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.
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.
To make a complaint about a health service, contact the Commonwealth Ombudsman or the health care complaints service in your state or territory:
- Australian Capital Territory – ACT Human Rights Commissioner
- New South Wales – NSW Health Care Complaints Commission
- Northern Territory – NT Health Complaints Commission
- Queensland – Qld Health Quality and Complaints Commission
- South Australia – SA Health and Community Services Complaints Commissioner
- Tasmania – Tas. Complaints Commissioner Office of Health
- Victoria – Vic. Health Complaints Commissioner
- Western Australia – WA Office of Health Review