Common Health Insurance Exclusions

We explain some of the common inclusions, restrictions, and exclusions in health insurance policies.

There are three categories of health services when it comes to health insurance policies – services that are included, restricted, and excluded. As every insurer has different inclusions, restrictions, and exclusions, these services are entirely dependent on the policy you choose.

Health insurance inclusions

Inclusions are the types of procedures or services that are covered by your health insurance policy; 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 of the common inclusions for Hospital Cover include:

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

A few of the common inclusions for Extras cover include:

Extras cover ·         Emergency ambulance fees
·         Dental care
·         Optical benefits (glasses, contact lenses)
·         Chiropractic care
·         Physiotherapy
·         Some pharmaceutical medicines

Note: The inclusions in these tables are used as a guide to inclusions available from a number of health insurance providers. Always check the product disclosure statement (PDS) and read the terms and conditions before making a purchase decision.

Health insurance restrictions

Restricted services are usually not covered in full, but you may receive some cover. Typically, your private health insurance will match the amount which the government would pay towards the service if you were in a public hospital, leaving you to pay the remaining ‘gap’.

An example of a health insurance restriction is when your policy only covers the cost of a hospital room. If this is the case, you may find yourself up for the majority of the cost of the procedure. This could be many thousands of dollars!

Be aware of these traps when choosing a policy. You don’t need to settle for a sub-standard policy – compare your options using our website:

Compare Health Insurance Policies with CANSTAR

Health insurance exclusions

Similar to inclusions, excluded services are those services that are not covered by or included in your private health insurance policy.

Because these services are not included, should you require access, you will be treated through the Medicare system. If Medicare does not cover these services, you will have to fork out the entire payment.

For example, you might have included dental and optical extras in your health insurance policy but not included chiro and physio options. If you had a physical injury, you would pay the full fee for all expenses that you incur while undergoing out-patient rehabilitation.

A pre-existing condition is another example of an exclusion. Many health insurance providers require you to disclose if you’ve received any medical care for a pre-existing ailment or illness 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.

Thinking about your health cover options

To avoid shock expenses, it’s important to consider what cover you need for your stage of life. Health needs and insurance preferences for young people and older people are often completely different, as policies are catered to their personal needs. Always make sure you read the product disclosure statement (PDS) and terms and conditions before making a purchase decision.

Compare the inclusions and exclusions in different health insurance policies using our website. You can also check out the comparison table below which features a snapshot of the current low premium market offerings, with links to the providers website. Please note that these tables have been formulated based on a single male seeking hospital cover in NSW. Try this tool for yourself here.

Compare Health Insurance Policies with CANSTAR


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