What are health insurance inclusions?
Inclusions are procedures and services that are covered by your private health insurance policy. This means that if you make a claim, all or part of the costs will be covered by your insurance. You may need to pay an excess when making a claim on your hospital cover, as outlined in your policy. While the specific inclusions on your policy will depend on the level of cover you have, a few examples of common inclusions are:
- Hospital accommodation
- Theatre fees
- Some pharmaceutical medicines
- In-hospital medical treatments (these can vary based on your policy category).
- General treatments and services (i.e. dental, optical, physio etc.) outlined in an extras policy
What are health insurance exclusions?
Exclusions are treatments and services that are not covered by your health insurance policy. Following the 2019 health insurance reforms in Australia, hospital cover is now classified into one of four categories—Gold, Silver, Bronze or Basic. These four tiers are standardised across health funds, so the list of inclusions will be the same no matter which health insurer you choose.
In health insurance terms, different types of treatments are referred to as 'clinical categories'. Gold-tier policies will tend to include cover for the most clinical categories, while Basic-tier policies will have the least. Health insurance providers may also sell ‘Plus’ policies (e.g. Bronze Plus or Silver Plus), which include specific additional medical services from higher clinical categories—usually at a higher premium.
How do health insurance exclusions work?
If a certain type of treatment is excluded from your hospital cover, then you won't be covered for this treatment in private hospital, and will need to be treated in the public system or face an extremely hefty bill.
Some of the most commonly-excluded treatments are joint replacements and pregnancy and birth-related services. These services tend to be among the most expensive, and are therefore only included on Gold-tier policies. If you have a Basic, Bronze or Silver policies, you'll typically find that these services are excluded, so you won't be able to claim for them.
What does this actually mean? If your policy excludes pregnancy and birth-related services and you wish to be admitted as a private patient in either a private or public hospital to have your baby, your insurance will not cover you for any in-hospital expenses. It’s likely, instead, that you’ll be admitted as a public patient in a public hospital via the Medicare system.
What procedures are commonly excluded or restricted?
According to the Private Health Insurance Ombudsman, procedures that can be commonly excluded or restricted from private health insurance include:
- Cardiac and cardiac-related services, such as heart investigations and surgery
- Cataract and eye lens procedures (eye surgery)
- Pregnancy and birth-related services
- Assisted reproductive services or infertility services (IVF)
- Hip and knee replacements (joint surgery)
- Rehabilitation and psychiatric services
- Plastic and reconstructive surgery, such as skin grafts following burns, skin flap repair and breast reconstructions following cancer.
What policies have the most inclusions?
Gold-tier policies are the most comprehensive, and therefore come with the fewest exclusions. Generally speaking though, if a medical procedure is not listed in the Medicare Benefits Schedule (MBS), it will not be covered by any hospital insurance policy including Gold ones. This can also extend to out-of-hospital services not covered by Medicare, such as dental, physiotherapy and chiropractic treatment, which will usually require an extras policy to be covered.
Certain expensive procedures may instead be restricted, meaning their coverage may be limited and you might incur out-of-pocket expenses if you need to claim for them. Regardless of whether a procedure is included in the category covered by your policy, you will generally have to serve waiting periods before you can claim for certain medical services (e.g. pregnancy services usually have a 12-month waiting period before you can claim).
How do you choose private health cover?
When comparing different health insurance providers and policies, it’s important to ask:
- What inclusions and exclusions does the cover have?
- What is the excess payable?
- Do you want a combined (hospital and extras), hospital only or extras only policy?
- Do you want to be exempt from the Medicare Levy Surcharge (MLS)?
You can compare private health insurance with Canstar, which can be a quick and easy way to search for a policy that may be suitable for your needs. You can also book a call with a Canstar health insurance specialist to chat about your health insurance needs.
You may also like to consider Canstar’s Health Insurance Awards, which recognise insurers who offer Australians outstanding value. If you’re considering a health insurance policy, read the Private Health Information Statement (PHIS) that applies as part of your decision-making.
