Disability and health insurance
Private health insurance can offer more flexibility and coverage for people with disabilities.
Key takeaways
- People with disabilities have complex health needs, which can make using Medicare and private health insurance more complex.
- Having a disability does not result in any private health exclusions, though some treatments may need a 12 month waiting period.
- People with a disability are slightly less likely to have private health insurance.
Can people with a disability get private health insurance?
In Australia, having a disability doesn't stop you from taking out private health insurance. Unlike some developed nations (looking at you America), Australian health funds are required to cover people with pre-existing conditions. That means disability doesn't rule anyone out from holding a health insurance policy.
That said, pre-existing conditions do come with a different waiting period for hospital cover. Depending on what disability you have, you may have to wait 12 months to make a claim on some treatment categories, rather than the typical 2 month waiting period for health insurance.
Medical care for people with a disability
People with disabilities will generally get their medical care the same way as everyone else, through Medicare or private health insurance. However, because people with a disability have more complex care needs, there are some additional government support schemes out there to help them. Here are a few places to get more information:
The NDIS: The National Disability Insurance Scheme is one of the main sources of funding for people with disabilities to get the support they need.
The Department of Social Services: This page on the DSS website has some great links to programs for people with a disability.
The Disability Gateway: Also from the DSS, the Disability Gateway is a great place to see what help is available.
Expert insight: Health insurance and disability
"Health insurance can be really helpful for individuals with disabilities as it ensures access to crucial medical care and treatments without the stress of overwhelming costs. Understanding the specifics of your policy, such as coverage limits and the coordination with other benefits, is vital to maximise your benefits and ensure continuous care. "
How can private health insurance help people with disability?
While the government provides some assistance to people with disability both financially and through community support services, private health insurance can also help to relieve the burden for both people with disability and their families. Ways in which private health insurance can help can be seen in the following case studies:
- Paying for non-PBS medicines. Jay has a debilitating spinal disease that requires regular medication to treat the chronic pain associated with the condition. Jay's private health extras cover helps him to cover the cost of these medicines, some of which are not listed with the Pharmaceutical Benefits Scheme (PBS) and therefore are not subsidised.
- Paying for diagnosis of a disability. Peter and Sue's son Alex exhibited signs of profound deafness at an early age and he was referred for specialist diagnosis and treatment. His parents were able to pay for most of these appointments thanks to government assistance, and their private health extras cover paid for Alex's hearing aids after an initial waiting period.
- Paying for hospital treatment of a disability. Karen was badly injured in a car accident and became unable to walk again. She needed extensive follow-up surgery to treat her condition and between Medicare and her no-gap hospital cover, she had no out-of-pocket expenses for any of her hospital visits.
What health insurance options are available for people with disability?
Health insurance options for people with disabilities are the same as options for those without disability. It falls into two main categories, Hospital cover and Extras cover. Here are the key differences:
- Hospital cover pays for your treatment and accommodation in a public or private hospital, treatment by a doctor of your choice, the option of a private or shared room, and generally shorter waits for elective surgery than the public hospital waiting list.
- Extras cover helps pay for ancillary services not covered by Medicare such as optical, dental, physiotherapy and chiropractic services.
Both types of health insurance can be taken out separately or, as is more often the case, combined in a single policy. Every hospital policy sold in Australia is classified into one of four government tiers, which set the minimum clinical categories it has to cover. A policy that meets a tier's minimum and includes extra categories on top can be sold as a "Plus" policy, such as Bronze Plus or Silver Plus:
- Basic only has to cover rehabilitation, hospital psychiatric services and palliative care, and insurers are allowed to offer even those on a restricted basis. Every other clinical category is optional, so a lot of treatment is excluded from basic hospital cover.
- Bronze covers 21 of the 38 clinical categories, adding cover for bone, joint and muscle, joint reconstructions, gynaecology, and chemotherapy, radiotherapy and immunotherapy for cancer.
- Silver covers 29 categories, adding heart and vascular system, lung and chest, back, neck and spine, dental surgery and implantation of hearing devices.
- Gold must cover all 38 categories, including cataracts, joint replacements, dialysis for chronic kidney failure, insulin pumps, pain management with device and sleep studies.
- These tiers apply to hospital cover only. Extras benefits, such as major dental and orthodontics, sit outside the tier system and vary by fund. If you need ongoing treatment for a disability, check which categories your policy restricts or excludes: a restricted benefit only covers you as a private patient in a public hospital.
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