A Claim example

Stephen was playing rugby for his club when tackled by an opposing player and suffered an injury to his left knee.  An ambulance was called and he was transported to the local hospital where he was given something for his pain and sent home.  After being in extreme discomfort that night he visited his local GP the next morning who gave him some pain relief, a certificate stating he was not fit to work for one week and referred him to a specialist orthopaedic surgeon.  Stephen visited the specialist the next week who ordered an x-ray which revealed that a full knee construction was needed.  As Stephen was unable to work due to his injury he arranged for the surgery to be performed the following Thursday.  The specialist provided a unfit for work certificate for an additional 4  weeks.  His operation was successful and he started on a course of physiotherapy and was able to return to work 12 weeks after the injury.  For a period of 8 weeks following his injury he hired crutches from the local chemist.

Stephen completed a 'Sports Injury Claim Form' two days after his injury, had his club secretary complete the club's section, his employer complete the employers sections and sent the claim form off to GAB Robins who recorded the claim.  At the time of visiting the specialist Steven had the 'Attending Physicians' section completed by him and this was sent off again to GAB Robins together with 'unfit for work' certificates.  Following payment of the medical expenses Stephen sent the receipts and additional 'unfit for work' certificates  to GAB Robins.

The claim was settled by the Insurer as follows -

 Private Practitioner Visit Scheduled amount covered by Medicare (*Gap not covered)
 Specialist Surgeon Scheduled amount covered by Medicare (*Gap not covered)
 X-Ray Scheduled amount covered by Medicare (*Gap not covered)
 Anaesthetist Scheduled amount covered by Medicare (*Gap not covered)
 Private Hospital accommodation 3 days at $420  $1,260.00
 Theatre Costs  $600.00
 Ambulance Costs   $300.00
 Crutches Hire  $150.00
 Pharmaceuticals  $110.00
 Physiotherapy $40 per visit  $600.00
 Sub Total  $3,020.00
 Benefit payable 80%  $2,416.00
 Less excess  $-100.00
TOTAL NON MEDICARE EXPENSES PAID  $2,316.00
 Plus loss of income 8 weeks @$300 per week (28 excess applies)  $2,400.00
 Total Claim Payment  $4,716.00

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