Private Health Insurance - Reimbursement of Expenses

This policy applies to requests received on or after 28 November 2007.

Policy

The TAC can reimburse the reasonable cost of hospital services, nursing services and medical services incurred by a private health insurance fund in respect of a person's transport accident injuries, when the application for payment is made by the private health insurer within 12 months of:

  • the service being provided to the injured person, or
  • a Victorian Civil and Administrative Tribunal (VCAT) decision being made in respect of these services,

whichever has occurred later.

Transport Accident Act 1986 reference: s.76A

Background

The TAC’s liability to reimburse a private health insurance fund costs relating to hospital services, nursing services or medical services received by a person in respect of injuries suffered in a transport accident is set out in section 76A of the Transport Accident Act 1986, (TAA 1986). Treatment and services resulting from a transport accident can be funded by the TAC and a claim for any services required should be lodged with the TAC. When the fund has paid for transport accident related treatment, the TAC can reimburse the fund for these services.

Guidelines

Who is eligible to seek reimbursement of treatment expenses paid by a private health insurance fund?

If a client has an accepted TAC claim, his/her private health insurance fund can request reimbursement of expenses incurred for treatment services required as a result of a transport accident injury.

What circumstances exist where a person may require funding of a transport accident related service from his/her private health insurance fund?

A person may need to seek funding from his/her private health insurance fund under the following circumstances:

  • The person does not have an accepted TAC claim at the time the service is required or the claim is lodged late.
  • A request for TAC funding has been denied or a decision delayed due to insufficient medical information. Refer to the Reviewing a TAC Decision policy.
  • Where the provider will not accept the TAC's fee schedule for a given service.
  • The client is required to meet the TAC medical excess and utilises his/her fund to meet these costs. Costs related to a 'medical service' incurred in meeting the medical excess can not be reimbursed. Refer to the Medical Excess policy.

There may also be other circumstances acceptable to the TAC.

What services are able to be reimbursed to a private health insurance fund?

Where a person has an accepted claim with the TAC, and is eligible for the services under the TAA 1986, the TAC can reimburse:

  • hospital services
  • medical services
  • nursing services.

How is an application for reimbursement assessed, and are there any factors that may limit the amount the TAC can reimburse?

The TAC will reimburse reasonable expenses up to the relevant TAC Fee Schedule.

Where there are co-payments made by the TAC client and the fund, the TAC will reimburse (or withhold) the fund's expenses in the first instance. Any outstanding balance up to the TAC fee for that service can then be reimbursed to the client.

For example, a client is required to pay $40 to a physiotherapist in conjunction with the fund's contribution of $20 (the full private cost of the consultation is $60). Upon application, the TAC will first reimburse the fund's $20 for the co-payment that was made. If the service that was received is funded by the TAC at $42.05 (standard consult fee for the 2007/08 financial year), the TAC can only reimburse the client $22.05 as this totals $42.05 in what the TAC has paid toward the individual service to both the client and the fund combined.

How do the time restrictions on requesting reimbursement from the TAC apply?

An application by a private health insurance fund for reimbursement for eligible services in respect of a transport accident injury must be made within the period of 12 months after whichever occurs later:

  • A claim and/or liability for the service being accepted by the TAC.
  • The hospital services, medical services or nursing services being provided to the person.
  • A finding by VCAT that the TAC is liable to pay compensation to the person.

What if the service was initially denied by the TAC and is later accepted without the involvement of the VCAT?

If liability for a service or injury is initially denied by the TAC and is subsequently accepted upon further medical evidence, for example, the 12 month period for which a request for reimbursement from the private health insurance fund can be submitted will begin from the date the service or injury was accepted or approved by the TAC, including the date of a new decision related to that service or injury.

Does the TAC require authorisation to exchange information with a person's private health insurance fund?

No further authorisation is required from a client with an accepted TAC claim. In line with s.131(2)(caa) of the TAA 1986, the TAC is able to communicate with a private health insurance fund where the fund has made an application under s.76A to the TAC, so long as the information communicated to the fund relates to that application.

Transport Accident Act 1986 reference: s.131(2)(caa)

In relation to reimbursement of expenses to a private health insurance fund, what will the TAC not fund?

The TAC will not fund reimbursement:

  • of services for a person other than the injured client
  • where the services are not related to a transport accident injury
  • for services that have been denied by the TAC and have not been found to be the liability of the TAC by the VCAT
  • above the TAC fee schedule for any eligible service
  • for requests received by the private health insurance fund prior to 28 November 2007
  • where the request is received from a fund beyond 12 months from the date of service or new decision regarding a service or injury, or beyond 12 months from the date a finding was made by the VCAT that the TAC is liable for the service, whichever is later.