take
there are services you wil be required to pay for yourself, and whether you
account of information provided by your treating doctors in making his or her
have completed any required waiting periods. If your current policy doesn’t
decision. You should ensure this assessment has been completed before you
include Assisted Reproductive Services, you will need to upgrade your policy.
are admitted to hospital for treatment. Otherwise, you may be liable for the
cost of the admission if benefits are denied by your fund on the basis of the
pre-existing conditions rule. For more information about waiting periods, see
Waiting periods apply when you take out or upgrade your hospital policy.
PHIO’s “Waiting Periods” brochure.
Australian funds apply the following maximum waiting periods:
Some funds also include Benefit Limitation Periods as a feature of some of
• a two month waiting period for any benefits;
their hospital policies. These are initial periods of membership during which
• a twelve month waiting period for benefits for pre-existing
only a minimal benefit is paid for some types of treatment. These Benefit
Limitation Periods may be from one to three years, depending on the policy.
• a twelve month waiting period for benefits for obstetrics (maternity)
Check with your fund for more information.
Issued by The Private Health Insurance Ombudsman March 2011 Assisted Reproductive Services and Private Health Insurance
What’s covered by private hospital insurance? What isn’t covered by private health insurance?
It’s important to know that that for IVF treatment, like most other medical
There are many components to IVF treatment and some of the associated
treatments, only in-patient services (where you are formally admitted as a
services occur outside of a hospital admission (out-patient services). These
private patient to the hospital) that have a valid Medicare item number will
services include consultations with your clinic and doctor, scans, ultrasounds,
attract a benefit from your health fund.
some diagnostic procedures and pathology services. Some of these services
may be claimable through Medicare and some wil be at your own expense.
This means that if there is no Medicare item number for the service or
There are also additional costs associated with egg transportation, testing and
treatment, your fund may not pay any benefits towards the cost of the
freezing that may be at your own expense.
procedure. The hospital should advise you prior to admission about any costs
you wil incur for the procedure and obtain your informed consent to
IVF treatment also includes the use of IVF drugs. Not all drugs will attract a
benefit from Medicare. Drugs that are not covered by Medicare include, but
are not limited to, Lucrin, Provera, Synarel, Orgalutran and progesterone
Generally, the main surgical procedure in an IVF cycle is the egg collection.
pessaries. Your health fund may provide a benefit toward the cost of some of
This procedure is also referred to as egg pick-up, oocyte pick-up, OPU, and
the IVF related drugs. It’s important that you contact your health fund to
sometimes egg harvesting. As this procedure is carried out in an operating
discuss what benefits are payable toward the IVF drugs specific to your
theatre, you will be admitted as an in-patient to hospital. If your policy covers
Assisted Reproductive Services, then the hospital accommodation and
theatre fees will be covered by your health fund. Your fund will also provide a
More Information
benefit towards your anaesthetist and treating doctors’ fees. You may have to
pay part of the medical fees yourself (the portion charged above the
To help determine what you wil be covered for, we strongly recommend you
Medicare Benefits Schedule fee, known as the ‘gap fee’) – check with your
ask your IVF clinic for a detailed quote of your expected treatment plan,
including all medical item numbers. Take this information to your fund –
having this quote will assist your fund in being able to accurately advise you
In some cases, you may also be admitted as an in-patient for the embryo
about how you are covered and what costs you are likely to incur.
transfer procedure. If this is the case, the same benefits as described above
For more information on private health insurance, contact our office:
Websitesan Phone: 1300 737 299 Issued by The Private Health Insurance Ombudsman March 2011
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Assisted Reproductive Services 
Assisted Reproductive Services