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Health insurance for elective surgery

How can private health insurance help if you need elective surgery?

Hospitals do a lot more than emergency treatments. In Australian hospitals, elective treatments are by far the most common reason for admission in both public and private hospitals and account for well over half of all hospital admissions1. Read on to find out more about common elective procedures, and how different insurers and plans cover them.

1Source: AIHW 2015-16 hospital statistics

What is an elective procedure?

Elective procedures are those that are not an urgent matter of life and death, and where it’s relatively safe to put patients on a waiting list.

For example, cataract removal surgery, hip replacements and knee reconstructions are all elective procedures. Even though you might be partially blind or unable to walk, it’s not a matter of life and death.

Generally, hospitals will consider elective surgery in different categories, based on their relative urgency. For instance, the NSW Bureau of Health Information identifies these categories as follows:

Urgency categories: Elective surgery guidelines
Category 1: Urgent
(Heart valve replacement, Amputation of limb)
Admission within 30 days desirable for a condition that has the potential to deteriorate quickly and become an emergency
Category 2: Semi-urgent
(Colposcopy, Amputation of digit)
Admission within 90 days desirable for a condition not likely to deteriorate quickly
Category 3: Non-urgent
Admission within 365 days acceptable for a condition unlikely to deteriorate quickly

Source: NSW Bureau of Health Information

Elective surgery and health insurance

Elective procedures are one of the main reasons people get private health insurance. In fact, 56% of all elective procedures in Australia in 2015–16 were done in private hospitals, even though there are more public hospitals.

Of those patients attending a private hospital for elective surgery, the majority did so with private health insurance.

It’s safe to say that the vast majority of Australians would agree that private health insurance is the best way to get elective surgery done, and that it’s well worth it for getting procedures completed.

And if you ever need to have elective surgery, you’ll probably feel the same.

What are the odds of needing elective surgery?

It naturally depends on your age and health, but in 2015–16 there was a total of 711,854 elective procedures carried out in public hospitals, which means roughly 1.5 million public and private elective procedures in that year alone.

Weigh that against the total population of Australia and it seems like the odds of needing an elective procedure are fairly high.

Common elective surgeries

Of those public hospital procedures, some of the most common were:

  • Cataract extraction: 67,755 procedures
  • Cystoscopy (bladder endoscopy): 48,721 procedures
  • Cholecystectomy (gallbladder removal): 18,767 procedures
  • Inguinal herniorrhaphy (a type of hernia surgery): 17,237 procedures
  • Tonsillectomy: 18,112 procedures
  • Total hip replacement: 11,120 procedures

With symptoms like vision or mobility impairment, kidney stones and hernias, patients would have been relieved to get the treatment done.

Unfortunately, many of them would have been waiting several months for it.

How long do people wait for surgery?

In 2015–16, the median wait time for elective surgery in public hospitals was 37 days. This means 50% of patients were waiting longer than that, and 10% of patients had to wait 260 days or longer.

Scarily, the quickest wait time of any elective procedures was still almost 2 weeks (13 days) and that was for coronary artery bypass grafts, a potentially lifesaving procedure to restore normal blood flow to an obstructed artery.

The longest wait times were found in ophthalmology (eye procedures) with a median wait time of 78 days, and the second longest in ear, nose and throat surgery at 74 days. The third longest was orthopaedic (foot) surgery at 67 days median wait.

Overall, 2% of public hospital patients had to wait more than a year for their treatment.

It’s also worth noting that all these numbers are probably lower than the actual wait times. These figures only reflect how long it was between being added to the waitlist and being admitted for surgery.

It doesn’t factor in the time taken on prior check-ups and the time taken to actually get on the waiting list.

Public hospital elective surgery wait times have been increasing in recent years, even as the rate of private hospital admissions also increases.

This suggests that the rate of patients needing to undergo elective procedures might be increasing faster than Australia’s public health system can handle.

Public vs private health insurance - does it make a difference?

Private health insurance can get you shorter wait times for elective procedures. If you’re struggling with a deteriorating quality of life as a result of health issues then every day you wait might make a difference.

And when the issue is extremely serious, such as a clogged artery, but not sufficiently life-threatening to qualify as an emergency, then it might make a particularly big difference.

The problem is that it’s not as simple as picking out any private health insurance policy. You might think you’re covered but on closer inspection won’t be. Or you might still be subject to waiting periods at the worst time possible.

How exclusions and waiting periods work

Waiting periods are fairly standard on most health insurance policies around Australia and you can expect a full 12-month waiting period for pre-existing conditions with all health funds Australia-wide.

This means it’s not possible to just take out health insurance after you need it. Fortunately, once you have cover you can switch between different health funds without needing go through the waiting periods again.

You’ll also need to watch out for the exclusions.

Cardiac procedures are one commonly excluded category that’s only covered by comprehensive or “Gold” level hospital health insurance. So if you were hoping to get that blocked artery taken care of in less than two weeks, you might need to have already had a top hospital policy.

How to compare health insurance for elective procedures

When you compare hospital health insurance policies, it’s important to be mindful of what each covered and not-covered procedure actually means for you.

For example, if major eye surgery is excluded then that means cataract removals won’t be covered.

A comprehensive hospital policy can cover everything that Medicare does, except in private hospital and without the full waiting lists.

Meanwhile, a mid-level hospital policy might exclude cardiac and eye treatments but could still cover hip, knee and other joint reconstructions.

And a basic hospital policy might cover little other than tonsil and adenoid removal, while the most basic public hospital or accident-only private health insurance policies might not cover any elective procedures in private hospital at all.

When you look for private health insurance, make sure to consider what each box ticked, or crossed out, really means for the cover you get.

Compare policies from 30+ Australian health funds

Picture: Shutterstock

Andrew Munro

Andrew writes for, comparing products, writing guides and looking for new ways to help people make smart decisions. He's a fan of insurance, business news and cryptocurrency.

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