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Using private health insurance

Understand your policy

Your health insurer must send you a standard information statement — similar to a product disclosure statement provided for financial services — at least once a year.

This statement gives you an overview of what's covered by your policy. There are different types of statements for:

  • hospital policies
  • general treatment policies, known as 'extras'
  • combined policies — both hospitals and extras

Keep in mind that the statement is only a summary. You should contact your health insurer to get all the details of your policy, including specific waiting periods.

Read more about how private health insurance works.

Make a claim

You can make a claim with your health insurer when you receive:

  • treatment in hospital as a private patient (if you have hospital cover)
  • other medical treatment not covered by Medicare — for example, dental treatments or physiotherapy (if you are covered for that treatment under an 'extras' policy)

Remember to check your policy before your treatment to make sure you can claim — not all policies cover all treatments and waiting periods may apply for some treatments.

Will there be a gap?

Private health insurance doesn't always cover all or every expense. Depending on your level of cover, you may have to pay some out-of-pocket expenses.

Read more about out-of-pocket expenses, gaps and informed financial consent.

Change your policy or insurer

You can change your health insurer or your cover at any time.

You may have to wait a period before you can make a claim if you change to a:

  • higher level of cover — a one-time waiver is available for psychiatric care
  • policy with lower excesses or gap fees

Otherwise, waiting periods you've already served are transferred to your new health insurer's policy.

Check whether there will be any new waiting periods, and how long they will be, before you decide to change insurers.

Suspend your policy

If you go overseas, you can ask your health Insurer to suspend your cover while you’re away. If they agree, this means:

  • you cannot claim while your cover is suspended
  • you can stop paying premiums while you are overseas
  • you can resume your cover when you’re back

If you haven’t finished serving your waiting periods when your suspension is granted, you’ll have to serve the remainder when you’re back.

You may also be able to suspend your cover if you’re having financial issues.

Check with your health insurer to see what their suspension policy is — different insurers have different rules.

Suspending your policy may not impact how Lifetime Health Cover loading applies to you, but it does affect Medicare levy surcharge exemptions.

If you need to go overseas and your health insurer won’t let you suspend your cover, you may decide to cancel your policy. Find out about permitted days without hospital cover.

If you’re behind in your premiums

If you are less than 2 months behind in your premiums, your health insurer must let you pay your outstanding premiums and keep your cover.

If you are more than 2 months behind in your premiums, your health insurer may decide to lapse your policy. This means you won’t have health insurance cover for any costs.

If you’re having difficulty paying your premiums, talk to your health insurer before you fall behind.

If your premiums increase

Premium increases always take effect on 1 April each year. Health insurers must let you know in advance if your premium will increase. This gives you time to shop around and compare health insurance policies.

Make a complaint

If you’re not happy with the service of your health insurer, contact the Private Health Insurance Ombudsman.

Last updated: 
17 February 2019