Row of multiethnic people sitting side by side while waiting for doctor in hospital lobby

Health Insurance and Going to Hospital

Your step by step guide to claiming health insurance when going to hospital

If you are in an accident or suffer a serious illness and require hospital treatment, the last thing you want to worry about is how you will be covered by your health insurance. This guide will cover everything you need to know regarding your treatment and how to take the right steps to ensure your expenses are adequately covered. It covers all the essentials in the hospital process from ensuring you have adequate health cover to making a claim and even packing a bag.

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1. Speak with a GP and specialist

It’s important to talk to your GP before going to hospital to ensure you won’t be paying any more than necessary for your treatment. If your GP needs to refer you to a specialist, tell them which private health insurance company you are with and ask for a referral to a specialist who is registered with that insurer. Alternatively, you can ask for an open referral, which is a list of specialists and you can then call your insurer to find out which specialist on the list provides services covered by your policy.

You should also consult your specialist before agreeing to go to hospital and in addition to asking them about your upcoming treatment (risks, benefits etc), also ask them if there will be any out of pocket expenses such as the cost of a prosthesis or fees charged by other specialists who may be involved in your treatment (i.e. anaesthetist, pathologist, radiologist etc).

2. Speak with your insurer

You should also contact your insurer prior to going to hospital and ask them a series of questions concerning your hospital treatment. These might include;

  • Does your policy cover all of your hospital treatment or is there a gap fee to pay or any additional out of pocket expenses?
  • Will you have to serve a waiting period before cover commences (in which case you may have to postpone your hospital treatment).
  • Is there an excess or co-payment required for any of the services covered in your policy?
  • Do your chosen specialist and hospital have agreements with your insurer?

As well as talking to your health insurance company, it’s also important to carefully read your policy’s Product Disclosure Statement (PDS) so that you fully understand what’s excluded, what’s covered and under what conditions.

3. Know what else you will have to pay for - Your informed consent

Informed financial consent is your agreement in writing to pay any additional fees or charges involved with your treatment that may not be covered by your insurance. If your specialist treatment involves out of pocket expenses, your specialist must explain these to you and present you with an itemised list, to which you must give your informed consent. Your chosen hospital must also advise you upfront of any additional costs, which you must agree to pay in writing before you can be admitted to hospital.

4. Choose the right hospital

Depending on your level of health cover, you can either choose to be admitted to hospital as a private patient in a private hospital or as a private patient in a public hospital. As a private patient in a private hospital, you will normally be covered for all treatments and services while in hospital, with your choice of hospital, specialist and approximate admission time (depending on availability). Many top hospital policies also include extras such as a daily newspaper, local phone calls, free-to-air TV and parking for relatives at no additional cost.

As a private patient in a public hospital, you will still have your choice of specialist, but you will have to share a room (private rooms are reserved for those who medically need them) and you may be liable for some out of pocket expenses not covered by your insurance. You will also not be able to choose the hospital you go to and you may have to go on a waiting list for treatment, depending on the nature of your medical condition.

5. Determine your private health insurance gaps

A private health insurance gap is another name for those out of pocket expenses not covered by your insurer. The gap is the difference between what Medicare pays (75% of the MBS fee set by the government for a medical service) and what a specialist or hospital charges for that service. If they charge more than the MBS fee (and some do), you would normally be required to pay the gap fee yourself (your insurer can only pay 25% of the MBS fee). However a number of insurers now have gap cover schemes to reduce or eliminate your out of pocket expenses, typically through an arrangement with the specialist or hospital.

What is generally covered by private health insurance?

Private health insurance will normally cover you for the following hospital treatments and services;

  • Hospital accommodation in either a private or shared room
  • Operating theatre, intensive care and labour ward fees
  • Supplied medicines approved by the PBS
  • Allied services such as physiotherapy and occupational therapy
  • Dressings and other consumables
  • Pathology and radiology diagnostic tests (recognised by Medicare)
  • Approved surgically-implanted prostheses (up to the benefit amount in the Government Prostheses List)
  • Emergency ambulance transport and treatment (depending on which state you live in)
  • The fees charged by specialists involved in your hospital treatment.

As mentioned above, some hospitals and specialists charge more than the MBS fee, so there may be a gap fee to pay on some of these services, unless your insurer offers a gap cover scheme.

What won't usually be covered?

Private health insurance will usually not cover (or fully cover) the following hospital treatments or services;

  • Treatment at a hospital that has no agreement with your insurer.
  • Treatment while you are still serving a waiting period on your health cover.
  • Accommodation in a private room, unless covered by your policy.
  • Treatments or services where an excess or co-payment applies.
  • Non-emergency patient-requested ambulance transport.
  • Cosmetic surgery or any surgery not clinically required.
  • Pharmacy items not opened when leaving hospital.
  • Aids supplied for use at home.
  • Pay TV, internet access, movies or non-local phone calls.
  • Hospital treatment without admission (classed as outpatient services).
  • Treatment covered by another source (i.e. travel insurance or worker’s compensation).
  • Hospital accommodation longer than 35 days (classed as a nursing home patient).
  • Treatments where no Medicare benefit is payable (i.e. dental surgery).
  • Treatment in a hospital outside Australia.
  • Treatment and services received more than two years ago.
  • Some high cost drugs.
  • Prostheses not approved by the government.

Are benefit payments per condition standardised?

No, each health insurer differs in their coverage amount depending on what condition you are treated for, with some paying more or less. This chart below outlines a number of commonly claimed for medical services and the benefit amount that some of Australia's largest insurers will pay on them:

Basal Cell Carcinoma or Squamous Cell Carcinoma removal from nose, eyelid, lip, ear, digit or genitalia$221.35$335.85$311.85$366.10$315.80$303.15$296.90$265.65$265.65
Breast, benign lesion surgical biopsy of excision$260.05$355.20$367.25$356.40$380.55$355.30$348.80$312.10$312.10
Carpal Tunnel Release$276.80$459.05$426.80$440.20$453.75$404.90$417.55$332.20$332.20
Cataract Surgery$760.55$1,242.25$1,163.30$1,239.70$1,184.20$1,126.25$1,144.90$912.80$912.80
Complicated Delivery (of baby)$1,629.35$2,649.15$2,307.90$1,855.90$2,406.65$2,198.50$2,280.10$1,955.20$1,955.25
Coronary Artery Bypass$2,200.00$3,665.20$3,404.40$3,783.30$3,294.85$3,265.15$3,064.80$2,640.00$2,640.00
Cytotoxic Chemotherapy$97.95$127.55$119.60$107.80$118.05$115.30$111.00$117.55$117.55
Femoral on Inguinal Hernia$464.50$640.60$657.50$909.70$662.70$636.05$623.05$557.40$557.40
Hip Replacement$1,317.80$2,146.75$2,318.15$2,214.50$2,094.35$2,000.75$2,013.85$1,581.40$1,581.40
Knee Replacement$2,047.60$2,146.75$2,318.15$2,563.40$2,094.35$2,000.75$2,013.85$1,581.40$1,581.40
Overnight investigation for sleep apnoea$588.00$747.65$707.85$682.20$703.45$694.25$709.40$705.60$705.60
Tonsils or Tonsils and Adenoid$295.70$522.05$493.85$513.90$481.30$472.35$442.65$354.85354.85
Uncomplicated Delivery (of baby)$693.95$2,150.35$1,979.05$1,484.50$2,057.05$1,886.95$1,550.60$832.74$832.74
Vaginal Hysterectomy$674.70$1,252.85$1,024.65$1,066.20$1,076.80$986.20$1,012.05$809.65$809.65
Varicose Veins$109.80$149.95$169.05$164.80$164.45$160.70$148.35$131.80131.80


I recognise most of these funds except for the AHSA, what is that?

The Australian Health Service Alliance is a management services organisation that represents a number of small to medium sized health insurance funds, allowing them to combine resources to deliver a higher quality of service to their members.

The funds represented by the ASHA are:

  • ACA Health Benefits Fund
  • Australian Unity Health Limited
  • CBHS Health Fund Limited
  • CUA Health Limited
  • Defence Health
  • GMF Health
  • Budget Direct Health Insurance
  • Frank Health Insurance
  • GU Health
  • HBF Health Ltd
  • Health Care Insurance Limited
  • Health Insurance Fund of Australia Limited
  • Health Partners
  • Navy Health
  • onemedifund
  • Peoplecare Health Insurance
  • Phoenix Health Fund
  • Police Health Limited
  • Queensland Country Health Fund Limited
  • Reserve Bank Health Society Ltd
  • rt health fund
  • Teachers Health Fund > UniHealth Insurance
  • Teachers Union Health
  • The Doctors' Health Fund Pty Ltd
  • Transport Health
  • Westfund

How to claim

Once you have been treated in hospital and are ready to go home, you will need to fill out the appropriate paperwork to claim from Medicare and your health insurer. The procedure is normally as follows:

  • Complete a claim form for your hospital costs and send it to your insurer (or if your hospital has an arrangement with your insurer, they will send it for you once completed).
  • Complete a ‘two-way’ claim form if you have out-of-pocket medical costs and submit it to Medicare, who will pay you a benefit and liaise with your insurer, who will also pay a portion of your costs.
  • Receive a statement of benefits from your insurer which itemises your costs and the benefit paid.
  • Check to see if you have reached the eligibility threshold for the Medicare and PBS Safety Nets, which provide financial assistance for those with high out-of-pocket expenses for outpatient services and medicines.

What should I bring with me to hospital?

While packing might seem straightforward, going to hospital can be a traumatic time for some and you may forget to pack some items. The following is a useful list of essentials that can serve as a starting point:

  • Documentation. This should include required cards such as your Medicare card, health fund membership card, any appropriate concession cards you may have, letters or referrals from GPs and specialists and any x-rays or medical documents relating to your condition.
  • Medicines. These should include both prescription and non-prescription medicines such as vitamins, herbal medicines and over-the-counter pain killers.
  • Personal items. These would typically include sleepwear, day clothes, underwear, non-slip footwear, toiletries, a radio, reading material and any personal aids such as spectacles, contact lenses or hearing aids.

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Picture: Shutterstock

William Eve

Will is a personal finance writer for specialising in content on insurance. While he cannot give personal advice to clients, Will enjoys explaining the intricacies of different types of protective cover to help individuals and businesses find affordable cover that won't leave them underinsured.

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