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Health insurance for appendicitis

What is appendicitis, and how much is covered by Medicare and health insurance?

Tim Falk
Tim Falk

Appendicitis is caused by an inflammation of the appendix, a small organ attached to the large intestine. Not only can the condition be very painful, but if left untreated, the inflamed appendix can burst and become life-threatening.

Do you know whether your private health insurance provides cover for the cost of the treatment of appendicitis? If so, how much of the procedure’s costs will it cover on top of the amount covered by Medicare? Read on for more information.

What costs will your health fund cover?

Appendicitis and appendix removal are commonly covered by most hospital cover health insurance policies in Australia. This includes cover for:

  • Hospital accommodation in a private or public hospital, in either a private or shared room
  • Operating theatre fees
  • Doctor’s fees and in-hospital consultations
  • In-hospital prescriptions and pharmaceuticals

The Medicare Benefits Schedule Fee for an appendectomy is $445.40, of which Medicare covers 75% and private health insurance covers the remaining 25%. If your doctor charges more than the scheduled fee for your appendectomy, whether or not the additional cost is covered will be determined by whether your doctor participates in your health fund’s gap cover scheme.

Find health insurance that covers appendix removal

Appendix removal can be found in a basic hospital policy. Below are some policies from Finder partners that cover the treatment. All include a 2 month waiting period for new conditions, and 12 months for pre-existing.

If you wish to continue to claim benefits for appendicitis treatments, you will need a policy of Basic, Bronze or higher tier.

Provider Tier Price per month Apply

starter bronze

 Bronze $86.80 Go to site

Hospital Bronze Plus

 Bronze $91.60 Go to site

* Prices are based on a single individual with $500 excess, less than $90,000 income, and living in Sydney.

Is appendicitis covered by Medicare, private health insurance or both?

Appendicitis is covered by both Medicare and private health insurance. Medicare covers 75% of the scheduled fee for an appendectomy as listed in the Medicare Benefits Schedule. The remaining 25% of the cost of the surgery can be covered by your private health insurer.

The good news is that surgical appendix removal is covered by the vast majority of private hospital cover policies. This ensures that you can receive cover for the cost of surgical and theatre fees, as well as for any pharmaceuticals you receive while in hospital. Depending on the level of cover you have, you will be covered for the cost of accommodation in a private hospital or a private room in a public hospital.

How does private health insurance cover appendix removal?

You will find appendix removal is covered under Bronze tier health insurance after April 1st, when government reforms come into effect. This means that all private health insurers will categorise appendix removal under a fairly basic and affordable hospital policy.

If you already have health insurance, chances are you've already served the waiting period, as it's included in most cover. You can switch and save without impacting that.

The majority of insurers cover the cost of surgical and theatre fees, as well as for any medicine you receive whilst in hospital. It will also generally cover the cost of accommodation in a private hospital or bed.

Another perk is the ability to choose your own doctor and hospital. This is really vital for many as treatment usually involves staying overnight – so comfort is important.
There will be some out of pocket expenses. To have a good indication of any out of pocket expenses, you should find out the price of the following:

  • Principal surgeon
  • Anaesthetist
  • Assistants
  • Diagnostics for example x-rays, lab tests and medical imaging

How much is an appendectomy without insurance?

The fee listed on the Medicare Benefits Schedule for an appendectomy is $445.40. As Medicare covers 75% or $334.05 of the scheduled fee, the remaining 25% of the fee will need to be covered by your private health insurance. That means that if you don't have private health cover in place, an appendectomy will cost you $111.35 in a private hospital.

What are the symptoms of appendicitis?

Appendicitis can cause a wide range of signs and symptoms, including:

  • Dull pain around the centre of the navel, progressing to sharp pain on the lower right side of the abdomen
  • Pain intensifies when the abdomen is touched
  • Fever
  • Vomiting and nausea
  • Diarrhoea or constipation
  • Loss of appetite
  • In some cases, pain around the lower back and hamstring

What will happen if appendicitis is left untreated?

If left untreated, appendicitis is a potentially life-threatening condition. With this in mind, doctors will always take a cautious approach and operate on a patient, even if a confirmed diagnosis of appendicitis has not been reached.

What does appendix removal surgery involve?

Surgical removal of the appendix is called an appendectomy. Your appendix is located in the lower ride side of the abdomen and ordinarily, the operation is carried out on an emergency basis to treat appendicitis - an inflamed appendix that could burst.
You will receive general anaesthesia. The appendix is usually removed through a 4-inch incision or by laparoscopy. If the appendix has formed an abscess, the procedure becomes slightly more complicated and will take longer. The surgeon will firstly drain the abscess of fluid and will then remove the appendix.

What is the appendix removal recovery time?

Depending upon your health condition and age, you should be able to get up and move around within 12-15 hours but you'll be sore and achy for longer than this. You can usually return to normal activities in two to four weeks.

How finder partners cover appendix in detail

Health fund What services are covered? Apply
ahm-fund-page-logoAHM AHM hospital cover policies cover the surgical removal of your appendix if you have appendicitis and need hospital treatment except for Starter Basic Hospital cover. This includes all agreed hospital charges in a partner private hospital in a shared or private room. In a public hospital, AHM will cover accommodation charges for a shared room and pay benefits towards the cost of a private room. A 12-month waiting period applies for pre-existing conditions, but this is shortened to two months in all other cases. More info
Australian Unity logoAustralian Unity If you require appendix removal, hospital cover from Australian Unity covers hospital accommodation costs, theatre fees, in-hospital pharmaceuticals and more . A two-month waiting period applies. More info
GMHBA-logo GMHBA GMHBA Hospital Cover includes cover for theatre fees, doctor's fees and accommodation in a public or private hospital when you need to have your appendix removed except for Basic Plus (Restricted). Pharmaceuticals you receive as an inpatient are also covered. A two-month waiting period applies. More info
HCF-Logo HCF HCF Hospital Cover provides cover for the cost of an appendectomy, including hospital accommodation, theatre fees, surgical fees and pharmaceuticals. Whether or not you receive treatment in a private or public hospital varies depending on the level of cover you select. A two-month waiting period applies. More info
health.com_.au_health.com.au health.com.au provides cover for accommodation in a public or private hospital, theatre fees, pharmaceuticals and surgical fees. A two-month waiting period applies. More info
hif logoHIF If you need to have your appendix surgically removed, cover is provided by HIF's suite of health insurance policies. This includes accommodation in a private hospital or as a private patient in a public hospital, plus theatre care, surgical fees and pharmaceuticals you receive in hospital. A two-month waiting period applies. More info
transport healthTransport Health All of Transport Health's hospital cover policies include cover for appendix removal. This includes hospital accommodation, emergency ambulance transport, theatre fees and pharmaceuticals. A two-month waiting period applies. More info

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