Plain English explanations of everything you need to know about private health insurance in Australia.
Private health insurance in Australia is split into two distinct types. You can hold one or both.
Hospital cover pays for treatment as a private patient in a hospital. This includes your accommodation, theatre fees, and a contribution toward medical costs. It gives you the right to choose your own specialist, access private hospitals, and in most cases avoid long public waiting lists for elective procedures.
Extras cover (also called ancillary or general treatment cover) pays for out-of-hospital healthcare services that Medicare does not fully cover. This includes dental, optical, physiotherapy, chiropractic, psychology, podiatry, and more.
Since 2019 the Australian Government requires all hospital policies to be classified into one of four tiers. This makes it easier to compare policies across different funds. Every fund must include a minimum set of clinical categories at each tier.
The most comprehensive level. Covers all 38 clinical categories including maternity, cardiac, joint replacements, weight loss surgery, and assisted reproductive services. No restrictions.
Indicative, NSW single age 30
Covers most hospital procedures. Typically excludes maternity, weight loss surgery, and IVF. Silver Plus policies add some Gold categories. A strong mid-tier option for most adults.
Indicative, NSW single age 30
Covers core hospital services. Some categories are Restricted rather than Included. Good for younger, healthy adults who want private hospital access without the higher Gold/Silver premium.
Indicative, NSW single age 30
The minimum level of hospital cover. Most categories are Restricted. Mainly used to avoid the Medicare Levy Surcharge or Lifetime Health Cover loading at minimal cost.
Indicative, NSW single age 30
This is one of the most misunderstood parts of private health insurance in Australia. When a clinical category is listed as Restricted on your policy, it does not mean you are completely uncovered. It means the fund will only pay the minimum government-set benefit toward your treatment.
In practice this means if you are treated in a private hospital for a Restricted category, the minimum benefit paid by your fund will almost certainly not cover the full cost of your private hospital accommodation and theatre fees. You will likely face significant out-of-pocket expenses.
If you are treated as a public patient in a public hospital for a Restricted category, the benefit is usually sufficient because public hospital costs are lower.
When you first take out private health insurance, or when you upgrade to a higher level of cover, most benefits have a waiting period before you can claim. This prevents people from taking out cover only when they know they need treatment.
| Type of treatment | Standard waiting period |
|---|---|
| General hospital treatment | 2 months |
| Pre-existing conditions (hospital) | 12 months |
| Obstetrics / pregnancy | 12 months |
| Psychiatric care, rehabilitation, palliative care | 2 months (maximum) |
| General extras (dental check-ups, optical) | 2 months typical |
| Major dental | 12 months typical |
| Orthodontics | 12 months typical |
| Ambulance (emergency) | 1 day or immediate |
Your PDS is the legal document that describes exactly what your policy covers. Every fund must provide one. It can be long and dense but knowing where to look saves time.
Extras cover varies enormously between funds and policy levels. Unlike hospital cover there are no government-regulated tiers for extras. Each fund sets its own annual limits and benefit amounts. Common extras categories include: