Joint Replacement: Man assessed to see if he requires joint replacement

Health insurance for joint replacement

Does health insurance cover joint replacement? Discover what benefits Aussie health funds offer.

Our joints run the risk of suffering wear and tear over time, and they can also be damaged by arthritis and a range of other medical conditions. This can eventually become so serious that the only treatment option is a joint replacement.

The good news is that private health insurance does provide cover for the cost of expensive joint replacement procedures. However, it’s important to shop around for a policy that provides the right type and level of cover for you.

Which Australian health funds cover joint replacement?

Health fundHospital policies that cover joint replacement *Related services that are also covered
HIF health insurance
  • GoldStar Hospital
  • Gold Hospital
    • GoldSaver Hospital
  • Joint reconstruction
health.com.au health insurance
  • High Hospital
  • Knee and shoulder reconstruction
Health Care Insurance
  • Premier Hospital
teachers health fund
  • Restricted health fund
  • Top Hospital
  • Mid Hospital
  • Basic Hospital
  • Knee and shoulder reconstruction
CBHS Health Fund
  • Restricted health fund
  • Comprehensive Hospital
  • Knee, hip and shoulder reconstruction
AHM health insurance
  • Top Hospital
  • White Deluxe
  • Joint reconstruction
Australian Unity
  • Platinum Hospital
  • Gold Hospital
  • Joint reconstruction
GMHBA health fund
  • Gold Hospital
  • Joint reconstruction
HCF health insurance
  • Premium Hospital
  • Mid Plus Hospital
  • Mid Hospital
  • Joint reconstruction
nib health insurance
  • Top Hospital
  • Advantage Hospital
  • Joint reconstruction
Transport Health insurance
  • Top Hospital Cover
  • Basic Hospital
  • Joint reconstruction

*All hospital policies apply a two month waiting period to joint replacement and reconstruction claims unless treatment is due to a pre-existing condition, in which case the waiting period is 12 months.

Health fundHospital policies that cover joint replacement*Related services that are also covered
ahm
  • Top Hospital
  • White Deluxe
  • Joint reconstruction
Australian Unity
  • Platinum Hospital
  • Gold Hospital
  • Joint reconstruction
Budget Direct
  • Top Hospital Cover
  • Public Hospital Cover
  • Joint reconstruction
Bupa
  • Top Hospital
  • Standard Hospital
  • Budget Hospital
  • Knee reconstruction
Cessnock District Health Fund
  • Gold Hospital
CUA Health
  • Premium Hospital
  • Premium Hospital - Non-obstetrics
  • Joint reconstruction
GMF
  • Complete Hospital Cover
GMHBA
  • Gold Hospital
  • Joint reconstruction
GU Health
  • Hospital cover
HBF
  • Top Hospital
  • Knee and shoulder reconstruction
HCF
  • Premium Hospital
  • Mid Plus Hospital
  • Mid Hospital
  • Joint reconstruction
Health Care Insurance
  • Premier Hospital
health.com.au
  • High Hospital
  • Knee and shoulder reconstruction
hif
  • GoldStar Hospital
  • Gold Hospital
    • GoldSaver Hospital
  • Joint reconstruction
Latrobe Health Services
  • Top Hospital
  • Member Share
  • Cover Wise
  • Loyal Members
  • Family Care
Medibank
  • Complete Hospital
  • Top Hospital
  • Top Hospital Essentials
  • Standard Hospital
  • Basic Hospital
  • Shoulder and knee reconstruction
Mildura Health Fund
  • Five Star Hospital Benefits
  • Basic Hospital Benefits
nib
  • Top Hospital
  • Advantage Hospital
  • Joint reconstruction
onemedifund
  • Private Plus Hospital
Peoplecare
  • Premium Hospital
  • Mid Hospital
Phoenix Health Fund
  • Top Hospital $500 Excess
  • Joint reconstruction
Queensland Country Health Fund
  • Top Hospital
  • Public Hospital
St. Lukes Health
  • Hospital Platinum
  • Hospital
  • Budget 500
Transport Health
  • Top Hospital Cover
  • Basic Hospital
  • Joint reconstruction
ACA Health
  • Restricted health fund
  • Deluxe Hospital
  • Private Hospital
  • Basic Hospital
CBHS health fund
  • Restricted health fund
  • Comprehensive Hospital
  • Knee, hip and shoulder reconstruction
Defence Health
  • Restricted health fund
  • Premier Hospital
  • Joint replacement
Doctors Health Fund
  • Restricted health fund
  • Top Cover
  • Prime Choice
Navy Health
  • Restricted health fund
  • Premium Hospital
  • Healthy Hospital
  • Knee reconstruction
Police Health
  • Restricted health fund
  • Top Hospital
  • Hip and knee reconstruction
Reserve Bank Health Society
  • Restricted health fund
  • Gold Hospital Cover
Teachers Health Fund
  • Restricted health fund
  • Top Hospital
  • Mid Hospital
  • Basic Hospital
  • Knee and shoulder reconstruction
TUH
  • Restricted health fund
  • Total Care Hospital

*All hospital policies apply a two month waiting period to joint replacement and reconstruction claims unless treatment is due to a pre-existing condition, in which case the waiting period is 12 months.

Speak with an adviser about your policy options and get a quote

Is joint replacement covered by Medicare or health insurance?

  • Medicare. Joint replacement surgery will usually be partially covered by Medicare, with the remaining gap to be covered by private health insurance hospital cover. The Medicare Benefits Schedule (MBS) lists benefits for a wide range of joint replacements; however, Medicare only covers 75% of the fee listed for a procedure, so you’ll need to take out private health insurance to cover the remaining costs.
  • Private health insurance. Some basic or lower-level hospital cover policies exclude joint replacements, so it’s important to choose a high-level hospital cover policy. In addition to hospital accommodation, theatre fees and charges from your doctor, your private health insurer will also cover the cost of the surgically-implanted prosthesis used to replace your joint. The Australian Government’s Prostheses List outlines all the prostheses for which private health insurers must pay a benefit.

What costs will private health insurance cover?

While health insurance can cover the cost of joint replacements, the level of cover provided varies substantially between health funds and individual policies. Some insurers will completely exclude joint replacements from lower tier hospital policies, while others will only pay a restricted benefit or cover specific joints such as knees. If you require health insurance for joint replacements you will need to take out a high-level hospital policy, which will generally include benefits for:

  • Accommodation in a public or private hospital
  • Theatre fees
  • In-hospital pharmaceuticals
  • Doctor and specialist fees
  • Prosthesis
  • Physiotherapy fees to help with your recovery

How much do Australians spend on joint replacement?

As Australia’s population continues to age, the incidence of arthritis and a range of other joint issues continues to increase. Unfortunately, this also means that a rising number of Australians require hip and knee replacements. To give you an idea of the costs involved, lets look at some figures:

Joint procedureStatistics
Hip replacements
  • In 2012-13, Australian private health insurance funds provided cover for more than 16,600 hip replacements, a 19% increase from 2011-12.
  • Health funds paid total benefits of $414 million to cover hip replacements in 2012-13, with Victoria having the highest rate of benefit payments at $25,000 per hip replacement surgery.
Knee replacements
  • As for knee replacements, more than 25,000 knee replacements were covered by Australian private health funds in 2012-13, an increase of 41% from the previous year.
  • This saw a total of $522 million in benefits paid, with Victoria once again recording the highest average benefit paid per surgery at $20,423.

Source of figures: https://www.privatehealthcareaustralia.org.au/variations-in-care-hip-and-knee-replacement/

Average national cost for knee and hip replacements from 2012 - 2013

Without private health insurance in place, joint replacement surgery can cost a substantial amount of money, as can be seen below.

How likely is it that I will need a hip or knee replacement?

  • Arthritis is the main contributing factor when Australians require joint replacement surgery. This debilitating condition affects more than 3.8 million Australians, and Arthritis Australia predicts that some 7 million people will suffer from arthritis by 2050.
  • While arthritis is commonly seen as a problem that only affects the elderly, almost 2.4 million Australians who currently suffer from arthritis are of working age. With this in mind, it’s worth re-assessing your health insurance needs as you grow older and considering whether you might be able to benefit from a policy that provides comprehensive cover for joint replacements.

Compare policies that cover joint replacement and receive a quote from an adviser

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Richard Laycock

Richard is the insurance editor at finder.com.au. He is on a mission to make insurance easier to understand.

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2 Responses

  1. Default Gravatar
    BarbaraNovember 15, 2016

    should knee & hip replacements be added to a travel policy if there has been no problems for 5 yrs or more

    • Staff
      RichardNovember 15, 2016Staff

      Hi Barbara,

      Thanks for getting in touch. Pre-existing conditions are assessed on a case-by-case basis. If you would like to find out more, please consult our pre-existing conditions and travel insurance article.

      All the best,
      Richard

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