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Apia Health Insurance

Find out if Apia health insurance is right for you.

Apia is one of the few funds in Australia that specialises in providing health insurance cover for over 50s and seniors. Underwritten by Suncorp for a high level of security. They take pride in offering sensible real world health insurance policies that cover what’s important without making you pay for unwanted extras.

This provider is not available via finder. You can visit www.apia.com.au for more information or compare alternative options below.

Apia health insurance options

Like almost all health insurance funds, Apia offers two different types of cover, hospital and extras.

  • All hospital cover policies are required to pay benefits for any in-hospital medical treatments that are also covered by Medicare. This covers almost all vital medical procedures. For added value, funds will also cover other non-essential procedures and get you private hospital access.
  • Extras policies cover treatments and procedures that are not covered by Medicare, such a physiotherapy, complex dental work, health aids and much more. The exact benefits offered by extras policies depend largely on the fund, and Apia’s extras focus on pragmatic benefits that a lot of over 50s can take advantage of.

Apia hospital cover options

Medicare, Australia’s public health insurance, will pay for vital medical treatments in public hospitals, usually in shared rooms. You cannot choose your doctor, have little control over your own treatment plan and can only access certain treatments through a waiting list, subject to availability. By contrast, Apia hospital cover lets you:

  • Receive benefits for a wider variety of treatments, including non-essentials
  • Choose your doctor and the specialists who treat you
  • Get covered for stays at private hospitals as well as public hospitals
  • Choose to stay in a private room
  • Have more say over your treatment plan and timeframe
  • Get quicker treatments and skip public hospital waiting lists

Apia offers two levels of hospital cover, Essential and Premium. The former is cost-effective basic cover, while the latter is a more comprehensive option.

  • Premium covers eye treatment and eye surgery, obesity surgery and renal dialysis while Essential does not.
  • Premium pays more benefits for psychiatric treatment while Essential only pays the minimum required.

Other than those differences, all Apia hospital cover policies offer the following:

What is coveredWhat it isWaiting period
Accidental injuryImmediate medical treatment following an accident1 day
All Medicare-approved treatmentsAll essential medical procedures that are also covered by MedicareVaries
AmbulanceAmbulance call outs, emergency transport and between-hospital patient transport1 day
Back surgerySurgery to treat back abnormalities or injuries such as spinal fusion or a herniated disc
  • 12 months for pre-existing conditions
  • 2 months for others
Brain surgerySurgery of the brain for reasons such as tumour removal, hemorrhage, blood clots, aneurysms and more
  • 12 months for pre-existing conditions
  • 2 months for others
Cancer treatmentApproved cancer treatments including surgery, radiotherapy and chemotherapy
  • 12 months for pre-existing conditions
  • 2 months for others
ColonoscopiesIntestinal diagnosis and examination for bowel cancer, polyps, unexplained pains and more
  • 12 months for pre-existing conditions
  • 2 months for others
Dental surgeryTeeth extractions and dental procedures that require general anaesthetic
  • 12 months for pre-existing conditions
  • 2 months for others
GastroscopiesMedical examination of the digestive system to investigate and diagnose issues such as ulcers, cancer, difficulty swallowing and more
  • 12 months for pre-existing conditions
  • 2 months for others
Gynaecological servicesFemale reproductive system health when not related to infertility, such as the treatment and diagnosis of endometriosis
  • 12 months for pre-existing conditions
  • 2 months for others
Heart proceduresPacemaker and defibrillator insertion, stent insertion, heart transplants, coronary angioplasties, heart valve surgeries and much more
  • 12 months for pre-existing conditions
  • 2 months for others
Hernia repairTreatment of hernias
  • 12 months for pre-existing conditions
  • 2 months for others
Joint investigationsDiagnostic joint surgery
  • 12 months for pre-existing conditions
  • 2 months for others
Joint reconstructionsReconstruction of damaged joints and ligaments
  • 12 months for pre-existing conditions
  • 2 months for others
Joint replacementReplacement of damaged joints with a prosthesis
  • 12 months for pre-existing conditions
  • 2 months for others
Palliative careOngoing pain-relief care, active living support for health issues2 months
RehabilitationPhysical therapy and exercise treatments for reasons such as stroke recovery or strengthening joints2 months
Stroke treatmentsTreatment for a stroke, usually urgent and to fix a blockage or haemorrhage
  • 12 months for pre-existing conditions
  • 2 months for others
  • Apia hospital cover will pay the full cost of hospital accommodation, operating theatre fees, intensive care, coronary and neonatal care, meals, medical supplies and all approved pharmaceuticals. Some of the more expensive types of medication, such as those used in oncology, may not be covered.
  • You can choose between a $250 excess or a $500 excess. This is a fee that you will need to pay once a year in any year where you make a claim for hospital benefits. Choose $500 for lower premiums, or $250 for a lower excess but higher premiums.

Apia extras cover options

Health insurance extras covers non-vital treatments and services such as glasses, podiatry, health aids and nonessential dental work. Apia has three levels of extras cover to choose from - Essential, Essential Plus and Premium. The limit is the most you can claim for a treatment in a year, and it steadily gets higher with more comprehensive policies. Essential and Essential Plus will pay 60% of the costs of the treatment back to you, while Premium will pay for 75% of the costs.

Is it covered?Essential (60%)Essential Plus (60%)Premium (75%)
AmbulanceYes, no limitYes, no limitYes, no limit
General dental$600 limit$700 limit$1,000 limit
Major dental$600$1,300$1,300
Preventative dentalYes, no limitYes, no limitYes, no limit
Optical$250$300$350
Physiotherapy$350$450$600
Chiropractic osteopathyNoNo$500
Dietary adviceNoNo$600
Exercise physiologyNoNo$300
Eye therapyNoNo$200
Health aidsNoNo$500
Hearing aids and speech processorsNoNo$1,200
Home nursing servicesNoNo$200
Natural therapiesNoNo$400
Occupational therapyNoNo$450
OrthodonticsNoNo$800

Apia lets you customise your extras policy. Get everything under a Premium policy, or choose Essential or Essential Plus and then add anything that’s important to you, such as hearing aid cover, orthoptics or extra pharmaceutical benefits.

General exclusions, waiting periods and excesses

As with all health insurance policies, Apia has exclusions, waiting periods and excesses.

Exclusions

These are circumstances in which you cannot claim benefits. Apia will not pay for:

  • Non-Medicare treatments. Typically this will only rule out newer robotic surgeries and experimental drugs and it won’t adversely impact your level of treatment.
  • Cosmetic procedures, including dental implants, if not medically necessary. For example, it will pay for a rhinoplasty if doctors recommend it as a treatment for apnoea, but will not pay for it for purely cosmetic reasons.
  • Beauty services, phone calls, TV hire, luxury rooms and other hospital costs that aren’t directly related to your treatment and care.
  • Admission or booking fees charged by specialists or hospitals.
  • Medications that are already covered by the pharmaceutical benefits scheme (PBS).
  • Blood drawing and storage, although it will pay for necessary blood tests.
  • Procedures performed in a doctor’s surgery rather than in a hospital.
  • Private hospital emergency or outpatient fees, and outpatient services performed by a doctor or specialist.
  • Special nursing requirements or at-home nursing care for patients discharged early.

Apia does exclusions differently

Many health insurance providers will exclude pre-existing conditions, meaning that they will never pay benefits for them. This is a problem for many seniors looking for health insurance because there will almost always be some pre-existing condition that needs to be covered. Apia does not exclude pre-existing conditions and you can still claim benefits for them.

Waiting periods

A waiting period is the amount of time you must wait after taking out or upgrading a policy before you can claim any benefits. Each kind of treatment usually has its own waiting period, and typically it’s around 2 months for less severe issues, and 12 months for potentially more expensive or severe issues. In some cases, such as for psychiatric treatment and palliative care, health insurance providers are legally not allowed to set a waiting period any longer than 2 months.

Apia does waiting periods differently

Because Apia’s policies are specially designed for seniors with whom health events are more likely to occur suddenly and with little warning, Apia only has no more than a 2-month waiting period for everything, even serious treatments that other funds won’t cover for 12 months. The exception is pre-existing conditions, which carry a 12-month waiting period with Apia.

Excesses

This is a fee to be paid whenever you make a claim. Some policies may have a separate excess for each treatment, or a separate hospital and extras excess to be paid each time you make a claim. If you’re not careful, a high excess can undermine the value for money of your health insurance policy.

Apia does excesses differently

Once again, Apia specialises in healthcare for seniors and can appreciate that you spend a lot more time with your doctor as you get older. Apia’s hospital policies carry just one yearly excess of either $250 or $500 (you decide). No matter how many times you go to hospital that year, you will not have to pay more than one excess.

What makes Apia’s health insurance so good for seniors?

As mentioned above, Apia handles exclusions, waiting periods and excesses differently to most funds, and in a way that seniors in particular can benefit from. In addition to this you can also tailor your policy to cost-effectively add specific types of cover without paying for benefits you’ll never use.

  • Apia keeps costs down by not offering any fertility and birthing services. No assisted reproductive services, no infertility investigations and no pregnancy or birth support. If you don’t need it, don’t pay for it.
  • Apia can more flexibly accommodate pre-existing conditions and other health challenges faced by the elderly.
  • Health insurance providers pay for your treatment by negotiating with hospitals directly. Apia has agreements with over 70% of Australian private hospitals, which lets them reduce hospital costs and keep your premiums down while simultaneously making sure you can find quality health care almost anywhere in Australia.
  • Compared to other funds, Apia has a lot of elderly policyholders. By working with hospitals directly they can use this to deliver good economy of scale and further reduce your premiums.
  • Best of all, Apia lets you customise your extras policy. Keep costs down by choosing an Essential or Essential Plus extras policy, and then add the advanced extras that are most important to you without paying for additions you don’t need.

Choose your advanced extras from just a few dollars per week

Advanced extrasWhat it isAnnual limitWaiting period
Chiropractic and osteopathyPhysical treatments focused on the back, joints and musculoskeletal system$3002 months
Podiatry and foot orthoticsSpecialist diagnosis and treatment of foot conditions and foot orthotics like insoles$2502 months
Non-PBS pharmaceuticalsPharmaceuticals that are not covered by the government benefit scheme, including new and experimental treatments$2502 months
Health aidsSurgical stockings, erectile dysfunction pumps, walking frames, blood coagulation devices, blood pressure monitors and other health aids$300 (separate appliance limits also apply)12 months
Healthier lifestyle benefitsActive living programs like yoga, pilates and personal trainers, approved weight management programs, smoking cessation programs and other healthy living programs$2506 months
Preventative testsThinPrep pap smears, bone density tests, bowel screenings, breast cancer screenings, blood tests and other preventative tests$200 (separate service limits also apply)6 months
Hearing aidsHearing aid devices$800 (separate appliance limits also apply)36 months
Eye therapy and orthopticsVision improvement and eye training programs, both alongside and as an alternative to glasses and contact lenses$2002 months

Does Apia offer a loyalty benefit?

It’s more important that you have a suitable health insurance policy for your needs than that you are with the “right” brand. Apia does not offer loyalty benefits, and you are encouraged to shop around for the most suitable policy rather than be loyal to a brand name. In fact, a lot of older Australians switch to Apia for precisely this reason. To make the transition easier without needing to risk new waiting periods all over again, Apia will recognise the waiting periods you’ve served with other funds. This means that if you’ve been with your old health insurance company for six months and you switch to Apia, those six months will be counted towards your Apia waiting periods and you can start claiming benefits immediately rather than having to start all over again.

Making a claim with Apia health insurance

Apia keeps it simple and gives you several options for claiming:

  • You can make a claim online. Simply login to your account on the Apia website and follow the instructions provided.
  • You can send in a claims form via fax, mail or email. Just fill in details of the treatment you are claiming and provide information on how you want them to pay you. Remember to include an itemised receipt.
  • Not sure how to make a claim? Just call 13 50 50. Apia can help you out 24 hours a day, 7 days a week.

Frequently asked questions

      Steps to find the right health insurance policy

      1. Choose Essential or Premium hospital cover
      2. Select one of the three Extras plans
      3. Add any desired Advanced Extras

      Compare health insurance funds

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      6 Responses

      1. Default Gravatar
        CharlesApril 4, 2018

        I am a member of Apia, could you tell me whether, I am covered for:Optometrists

        • finder Customer Care
          NikkiApril 4, 2018Staff

          Hi Charles!

          Thanks for your message and for visiting finder – the leading comparison website & general information service built to give you advice in your buying decision needs. How are you doing today?

          APIA Health Insurance covers optical however it would vary according to the plan you have. Essential Plan covers $250, Essential Plus covers, $300 and Premium covers $350.

          Hope this helps!

          Cheers,
          Nikki

      2. Default Gravatar
        JJApril 28, 2017

        I am a provider of medical services. Do I need to register as a provider with you? Unable to get anything on the web to do claims, etc – like fees schedule.

        Please let me know.

        • finder Customer Care
          ZubairMay 1, 2017Staff

          Hi JJ,

          Thank you for your question.

          You have contacted finder.com.au, a comparison and information service and not actually Apia Health Fund. You will need to contact Apia Health Fund directly about this matter.

          Cheers,
          Zubair

      3. Default Gravatar
        KerryOctober 12, 2016

        Dose APIA have an Eye Surgery option and if this maybe something
        that will be considered in the near future?

        • finder Customer Care
          RichardOctober 13, 2016Staff

          Hi Kerry,

          Thanks for getting in touch. Apia does provide cover for eye surgery on its Premium Hospital Cover option.

          Unfortunately, Apia is not currently one of the funds in our comparison panel. If you would like to compare cover options from the funds in our panel, you can do so by heading over to our health insurance for over 65s page and either comparing you options online or by completing a contact form to speak with an adviser.

          All the best,
          Richard

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