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Health insurance for elective surgery
Get covered and skip the queue with private health insurance for elective surgery
Elective surgery may not be necessary to save your life, but there's a good chance it will improve the quality of your life. When Medicare tells you to wait, private cover can step in and save the day.
Skip the queue, choose your doctor and get your own private room by taking out private insurance that covers elective surgery.
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What is an elective surgery?
If your surgery can't be put off by more than 24 hours, its an emergency. Anything else is considered elective surgery and you'll be put on a waiting list if you use the public system.
Elective doesn't mean unnecessary, and some people will need their elective surgery performed sooner rather than later, so doctors will monitor your condition and schedule your elective surgery according to how urgent you need it.
There are three levels of urgency doctors use to decide whose first in the queue for elective surgery: urgent, semi-urgent and non-urgent. Here's how each are defined and what you can expect based on what category your surgery belongs to:
|Urgency Category||Definition||Examples||Ideal maximum wait time|
|Urgent||Condition that could deteriorate quickly and become an emergency||Limb amputation, heart valve replacement||Admission within 30 days|
|Semi-urgent||Condition that causes some pain, dysfunction or disability but is not likely to deteriorate quickly or become an emergency||Hip replacement, prostate removal||Admission within 90 days|
|Non-urgent||Condition that causes minimal or no pain, dysfunction or disability, is unlikely to deteriorate quickly and does not have the potential to become an emergency||Varicose vein removal, septum reconstruction||Admission within 365 days|
Source: NSW Bureau of Health Information
Is elective surgery covered by private health insurance?
Depending on your level of cover, private health insurance will cover a large number of elective surgeries. After all, everything except emergency, life-saving surgeries are considered to be elective.
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.
There are some elective surgeries that are excluded from all but a few of the most premium policies, including weight loss surgery and in vitro fertilisation. Almost no policy offers cover for non-medical plastic surgery.
What are the most common elective surgeries?
In 2015–16 there were roughly 1.5 million public and private elective procedures in that year alone. Of the 0.7 million procedures done in public hospitals procedures, some of the most common were:
- Cataract surgery (9.5%)
- Bladder endoscopy (6.8%)
- Gallbladder removal (2.6%)
- Hernia surgery (2.4%)
- Tonsil removal (2.5%)
- Total hip replacement (1.6%)
Most of these would probably be considered semi-urgent or non-urgent, meaning people getting treated for these conditions in the public system would have to queue and potentially deal with discomfort or pain for several months.
How long do people wait for elective surgery?
In 2015–16, the median wait time for elective surgery (including urgent ones) in public hospitals was 37 days, meaning half of all patients waited longer than that. Nearly 10% of patients had to wait 260 days or longer, and an unlucky 2% waited more than a year.
The quickest wait time of any elective procedure was 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.
Here are the procedures with the longest median wait times:
- Eye surgery: 78 days
- Ear, nose and throat surgery: 74 days.
- Foot surgery: 67 days
The actual wait times are probably even longer, because these figures only reflect the period of time between being added to the waitlist and being admitted for surgery. It doesn’t factor in the time it takes for prior check-ups and the time it takes to get put on the waiting list.
Public hospital elective surgery wait times have been increasing in recent years, even as the rate of private hospital admissions has also increased. This suggests that the rate of patients needing to undergo elective procedures might be increasing faster than Australia’s public health system can handle.
Is private health insurance a better way to cover elective surgery?
Private health insurance can get you shorter wait times for elective procedures, and this can make a huge difference if your condition is affecting your quality of life.
Getting in sooner can also have health implications. For example a clogged artery is extremely serious, but not sufficiently life-threatening to qualify as an emergency.
Just be aware that not all insurance companies cover all surgeries. For example, you'll probably need a top-tier policy if you want to have major heart surgery covered.
How do private health insurance waiting periods work
Waiting periods are fairly standard on most health insurance policies around Australia and you can expect a waiting period for most treatments no matter what fund you are with. These waiting periods range from 0-2 days for accidents and ambulance cover to 12 months for pregnancy and pre-existing conditions.
This means it’s not possible to just take out health insurance the moment you need it. Fortunately, once you have cover you can switch between different health funds without needing go through the waiting periods again.
How to compare health insurance for elective surgery
When you compare hospital health insurance policies, it’s important to understand what's covered and what's not. For example, if major eye surgery is excluded, then that means cataract removals won’t be covered.
Most brands offer three to four levels of cover: top, medium, basic and public hospital. What's included in each differs from brand to brand, but here is how the levels commonly look:
- Top hospital cover. Covers most of what Medicare does, although you might have to do a little digging to find cover for relatively uncommon elective surgeries like weight loss surgery.
- Medium hospital cover. Covers most of what you'd find with top cover, but without cover for some of the most expensive and complicated elective surgeries like hip replacements.
- Basic hospital cover. Covers most basic procedures, but excludes everything mid cover excludes plus a handful of other somewhat complicated procedures like heart procedures and minor joint replacements.
- Public hospital cover. A form of basic cover that lets you choose your private doctor, but only in a public hospital. It covers many of the same treatments as basic, but has higher out-of-pocket fees and you must join the public queue and wait for your treatment.
Picture: Natanael Melchor - Unsplash
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