These rules set out the General Conditions (Fund Rules A to G) and the Schedule of Benefits and Specific Conditions applying to the operation of Peoplecare Health Insurance (“Peoplecare”).
Updated Fund Rules 1 July 2025
Private health insurance can be complex and we’re committed to making sure the information regarding your health cover is clear and easy to understand. Outlined below are key changes (effective 1 July 2025) to the Fund Rules that may be most relevant to your health cover.
- Policy holder obligations: Fund Rule A9 has been updated to include an obligation on the policy holder to inform other members on the policy of the contents of any notices provided to them by Peoplecare that are not specific to the policy holder.
- Definition of Accident: The definition of ‘Accident’ in Fund Rule B2 has been updated to: (a) an unforeseen event, occurring by chance and caused by an external force or object, which causes involuntary bodily injury to a member, requiring medical treatment by a Registered Medical Practitioner or Emergency Department (excluding by anyone on the same Policy) within 48 hours of the event. Any further treatment required must be completed within 90 days of the event or timeframe otherwise agreed by Peoplecare.
- Other definitions: Several definitions in Fund Rule B2 have been amended or added to provide further clarity on how Peoplecare defines these terms.
- Rights of policy holders and members: Fund Rule C1 has been updated to include a new section on the rights of policy holders and members (for example, which members on your policy are entitled to upgrade or downgrade your level of health cover).
- Membership application rejection: Fund Rule C4 has been amended to include a right for Peoplecare to reasonably reject an application for membership.
- Transfers between health funds: Fund Rule C6 has been updated to clarify the processes relating to transfers to and from Peoplecare to another health fund, including explaining when waiting periods will and will not apply and when benefits paid under a previous health cover will be taken into account.
- Policy termination rights: Fund Rule C8 has been amended to give Peoplecare broader rights to terminate a policy if a member misleads or deceives Peoplecare or has materially or repeatedly breached any of the Fund Rules or any other term or condition of membership.
- Temporary membership suspension: Fund Rule C9 has been updated to clarify when suspension will be effective and to clarify the effects of the suspension.
- Product closure and migration: A new Fund Rule C10 has been included regarding Peoplecare's right to close a product and migrate members to another open product.
- Benefit payments for treatments: Fund Rules E1, E2 and E3 have been updated to provide further clarity around how and when we pay benefits for hospital treatment and general treatment, including introducing a process to de-recognise providers on limited grounds (eg, fraudulent conduct) so that treatments rendered by such providers are not eligible for benefits.
- Calculation of benefits: Fund Rules E2 and E3 has been amended to provide clarity around how benefits are paid and what impacts payment of benefits.
- Recovery of benefits paid in error: Fund Rule E4 has been updated to include a right for Peoplecare to recover benefits which have been paid to a member in error.
- Exclusions: Fund Rule F3 has been amended to include circumstances where benefits are not payable.
- Compensation and provisional payment of claims: Fund Rule F5 has been updated to clarify that benefits are not payable for treatment for which the member has received (or is entitled to receive) compensation in respect of that treatment and the rights of Peoplecare and members in relation to the provisional payment of claims in these circumstances.
- Claim processes: Fund Rule G has been updated to include further information regarding how claims can be made, evidence required and other relevant matters regarding making a claim.
To view all the changes to the Fund Rules you can view the updated copy of the Fund Rules effective on and after 1st July 2025 here.