Exclusions

Many health insurance policies have exclusions (services or circumstances they don’t cover); if you don’t check what these exclusions are ahead of time, you could find yourself disappointed and handling unexpected costs when you’d really rather be focusing on your health.

Being informed can help you navigate exclusions like a pro – that means knowing what health services you could need in the near future and matching them up to a policy. A policy with more exclusions (or a lower level of cover) isn’t necessarily a bad choice; what matters is limiting exclusions across the services you could need.

Possibly high premiums

A health insurance policy with a higher level of cover often means a higher premium, so you want to be sure you’re getting the most out of your policy. If not, it could be worth lowering your cover to better suit your needs – and getting a lower premium to boot, too.

Given most health insurance premiums increase each 1 April to keep in line with health industry expenses, regularly reviewing your cover to make sure you’re getting value from it can help keep your premium manageable.

Along with being an informed shopper who regularly reviews and compares their health insurance, you could shrink your premium by claiming the Australian Government’s private health insurance rebate (if you’re eligible).

And, if you take out hospital insurance early (before you turn 30), you’ll also be able to take advantage of the age-based discount of up to 10%. Similarly, health funds sometimes offer discounts or a few months free to encourage new members to join.

Unexpected out-of-pocket costs

Health insurance can include cover for a service yet still come with out-of-pocket expenses or a ‘gap’ to pay, but your health fund and your policy documents will make it clear when these costs can come up. Often, you can get information about what the out-of-pocket cost will be, so you can make informed financial decisions about your health care ahead of time. This can include knowing which doctors and hospitals have agreements with your health fund to keep your out-of-pocket costs down.

If you’re looking to keep your out-of-pocket costs as low as possible, keep an eye out for no-gap options. Many health funds offer these for popular services, like general dental. Taking advantage of these can make it easier to be proactive with your health, helping reduce your risk of needing more expensive services that may come with out-of-pocket costs.

Long waiting periods

You’ll need to serve your policy’s waiting periods before you can make a claim on your cover. The maximum waiting period for any hospital insurance service is 12 months, but there are no restrictions for maximum waiting periods on extras cover.

But waiting periods help keep health insurance premiums low, stopping people from taking cover out when they need expensive treatments and then ditching it as soon as they’re finished.

Instead, it can be a smart move to take out health insurance when you’re younger (and likely healthier). Most hospital services only have a 2-month waiting period at most. It’s just services for pre-existing conditions and pregnancy that come with 12-month maximum waiting periods.

Then, once a waiting period is served, you generally don’t have to wait through it again unless you are without cover for a time or you reduce your cover so the service is no longer included.

In the case of extras, you can look for policies that come with short or even no waiting periods. For instance, preventative dental cover is a common no waiting period service. Other services might come with a waiting period of only a couple of months.

Where there are waiting periods, don’t forget you can compare options and look for a policy with shorter waiting periods.

Small limits

Extras health cover often comes with limits which restrict how much you can claim back; this can become an issue if you’re hitting the limit well before the (typically) annual reset. Never getting close to hitting your limit can also be a problem, suggesting you might have (and are paying for) more cover than you need.

Use your limits and your experiences with them to help you check if you’re cover suits your needs, as well as compare other options. This can include looking at how limits are handled, for instance; sometimes they’re shared between different services and/or people on the policy.

Out-of-pocket costs

While a public hospital patient doesn’t have any out-of-pocket costs – as Medicare covers the bill – private patients can have out-of-pocket costs, including paying an excess (e.g. $500) on admission as well as any gap payments.

Private hospital patients undergoing carpal tunnel release surgery in 2023–24 had a typical out-of-pocket cost of $500 once Medicare and insurers paid their parts.³Medical Costs Finder, Carpal tunnel release This did not include any excess the patients had to pay as part of using their insurance, or hospital fees, such as accommodation costs.

However, ensuring your doctor and hospital have an agreement with your fund may reduce the likelihood of gap fees.

Outside of hospital, there are some services Medicare usually doesn’t cover, like dental and physio, but private extras cover can cover some of the costs.

For instance, the average fee for a selection of popular extras services in 2025 ranged from about $80–$140, but those with health cover only had an average out-of-pocket cost of around $45–$60.⁴Australian Prudential Regulatory Authority, Private health insurance membership and benefits, Dec-25 So, on average, health insurers covered approximately 40%–60% of the service costs.

However, patients without private health insurance can need to pay the full cost of these sorts of services. The table below explores these fees in more detail.

Popular extras benefits breakdown

Note: These figures reflect indicative fees, health insurance benefits and out-of-pocket costs for services, based on data from the Australian Prudential Regulatory Authority and rounded where appropriate. Actual costs may vary depending on provider fees, health fund benefits and services needed. Data retrieved March 2026.

Waiting times

Private patients had a median wait of 26 days for the 25 most common elective surgery at public hospitals in 2023–24, while public patients had a median wait of 48 days.⁵Australian Institute of Health and Welfare – Waiting times by patient demographics Similarly, 90% of private patients were admitted within 172 days, while 90% of public patients were admitted within 330 days. Public patients were more likely to wait for over a year for elective surgery, too – 6.4% of public patients waited over a year, compared to 3.2% of private patients.

A shorter wait for elective surgery can reduce the impact on your quality of life, including needing to adjust your work schedule or have extra help to do daily chores. Additionally, being seen sooner can mean your condition has less time to worsen or affect other aspects of your wellbeing.

Private and public patient elective surgery waiting times in public hospital

Note: These figures reflect indicative wait times for common elective surgeries, based on data from the Australian Institute of Health and Welfare. Actual waiting times may vary depending on intended surgeries, choice of hospital and urgency category. Data retrieved March 2026.

Choice

Private patients have greater choice in their hospital experience, including choosing their treating doctor and being able to request a private room. This can help patients feel more confident in their treatment and comfortable in hospital.

Additionally, private patients can schedule their hospital admission around their life, like before or after a planned holiday. Public patients, unfortunately, cannot schedule ahead this way.