Getting the best from your private health insurance

Know what's included in your private health insurance policy and when to claim. Find out how to manage your premiums, suspend your policy while overseas, change to a different health insurer, or make a complaint.

Understand what’s covered under your policy

Your health insurer must send you a private health information statement at least once a year. The information statement is like a financial services product disclosure statement.

This statement is an overview of what your policy covers. There are different types of statements for:

The statement is only a summary. Contact your health insurer for all details of your policy including specific waiting periods.

You can claim benefits from your health insurer when you:

  • are treated in hospital as a private patient, if you have hospital cover
  • have other medical treatment not covered by Medicare, if your extras policy covers the treatment

Read more about what private health insurance covers.

Know what you can claim

Before you have medical treatment, check whether the service or treatment you want is covered.

You might be covered for a treatment but have to serve a waiting period before you can claim.

Most insurers set an annual claim limit. This is the amount you can claim for any given covered service each year.

Understand additional costs

Depending on your level of cover, you may have to pay some out of pocket expenses.

Informed financial consent

It’s your right to get an estimate of how much your treatment will cost. See the Commonwealth Ombudsman’s guidance on informed financial consent.

You can also read the Australian Medical Association’s guide on informed financial consent for doctors and patients.

Before you go into hospital as a private patient check if you might have to pay a gap. To find out how much you may have to pay, use the Medical Costs Finder.

You can also talk to:

  • the doctors or specialists who will treat you in hospital
  • the hospital you’ll be treated in
  • your health insurer

Changing your policy or insurer

You can change your health insurer or your cover at any time.

You may have to wait a period before you can make a claim if you change to a:

  • higher level of cover
  • policy with lower excesses or gap fees

If you switch to a new policy that offers the same benefits as your old policy, waiting periods you've already served will be transferred to the new policy. This applies even if you change your insurer.

You can claim a once-only waiting period exemption for mental health care services.

Before you decide to change insurer, check:

  • whether there will be any new waiting periods
  • how long the waiting periods will be

Learn more about waiting periods and exemptions.

Suspending your policy

You can ask your health insurer to suspend your cover if you go overseas. If your insurer agrees to suspend your cover you can:

  • stop paying premiums while you are overseas
  • resume your cover when you’re back

You can’t claim while your cover is suspended.

If you haven’t finished your waiting periods when your cover is suspended, you’ll have to finish that waiting period when you return.

You may also be able to suspend your cover if you’re having financial issues.

Check with your health insurer to see what their suspension policy is. Different insurers have different rules.

Suspending your policy may not impact how Lifetime Health Cover applies to you, but it does affect Medicare levy surcharge exemptions.

If you need to go overseas and your health insurer won’t let you suspend your cover, you may decide to cancel your policy. Find out about permitted days without hospital cover.

Paying your premiums

You must pay your premiums to maintain your cover.

If you are less than 2 months behind in your premiums, your health insurer must let you pay your outstanding premiums and keep your cover.

Your health insurer can lapse your policy if you are more than 2 months behind on your premium payments. This means you won’t have health insurance cover for any costs.

Talk to your insurer before you fall behind if you’re having difficulty paying your premiums.

Premium increases are governed by private health insurance laws.

Making a complaint

If you’re not happy with the service of your health insurer, contact the Commonwealth Ombudsman.

Last updated: 
19 February 2020

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