AMA private health insurance report card

17 March 2016

Provides consumers with useful information about private health insurance that will allow them to choose the policy that best meets their needs.

One of the fundamental reasons people purchase health insurance is to provide ‘peace of mind’. There are thousands of products available for you to choose from. Compare them in detail and think carefully before shopping for price alone. The general rule is that the cheaper the premium, the less the policy will cover. Cheap policies may contain a number of important exclusions for common procedures (hips and knees) or higher out of pocket expenses and smaller rebates.

Private health insurance is categorised into four levels of cover.

• Top Private Hospital Cover - must cover all services where Medicare pays a benefit.

• Medium Private Hospital Cover - excludes or restricts one or more of the following but includes any services in the basic classification: pregnancy and birth-related services, assisted reproductive services, cataract and eye lens procedures, joint replacements i.e. shoulder, knee, hip and elbow including revisions, hip and knee replacements, hip replacements, dialysis for chronic renal failure, and sterilisation.

• Basic Private Hospital Cover - excludes or restricts one or more of the following: cardiac and cardiac related services, non-cosmetic plastic surgery, rehabilitation, psychiatric services, and palliative care.

• Public Hospital Cover - covers minimum benefits for treatment in public hospital only. Public hospital waiting lists still apply.

The premiums for policies in the Top Cover category are more expensive than premiums for policies in the other categories.

The AMA recommends that all policy holders carefully read any information their insurer sends them about their policy. People with policies in the Medium or Basic private hospital category generally need to pay more attention to their private health insurance, as terms and conditions (exclusions and rebates) can change at any time during the policy. You will have to upgrade your policy if you want to be covered for any services that are removed or not included in these policies.

The following table lists the names of the insurers’ policies under the Top, Medium, Basic Private Hospital, and Public Hospital categories. This will allow you to easily identify the level of cover you are being provided and if your policy is likely to change.

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Australian Medical Association, 2016, AMA private health insurance report card, Australian Medical Association, viewed 20 January 2017, <>.

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