Obstetrics and Private Health Insurance

Planning For Private Hospital Cover

If you want to be covered for obstetrics (pregnancy and birth related services) in a private hospital and with a private obstetrician, you need to take out private hospital cover or upgrade your existing policy well before you’re pregnant.

All health funds have a 12 month waiting period for obstetric services and they’re usually very strict in applying this rule. This means you need to have held the appropriate level of private health cover for at least 12 months before you’re admitted to hospital.

Take care when choosing which health insurance policy to buy – many of the lower cost policies don’t cover obstetrics, or pay restricted benefits that will only cover you as a private patient in a public hospital. If you want to have your baby delivered in a private hospital, you will need to have a policy that covers you for this. Otherwise, you could incur large out-of-pocket costs if you don’t have adequate cover.

Always check with the hospital, your fund and your doctor before proceeding with a hospital booking to ensure you will be covered and to discuss what costs you may incur.

Making Sure Your Baby is Included on Your Policy

In order to cover your baby from birth, without waiting periods, you must check that your hospital policy will cover dependent children as well as yourself. A single hospital policy covers you – but it won’t cover your baby.

It’s important to ensure your baby is covered from birth in case he or she requires hospital care immediately. This could occur in cases of premature birth where a baby is admitted to a Special Care Nursery or Intensive Care Unit. This type of admission is very costly and can rise into the tens of thousands of dollars.

Every fund has different rules about covering newborn babies. Check with your health fund as early as you can about which rules apply to you.

Most funds will require you to upgrade your policy to a ‘family’ level one to three months prior to the baby’s birth. However, some funds may require you to upgrade your policy to a ‘family’ level as early as 12 months prior to birth in order to cover your baby for possible congenital conditions.

Paying an Excess for Your Baby in Hospital

If your baby is healthy, he or she won’t be formally admitted to hospital. This means the hospital won’t raise a charge for the baby’s care. However, if your baby needs treatment while in hospital, he or she may be admitted as an in-patient of the hospital and the hospital will raise a charge to cover the cost of the baby’s care. This means any excess or co-payment that is payable on your policy may also apply to your baby.

If you’re expecting twins (or any multiple birth) at least one baby will be formally admitted to hospital, even if they are both healthy. This means any excess or copayment that is payable on your policy may also apply to your baby. If your children aren’t insured you will be responsible for the full hospital cost.

IVF and Assisted Reproductive Services

 In vitro fertilisation (IVF) treatment is a process to treat infertility. IVF and other assisted reproductive services aren’t automatically covered on policies that cover natural births and obstetrics. Even on policies which include IVF, the treatment has several steps and only the component which involves an admission to hospital can be covered under private hospital insurance. Services which occur outside of a hospital admission, including consultations and tests, may be claimable on Medicare or paid out of your own pocket.

Check with your fund before proceeding with IVF or similar treatments to confirm what services you will be required to pay for and that you have completed any required waiting periods. The standard waiting period of IVF treatment is 12 months but some policies also restrict benefits for up to three years. Check with your doctor and IVF clinic for more information and quotes.

For more information, see our Assisted Reproductive Services factsheet.

What’s Not Covered

Private hospital cover gives you the choice of a private obstetrician and private hospital, and will cover a portion of your medical fees. However, it won’t cover all the costs associated with your pregnancy. Some of the out-of-pocket expenses you may incur include:

  • Medical services incurred outside of hospital including specialist consultations and obstetrician’s check-ups. These costs, like your visits to your GP, can only be claimed on Medicare.
  • The ‘gap’ on medical services incurred while admitted to hospital. Your health fund and Medicare will cover the equivalent of the Medicare Benefits Schedule fee, but the remainder is your own expense. Discuss the situation with your doctor – ask if he or she has a ‘no gap’ or “known gap” agreement with your health fund and request a written quote of expenses at the start of your treatment.
  • Excesses and co-payments. Some health insurance policies require you to pay an excess or co-payment for admissions to hospital. The amount payable may depend upon whether your baby is formally admitted to hospital (see above).
  • Your baby’s pre-release check-up. Before you and your baby can go home, a paediatrician from the hospital will check on his or her progress. If your baby has not been admitted as a patient to hospital, as is the case with most births without complications, the fee for the paediatrician’s visit cannot be claimed on your private health insurance policy. This cost can only be claimed on Medicare and usually a gap is payable, depending on how much the paediatrician charges above the Medicare Scheduled fee.

More Information

To check and upgrade your cover, contact your health fund. To obtain quotes and find out your out-of-pocket expenses, contact your health fund and your obstetrician.

For more information on private health insurance, contact our office:

Websites: www.phio.gov.au and www.privatehealth.gov.au

Phone: 1300 737 299

Download the factsheet as a PDF