|Rehabilitation||Hospital treatment for physical rehabilitation related to surgery or illness. For example, inpatient and admitted day patient rehabilitation, stroke recovery and cardiac rehabilitation.||✔R|
|Hospital psychiatric services||Hospital treatment for the treatment and care of patients with psychiatric, mental, addiction or behavioural disorders. For example, psychoses such as schizophrenia, mood disorders such as depression, eating disorders and addiction therapy.||✔R|
|Palliative care||Hospital treatment for care which provides quality of life for a patient with a terminal illness, including treatment to alleviate and manage pain.||✔R|
|Brain and nervous system||Hospital treatment for the investigation and treatment of the brain, brain-related conditions, spinal cord and peripheral nervous system. For example, strokes, brain or spinal cord tumours, head injuries, epilepsy and Parkinson’s disease.||✔✩|
|Eye (not cataracts)||Hospital treatment for the investigation and treatment of the eye and the contents of the eye socket. For example, retinal detachment, tear duct conditions, eye infections and medically managed trauma to the eye. Cataract procedures are listed separately under ‘Cataracts’, which is only covered in the Gold hospital cover.||✔✩|
|Ear, nose and throat||Hospital treatment for the investigation and treatment of the ear, nose, throat, middle ear, thyroid, parathyroid, larynx, lymph nodes and related areas of the head and neck. For example, damaged eardrums, sinus surgery, removal of foreign bodies, stapedectomy and throat cancer.||✔✩|
|Tonsils, adenoids and grommets||Hospital treatment of the tonsils, adenoids and insertion or removal of grommets.||✔✩|
|Bone, joint and muscle||Hospital treatment for the investigation and treatment of diseases, disorders and injuries of the musculoskeletal system. For example, carpal tunnel, fractures, hand surgery, joint fusion, bone spurs, osteomyelitis and bone cancer.||✔✩|
|Joint reconstructions||Hospital treatment for surgery for joint reconstructions. For example, torn tendons, rotator cuff tears and damaged ligaments. Joint replacement surgery is listed separately under ‘Joint Replacements’, which is only covered in the Gold tier.||✔✩|
|Kidney and bladder||Hospital treatment for the investigation and treatment of the kidney, adrenal gland and bladder. For example, kidney stones, adrenal gland tumours and incontinence. Dialysis is listed separately under ‘Dialysis for chronic kidney failure’, which is only covered in the Gold tier.||✔✩|
|Male reproductive system||Hospital treatment for the investigation and treatment of the male reproductive system, including the prostate.||✔✩|
|Digestive system||Hospital treatment for the investigation and treatment of the digestive system, including the oesophagus, stomach, gall bladder, pancreas, spleen, liver and bowel. For example, oesophageal cancer, irritable bowel syndrome, gall stones and haemorrhoids.||✔✩|
|Hernia and appendix||Hospital treatment for the investigation and treatment of a hernia or appendicitis. Digestive conditions are listed separately under ‘Digestive system’.||✔✩|
|Gastrointestinal endoscopy||Hospital treatment for the diagnosis, investigation and treatment of the internal parts of the gastrointestinal system using an endoscope. For example, colonoscopy, gastroscopy and endoscopic retrograde cholangiopancreatography (ERCP).|
Non-endoscopic procedures for the digestive system are listed separately under ‘Digestive system’.
|Gynaecology||Hospital treatment for the investigation and treatment of the female reproductive system. For example, endometriosis, polycystic ovaries, female sterilisation and cervical cancer.||✔✩|
|Miscarriage and termination of pregnancy||Hospital treatment for the investigation and treatment of a miscarriage or for termination of pregnancy.||✔✩|
|Chemotherapy, radiotherapy and immunotherapy for cancer||Hospital treatment for chemotherapy, radiotherapy and immunotherapy for the treatment of cancer or benign tumours. Surgical treatment of cancer is listed separately under each body system.||✔✩|
|Pain management (without a device)||Hospital treatment for pain management that doesn’t require the insertion or surgical management of a device. For example, treatment of nerve pain and chest pain due to cancer by injection of a nerve block.|
Pain management using a device (e.g. an infusion pump or neurostimulator) is listed separately under ‘Pain management with device’, which is only covered in the Gold tier.
|Skin||Hospital treatment for the investigation and treatment of skin, skin-related conditions and nails. For example, melanoma, minor wound repair and abscesses. The removal of foreign bodies and plastic surgery that is medically necessary and related to the treatment of a skin-related condition is also included.|
Removal of excess skin due to weight loss is listed separately under ‘Weight loss surgery’, which is only covered in the Gold tier.
|Breast surgery (medically necessary)||Hospital treatment for the investigation and treatment of breast disorders and associated lymph nodes, and reconstruction/reduction following breast surgery or a preventative mastectomy. For example, breast lesions, breast tumours, asymmetry due to breast cancer surgery and gynecomastia.|
This clinical category doesn’t pay benefits for cosmetic breast surgery that isn’t medically necessary.
|Diabetes management (excluding insulin pumps)||Hospital treatment for the investigation and management of diabetes. For example, stabilisation of hypo- or hyper-glycaemia and contour problems due to insulin injections. Treatment for diabetes-related conditions is listed separately under each body system affected. For example, treatment for diabetes-related eye conditions is listed separately under ‘Eye’.||✔✩|
|Heart and vascular system||Hospital treatment for the investigation and treatment of the heart, heart-related conditions and vascular system. For example, heart failure and heart attacks, monitoring of heart conditions, varicose veins and removal of plaque from arterial walls.||✔✩|
|Lung and chest||Hospital treatment for the investigation and treatment of the lungs, lung-related conditions, mediastinum and chest. For example, lung cancer, respiratory disorders such as asthma, pneumonia and treatment of trauma to the chest.||✔✩|
|Blood||Hospital treatment for the investigation and treatment of blood and blood-related conditions. For example, blood clotting disorders and bone marrow transplants.||✔✩|
|Back, neck and spine||Hospital treatment for the investigation and treatment of the back, neck and spinal column, including spinal fusion. For example, sciatica, prolapsed or herniated disc, spinal disc replacement and spine curvature disorders such as scoliosis, kyphosis and lordosis.||✔✩|
|Plastic and reconstructive surgery (medically necessary)||Hospital treatment which is medically necessary for the investigation and treatment of any physical deformity, whether congenital or the result of illness or accident. For example, burns requiring a graft, cleft palate, club foot and angioma.|
Plastic surgery that is medically necessary relating to the treatment of a skin-related condition is listed separately under ‘Skin’.
|Dental surgery||Hospital treatment for surgery to the teeth and gums. For example, surgery to remove wisdom teeth and dental implant surgery.||✔✩|
|Podiatric surgery (provided by a registered podiatric surgeon)||Hospital treatment for the investigation and treatment of conditions affecting the foot and ankle, provided by a registered podiatric surgeon. Limited to cover for accommodation and the cost of a prosthesis as listed in the prostheses list of the Private Health Insurance (Prostheses) Rules.|
Insurers aren’t required to pay for any other hospital treatment benefits for this clinical category but may choose to do so.
|Implantation of hearing devices||Hospital treatment to correct hearing loss, including implantation of a prosthetic hearing device. Stapedectomy is listed separately under ‘Ear, nose and throat’.||✔✩|
|✔ = This clinical category is covered.|
R = You may only be covered for restricted services^ and treatments under these clinical categories.
✩ = These clinical categories are a minimum requirement of the Silver tier.
Source: Department of Health – Hospital cover product tiers and clinical categories: How product tiers work. Updated 1 August 22.