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Access Gap Cover

Our initiative to help policy holders minimise, or in some cases, eliminate out-of-pocket expenses for inpatient medical services at a hospital or day surgery.


We refer to accommodation in two ways. Accommodation in a hospital refers to meals and a bed, and the associated hospital provided services such as nursing care. It does not include treatment by doctors or other health professionals.

We also refer to accommodation when we’re talking about our subsidised facilities in Brisbane or Townsville, available to Members who need to travel to these cities for their medical care.


A type of alternative medicine that treats the patient by inserting and manipulating fine needles into specific points on the body, with the aim of relieving pain and for therapeutic purposes.

Ancillary cover

Most commonly referred to as “Extras cover”, ancillary covers you for services such as optical, dental and physiotherapy that are not subsidised by Medicare. Extras cover can be packaged with hospital cover.

Annual limits

The maximum amount of benefits that can be paid to a Member in their membership year.


APRA is Australia's prudential regulator of banks, insurance companies (including private health insurers) and most superannuation funds.

Assisted reproductive services

Services such as IVF.


Treatment for hearing loss and the proactive prevention of hearing damage by an approved audiologist.

Australian Government Rebate on private health insurance

The Australian Government Rebate on private health insurance provides a financial incentive to assist Australians in affording private health cover. Rebate eligibility is based on a Member/s age and assessable income and the rebate amount will be indexed by CPI (Consumer Price Index) each year. The rebate is available for Australian residents that hold a green or blue Medicare card, and is applicable on both hospital and extras products.

You can choose to claim the rebate automatically through reduced premiums, or claim it back on completion of your annual tax return.


The amount we’ll pay towards services received by an approved provider.

Cardio-thoracic procedures

Cardio-thoracic procedures including heart and lung surgeries. Cardio means the heart and thoracic refers to the chest.

Cataract surgery

Involves the removal of the “opaque” natural lens of the eye (the cataract), and replaces it with an artificial transparent lens to restore the individual’s sight. Cataract surgery is usually performed by an ophthalmologist (an eye surgeon) in a hospital using local anaesthetic.


A claim is your request for a benefit to be paid on a service received by an approved provider. You can claim on-the-spot through the HICAPS or CSC HealthPoint electronic claims systems, to pay a reduced amount on that service. Alternatively you can claim after the fact via our Mobile App or you can download a claim form and send it to us and we’ll rebate the money to you through direct debit. 

Cooling off period

A period of 30 days from the commencement date of your new policy or upgrade of cover. If you change your mind and haven’t made any claims, you can cancel your membership and receive a full refund of any premiums paid.

Cosmetic surgery

Cosmetic surgery is an elective surgery concerned with correction or restoration to parts of the body mainly for the purposes of enhancing the appearance. Cosmetic surgery includes but is not limited to services such as breast augmentation, rhinoplasty, facelifts, liposuction, tummy tuck, filler injections etc. In most cases this does not attract a Medicare benefit and therefore does not attract a benefit from private health insurance. 

Couple membership

Covers the policy holder and their partner

Day surgery

A private hospital or facility where patients are admitted, treated and discharged on the same day.


Child dependent

A child, adopted child, foster child, or stepchild of the policy holder or their covered partner who isn’t married or living in a de facto relationship and is under the age of 21.

Student or apprentice dependent

A child dependent of the policy holder or their covered partner who isn’t married or living in a de facto relationship, who is receiving full-time education at a school, college, or university, or is working as an apprentice, and is aged 21 to 31 (inclusive).

Adult dependent

A child dependent of the policy holder or their covered partner who isn’t married or living in a de facto relationship and is aged 21 to 31 (inclusive).

Diagnostic dental

Dental services including examinations, consultations and x-rays.


Dietitians provide advice on food and nutrition, to promote good health and proper eating. Dietitians play an important role in educating individuals and groups on good nutritional habits.

Elective surgery

Elective surgery is the surgical treatment of a condition that a doctor does not consider as requiring immediate treatment.

Electronic claiming

Electronic claiming allows you to claim on-the-spot for extras services using your Territory Health Fund membership card and the HICAPS and HealthPoint systems. Your benefit will be deducted immediately from your service fee, and you’ll only have to pay any additional out-of-pocket expenses, if there are any.


Dental services including root canal therapy and root fillings.


An excess is the amount you agree to pay before a hospital benefit is paid by Territory Health Fund, just like any insurance policy. You can choose your level of excess being a $250 or $500 excess, on private hospital cover options. The higher your level of excess, the lower your premium will be, as you agree to pay a larger sum towards your hospital costs.

At Territory Health Fund, the maximum excess that applies per person within any one Membership Year is $250 or $500, depending on the chosen excess option, regardless of the number of times you’re admitted to hospital.


Conditions or services that are not covered by your health insurance policy, meaning we won’t pay a benefit towards these services.

Extended family membership

Covers the policy holder, their partner and any of their dependents (at least one of whom is an adult dependent). Refer to “Dependents” for more information about dependent criteria.


Extras is a commonly used term to describe ancillary health services such as dental, optical, chiropractics and physio treatment.

Family membership

Covers the policy holder, their partner and any of their child dependents and/or student or apprentice dependents

Foot orthoses

Foot inserts designed to help support the feet, improve foot posture and correct imbalances. A podiatrist can help make and fit foot orthoses. Also known as orthotic devices or orthotics.

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Healthy Living benefit

Healthy Living benefits are included as part of our Extras options, to encourage our Members to stay healthy. Healthy Living benefits are payable on services such as quit smoking programs, skin cancer checks, weight loss programs and more. 


A form of alternative medicine that aims to stimulate the body’s own healing response to disease using highly diluted preparations.

Hospital cover

Hospital cover policies help cover the cost of in-hospital treatment by your doctor and hospital costs such as accommodation and theatre fees.


A person who has been admitted to an approved hospital or day surgery and discharged following treatment.

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Lifetime Health Cover loading

Lifetime Health Cover (LHC) is a Federal Government initiative designed to reward people for taking out hospital insurance at a younger age and keeping it, by securing lower premium payments.

Under LHC you have until July 1 after your 31st birthday to take out hospital cover. If you purchase hospital cover after this date you may pay an additional 2% loading on top of your Hospital premium for each year you are over 30. The loading is capped at 70% and is removed after 10 years of continuous hospital insurance cover.


Limits are the number of times you can claim on a particular service, or a set dollar value of claims that you can make Membership Year. Limits apply to extras cover and to Mechanical Aids and Appliances covered by hospital cover.

Major dental

Any significant dental service, such as a tooth extraction.

Massage therapy

Massage therapy involves healing by working with the soft tissues of the body, to improve the functioning of joints and muscles and promoting circulation. Benefits are paid for remedial massage and myotherapy.

Mechanical aids and appliances

Mechanical aids and appliances include products such as blood pressure monitors, glucometers, Tens machines, crutches, walking frames, or wigs. Some restrictions, including benefit limits and hire only conditions, apply to certain mechanical appliances or artificial aids.

Medical gap

The Medical Gap is the 25% gap between the 75% Medicare rebate and the Medicare Benefits Schedule fee for inpatient services. If your doctor doesn’t participate in the Access Gap program, Territory Health Fund will only cover the medical gap.

Medically necessary

Treatment that is deemed necessary by a medical practitioner.

Medicare Benefits Schedule

The Medicare Benefits Schedule (MBS) is the schedule of fees set by the government for standard medical services. Whether you have private health insurance or are a patient paying for all your own costs, the government provides a rebate on nearly all medical fees. The rebate is currently 75% of the MBS for in-hospital medical fees.

Medicare levy surcharge

An additional 1-1.5% surcharge levied on high income earners in Australia who don’t have private hospital cover. The surcharge is calculated on taxable income and is on top of the standard 1.5% Medicare Levy paid by all Australian taxpayers.

Membership Year

A period of 12 months in which the Member makes contributions, commencing from the anniversary of your joining date.


Naturopathy is a type of alternative medicine that uses treatments like nutrition, dietetics etc. for a non-invasive approach to the treatment of symptoms of illness.


The management of pregnancy, labour and delivery and the care associated with the birth of the child, provided in hospital.

Occupational therapy

The treatment or rehabilitation of individuals suffering physical or emotional disabilities.


Dental services specialising in the diagnosis, prevention and treatment of problems in the alignment of teeth and jaws.


A form of manual medicine which recognises the link between the structure of the body and the way it functions, using hands-on techniques to identify types of dysfunction in the body.

Out-of-pocket expenses

Out-of-pocket expenses are the additional costs once all Medicare and private health insurance benefits have been expended. Usually, out-of-pocket expenses apply when you’re not fully covered for a particular treatment or service, or when a set benefit limit applies.


A patient who has received medical treatment in a doctor’s surgery or casualty department and has not been admitted into hospital.


A person living with the policy holder in a marital or de facto relationship


Specialised gum treatment.

Pharmaceutical Benefits Scheme (PBS)

The Pharmaceutical Benefits Scheme provides a Government subsidy to reduce the price of some prescription medicines


The Private Health Insurance Ombudsman provides an independent service to help consumers with health insurance problems and enquiries. The Ombudsman deals with complaints from health fund members, health funds, private hospitals or medical practitioners

Plastic/reconstructive surgery

Medically necessary surgery to correct functional impairments resulting from injury.


Treatment of the foot, ankle or lower leg by a qualified podiatrist.


A Territory Health Fund health insurance cover arrangement. A policy may include cover for hospital, extras or a combination thereof.

Policy holder

The person who ‘owns’ the Territory Health Fund private health insurance policy


The ability to transfer between registered health funds, without the need to re-serve waiting periods.

Pre-existing condition

A pre-existing ailment, illness or condition is one where signs or symptoms of the condition were present at any time during the six months prior to applying for membership of Territory Health Fund or an upgrade of cover, determined by a Territory Health Fund appointed medical practitioner. You may have a pre-existing condition, ailment or illness without even being aware of it.


The amount you pay for your health insurance cover.

Preventative dental

Dental services such as cleaning and scaling, fluoride treatment, oral hygiene instruction and mouth guards.

Private Health Information Statements (PHIS)

Private Health Information Statements (PHIS) are available on all private health insurance policies sold in Australia. Health insurers are required by law to provide these Statements to their Members, to allow you to review your existing policy or compare private health insurance products using


Dental services relating to dentures etc.


A prosthesis is a surgically implanted medical device or artificial body part, like hip and knee joints and heart pacemakers. There will always be a prosthesis type that is covered by your hospital cover if your surgery requires the implantation of a prosthesis. However, other types of prostheses may cost more than the standard "no gap" item, in which case you will need to pay the additional costs.

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Recognised provider

A recognised provider is a medical practitioner that Territory Health Fund will pay benefits on. This applies to all ancillary, dental and nursing or midwifery services. Recognition is subject to change without notice.

Restorative dental

Dental services such as composite and amalgam fillings.

Restricted services

Under a restricted service, you will only be covered for your choice of doctor for shared ward accommodation in a public hospital. Undergoing treatment in a private hospital for a restricted service is likely to result in large out-of-pocket expenses.

Simple extraction

Standard tooth removal provided by a qualified dentist.

Single membership

Covers the policy holder.

Single parent family extended membership

Covers the policy holder and any of their dependents (at least one of whom is an adult dependent). Refer to “Dependents” for more information about dependent criteria.

Single parent family membership

Covers the policy holder and any of their child dependent and/or student or apprentice dependents

Surgical extraction

Surgical removal of teeth, such as wisdom teeth removal or removal of impacted teeth, by a qualified dentist or surgeon.

Tax benefits

High income earners are required to pay a Medicare Levy Surcharge of up to 1.5% in addition to the standard MLS if they do not have private health insurance. For individuals, couples or families earning over the threshold, having private health insurance means they will avoid this surcharge, which may cost more than your private health insurance premiums.

Theatre fees

The costs for performing a procedure in an operating room, including those performed at a day surgery.

Transfer certificate

A document transferred between registered health funds, which provides the details of the member’s history at their previous fund, including the Certified Age of Entry (CAE), financial status and claims history.

A transfer certificate is required before a member is eligible to claim on services from Territory Health Fund.

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Waiting period

A waiting period is the length of time you need to wait after taking out your health cover, before you are able to receive benefits for services or items covered. Members transferring to an equivalent level of cover from other recognised Australian health funds will not need to re-serve waiting periods.