In some circumstances, downgrading to a more affordable policy might be an alternative, but there will be exclusions.<\/p>\n
For those thinking about a change, we’ve compiled a list of questions to ask based on our series looking at some of the pitfalls patients are telling us they’re experiencing.<\/p>\n
While most consumers are aware of checking for waiting periods and excesses, these are some of the other complexities that are worth investigating as well.<\/p>\n
Are joint replacements covered under the policy?<\/p>\n
Joint replacements, like knee and hip replacements, only legally have to be covered under expensive gold-level private health policies.<\/p>\n
However, some insurers voluntarily offer them under silver plus policies.<\/p>\n
As our stories reported, some patients mistakenly thought joint replacements<\/a> on their policy only referred to elective replacements that could be needed from wear and tear.<\/p>\n Private health patients stung by exclusions after downgrading policies<\/a><\/p>\n Since 2020, 360,000 people have left gold health insurance policies. But some have been left out of pocket for surgeries they thought they were insured for.<\/p>\n As a result, they chose to downgrade from gold to save money and joint replacements were no longer covered.<\/p>\n Patients were under the belief they could simply upgrade later in life, with some failing to consider they might need a joint replacement in the case of an accident.<\/p>\n Orthopaedic surgeons tell us there also can be a fine line between a joint reconstruction, covered under cheaper policies, and joint replacements.<\/p>\n You might not know what’s needed until your care is well advanced.<\/p>\n Do I have accident cover and what does it include?<\/p>\n Accident cover is not to be confused with ambulance cover.<\/p>\n ABC Business Daily podcast<\/a><\/p>\n The podcast that helps you unpack the latest business and finance news. Analysing the stories moving share markets, shaping industries and affecting the Australian economy.\u00a0<\/p>\n Accident cover essentially upgrades you to gold-level policy benefits if you’re injured in an accident.<\/p>\n But check with your insurer. As we reported, accident cover is often offered in cheaper basic and bronze-level insurance policies. It’s not always in silver policies.<\/p>\n Patients also say the definition of an accident varies widely between policies, with some insurers saying you need to have the surgery within 90 or 180 days or a year of the accident.<\/p>\n The accident also often needs to have happened in Australia and you need to have sought care within three to seven days. So check your policy or ask your insurer.<\/p>\n Do I need ambulance cover in my state?<\/p>\n Ambulance cover varies widely across Australia because state governments bill public patients differently in each state.<\/p>\n In Queensland and Tasmania, it’s free for residents but not visitors, with only some reciprocal agreements between states.<\/p>\n Other states have a maze of concession programs or roadside assistance-style subscription schemes.<\/p>\n Consequently, some patients in states with free ambulance choose not to add it to their private health policy, but sometimes people move interstate and forget to put it back in.<\/p>\n Are ambulance services free if I’m travelling interstate?<\/a><\/p>\n Emergency ambulance services aren’t always free if you’re travelling interstate.<\/p>\n Many insurers also only cover people in an emergency, not general patient transport, unless specified.<\/p>\n Others only cover patients taken to hospital and not those treated at the scene.<\/p>\n If you get an ambulance bill, always check before handing over payment, as your insurer may cover the invoice.<\/p>\n Similarly, some veteran, workplace or third-party car insurance schemes may pick up the bill.<\/p>\n Or, you may be eligible for a concession.<\/p>\n Ambulance bills and fee exemptions can vary widely between the states. (Supplied: Queensland Ambulance Service)<\/p>\n Also, be wary of the private hospital emergency room bill. Legally, private health insurance only covers patients admitted to hospital.<\/p>\n If you choose to go to a private emergency room, make sure you’re going to be admitted because if you are just treated in emergency and discharged it can result in a bill.<\/p>\n Medicare might pick up some of the tab.<\/p>\n Where are your contracted hospitals?<\/p>\n A no-gap agreement is an agreement between a doctor and an insurer not to charge a patient a gap payment for their procedures.<\/p>\n A known-gap agreement allows a patient co-payment of up to $500, or $800 for obstetrics.<\/p>\n There are parallel agreements between hospitals and insurers for no-gap or known-gap billing for their services as well \u2014 like the room and theatre frees.<\/p>\n Check with your insurer where their contracted hospitals are for no-gap hospital fees because if there isn’t one nearby, you might need to a find an insurer which does to avoid out-of-pocket costs.<\/p>\n Customers should check which hospitals their health insurer has no-gap agreements with. (ABC News)<\/p>\n They usually list their network hospitals online. You also need to ask your specialist up-front if they will treat you as a no-gap or known-gap patient, you can’t do it after you get a surprise bill.<\/p>\n If you know what procedures you may need, check with your insurer who their no-gap doctors are \u2014 they’re online.<\/p>\n Query hospital and doctors’ bills as it’s illegal to charge gaps under a no-gap agreement.<\/p>\n Anaesthetist, surgical assistant and complex pathology testing bills are often surprise bills for patients.<\/p>\n Anaesthetist and surgical assistants aren’t included in treating doctor and hospital no-gap deals and need to agree separately to no-gap you.<\/p>\n![\"Queensland](\"https:\/\/www.newsbeep.com\/au\/wp-content\/uploads\/2026\/04\/3ed329e9c3c24dbde21a302921939337.jpeg\")
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