Common health insurance inclusions, exclusions and restrictions

When taking out private hospital insurance, you might think that you will be able to make a claim for a certain medical 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?

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 to help cover part of this cost as outlined in your policy. 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 category).

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What are health insurance exclusions?

Exclusions are hospital services that are not covered by your private health insurance. Following the 2019 health insurance reforms in Australia, hospital cover 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 medical service inclusions, while policies on the Basic tier will have the most basic inclusions. Health insurers may also sell ‘plus’ policies (e.g. bronze plus or silver plus), which include specific additional medical services from higher clinical categories—usually at a higher premium.

Some common examples of basic, bronze and silver plan exclusions might be joint replacements and pregnancy and birth-related services. These services tend to only be included on Gold-tier policies, due to their high overall costs. If your health insurance policy excludes pregnancy and birth-related services and you wish to be admitted to a private hospital to have the baby, you will not be covered for any hospital or medical expenses. It’s likely, instead, that you will be admitted as a public patient in a public hospital via the Medicare system.

Read More: Private vs public hospitals – what’s the difference?

Gold plan exclusions are few and far between, reflected by the price of these kinds of policies and their comprehensive coverage. Generally speaking though, if a medical procedure is not listed in the Medicare Benefits Schedule (MBS), it will not be covered by any private hospital insurance policy including Gold. This can also extend to ancillary health services, such as dental, physiotherapy and chiropractic, which will usually require an extras policy to be covered.

Certain expensive procedures may instead be restricted, meaning their coverage may be limited and you might incur out-of-pocket expenses if you need to claim for them. Regardless of whether a procedure is included in the category covered by your policy, you will generally have to serve waiting periods before you can claim for certain medical services (e.g. pregnancy services usually have a 12-month waiting period before you can claim).

What procedures are commonly excluded or restricted?

According to the Private Health Insurance Ombudsman, procedures that can be 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 or infertility services (IVF)

• 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.

How do you choose private health cover?

When comparing different health insurance providers and policies, it’s important to ask:

• What inclusions and exclusions does the cover have?

• What is the excess payable?

• Do you want a combined (hospital and extras), hospital only or extras only policy?

• Do you want to be exempt from the Medicare Levy Surcharge (MLS)?

You can compare private health insurance with Canstar, which can be a quick and easy way to search for a policy that may be suitable for your needs. You can also book a call with a health insurance specialist to chat about your health insurance needs.

You may also like to consider Canstar’s Health Insurance Awards, which recognise health insurance providers who offer Australians outstanding value. If you’re considering a health insurance policy, it may be helpful to read the Private Health Information Statement (PHIS) that applies as part of your decision-making.

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Additional reporting by Nick Whiting

Cover image source: PeopleImages.com – Yuri A/Shutterstock.com