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What Health and Medical Insurance Covers
Health insurance covers hospital admissions, medical procedures and selected out-of-hospital services, helping individuals and families manage the cost of care in Australia.
Private health insurance lowers your out-of-pocket costs and gets you into treatment sooner. You choose the hospital and, in most cases, the specialist who treats you.
Whether you are an individual, a family or an overseas visitor, health and medical insurance is an important part of personal protection in Australia. It works alongside personal accident insurance, which replaces income while you cannot work. It sits within our personal insurance range at Fortis Risk Solutions.
Health Insurance: Cover Sections and Benefits
What Health and Medical Insurance does not cover
Health insurance pays towards treatment, and every policy draws lines around which treatment and when. The schedule of included services matters more than the brochure. Common exclusions and limits are:
- Waiting periods at the start of a policy, with longer waits for pre existing conditions and pregnancy
- Services excluded or restricted at the level of hospital cover chosen
- The gap between the fee a doctor charges and the amount the fund and Medicare pay
- Cosmetic procedures and treatment that Medicare does not recognise
- Annual limits on extras such as dental, optical and physiotherapy
- Treatment received overseas, which belongs on a travel policy
- Ambulance transport in some states, unless the benefit or a membership is held
Visitor and working visa products have their own rules again. FRS checks the visa condition, the waiting periods and the excess against your circumstances so the level of health insurance matches what you will use.
How Health and Medical Insurance premiums are set
Health insurance is community rated, so a fund cannot charge you more because of your medical history. The price difference comes from the product and from your own circumstances:
- The tier of hospital cover chosen and the services included at that tier
- The hospital excess selected, and whether it applies for each person or for each policy
- The extras limits taken for dental, optical, physiotherapy and similar services
- Whether the policy is single, couple, family or single parent
- The state you live in, because funds set prices state by state
- Any loading that applies where hospital cover was first taken out later in life
- Rebate entitlement, which depends on income and age
Visitor and overseas student products are priced on visa type and duration instead. FRS compares funds against the treatment you expect to use, not against the lowest advertised rate.
How to claim on Health and Medical Insurance
Most health insurance claims are settled at the point of service. The hospital or the practitioner claims from the fund directly and you pay any gap, so you only lodge paperwork yourself where the provider does not claim on the spot. How it works, and where FRS helps:
- Ask the hospital or specialist for written informed financial consent before admission, so the gap is known in advance
- Present the membership card so the provider can claim electronically from the fund
- For extras, use the terminal at the clinic, or send the itemised receipt to the fund through its app
- Keep receipts, referrals and item numbers for anything claimed after the visit
- Contact FRS if a benefit is reduced or refused, and we take it up with the fund for you
- We review the tier and the excess each year against how the policy was actually used
For any policy placed by FRS you can also start the process on our make a claim page.
Health and Medical Insurance compared with Personal Sickness & Accident
| Question | Health and Medical | Personal Sickness and Accident |
|---|---|---|
| What it covers | The cost of hospital and extras treatment | A weekly benefit replacing income while you cannot work |
| Who buys it | Individuals, families, and people on working or student visas | Sole traders, contractors and working directors |
| Typical trigger | Admission to hospital, or a visit to a dentist or physiotherapist | Injury or illness that keeps you away from work |
| Sits with | Ambulance membership and travel cover | Business pack and workers compensation |
They answer different questions. One pays the provider, the other pays you. A self employed person with a broken wrist needs the surgery paid and the lost weeks replaced, which is why personal sickness and accident cover usually sits alongside a hospital policy rather than instead of it.
Health Insurance FAQs
No. Medicare covers public healthcare, but private health insurance gives you greater choice, shorter waiting times and access to private hospitals and specialists.
Hospital cover applies to treatment as a private patient in hospital. Extras cover applies to out-of-hospital services such as dental, optical and physiotherapy.
Yes. Waiting periods apply to certain services, particularly pre-existing conditions, maternity and major dental.
No. Out-of-pocket costs can still apply, depending on Medicare rebates, provider fees and policy limits.
Health insurance policies vary widely in inclusions, exclusions and value. As your adviser, FRS helps you:
- Compare policies across multiple health funds
- Match cover to your life stage, income and healthcare needs
- Explain waiting periods and exclusions
- Review the policy each year so it still earns its premium
FRS also arranges home and contents insurance for the family home. Owners of higher-value properties are usually better served by prestige home insurance.