Understanding your options

 

When should I review my cover?

The Ombudsman recommends it’s worthwhile reviewing your health insurance at least once a year and comparing it with other policies offered by your fund and other health insurers.

This is particularly important if your circumstances change or your health fund changes the:

    • benefits they pay;

    • services included on your policy; or

    • providers they have contracts with.


How do I review my cover?

The Government’s Private Health website is the most comprehensive comparison tool.

You can also contact brokers (such as iSelect and Compare The Market) or speak with health funds directly, to discuss which policy is best suited to you.

There are thousands of different products to choose from, so we have a couple of resources that may help:


Private Health Insurance Checklist

Reviewing your private health insurance can be overwhelming, so we have summarised below the important steps recommended by the ACCC and included some additional resources to make it easier:

1. Know your needs – Assess your healthcare needs to tailor your level of cover now and into the future.  To assist, we have created a list of clinical categories by gender and age, based on our clinical experience.

2. Shop around – Compare products them in detail, some cheaper products may not be value for money in the long run. Make sure you’ve got the right policy with the right health insurer for your needs.  To assist, we have brought together information from the Ombudsman annual report on the service delivery and performance of health insurers.

3. Don’t set and forget – Consider switching insurers to get a better deal - it won’t cost you anything to switch, and as a general rule it is not necessary to ‘re-serve’ a waiting period for similar hospital cover. The Government’s Private Health website is the most comprehensive comparison tool.

4. Understand the terms and conditions – Check your policy covers the doctors, hospitals and other providers and services you may want or need to use.  Ramsay has agreements with every health insurer, except Bupa.

https://www.accc.gov.au/consumers/health-home-travel/private-health-insurance

Clinical categories by gender and age

The Government’s four-tiered health insurance products make it easier than ever before to know which treatments and services (called Clinical Categories) are covered or excluded under each product.

Gold and Silver products are the most comprehensive options. Bronze or Basic products are the least comprehensive options. Whilst less comprehensive products could be significantly cheaper, they may not be sufficient for some people.

It is hard to predict what treatments and services you might need in the future, so we used our clinical experience to create a list of the most common reasons for admission to our hospitals:

0-20 21-30 31-40 41-50 51-60 61-70 71-80  80+
 Clinical Category
Gastrointestinal endoscopy Gastrointestinal endoscopy Gastrointestinal endoscopy Gastrointestinal endoscopy Gastrointestinal endoscopy Gastrointestinal endoscopy Gastrointestinal endoscopy Gastrointestinal endoscopy
Tonsils, adenoids and grommets Gynaecology Pregnancy and birth Gynaecology Gynaecology Heart and vascular system Heart and vascular system Heart and vascular system
Heart and vascular system Pregnancy and birth Gynaecology Kidney and bladder Heart and vascular system Kidney and bladder Kidney and bladder Kidney and bladder
Gynaecology Heart and Vascular system Heart and Vascular system Heart and Vascular system Bone, joint and muscle
Bone, joint and muscle Chemotherapy, radiotherapy and immunotherapy Chemotherapy, radiotherapy and immunotherapy
Ear, nose and throat Hospital psychiatric services Chemotherapy, radiotherapy and immunotherapy for cancer Digestive system
Kidney and bladder
Chemotherapy, radiotherapy and immunotherapy  Joint replacements Hospital psychiatric services
Bone joint and muscle Chemotherapy, radiotherapy and immunotherapy for cancer Digestive system Kidney and bladder Chemotherapy, radiotherapy and immunotherapy  Gynaecology Bone, joint and muscle Bone, joint and muscle
Hospital psychiatric services Kidney and bladder Kidney and bladder
Chemotherapy, radiotherapy and immunotherapy for cancer
Digestive system
Joint replacements Cataracts Skin
Chemotherapy, radiotherapy and immunotherapy for cancer Bone joint and muscle Hospital psychiatric services Bone joint and muscle
Skin Digestive system Hospital psychiatric services
Plastic and reconstructive surgery (medically necessary)
Kidney and bladder Digestive system Bone joint and muscle Ear, nose and throat
Hospital psychiatric services
Hospital psychiatric services Digestive system Rehabilitation
Skin Ear, nose and throat Ear, nose and throat Skin Ear, nose and throat
Skin
Skin Digestive system
0-20 21-30 31-40 41-50 51-60 61-70 71-80  80+
 Clinical Category
Gastrointestinal endoscopy Gastrointestinal endoscopy Gastrointestinal endoscopy Gastrointestinal endoscopy Gastrointestinal endoscopy Gastrointestinal endoscopy Gastrointestinal endoscopy Gastrointestinal endoscopy
Tonsils, adenoids and grommets Joint reconstructions Heart and vascular system Heart and vascular system Heart and vascular system Heart and vascular system Heart and vascular system Heart and vascular system
Ear, nose and throat Bone, joint and muscle Digestive system Kidney and bladder Kidney and bladder Kidney and bladder Kidney and bladder Kidney and bladder
Bone, joint and muscle Heart and Vascular system Ear, nose and throat Bone, joint and muscle Bone, joint and muscle
Male reproductive system Chemotherapy, radiotherapy and immunotherapy Chemotherapy, radiotherapy and immunotherapy
Heart and vascular system Ear, nose and throat Bone, joint and muscle Digestive system
Digestive system
Chemotherapy, radiotherapy and immunotherapy  Skin Plastic and reconstructive surgery (medically necessary)
Skin Kidney and bladder Kidney and bladder Joint reconstructions Male reproductive system Joint replacements Male reproductive system Skin
Chemotherapy, radiotherapy and immunotherapy for cancer Skin Joint reconstructions
Ear, nose and throat
Chemotherapy, radiotherapy and immunotherapy
Bone, joint and muscle  Bone, joint and muscle
Hospital psychiatric services
Joint reconstructions Hospital psychiatric services Male reproductive system Chemotherapy, radiotherapy and immunotherapy for cancer
Skin Digestive system Plastic and reconstructive surgery (medically necessary)
Rehabilitation
Kidney and bladder Chemotherapy, radiotherapy and immunotherapy for cancer Chemotherapy, radiotherapy and immunotherapy for cancer Male reproductive system
Ear, nose and throat
Skin Joint replacements Bone, joint and muscle
Hospital psychiatric services Digestive system Hospital psychiatric services Skin Joint replacements
Plastic and reconstructive surgery (medically necessary)
Hospital psychiatric services
Digestive system

This is general information only and you should consider your own personal circumstances and requirements when choosing health cover.

You also have the option of a combined policy which includes both hospital and extras cover.

Ombudsman annual report on the service delivery and performance of health insurers

The Private Health Insurance Ombudsman prepares an annual report on the service delivery and performance of Australian health insurers. The following is a selection of statistics about benefits paid by individual health insurers in each State and Territory - the full report and an explanation of these figures is available from the Ombudsman's website.

The tables include both 'open' membership insurers (available to the general public) and 'restricted' insurers (available to specific employment groups, professional associations or unions).

This table indicates what percentage of total medical services is covered by each insurer as either ‘no gap’ or ‘known gap’. This is an average across each insurer's hospital treatment products.

A higher percentage indicates that, on average, the insurer's members are covered for a higher proportion of medical charges.To sort from highest to lowest for a particular State/Territory, click on the corresponding heading.

 

Fund Name Membership Criteria ACT NSW VIC QLD SA WA TAS NT Australia
ACA Restricted 87.60% 97.60% 98.80% 99.00% 100.00% 97.40% 95.80% 100.00% 98.10%
AIA Health Open 90.40% 92.90% 97.30% 97.40% 98.90% 96.00% 100.00% 100.00% 96.00%
Australian Unity Open 92.00% 96.90% 98.30% 97.40% 98.90% 97.90% 98.80% 91.70% 98.00%
BUPA Open 94.40% 96.90% 99.20% 98.60% 99.80% 97.50% 99.40% 97.70% 98.30%
CBHS Restricted 97.30% 98.40% 98.90% 98.90% 99.70% 97.40% 99.10% 97.90% 98.60%
CBHS Corporate Open 54.40% 93.60% 88.10% 91.20% 95.90% 92.90% 97.00% na 91.30%
CDH Open 90.90% 96.50% 86.10% 86.40% 98.80% 81.50% 91.30% na 95.30%
CUA Health Open 88.20% 97.20% 98.50% 98.60% 99.90% 97.50% 98.40% 98.30% 98.30%
Defence Health Restricted 93.20% 97.00% 98.90% 98.00% 99.60% 97.80% 99.20% 96.50% 98.00%
Doctors' Health Restricted 97.70% 98.10% 98.90% 99.10% 99.50% 98.50% 98.60% 100.00% 98.60%
GMHBA Open 78.80% 92.90% 97.50% 93.40% 98.50% 95.00% 82.40% 92.00% 96.30%
HBF Open 99.80% 99.60% 99.90% 99.80% 100.00% 99.80% 99.80% 99.50% 99.80%
HCF Open 98.80% 99.20% 99.80% 99.10% 99.90% 98.00% 99.80% 99.00% 99.20%
HCI Open 99.50% 96.60% 98.90% 98.00% 99.10% 98.20% 98.50% 0.00% 98.50%
Health Partners Open 92.80% 97.20% 98.50% 97.90% 99.80% 94.80% 99.80% 100.00% 99.50%
Health.com.au Open 89.40% 95.40% 97.40% 97.10% 96.60% 97.10% 99.40% 94.40% 96.40%
HIF Open 88.80% 96.60% 98.40% 97.70% 99.70% 98.00% 97.00% 100.00% 97.90%
Latrobe Open 98.20% 98.70% 99.80% 98.60% 100.00% 98.00% 98.90% 100.00% 99.70%
MDHF Open 100.00% 99.90% 99.80% 98.50% 99.60% 102.90% 98.50% 100.00% 99.80%
Medibank Open 94.40% 97.00% 97.50% 95.90% 99.40% 90.20% 98.90% 95.90% 96.50%
Navy Health Restricted 93.40% 96.80% 98.60% 97.70% 99.60% 97.90% 97.60% 96.80% 97.60%
NIB Open 68.90% 93.60% 92.80% 89.30% 94.40% 92.00% 95.20% 81.30% 92.60%
Nurses and Midwives Restricted 97.80% 97.10% 97.30% 97.20% 99.10% 97.00% 95.40% 88.80% 97.20%
Onemedifund Open 80.60% 96.70% 98.80% 99.30% 99.70% 98.10% 99.60% na 97.90%
Peoplecare Open 93.30% 97.90% 98.90% 98.30% 99.60% 98.20% 98.70% 99.00% 98.30%
Phoenix Open 89.10% 98.70% 98.80% 98.40% 99.40% 98.60% 99.60% 98.40% 98.70%
Police Health Restricted 93.50% 96.20% 97.70% 97.00% 99.50% 97.60% 98.50% 95.90% 97.90%
QCH Open 99.00% 98.00% 98.10% 97.80% 99.10% 99.20% 100.00% 95.80% 97.90%
Reserve Bank Restricted 90.90% 96.40% 98.70% 99.70% 100.00% 97.70% 98.20% na 97.60%
RT Health Fund Restricted 95.60% 98.40% 98.80% 98.70% 99.60% 97.90% 99.30% 91.80% 98.50%
St Lukes Open 95.30% 88.80% 94.20% 85.90% 96.20% 95.10% 97.90% 100.00% 97.00%
Teachers Health Restricted 94.90% 97.50% 98.90% 98.30% 99.60% 98.10% 99.30% 96.70% 97.80%
Transport Health Open 100.00% 96.00% 98.20% 98.80% 99.50% 100.00% 100.00% na 98.20%
TUH Restricted 86.90% 98.00% 98.10% 98.50% 100.00% 99.80% 98.60% 99.30% 98.40%
Westfund Open 94.00% 98.00% 97.60% 98.10% 98.50% 97.90% 97.70% 92.10% 98.00%

 

*Bupa and Ramsay have not been able to reach agreement on a new contract. The existing agreement will terminate on 2 August 2022. Ramsay will absorb the gap between its increased costs of delivering care and the benefits paid by Bupa for a short time (further details available at Information for Patients).

‘no gap’ means the patient does not incur any out-of-pocket costs, as the full cost is covered by Medicare and the health fund.

‘known gap’ means the patient incurs an upfront out-of-pocket cost, usually capped at $500, with the remainder covered by Medicare and the health fund.

This table provides a general comparison of health insurance for medical costs.  More expensive products generally cover more of the charges than indicated by this average, while cheaper products may cover less.

'N/A' signifies no activity in that state. 100 per cent is likely to indicate small numbers (e.g. only 1 episode).

This table indicates what percentage of total charges, associated with hospital treatment services, is covered by each insurer. This is an average across each insurer's hospital treatment products.

A higher percentage indicates that, on average, the insurer's members are covered for a higher proportion of private hospital charges.  To sort from highest to lowest for a particular State/Territory, click on the corresponding heading.

 

Fund Name Membership Criteria ACT NSW VIC QLD SA WA TAS NT Australia
ACA Restricted 85.10% 94.00% 96.20% 94.30% 96.90% 91.10% 95.60% 97.20% 94.30%
AIA Health Open 74.40% 81.90% 85.70% 85.70% 86.60% 86.60% 91.10% 72.00% 84.50%
Australian Unity Open 80.90% 86.80% 91.20% 88.30% 89.50% 89.00% 91.10% 82.40% 89.90%
BUPA Open 82.90% 89.30% 93.00% 91.10% 94.90% 89.70% 93.80% 90.80% 91.50%
CBHS Restricted 83.30% 90.40% 93.40% 92.20% 94.70% 92.80% 93.20% 87.10% 91.70%
CBHS Corporate Open 91.00% 83.30% 86.80% 92.80% 92.50% 92.90% 92.20% na 87.80%
CDH Open 66.50% 95.70% 89.80% 89.80% 80.70% 90.90% 91.30% na 94.80%
CUA Health Open 69.90% 89.00% 89.70% 91.70% 90.20% 89.40% 91.30% 78.00% 90.90%
Defence Health Restricted 85.00% 89.70% 92.30% 90.70% 93.00% 90.50% 93.30% 88.10% 90.80%
Doctors' Health Restricted 92.70% 91.60% 92.80% 93.20% 92.20% 88.90% 90.90% 90.20% 92.30%
GMHBA Open 76.90% 86.10% 92.00% 86.10% 90.00% 91.30% 88.90% 78.80% 90.50%
HBF Open 89.40% 89.50% 92.60% 91.70% 92.30% 95.10% 95.10% 88.20% 94.80%
HCF Open 84.20% 91.00% 91.70% 90.00% 93.40% 89.50% 92.60% 88.90% 90.80%
HCI Open 94.90% 90.00% 94.00% 91.00% 92.40% 97.50% 94.50% 68.50% 93.60%
Health Partners Open 85.70% 91.60% 90.70% 90.40% 94.60% 84.60% 93.90% 93.40% 93.80%
Health.com.au Open 73.60% 80.90% 82.50% 83.60% 85.00% 84.70% 71.70% 86.90% 82.00%
HIF Open 79.50% 86.40% 88.80% 87.90% 89.60% 91.30% 88.70% 94.50% 90.20%
Latrobe Open 83.40% 89.40% 91.50% 88.00% 92.50% 87.70% 89.40% 83.00% 91.20%
MDHF Open 73.80% 93.30% 93.40% 90.40% 91.90% 81.50% 86.00% 100.00% 93.20%
Medibank Open 83.60% 89.30% 92.30% 89.90% 92.00% 90.30% 93.50% 90.00% 90.60%
Navy Health Restricted 85.70% 90.80% 91.90% 90.40% 93.90% 92.20% 91.10% 87.10% 90.90%
NIB Open 76.70% 87.30% 86.00% 84.80% 90.10% 86.90% 90.80% 82.90% 86.70%
Nurses and Midwives Restricted 85.60% 88.80% 90.30% 89.40% 90.70% 88.70% 87.00% 81.40% 89.30%
Onemedifund Open 85.10% 93.00% 94.80% 95.50% 96.60% 94.80% 96.00% na 94.20%
Peoplecare Open 83.80% 91.70% 92.80% 91.10% 94.50% 92.50% 93.30% 96.00% 92.00%
Phoenix Open 84.70% 93.50% 91.60% 91.40% 93.00% 95.80% 93.80% 85.30% 92.70%
Police Health Restricted 87.80% 91.40% 94.50% 90.90% 96.30% 93.10% 95.80% 90.80% 93.30%
QCH Open 91.00% 91.40% 86.30% 88.70% 96.20% 91.30% 94.20% 82.90% 88.70%
Reserve Bank Restricted 72.20% 91.70% 96.60% 98.30% 98.70% 96.40% 97.60% na 94.00%
RT Health Fund Restricted 74.00% 93.90% 91.40% 92.70% 92.90% 89.70% 94.30% 83.30% 93.20%
St Lukes Open 86.70% 91.20% 91.70% 90.90% 93.30% 90.80% 93.40% 91.10% 93.10%
Teachers Health Restricted 86.70% 91.20% 92.30% 93.10% 93.60% 91.90% 94.40% 90.90% 91.50%
Transport Health Open 86.50% 88.00% 93.40% 88.70% 83.60% 87.40% 87.60% na 92.60%
TUH Restricted 67.30% 90.00% 89.30% 91.50% 91.60% 93.50% 92.40% 97.10% 91.40%
Westfund Open 85.10% 93.30% 91.00% 91.20% 93.60% 90.40% 91.50% 72.40% 92.30%

 

*Bupa and Ramsay have not been able to reach agreement on a new contract. The existing agreement will terminate on 2 August 2022. Ramsay will absorb the gap between its increased costs of delivering care and the benefits paid by Bupa for a short time (further details available at Information for Patients).

This table provides a general comparison of health insurance for private patient hospital treatment. More expensive products generally cover more of the charges than indicated by this average, while cheaper products may cover less.

Includes charges for hospital accommodation, theatre costs, prostheses and specialist fees (not including the Medicare benefit) and associated benefits (after any excesses and co-payments are deducted).

'N/A' signifies no activity in that state. 100 per cent is likely to indicate small numbers (e.g. only 1 episode).

This table indicates what percentage of total charges, associated with general treatment services, is covered by each insurer. This is an average across each insurer's general treatment products.

A higher percentage indicates that, on average, the insurer's members are covered for a higher proportion of general treatment charges.  To sort from highest to lowest for a particular State/Territory, click on the corresponding heading.

 

Fund Name Membership Criteria ACT NSW VIC QLD SA WA TAS NT Australia
ACA Restricted 61.70% 57.40% 58.90% 59.50% 63.60% 58.80% 54.90% 64.30% 58.30%
AIA Health Open 50.30% 49.40% 51.40% 50.70% 51.50% 51.60% 51.10% 52.30% 50.50%
Australian Unity Open 44.60% 47.30% 49.30% 49.30% 51.70% 49.00% 46.50% 46.40% 49.00%
BUPA Open 46.60% 50.20% 48.80% 52.50% 55.40% 57.60% 50.90% 59.30% 51.80%
CBHS Restricted 44.50% 47.80% 49.20% 50.50% 52.80% 50.40% 47.80% 47.30% 48.90%
CBHS Corporate Open 56.50% 51.30% 54.10% 51.70% 54.80% 55.60% 62.20% na 52.10%
CDH Open 42.90% 35.50% 36.20% 38.60% 35.70% 35.80% 39.60% na 35.70%
CUA Health Open 43.20% 50.80% 47.70% 47.70% 51.80% 47.00% 49.70% 46.90% 48.60%
Defence Health Restricted 39.80% 41.10% 45.90% 44.60% 49.60% 46.40% 44.60% 48.00% 44.50%
Doctors' Health Restricted 55.10% 54.10% 54.90% 55.80% 57.00% 56.50% 53.40% 59.80% 54.90%
GMHBA Open 49.90% 51.00% 49.20% 52.20% 52.50% 49.30% 47.60% 51.10% 49.90%
HBF Open 45.30% 49.80% 50.20% 49.10% 52.40% 56.30% 50.00% 49.90% 55.60%
HCF Open 50.30% 49.30% 56.10% 56.90% 61.60% 60.70% 53.40% 54.60% 52.60%
HCI Open 40.50% 52.10% 49.70% 47.00% 52.10% 50.50% 46.40% 40.50% 48.40%
Health Partners Open 53.40% 54.10% 45.40% 42.40% 57.20% 42.70% 44.90% 49.60% 56.70%
Health.com.au Open 43.50% 45.20% 46.80% 46.40% 50.20% 47.50% 44.60% 41.20% 46.20%
HIF Open 42.10% 46.20% 46.60% 47.40% 49.20% 48.00% 47.10% 44.60% 47.60%
Latrobe Open 34.10% 43.10% 38.70% 42.70% 47.30% 45.00% 36.40% 41.40% 39.40%
MDHF Open 44.50% 53.70% 53.00% 50.20% 49.50% 49.60% 51.70% 45.40% 52.80%
Medibank Open 49.00% 51.60% 53.80% 55.40% 58.30% 58.30% 54.70% 60.00% 54.30%
Navy Health Restricted 43.60% 47.50% 51.40% 50.50% 54.90% 52.70% 48.10% 47.20% 49.60%
NIB Open 55.80% 55.90% 59.60% 56.50% 59.30% 62.10% 61.60% 58.70% 57.10%
Nurses and Midwives Restricted 44.90% 52.10% 49.40% 49.90% 54.40% 51.00% 45.20% 50.10% 51.10%
Onemedifund Open 42.50% 51.60% 55.50% 51.20% 54.80% 56.90% 52.90% na 53.30%
Peoplecare Open 44.70% 47.90% 47.70% 46.20% 50.80% 46.60% 42.70% 46.10% 47.70%
Phoenix Open 52.70% 53.90% 54.30% 55.70% 55.50% 53.50% 54.10% 55.60% 54.40%
Police Health Restricted 63.20% 65.30% 67.50% 66.70% 70.40% 68.40% 66.80% 67.60% 68.00%
QCH Open 39.10% 48.40% 50.60% 51.90% 50.80% 46.50% 48.90% 49.40% 51.70%
Reserve Bank Restricted 67.60% 72.20% 73.40% 75.20% 79.10% 78.10% 72.90% 90.00% 72.90%
RT Health Fund Restricted 38.40% 45.80% 42.90% 45.20% 46.90% 46.20% 39.50% 39.30% 45.30%
St Lukes Open 56.80% 60.70% 58.90% 59.30% 65.10% 60.50% 59.40% 59.10% 59.00%
Teachers Health Restricted 40.70% 46.60% 46.20% 46.80% 49.90% 48.90% 45.50% 43.30% 46.70%
Transport Health Open 38.10% 47.30% 53.50% 48.50% 49.80% 47.90% 44.90% 49.50% 51.60%
TUH Restricted 45.20% 49.10% 47.50% 54.90% 49.00% 46.40% 51.50% 48.30% 54.30%
Westfund Open 41.30% 47.30% 42.60% 48.70% 44.70% 45.20% 41.90% 42.20% 47.50%

 

*Bupa and Ramsay have not been able to reach agreement on a new contract. The existing agreement will terminate on 2 August 2022. Ramsay will absorb the gap between its increased costs of delivering care and the benefits paid by Bupa for a short time (further details available at Information for Patients).

This table provides a general comparison of health insurance for private patient general treatment.  More expensive products generally cover more of the charges than indicated by this average, while cheaper products may cover less.

'N/A' signifies no activity in that state. 100 per cent is likely to indicate small numbers (e.g. only 1 episode).

How do I change health insurers?

Thousands of people change health insurers each year, so it’s simple to switch.

Once you’ve picked a new health insurer, they normally do the ‘admin’ for you – such as cancelling with your old health insurer, ending your direct debit and requesting your clearance certificate.

This process can take a couple of weeks, so if the direct debit with your old health insurer is due soon you might end up paying premiums for overlapping dates.  If this is the case, discuss your options with your new health insurer (which may include delaying your start date or receiving a refund from your old health insurer).

 

Will I be charged more because of my conditions?

Unlike other types of insurance, private health insurance is ‘community rated’. This means everyone pays the same price for the same policy regardless of age, health status or other risk factors.

This contrasts with other types of insurance such as car and life insurance which are risk rated and influenced by factors such as your driving record, age etc.

For example, a single, healthy 20 year-old and a single, unwell 60 year-old will both pay the same premium for the same cover. However, the cost of premiums for similar cover may vary between health insurers.

‘Community Rating’ was developed by the Australian Government to make sure that people with a higher level of claims are not disadvantaged – for example, if you have a history of health issues, this does not mean you should pay a much higher premium. Private health insurance is there to cover everyone, whether you have a health condition or not. Community rating means that everyone is entitled to buy the same product, at the same price, and is guaranteed the right to renew their policy.

 

Alternatively, CHOICE has mapped out the process for anyone doing all the admin themselves: