Common health insurance inclusions, exclusions and restrictions

Here are some of the common inclusions, exclusions, and restrictions in private health insurance policies with hospital cover.

Every insurer has different inclusions, exclusions and restrictions. The level of benefits and premiums you pay depends on the type of policy you choose, whether you take out hospital cover, extras cover or a combined hospital and extras cover.

When looking at hospital cover, you need to understand what are inclusions, exclusions and restrictions. So, let’s break it down.

What are health insurance inclusions?

Inclusions are the types of procedures or services that are covered by your health insurance policy. That means if you make a claim on these items, you will receive the benefit stated in your policy.

These services are paid for in part or in full by your health fund, depending on your choice of insurer, the level of cover your policy provides, and the amount of excess you pay per claim.

A few common inclusions for hospital cover are:

  • Hospital accommodation
  • Theatre fees
  • Emergency ambulance fees
  • Some pharmaceutical medicines
  • In-hospital medical treatment

What are health insurance exclusions?

In contrast to inclusions, exclusions mean you won’t be covered for any hospital or medical expenses related to that condition.

Because excluded conditions are not included, should you require treatment of those conditions, you would need to be treated through the Medicare system. If those conditions are not covered by Medicare, you would be responsible for covering the medical expenses out of your own pocket.

An example of a health insurance exclusion could be if your policy excludes cardiac services. In this case, if you went into hospital as a private patient to receive cardiac surgery, your health fund would not cover any benefits towards either your hospital or medical costs.

What are health insurance restrictions?

Restricted health insurance benefits are health services that you are partially covered for, meaning the cover is limited.

According to the Private Health Insurance Ombudsman, restricted benefits are not sufficient to cover the full hospital costs of a private hospital admission, meaning you would need to pay for the difference in cost.

Restricted benefits won’t fully cover costs of a private hospital admission. Say for example, you go to a private hospital for a knee replacement and that is one of your restricted benefits. This means your health fund won’t pay for the theatre fees and may only cover a portion of your hospital accommodation costs. This could leave you with expensive out-of-pocket costs.

The table below displays a snapshot of private health insurance policies with hospital and extras cover on Canstar’s database, sorted by monthly premium (lowest to highest) then by provider name (alphabetically). The products displayed have cardiac as well as hip and knee replacement hospital inclusions. Please note the results are based on couples living in NSW.

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What procedures are restricted and/or excluded?

Health insurance policies can vary significantly across health funds. Some policies could have restrictions and exclusions on treatment services, while others may have restrictions or exclusions.

A few common excluded or restricted services include:

  • Pregnancy and birth-related services
  • Hip and knee replacements
  • Cardiac and cardiac related services such as surgery or heart investigations
  • Psychiatric and rehabilitation services
  • Cataract and eye surgery
  • Plastic surgery

It’s worth checking in with your health fund to see what restrictions or exclusions may apply to your policy.

How to get the most out of your health insurance policy

To avoid shock expenses, it’s important to consider what cover you may need at every stage of your life. It’s a good idea to be aware of any restrictions or exclusions that may apply to your policy, review your policy each year and compare with other health funds.

Comparing your options and being aware of your health coverage can help ensure your policy meets your changing health needs and doesn’t leave you paying exorbitant out-of-pocket expenses and high premiums.

You may also be able to upgrade your existing private health insurance policy to include services you require as a private patient that may have previously been restricted or excluded – but you may have to be patient. Many health insurance providers require you to disclose if you have received any medical care for a pre-existing condition before taking out their policy. It is possible to still be covered for a pre-existing condition, however a waiting period of up to 12 months may apply before you can claim benefits.

If any immediate treatment is required for a restricted or excluded service on your health insurance policy, it could be worth discussing treatment options with your doctor or considering covering the cost of the treatment yourself.

Carefully reading your health fund’s product disclosure statement and regularly reviewing your health insurance needs, may help you avoid paying out-of-pocket expenses altogether and help you confidently make a claim.

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