Common health insurance inclusions, exclusions and restrictions

When taking out private hospital insurance, it’s important to understand what you are covered for, and what you are not. You might think that you will be able to make a claim for a certain service, only to find  your cover is not quite as comprehensive as you first thought. So, what are the common inclusions, exclusions and restrictions with private hospital cover, and how do they work?

Every private health insurance policy will have inclusions, exclusions and restrictions. The term ‘inclusions’ refers to procedures and services that are covered by the policy. ‘Exclusions’ refers to procedures and services that are not covered. ‘Restrictions’ refers to procedures and services that are covered, but potentially only to a limited extent, meaning you may incur out-of-pocket expenses if you need to claim for them.

What are health insurance inclusions?

Inclusions are procedures and services that are covered by your private hospital insurance policy. This means that if you make a claim, all or part of the costs will be covered by your private hospital insurance. You may need to pay an excess though for hospital treatments. While the specific inclusions on your policy will depend on the level of cover you have, a few examples of common inclusions are:

• hospital accommodation
• theatre fees
• some pharmaceutical medicines
• in-hospital medical treatments (these can vary based on your policy)

Compare health insurance

What are health insurance exclusions?

Exclusions are services that are not covered by your private health insurance. Following the 2019 health insurance reforms in Australia, hospital insurance is now classified into one of four categories – Gold, Silver, Bronze or Basic. These four tiers are standardised across health funds, and in general terms, policies on the Gold tier will have the most comprehensive list of inclusions, while policies on the Basic tier will have the most basic inclusions.

A common example of an exclusion might be pregnancy and birth-related services. While these services tend to be included on Gold-tier policies, they are generally excluded on Silver, Bronze and Basic policies. If your health insurance policy excludes pregnancy and birth-related services and you need to be admitted to hospital to have a baby, you will not be covered for any hospital or medical expenses. It is likely, instead, that you will be admitted as a public hospital patient via the Medicare system.

What procedures are commonly excluded?

According to the Private Health Insurance Ombudsman, procedures that are commonly excluded or restricted from private health insurance include:

• cardiac and cardiac-related services, such as heart investigations and surgery
• cataract and eye lens procedures (eye surgery)
• pregnancy and birth-related services
• assisted reproductive services (infertility services)
• hip and knee replacements (joint surgery)
• rehabilitation and psychiatric services
• plastic and reconstructive surgery, such as skin grafts following burns, skin flap repair and breast reconstructions following cancer

If you want to understand more about the various tiers of private hospital cover and services that are generally included and excluded in each, you can read our guide to the four categories of private hospital insurance.

How do you choose private health cover?

If you’re in the market for private health insurance and are curious about where to get started, Canstar has a guide to the things to consider when choosing private health cover. Generally speaking, it is important to ask:

• What inclusions does the cover have?
• What is the excess payable?
• Do you want extras cover as well as, or instead of, hospital?
• Do you want to be exempt from the Medicare Levy Surcharge (MLS)?

You can compare private health insurance with Canstar if you are looking for a policy that may be suitable for you and your needs. You may also like to consider our Medicare Levy Surcharge (MLS), in which we recognise health insurance providers who offer Australians value for money. If you are considering a health insurance policy, it may be helpful to read the Product Disclosure Statement (PDS) and Target Market Determination that apply as part of your decision-making.

Compare health insurance

Cover image source: Drazen Zigic/Shutterstock.com