Your policy says your treatment is covered. That doesn't necessarily mean you'll pay nothing.
Hospital Cover and Extras Cover Are Genuinely Different Products
Hospital cover pays toward treatment as an admitted patient in hospital. Extras cover (sometimes called "ancillary" cover) is separate, and pays toward things like dental, physiotherapy, and optical that generally aren't covered by Medicare or hospital cover at all. Many people assume having "private health insurance" broadly covers whatever comes up — but if you only hold hospital cover, dental and physio costs remain entirely out of pocket regardless of your hospital-level tier.
Even With the Right Cover, Gaps and Exclusions Still Apply
- Waiting periods: new policies, or upgrades to a higher tier, typically carry waiting periods before certain treatments are covered — sometimes 12 months for pre-existing conditions or specific procedure categories. Confirm your specific waiting period status before assuming a treatment is covered today.
- Restrictions vs. exclusions: a "restricted" service on your policy means you get some benefit but likely at a reduced rate (common on lower hospital tiers for things like joint replacements) — not full coverage. An "excluded" service means no benefit at all for that category.
- The medical gap: even when your hospital cover applies, your specialist's fee above the Medicare Benefits Schedule rate is a separate gap payment your insurer may or may not fully cover, depending on whether a no-gap or known-gap arrangement is in place for your specific doctor.
- Excesses and co-payments: many policies include a per-admission excess or daily co-payment that applies regardless of what else is covered.
Confirm Coverage Before Treatment, Not After
Before accepting any planned treatment, contact your insurer directly and ask: is this specific treatment covered under my current policy tier, am I still within any waiting period, what excess or co-payment applies, and is this a restricted or fully covered service. Get this confirmation in writing where possible, and separately confirm any medical gap with your treating doctor.
What This Means Practically
- Don't assume "covered" means "no cost" — check hospital cover, extras cover, waiting periods, restrictions, and gap payments separately.
- Call your insurer before treatment to confirm your specific policy's status for that specific procedure, not just the general benefit level advertised.
- Ask your insurer specifically whether the service is "restricted" rather than fully covered — this distinction changes what you'll actually pay.
- Confirm the medical gap with your treating doctor separately from confirming hospital cover with your insurer — they're two different conversations.
Related Kibbo Tools
Sources
- Australian Government Department of Health, Disability and Ageing — What private health insurance covers. health.gov.au