How do I make a claim on my health cover?

If you visit a healthcare provider within our First Choice network, they can submit a claim for your eligible costs* so you won’t need to pay these. Other healthcare providers may ask you to pay all the costs on the day of your visit, even if you have pre-approval from nib. You can ask them about this before your appointment.

Some of the costs you may need to pay on the day could include:

• An excess payment - the amount you contribute if you make a claim. This only applies to hospital policies and is outlined in your Policy document.

• Co-payment - some specialist and diagnostic benefits on your policy may require a co-payment, which is the portion of a claim that you pay. Where this applies, you'll need to pay a percentage of the eligible cost.

• Any costs that aren’t covered under your plan i.e. costs above your benefit limit and/or not covered by your policy.

• Gap payments - the difference between what a healthcare provider charges and what the average market price is for treatment.

A pre-approval will outline which of these costs, if any, you may be required to pay.

*If you see a First Choice healthcare provider for a claim covered by your policy, nib will pay 100% of your eligible costs up to your benefit limit, subject to any excess payable and in line with your policy terms.

When you make a claim, your excess is deducted from the approved amount we will pay for your consultation or treatment. You need to pay this excess amount to your healthcare provider directly. They may ask you to pay for this on the day or send you an invoice.

Some benefits on your policy may require a co-payment, which is the portion of a claim that you pay. Where this applies, you'll need to pay a percentage of the eligible cost.

A 20% co-payment will apply to some benefits that cover specialist consultations and diagnostic tests. The co-payment doesn’t apply to tests listed in the Diagnostics Schedule. For example, if a covered procedure like a CT scan costs $2,000, a 20% co-payment will be applied first — that’s $400. The remaining $1,600 is then subject to your excess, if you have one. If your excess is $500, this will be deducted next. So, you’ll pay a total of $900 toward the cost of the CT scan, and we’ll cover the remaining $1,100.

Sometimes your consultation or treatment costs less than your excess. If this happens, you pay the full amount of your consultation or treatment to your healthcare provider as there are no remaining approved costs to be paid by us.

You choose your excess amount and, depending on the policy you have, you may pay your excess per claim or per year. You can request to increase or decrease this amount by contacting us. To find out how much your excess is and how it works, log in to my nib and check your Policy document and latest Acceptance or Renewal certificate.

To make your claim hassle-free, some First Choice network healthcare providers can submit pre-approvals and claims on your behalf. That means you can focus on getting well. When you use nib’s Find a Provider directory, you can filter your search results to find healthcare providers who also take care of your paperwork.