How do I make a private health insurance claim?

It can sometimes feel overwhelming when you have to sit down and make a private health insurance claim. But fear not – making a claim doesn't have to be a head-scratcher.

Whether you’ve had to race to the emergency department, visited your dentist or optometrist, or have recently had surgery, your private health insurance might just come to the rescue. So let’s break down the process of how to make a claim in Australia – from the different ways you can submit a claim to how long you can expect before the money arrives in your account.

First things first: familiarise yourself with your policy and look specifically at the services it covers. Typically, private health insurance comprises three main categories – hospital, extras and ambulance cover. While hospital cover caters to in-hospital treatments, extras cover handles out-of-hospital services like dental and physio. Then there’s ambulance cover, which takes care of the expensive emergency transport costs.

Once you’ve sorted which service you want to make a private health insurance claim on, it’s time to figure out how you are actually going to submit that claim. Here are some of the most popular ways to do it:

• In-person: Many healthcare providers use HICAPS machines, which means you can simply swipe your health fund membership card during payment. The system automatically deducts the rebate, and you only pay the difference or ‘gap’ fee.
• Online: Most insurers have a portal where you can submit a claim online. All you’ll need to do is set up an online account, log in and follow your insurer’s steps to make the claim submission. You might need to input the healthcare provider’s details, item codes and payment amounts, as well as upload copies of your receipts.
• Through an app: Some insurers also have dedicated apps to make claiming easier. Download your insurer’s app, log in and upload photos of your receipts. The process is essentially the same as doing it online but more convenient.
• Use the post: If technology isn’t your preferred route or if you just don’t want to learn a new way to claim, you can print out your insurer’s claim forms, fill them out and then mail them directly to the customer service centre. Be sure to include original receipts and an itemised list of service details.
• Through the hospital: For hospital claims, your health fund might need a filled-out claim form, which will be available on their website or possibly from the hospital where you received treatment. Don’t forget to include an official, itemised receipt from the hospital.

Want to get money back from your health insurance as soon as possible? Timing is key! Try to make your claim as soon as you have all the info you need for the services you received.

Most insurers have a limit on how long you can wait before making a claim – usually, it's within two years from when you got the service. If you wait too long, your benefits might not be payable.

Bottom line? The trick is to be quick and not let those deadlines slip by!

Once you get set up with a private health insurance policy, you might be wondering, “When can I actually start claiming?” Well, here’s the deal: there are waiting periods for different services. Immediate access usually kicks in for emergencies, accidents and ambulance services. But for things like major dental work or pregnancy-related services, there’s often a waiting period of around 12 months.

Yes, it can feel like a bit of a slog for longer waiting periods like pregnancy and obstetrics services, but once the waiting time is up you’re all set to start claiming. Always check your policy details to get the lowdown on specific waiting periods because they can vary.

• Know your waiting periods: Stay across the waiting periods for different services in your private health insurance policy. Familiarise yourself with the specific waiting times for things like major dental work, obstetrics or elective surgeries.
• Plan ahead: If you have a big health event on the horizon, like starting a family or needing elective surgery, then you’ll want to plan ahead. Be aware of the waiting periods so you can time your insurance to match.
• Emergency services are immediate: Remember that you’ll usually get immediate access to cover for emergency services, accidents and ambulances.
• Read the small print: Take the time to read your policy in full. The waiting periods can vary depending on your provider, so stay well-informed so you know exactly when to claim.
• Stay across policy changes: Insurance policies can – and often do – change over the years. Keep tabs on these changes and make note of any specific tweaks to your policy, especially around waiting periods.

If your health fund denies your health insurance claim in the first instance, don’t panic! Check their reasoning for the denial – it could be a simple misunderstanding or that you haven’t included the right information. Reach out to your provider and get them to clarify the situation. In some cases, it might even be down to an administrative error on their part, or that you’ve made a claim for a service that’s not covered under your policy. 

If the problem continues, you always have the option of lodging an official complaint. Be persistent and clear in your communications and, if necessary, look into avenues like involving the Commonwealth Ombudsman.

Don’t forget to tell your insurer about any pre-existing health issues when you sign up for private health insurance. This is super important for a smooth experience and to avoid any problems when you need to make a claim. If you forget, your claims might get rejected, or your policy could even be cancelled!

Claiming private health insurance is a lot more straightforward than you probably imagined. Just remember to tell your insurer about any pre-existing conditions from the get-go, be mindful of waiting periods and don't forget to claim within two years of receiving the service.

Your insurer is there to help, so don’t be shy about reaching out and asking questions. Stay informed, stay healthy!