An exclusion is when you agree not to be covered at all for certain treatments. For example you may have hospital cover but it excludes joint replacements.

A restriction is when you agree to receive very limited benefits for certain treatments. For example you may be covered for joint replacements only at a public hospital, and if the joint replacement is undertaken in a private hospital, only basic accommodation benefits and no procedure benefits are paid – which may leave you with substantial out-of-pocket costs.

At Emergency Services Health our Hospital cover has no exclusions and no restrictions (other than where Waiting Periods apply for transfers before benefits or higher benefits, as applicable, are payable) because we don’t think our members should have to predict what health needs they or their family will have in the future. You wouldn’t insure just half of your house or car, so why insure just part of your health?

It’s important to note that all health insurers are governed by the Private Health Insurance Act 2007. This legislation sets out what health insurers can and cannot pay benefits towards. Within the hospital as an inpatient, health insurers can only pay benefits towards treatment and procedures where Medicare pays a benefit. That means for some services, like elective cosmetic surgery, health insurers cannot pay a benefit towards this treatment, and this is not classed as a restriction or an exclusion on a policy.

Items that are not covered by our Hospital policy, that are not considered exclusions or restrictions, include (but are not limited to);

  • Services incurred before Waiting Periods have been served.
  • Outpatient services, unless there is an agreement between Emergency Services Health and the hospital.
  • Treatment for which Medicare does not pay a benefit, including cosmetic surgery. (Some benefits may be payable for hospital treatment following this surgery. Please contact us for more details.)
  • Services that are provided outside of the Commonwealth of Australia.
  • Services where an entitlement exists or may exist under any compensation, sports club or third party insurance.
  • A claim for a service that is submitted more than two years after the date of service.
  • Pharmaceuticals not related to the reason for hospitalisation or not covered under the agreement with the hospital or provided on discharge.
  • Exceptional high cost drugs where no or limited benefits are paid.
  • Prostheses items that are not included on the Federal Government’s approved Prostheses List.
  • Charges greater than the benefit defined in the Federal Government’s approved Prostheses List.
  • Personal and take-home items. E.g. newspapers, toiletries, television, hairdressing, manicure, etc.
  • Treatment provided to a person in a private hospital emergency department (out-patient).
  • Aged care and accommodation in an aged care facility.
  • If you’re in hospital for more than 35 consecutive days and not classified as an acute care patient, your benefits will significantly reduce.
  • Benefits for ambulance services covered by a third party arrangement such as a State/Territory transportation scheme.
  • Fees from a podiatric surgeon (benefits may be payable under our Extras cover) or related anaesthetic fees.
  • Use of robotic assisted systems not covered under the hospital contract. 

Should you require information about a particular treatment or benefit please contact us.