Understanding Hospital cover

Here you’ll find Q&As that cover three terms you may see on our Hospital Product Sheets: restricted services, waiting periods and pre-existing conditions.

Specialists’ costs

Before you agree to treatment, ask the specialist if they’ll treat you under the Access Gap Cover scheme.

If they agree, the maximum you’ll pay is as a known gap of up to $500 per doctor per hospital episode ($800 for obstetrics), or even no gap at all.

It’s the same for any other specialists involved in your hospital care, like an anaesthetist or assistant surgeon.

Specialists aren’t obliged to participate in the scheme, so if one won’t, you can look for another specialist who might.

Hospital costs

Your out-of-pocket hospital expenses will depend on which type of hospital you go to (public or private), and how much that hospital charges private patients for the service.

Public hospitals

If your specialist can treat you as a private patient in a public hospital, ask if the hospital charges private patients the government set fee (for a shared room) for that service.

If the hospital charges more than government set fee, you’ll have to pay the difference. This can vary a lot, so be clear on this before you agree to any treatment.

At a glance

We pay – Accommodation (up to the government fee for a shared room).

You pay – Any excess on your cover and the balance of your accommodation costs.

Private hospitals

If you’re treated at a private hospital, you’re likely to have significant out-of-pocket costs.

As with public hospitals, we pay up to the set government fee (for a shared room) for your hospital accommodation. But a private hospital will probably charge more than that.

At a private hospital you’ll also have to pay for any operating theatre, intensive care or neonatal intensive care costs, because they’re not included in the accommodation cost (which they are at public hospitals).

Again, you need to understand those costs before you consent to treatment to avoid bill shock later on.

At a glance

We pay – Accommodation (up to the government fee for a shared room).

You pay – Any excess on your cover, the balance of your accommodation costs, and any other costs involved in your hospital stay.

To keep health insurance fair for everyone, you may need to wait for a while before you can claim. This can happen if you:

• are new to private health insurance
• upgrade your cover to include things that weren’t covered before
• upgrade your cover when you join from another health fund.

If you leave another fund, you need to join us within 60 days to avoid re-serving any applicable waiting periods.

A pre-existing condition is an illness, ailment or condition where the signs or symptoms existed at any time during the six months before you got your Hospital cover or transferred to a higher level of cover. 

Where relevant, we appoint a medical practitioner to determine whether you have a pre-existing condition, based on information provided by your treating doctor or specialist.