What do I tell my insurer before I go to hospital? 

If you have Private Health Insurance and you’re being admitted to hospital for a procedure or treatment, don’t assume your insurer will cover all your Hospital Cover costs. Whether you’re going in as a private patient in a private hospital, or a private patient in a public hospital, you may need to pay some costs towards your treatment and hospital stay. Make sure you talk to your health insurer ahead of time so you don’t get any unpleasant surprises.  

So, if you’re going to hospital on health insurance, what do you need to tell your insurer first?

What to ask your insurer before being admitted 

Before you go to hospital, ask your health insurer: 

• Am I covered for this treatment or procedure, and are there any exclusions? 

• What excess do I have to pay? 

• Do any waiting periods apply to me? 

• Will I have to pay any co-payments under my policy? 

• How does the claim process work? 

Be aware that your premium payments will need to be up-to-date. 

What to ask your doctor or specialist before going to hospital on health insurance

• Will there be out-of-pocket expenses? If so, how much? 

• What are the Medical Benefits Scheme (MBS) item numbers for this treatment? (You can use this information to find out how much your health insurer will cover.)  

• What other medical professionals will be involved in this treatment (e.g. anaesthetists)? How much do they charge and will there be Gaps? 

• How and when will I be billed? 

• What hospital fees will apply (e.g. for accommodation and theatre costs)? Will these be billed separately? And if the hospital is not part of this insurer’s hospital network, can I choose a different hospital for this procedure? 

• Are there any other charges I should know about? 

• Is this treatment urgent? (If waiting periods apply to your policy, and your doctor says it’s okay, you could consider delaying your procedure until your cover kicks in.) 

If you’re a private patient in a private hospital  

As a private patient in a private hospital, most of your costs will be met by Medicare and your health insurer, if you have Hospital Cover that includes the type of treatment or procedure you’re receiving. However there may still be costs such as an excess, co-payment and out-of-pocket expenses (such as Hospital Gap and Medical Gap). Talk to your insurer and your doctors in advance to get details of these costs, and find out if there are ways to reduce them. For example, many insurers have agreements with certain hospitals and specialists, which means choosing them for treatment will reduce your out-of-pocket hospital expenses. 

Is my procedure or treatment covered by my level of Hospital Cover?

If you’re a private patient in public hospital 

If you choose to be treated as a private patient in a public hospital, some of your hospital costs will be met by Medicare, and the remaining costs for doctors, specialists and accommodation will be covered by your private health insurer (in part or in full, depending on your level of cover). There may be an excess and out-of-pocket costs to pay.  

What if I’m not covered? 

If you think you’ll need a hospital treatment or procedure in the near future, and your current health insurance policy doesn’t cover it, now’s the time to look for a policy that does. If you switch to a higher level of cover, you’ll have to serve a waiting period, which is why it’s important to switch policies well ahead of time. Try the healthslips.com.au Calculator to find a policy that’s right for you. It’s free to use, it shows you every policy on the market and you don’t have to enter any contact details. 

Look for the best-priced health insurance policy. 

Trudie McConnochie

Writer and Researcher

Knowledge is power – that’s the guiding principle behind everything Trudie writes, and it’s a philosophy she brings to her work at healthslips.com.au. By breaking down complex information into easy-to-understand blogs and stories, she aims to empower Australians to make the best choices and an informed decision around private health insurance.

Trudie understands firsthand some of the complexity of private health insurance having moved to Australia from New Zealand and having to navigate a vastly different public healthcare system and health insurance structure.

Trudie holds a Bachelor of Communication Studies (journalism major) from the Auckland University of Technology.

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