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What is a restricted treatment for health insurance?

Some private hospital insurance policies will list treatments as 'restricted'. Restricted treatments are when your health insurer only pays for a limited part of the hospital bill.

What you need to know

  • Restricted services mean you will not be covered for the total cost of the MBS fee.
  • All hospital policies must offer restricted cover for rehabilitation, hospital psychiatric services and palliative care.
  • Health insurers will clearly outline what is covered, excluded and restricted when you view its cover options.

What is a restricted service?

Restricted service

Restricted services are treatments that your health insurer will over pay a limited benefit towards. This means you'll likely have out of pocket expenses. Since the 2019 private health insurance reforms, all health funds must offer restricted cover for rehabilitation, hospital psychiatric services and palliative care.

Covered service

With a covered services, your health insurer will pay the full benefit towards the cost of treatment – so long as it's listed on your hospital cover policy. This means that when you're treated as a private patient in a private hospital, medicare will generally pay 75% of the MBS costs and your private health insurance will pay the remaining 25%.

Excluded service

Excluded services are treatments that your health insurer will pay no benefit towards. For example, if you hold a basic or bronze level of cover, you probably won't be covered for pregnancy and birth, so you'll have significant out of pocket expenses.

Did you know?
All health insurance funds are required to cover specific services. To learn more about what they are, check out our guide to the 4 tiers of health insurance: basic, bronze, silver and gold.

What types of procedures are restricted?

Any hospital treatment can have restricted cover on a particular policy, However, the most common restricted services include:

  • Rehabilitation
  • Hospital psychiatric services
  • Palliative care

This is generally because all health insurers are required to offer restricted cover for these treatments. In most cases, you won't find them fully covered until you get gold level cover.

Finder survey: How many Australians understand how health insurance works?

Source: Finder survey by Pure Profile of 1006 Australians, December 2023

How can restrictions treatments affect you?

Restricted services generally mean you'll have significantly larger out of pocket expenses. This is because you won't be covered for the full cost of treatment.

Even if the service is fully covered by your health fund though, you might still have out of pocket expenses. This is because private hospital insurance generally pays the remaining 25% of the MBS fee – Medicare covers the other 75%. However, medical professionals in the private system are not obligated to adhere to the MBS fee. If they charge more, you might have to pay the difference, unless you have no gap cover.

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