Health insurance for elective surgery

What is elective surgery?

Elective surgery is any surgery that's isn't a medical emergency, so can be scheduled in advance. Generally, if your surgery can't be put off by more than 24 hours, then it's considered an emergency.

Are elective surgeries not important?

The name 'elective' is a bit misleading - it suggests the surgery isn't necessary, but it often is. It's sometimes just called 'planned surgery', which is probably a better name. In fact, elective surgery can include a range of really important procedures, including joint reconstructions and replacements, cancer treatment like biopsies, and cataract removal.

Elective surgery categories

There are 3 categories of urgency doctors use to decide who's first in the queue for elective surgery: urgent, semi-urgent and non-urgent. These are also referred to as category 1, 2 and 3.

Here's how each is defined and what you can expect based on what category your surgery belongs to:

Some treatments can fall into a few different categories, depending on the severity. For example, cataract extractions are category 3. However, with severe disability it moves to category 2, and with angle closure glaucoma it moves up to category 1. If you have a particular elective surgery you might need, speak to your GP or specialist to find out which category it fits into.

Is elective surgery covered by private health insurance?

Elective procedures are one of the main reasons people get private health insurance. Depending on your level of cover, private health insurance will cover a large number of elective surgeries. After all, everything except emergency, life-saving surgeries are considered to be elective.

There are some elective surgeries that are excluded from all but a few of the most premium policies, including weight loss surgery and in vitro fertilisation. Almost no policy offers cover for non-medical plastic surgery.

Getting private health cover lets you access treatment in a private hospital. In turn, you can get around some of the high wait times for elective surgery.

Public waiting times for elective surgery

The biggest drawback of getting elective surgery through Medicare are the waiting times. They are a lot longer than you would want, up to a year or more. Here are a few stats from the most recent data from the Australian Institute of Health and Welfare, covering the 2022-2023 financial year:

• 50% of patients were admitted for elective surgery within 49 days.
• 9.6% of patients waited a year or more - that's up from just 2.1% of patients in 2018–19.
• The median waiting time for Indigenous Australians was 56 days, but just 49 days for other Australians.

Clearly there is some room for improvement. No Aussies should be waiting over a year for elective surgery, and there should be no gap between the health outcomes of Indigenous and non-Indigenous Australians.

Elective surgery with the longest waiting times

Here were the procedures with the longest public median wait times in 2022-2023:

Septoplasty

Median wait time: 365 days (up from 315 the year before)

Myringoplasty

Median wait time: 283 days (up from 259 the year before)

Hip replacement

Median wait time: 175 days (up from 153 the year before)

Elective surgery with the shortest waiting times

Of the 25 most common surgeries, these had the shortest public median wait times in 2022-2023:

• Curettage and evacuation of uterus: 4 day median wait time
• Breast lump–excision and/or biopsy: 17 day median wait time

Shorter waiting times are typically associated with near-emergency situations. These could result from a suspected or confirmed cancer diagnosis, complications in child birth or from an accident with some technical not emergency impacts.

How to compare health insurance for elective surgery

When you compare hospital health insurance policies, it’s important to understand what's covered and what's not. For example, if major eye surgery is excluded, then that means cataract removals won’t be covered.

Most brands offer three to four levels of cover: top, medium, basic and public hospital. What's included in each differs from brand to brand, but here is how the levels commonly look:

• Top hospital cover. Covers most of what Medicare does, although you might have to do a little digging to find cover for relatively uncommon elective surgeries like weight loss surgery.
• Medium hospital cover. Covers most of what you'd find with top cover, but without cover for some of the most expensive and complicated elective surgeries like hip replacements.
• Basic hospital cover. Covers most basic procedures, but excludes everything mid cover excludes plus a handful of other somewhat complicated procedures like heart procedures and minor joint replacements.
• Public hospital cover. A form of basic cover that lets you choose your private doctor, but only in a public hospital. It covers many of the same treatments as basic, but has higher out-of-pocket fees and you must join the public queue and wait for your treatment.

Frequently asked questions about elective surgery

• What's the difference between elective and non-elective surgery?

  An elective surgery is one that's booked in advance as it doesn't involve a medical emergency, such as cataract surgery. Whereas non-elective surgery needs to be done urgently, including to preserve life. For example, after the trauma of a car accident.

• Is private health insurance a better way to cover elective surgery?

  Private health insurance can get you shorter wait times for elective procedures, and this can make a huge difference if your condition is affecting your quality of life.

  Getting in sooner can also have health implications. For example a clogged artery is extremely serious, but not sufficiently life-threatening to qualify as an emergency.

  Just be aware that not all insurance companies cover all surgeries. For example, you'll probably need a top-tier policy if you want to have major heart surgery covered.

• How do private health insurance waiting periods work?

  Waiting periods are fairly standard on most health insurance policies around Australia and you can expect a waiting period for most treatments no matter what fund you are with. These waiting periods range from 0-2 days for accidents and ambulance cover to 12 months for pregnancy and pre-existing conditions.

  This means it's not possible to just take out health insurance the moment you need it. Fortunately, once you have cover you can switch between different health funds without needing go through the waiting periods again.

• If I switch health funds, do I have to re-serve waiting periods?

  It depends. You typically won't need to if you had equivalent cover with another fund. But if you didn't previously have cover for a service that your new policy includes, then it's likely you'll need to serve a waiting period.

• What if my condition gets worse?

  If your condition gets worse, and your surgery becomes more essential, there's a chance your procedure will be rearranged.

  If you're waiting for surgery, make sure to stay in regular contact with your GP. They'll help keep you fit and healthy so you're ready for the surgery when it is rearranged, and they'll make contact with the hospital if there are any changes in your condition while you're waiting.

  If you have any medical questions or concerns, you should always speak to your doctor.

To make sure you get accurate and helpful information, this guide has been edited by Tim Bennett as part of our fact-checking process.

Written by

James Martin

Editor

James Martin was the insurance editor at Finder. He has written on a range of insurance and finance topics for over 7 years. James often shares his insurance expertise as a media spokesperson and has appeared on Prime 7 News, WIN News, Insurance News, 7NEWS and The Guardian. He holds a Tier 1 General Insurance (General Advice) certification and a Tier 1 Generic Knowledge certification, both of which meet the requirements of ASIC Regulatory Guide 146 (RG146). See full bio

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