Private health insurance
Introduction
There are approximately 38 private health insurance funds in Australia. Five insurers collectively control 80% of Australia's private health insurance market.
In this guide, we will focus on these five funds. Regardless of which fund you are insured with, private health insurance claim outcomes vary significantly between insurers and policy levels.
Confirming specific benefits, limits, and conditions with your insurer before seeking treatment is crucial.
General advice
Coverage varies
Claim outcomes depend on the following:
- The specific private health insurer.
- The policy level (basic, medium, or comprehensive extras).
- The service provider's qualifications.
Limits and exclusions
Annual limits, per-session rebates, or percentage-based reimbursements apply.
Some policies may exclude specific therapies or require pre-approval for claims.
How to check your coverage
Hand therapy practitioners are either qualified physiotherapists or occupational therapists.
Hand therapy practitioners cannot guarantee service rebates, as final approval rests with the insurer. Contact your health fund directly for accurate and up-to-date information about your coverage.
Patients are advised to:
- Review their health fund's Product Disclosure Statement (PDS).
- Use online member portals to check available benefits.
- Contact their health insurer directly for clarification before starting therapy.
Health insurance market
As of 2023, Australia's private health insurance market is heavily concentrated among a few major players. Here are the top funds by market share:
Medibank Private - 27%
BUPA - 25%
HCF - 11%
NIB - 9%
HBF - 8%.
Overview of coverage
Medibank Private offers extras that cover hand therapy under physiotherapy or occupational therapy. Coverage varies based on the specific policy, with limits typically set annually for each service.
BUPA* recognises hand therapy, reimbursable under extras cover for occupational therapy or physiotherapy, depending on the provider's qualifications in its extra’s coverage. Coverage limits depend on the level of extras selected.
HCF recognises hand therapy if billed under physiotherapy or occupational therapy codes by a qualified therapist with annual limits and percentage rebates. It's recommended that eligibility be verified with HCF before receiving treatment.
NIB has extras cover hand therapy under physiotherapy or occupational therapy benefits, with fixed amounts depending on the policy. Policyholders receive a fixed benefit or percentage reimbursement for services, subject to annual limits. NIB members should consult their policy details for exact coverage.
HBF allows claims for hand therapy provided by physiotherapists or occupational therapists. Services must align with policy inclusions. Coverage and limits vary, so members should confirm with HBF directly.
Coverage for orthoses (splints)
The five major funds generally cover custom-made orthoses for immobilisation or rehabilitation. The extent of coverage depends on the specific policy and extras cover purchased.
Currently, orthoses cannot be claimed through a HICAPS/Tyro terminal.
However, the AHTA is working with private health insurance companies to make this available to patients.
How can I claim for an orthoses?
Patients must manually claim a rebate from their private health insurer.
To claim, a patient requires an invoice with the following details from their hand therapy practice.
- Full name of the patient receiving the orthosis.
- Name, qualifications, and registration details (e.g., AHPRA registration number) of the practitioner who provided the service.
- A clear description of the custom-made orthosis (e.g., "custom wrist splint for rehabilitation").
- Some funds may require clinical notes or a referral letter from the practitioner to justify the need for the orthosis, especially for high-cost devices.
- The total cost of the orthosis, including any materials.
- The exact date when the service was provided.
BUPA and other funds
BUPA requires the practitioner to be an Accredited Hand Therapist or a BUPA approved AHTA Associate Member
Check in advance with the health fund whether the orthosis is claimable and whether any pre-approval is needed. Ensure the invoice includes all requested details to avoid delays in claim processing.
Print or download this guide via the link below.
2025 AHTA Guide – Private Health Insurance Claims