Explore Health Insurance

What is a pre-existing condition?

A pre-existing condition is any illness, ailment or condition that you had signs or symptoms of in the six month period before you took out a policy, or upgraded to a higher level of cover. This may or may not have been diagnosed at the time. There is usually a twelve-month waiting period for pre-existing conditions, with the exception of rehabilitation, psychiatric or palliative care, where it is two months.

I have a pre-existing condition. Can I still get Private Health Insurance?

Yes, you can. The only limitation is the waiting period. Once you have served the relevant waiting period you will receive the full benefit associated with the condition – as long as it is covered by the policy, of course.

What is a clearance certificate?

This is a document that contains important information on your current policy, and is used when you move from one Fund to another. Under the Private Health Insurance Act, there are “portability” rules, which ensure that any waiting periods that you have served are recognised and applied by your new Fund. To make sure you are able to take advantage of this, it is important that your premiums are completely up to date before you transfer. In most cases, your new Fund will take care of the transfer certificate procedure on your behalf, so long as you have clearly requested it in the application process.

I’ve just turned 30; do I have to purchase private cover?

Private cover is not compulsory. However, in order to encourage people to take out policies earlier in life, the government requires providers to add a loading when over-thirties join up. This is called Lifetime Health Cover (LHC) and is calculated as an uplift when you take out a policy, of 2% for each year you are past thirty. It comes into play on the 1st of July following your 31st birthday, so the earlier you join the better. Once you have a policy, the uplift does not increase further so long as you have cover.  See Lifetime Health Cover for full details.

What is the Private Health Insurance Rebate?

Australians who take out private cover are eligible to receive a rebate from the Government to help cover the cost of their premiums. This rebate, known as the Australian Government Rebate, is income tested and also calculated based on your age and the number of dependants you have.   Higher income earners may receive no rebate, but most people receive a rebate of 30 cents for every dollar that they pay for their policy.

Most policyholders take any rebate as a deduction off their premiums, but it is also possible to collect the rebate from a Medicare office, or claim it back at tax time.  See Australian Government Rebate for full details.

Do I have to pay the Medicare Levy Surcharge?

The Medicare Levy Surcharge (MLS) is income-dependent, and applies to Australian tax payers who do not have private hospital cover, and can be as much as an additional 1.5% on taxable income. To be exempt from paying the surcharge, you must hold a policy that covers some or all of the fees and charges for a stay in hospital – in other words, a policy that covers Extras only does not qualify for MLS exemption.  See Medicare Levy Surcharge for further information.

Can I change my level of cover?

Yes, you can change insurance policies – even your provider at any time. You need to bear in mind that if you change to a higher level of cover, you may have to serve the relevant waiting period before you can make any claims at that higher level. This applies also if you move to a policy that has lower excess payments, co-payments or gap fees. It is also important to note that if you allow your membership premiums on your current policy to lapse, your new insurer may not carry forward your cover in this way – your payments need to have been continuous. Some health funds will allow a short gap of 1 or 2 months between transfers, but this is not guaranteed, as rules do vary between funds. If your payments are not up to date, you will need to check with your new insurer before switching whether they will accept the waiting periods you have already served.

What doesn’t private health insurance cover?

First of all, it is important to understand that private health plans do not cover out-of-hospital medical services which are covered by Medicare. This includes GP visits, consultations with specialists (in their rooms), diagnostic imaging and tests.

Also, it is possible that your policy may not cover the total cost of the doctors’ services provided to you in hospital, or hospital accommodation costs, which could leave you with an out-of-pocket expense called a ‘gap’.

So it is very important that, prior to any treatment, you contact your provider to confirm that you are covered for the procedure, and what – if any – your out-of-pocket expenses will be.

What are exclusions?

Just as the name suggests, exclusions are conditions and or services which your policy “excludes” or does not cover.   Different policies will show different exclusions, which makes comparing policies very important – your aim will be to find a policy that includes the services that you might need, but excludes those that you do not, and therefore delivers the best value to you for the premium you pay.

Where exclusions apply, your provider will pay no benefit, and you will need to rely upon Medicare, so if you require treatment for a service that is excluded from your policy, it is important to check your options with your Doctor.

What are restrictions?

Restrictions in your policy indicate that some benefit may be available, but this will be to a limited extent. Some examples of restrictions include being covered for a benefit but only as a private patient in a public hospital, or having limited cover for that benefit during an extra waiting period called a BLP. Always check the fund’s policy brochure for details of any restrictions that may apply to your policy.

What is an excess?

Taking an excess on your policy essentially means that you are accepting a lower premium in exchange for paying a lump sum if and when you have to go into hospital. The rules on when you are required to pay this excess will vary from policy to policy – some will only charge the excess amount once per year, for example, while others may apply it for each admission. It is also important to note that in order to avoid the Medicare Levy Surcharge, your agreed excess payment must not exceed $500 for Singles, or $1,000 for Couples and Families. Always check the fund’s policy brochure for details of any excesses that may apply to your policy.

What is a co-payment?

Co-payment is similar to Excess, in that you are agreeing to an additional payment on admission to hospital, in exchange for a lower premium. The difference is that it is a generally a lower amount that is applied for each day of your stay, up to a certain number of days.

Always check with your insurer before you organise the treatment what co-payments you may need to pay.

Who is classed as a dependent child?

A dependent child is an unmarried person under the age of 18 years, and these are automatically covered within “Family” policies. Some Health Funds also categorise those between the ages of 18 and 24 years as a dependent child, but most often require other conditions to be met, typically that the person is a full-time student. These conditions will vary between insurers, so please call us if you need assistance determining whether your child can be added to the policy you are interested in.

Who is Comparethemarket.com.au?

Comparethemarket.com.au is a comparison website. We compare products and services for a range of suppliers all in the one place allowing consumers to quickly and conveniently make an informed decision about which supplier is best for them.

Who are PHIO?

Their full title is the Private Health Insurance Ombudsman, and their primary function is to deal with enquiries and complaints about all aspects of private health insurance.  They are an Australian Government agency, but act independently of both the Government and the providers when it comes to handling complaints and disputes.

PHIO manages the privatehealth.gov.au website, and provides advice to the general public as well as the health insurance industry and government. They also publish regular bulletins on the performance of providers, with an emphasis on the nature of the complaints they receive, and how those are resolved.

The Private Health Insurance Ombudsman can be contacted on 1300 737 299 or by email phio.info@ombudsman.gov.au

What is a Benefit Limitation Period?

A benefit limitation period (BLP) is where the Health Fund restricts the benefits available for a particular condition or treatment, for a set period of time. This period will be in addition to the normal Waiting Period, and the restrictions will be removed once the BLP is served.

You should check the policy details to ensure that you fully understand how the benefit limitation periods – if any – apply to your health cover.

What are non-PBS Pharmaceuticals?

The Australian government’s Pharmaceutical Benefits Scheme (PBS) subsidises the cost of a specific list of drugs, which are then available to the public at a lower cost. Non-PBS pharmaceuticals are those that do not appear on this list, and which therefore will cost considerable more.  Where your Fund specifies that it covers non-PBS pharmaceuticals within a particular policy, it is still important to check whether there are additional limitations, such as specific exclusions or co-payment requirements.

What is an Aggregator?

An Aggregator refers to an internet company which has the capability to search a volume of stored information to provide a comparison in line with needs identified by the customer and distribute it through a single website.

What is an agreement hospital?

An agreement hospital is a Private Hospital or day surgery that has a contract with a particular insurer to provide inpatient services with low or no out-of-pocket expense. As individual providers will have different arrangements with different hospitals, it is important to first check whether the hospital you might have in mind for a particular reason – your chosen physician works there, or simply because it is nearby – is listed by your chosen Fund.

What does community rated mean?

Community rating is a key component of the Australian Private Health Insurance landscape. Unlike General Insurance, where the premium is dependent upon a specific evaluation of your circumstances, the “risk” in Private Health insurance is spread across the whole population. This essentially means that the Fund cannot refuse you as a policyholder, and that – with some exceptions – you will be paying the same premium as everyone else. The exceptions are only in the additional amount you might pay through an age loading (see: Lifetime Health Cover Loading for full details), or in the amount of means-tested tax rebate you may be eligible for. (See: Australian Government Rebate for full details)

What is Lifetime health cover loading?

Back in July 2000, the Government introduced Lifetime health cover (LHC) as an incentive for people to take out a form of hospital insurance earlier in life. If you take out hospital cover with a Health Fund before the 1st of July following your 31st birthday, you will establish your “Certified Age at Entry” as 30, and will be required to pay no age-related uplift. However, if you decide to take out hospital cover at a later stage, you will pay a 2% loading on top of your premium for every year you are over 30, up to a maximum loading of 70%. So if you take out a policy for the first time at age 40, you can expect to pay an LHC loading of 20% on your premium.

What is an inpatient?

An inpatient is someone who is admitted to hospital and stays there overnight, or for an unspecified time period.

I’ve just become a permanent resident; can I purchase private hospital cover without Lifetime Health Cover loading?

From the time you register with Medicare, you have one year to take out private hospital insurance cover without incurring any LHC loading. If you sign up after this period of time, the full loading will be applied.

Why are there waiting periods and how long are they?

Waiting periods are there to ensure that no-one is able to take particular advantage of the system, by signing up one day, claiming the next, and letting their cover lapse thereafter. This type of behaviour would disadvantage other members, as it could result in increased premiums for all fund members. Standard waiting periods for hospital cover are as follows.

12 months for pre-existing conditions, except where these are related to psychiatric care, rehabilitation or palliative care, where the period is two months

  • 12 months for obstetrics (pregnancy)
  • 2 months in all other circumstances.
  • The waiting periods for Extras are set by individual funds.  Make sure you are fully aware of all the waiting periods you may have to serve.

Does the cost of policies increase each year?

Usually, yes it does. Unfortunately, the overall cost of healthcare in this country increases every year, and the providers need to keep pace with this in order to provide you with adequate cover. Each year, a Fund will apply to the Minister for Health and Ageing to approve any premium changes, at least 60 days before the proposed change is planned to take effect.  Rate increases most often happen in April each year.

How can I be sure my Fund will be able to pay if I make a claim?

All registered private health insurers in Australia are monitored by the government agency  PHIAC (the Private Health Insurance Administration Council).  Their most critical role is to ensure that each individual insurer is financially sound. Each year, PHIAC publishes a complete list of all Funds, detailing their revenues, expenses and the prudential reserves that are available to ensure claims are able to be paid.

Can you choose to be treated as a public patient in a public hospital if you have Private Hospital Cover?

This is an option that is always available to you, to be treated as a public patient even though you have private cover. You cannot however choose your own doctor, and you may not have a choice about when you are admitted to hospital.

If I go overseas, how can I avoid waiting periods and pre-existing ailment restrictions when I get back?

There are a number of ways that you might be able to do this. Many Funds are prepared to suspend your health cover while you are overseas, and to allow you to resume when you return.  You cannot take this for granted, however, and need to ask the Fund before you stop payments. Assuming they are agreeable, you will not have to pay premiums while you are overseas, and on your return will be able to resume your private cover without having to re-serve any additional waiting periods.  If you are part-way through serving a waiting period, you will have to serve the balance on your return. You will also retain your Lifetime Health Cover loading, if you have one, so long as you re-establish your cover within the agreed timeframe on your return.

While your cover is suspended during your time overseas, you will remain a member with your Fund, but you will not be covered, and so will not be able to claim.

As always, the rules may vary slightly between Funds as to the length of time and the criteria for acceptance of the suspension, so you should always check with your insurer ahead of time.

Do I have to get private cover?

No, it isn’t mandatory, but it could be a very good idea.  Taking out a policy does not affect your Medicare entitlements, and provides you with access to the Private Health system.  Also, if you earn above a certain amount and don’t have Private Hospital coverage, you may have to pay additional tax (see Medicare Levy Surcharge). And don’t forget there are incentives to join up early, to avoid the surcharges that apply to Private Hospital coverage when you join over the age of 30 (see Lifetime Health Cover).

Do I pay GST on Premiums?

Private Health Insurance premiums are free of GST. The only exceptions to this are Visitors Health Insurance and Overseas Student Health cover, which are classified as General Insurance, and as such attract GST.

What is a Restricted Fund?

Restricted funds provide cover to members of a specific industry or group. In some cases, family members and extended family are also eligible

Do I have to wait until my policy expires before I can switch?

No, you can make the change at any time, and your present insurer will refund you the balance of any premiums you have paid. In some cases they may deduct a small administration fee. To ensure that you can take advantage of any waiting periods you have served, you need to make sure that your premium payments are up to date.

Does it cost me anything to use ComparetheMarket.com.au?

No. The Funds themselves will pay ComparetheMarket.com.au a commission for guiding you through the process of choosing the policy from their range that suits your needs.

Why don’t you have all the Health Funds on your web site?

Quite simply, not every insurer is prepared to show their products through us – we know, because we have asked! We have a selection of Funds and will continue to expand the range as more Funds become comfortable that we present fair, unbiased comparison to you, on how to select the policy that suits your needs.

What should I do if I don’t hear from the Health Fund I’ve joined?

Give us a call, on 1800 77 77 12. Sometimes it could take up to ten working days for the documentation to reach you, but if you are at all concerned, just pick up the phone and we will chase them up for you.

Why do you need me to give you my personal details before you show me any policies?

It is important that we ask you your date of birth and so on; so that we can make sure we give you an accurate price when you get to the product pages. Your birth date and whether you have had private cover before will work towards determining your Lifetime Health Cover, and the questions on your financial status are needed to allow you to select an appropriate Tax Rebate band.  Your email address will assist you to locate any quotes you have previously saved or help us to locate your details if you need assistance from our call centre.

Do I have a cooling off period?

Whenever you take out a new policy, you will have thirty days in which to change your mind, so long as you have not made a claim on that policy. If you decide that the policy is not for you, simply advise your Fund to cancel – they will refund any premiums that you may have already paid. But please note that if you have already cancelled a previous policy in order to take out the new one, it will not be automatically reinstated.

Complaints and IDR Process

Even though we do our very best to meet the highest possible standards in our work, there may be occasions where you feel we have slipped up, and that you would like us to put things right.

The very first thing to do is to let us know as soon as possible. If you are already on the phone to us, please let the consultant know straight away that you have a concern. If that is impractical, you can:

Call one of our Team Leaders on 1800 880 111 when you have a moment

Email us at email@comparethemarket.com.au, or

Write to the Health Account Manager, Compare The Market Pty Ltd PO Box 301, Toowong, QLD, 4066

If we cannot resolve your complaint immediately, we have an escalation procedure that ensures that your problem receives our full attention.. Your concerns will immediately be passed to a Team Leader, who will discuss them with you within 24 hours, and make sure that we have all the information. If the Team Leader is still unable to satisfactorily set things right, we have an Independent Reviewer who will take up the case, and is committed to respond fully to you within ten days. Finally, you always, at any stage, have the option to refer the matter to the Industry Ombudsman.


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