While taxes might allow you to hand over your receipts for an expert to sort through, understanding what’s covered by your health insurance is a bit more hands-on.

And since it can be confusing, we’ve pulled together this guide, focusing on items members may think are covered but aren’t. We’ll bust some common myths by explaining the facts, providing real-world examples, and showing your claiming options.

This isn’t just about avoiding stress and saving you time. It’s also about ensuring you get the most from your cover—after all it’s your money!

Let’s clear up some of the confusion.

Myth: I can claim for any medical scans, screenings and tests through my fund

One helpful thing to note about private health insurance is that it often won’t cover things that Medicare does. This is true for services such as MRI, ultrasound, CT scans and x-rays. The same goes for pathology tests (e.g. blood, urine, stool).

Usually, if you have a referral from a medical practitioner, these scans and tests will either be bulk-billed or you can claim a Medicare rebate for them.  

For instance, with MRIs, you could claim a Medicare rebate if it’s:

• referred by a medical practitioner
• listed on the Medicare Benefits Schedule (MBS)
• provided by an accredited practitioner
• done on eligible equipment.

Myth: I can claim for any eye scan with my optical cover

Because most optometrists bulk bill for standard eye tests, there’s no need to claim this with your health fund.

It’s a different story for specialised scans, like optical coherence tomography (OCT) or digital retinal imaging. Medicare typically doesn’t cover these procedures unless they are for a specific eye condition. Whether you can claim for this through your Extras will depend on the level and type of cover you’ve got.

So it’s best to check your cover and chat to your optometrist about your options.

Myth: I should send in all my hospital receipts and documents since Hospital cover includes all fees

It’s easy to think that if you have Hospital cover, your health fund will take care of all the costs.

In reality, what’s typically covered is the cost of the hospital stay (known as ‘accommodation’) and medical services you receive as an inpatient. In other words, costs that relate to hospital admission and treatment.

We go into a bit more detail about the ins and outs in our going to hospital guide.

One thing to note is if you’re treated under Access Gap Cover, you won’t need to send us any bills or receipts.

And if you’re admitted at a private hospital we have a contract with, we’ll usually cover most of the costs for things like your stay, food and use of the operating theatre.

You also won’t need to send us:

• Quotes, estimates or consent. Copies of quotes, estimates of fees or Informed Financial Consent are super important for understanding potential costs before going to hospital, but these aren’t needed to process your claims.
• Receipts for additional charges. This could be for things that you’re not covered for, hospital admin costs, services, consultations and treatment you received outside of your hospital stay or any excess.

Myth: Extras cover lets me claim for any treatment or items supplied by a health professional

Extras cover helps with the cost of a wide range of therapies and services that support your health and wellbeing – from physio and chiro to dental and optical. But that doesn’t mean you can also claim for related products or procedures.

Take podiatry, for example. While consultations with a podiatrist are generally covered under Extras, certain items or services within that visit might not be. This includes things like:

• Off-the-shelf orthotics: Items that are pre-made and don’t require specific professional modification to fit your foot.
• Additional treatments or items: Charges for items such as shockwave therapy, dressings, or local anaesthetic.
• General aids and appliances: Things like neoprene braces, Therabands, trigger balls, or Pilates socks, even if purchased from your therapist, are generally not claimable as they’re considered retail items rather than a direct service or custom-made aid.

To make sure you’re getting the most from your cover and avoiding any unexpected costs, it’s a good idea to check your cover details and search our network of providers for offers available to you.

The biggest myth of all: you need to know it all!

We hope this guide has helped clear up some common misconceptions about what you can and can’t claim. But here’s the most important myth to bust: you don’t need to be a health insurance expert!

While understanding your cover empowers you to get the most value from your membership, avoid unexpected costs, and save time on admin, we’re always here to bridge the gap. If you’re ever in doubt about a treatment, service, or item, the easiest and most effective way to get a clear answer is to contact our friendly team. You don’t have to navigate it all on your own.