Private Health Insurance For Joint Replacements

Many older Australians are familiar with the pain and discomfort of needing a joint replacement. What makes it worse is not having private health cover – or not being on the right policy – and having to sit out lengthy waiting periods or pay hefty out-of-pocket expenses.

To ensure you are covered for total or partial joint replacement surgery, it’s vital that you are on the right level of health insurance. This guide will explain everything you need to know about joint replacements, including costs and hospital cover, so you can get back to living your best life.

What is a joint replacement?

Surgical joint replacement is a surgical procedure performed by an orthopaedic surgeon. The purpose of this surgery is to remove the damaged joint and replace it with an artificial joint in order to relieve pain and improve your quality of life. 

The prosthetic joint can be made from metal, ceramic or a heavy-duty plastic, and is designed to move in the same way as your natural joint.

Joint replacement may be required in a range of different areas of the body, with common procedures focusing on knees and hips. 

However, joint replacements for ankles, wrists, elbows and parts of the spine are also frequently performed in Australian hospitals.

While partial joint replacements do occur, the majority of patients who have damaged joints require total joint replacement surgery.

Recovery times vary depending on the joint being replaced, as well as the patient’s age and lifestyle. The length of relief will also depend on the individual and the type of joint replacement.

How much does a joint replacement cost?

That depends on a variety of factors, including the type of joint replacement surgery you require, the fees charged by your medical team – including orthopaedic surgeon and anaesthetist – hospital costs, accommodation and theatre fees, and your existing health cover.

Costs will also vary depending on where you are located around the country. However, as of August 2022 the average cost for a procedure like knee replacement surgery, based on an insurer on our panel, is roughly $25,975. 

However, the cost could vary depending on your health insurer, your choice of surgeon and more. 

Also, according to the latest data from the Australian Prudential Regulation Authority (APRA), patients needing orthopaedic medical services can expect to cover a gap of 27% for their procedure, on average^.

This gap fee may be higher if your procedure is considered a reconstruction, as there’s a gap fee of 47%^, on average, for this procedure… although the procedure itself may cost less.

Will I have to pay out-of-pocket expenses?

While private patients are covered for joint replacements – at least partially – by Medicare, there will be out-of-pocket expenses whether you are using the public or private hospital. The biggest drawback about being a Medicare/Public Patient is that you will likely have to wait several months for an opening in surgery.

The private system is preferable, especially if your joint issue is causing ongoing pain and distress. However, as a private patient, Medicare will only cover 75% of the MBS fee.

So for the remaining 25% of the Medicare Schedule Fee will need to be covered by your health insurance or as an out of pocket cost if you don’t have appropriate health cover.

There may also be other out-of-pocket costs prior to surgery, which your medical practitioner will advise you of.

Because reconstruction and replacement surgery have some of the highest gap fees, it’s important that you are on the right level of health cover for your needs and that joint replacement surgery isn’t on the exclusion list for your chosen tier.

What’s the difference between total and partial joint replacement surgery?

Total joint replacement surgery is the most common type and involves the whole of the damaged joint being removed and then replaced with an artificial joint.

A partial joint replacement involves using artificial prosthetics to replace only the damaged sections of the joint, rather than the entire joint.

How long do joint replacements last?

That depends on the type of joint replacement you need, as well as your age and lifestyle habits.

However, studies show that almost 90% of hip replacements continue to function well 15 years after implantation, and total knee replacements last even longer – with 90% lasting 20 years.

What level of hospital cover includes joint replacements?

Depending on the insurer you choose for your health cover, joint replacement will most commonly be found in Gold Tier hospital policies. However, some providers may also include joint replacement surgery in their Silver Plus policies.

It’s important when searching for health insurance that you review all the inclusions and exclusions for different tiers so that you are adequately covered for your current needs.

What kind of waiting periods apply for joint replacements?

When you take out private health cover, most insurers will require you to serve a two-month waiting period before you can make a claim for joint replacement surgery. However, the joint issues is regarded as a pre-existing condition, the waiting period you need to serve will increase to 12 months.

We recommend using our seniors guide for private health insurance as a helpful way to find exactly what you’re looking for.

What’s the difference between a joint replacement and a joint reconstruction?

Joint replacement involves the surgical removal of a damaged joint – either total or partial – and the replacement of it with an artificial joint.

Conversely, joint reconstruction is a less-invasive procedure that attempts to rebuild some of the joint architecture that has been damaged. Sometimes this may involve artificial parts.

In terms of insurance, it’s important to note that joint replacement is generally only covered in Gold Tier or Silver Plus policies, whereas joint reconstruction is often covered in the Bronze Tier of private health insurance. Make sure you do your research and find out which procedures are covered and which are excluded.

Compare Club specialises in finding affordable health cover that meets the unique needs of all Australians^^. To find exactly what you need, including joint replacement cover, start comparing today.

^APRA, Quarterly private health insurance statistics, March 2022, released 2nd May 2022.

Chris Stanley is the sales & operations manager of health insurance at Compare Club. With extensive experience and expertise, Chris is a trusted leader known for his deep understanding of health insurance markets, policies, and coverage options. As the sales & operations manager of health insurance, Chris leads a team of dedicated professionals committed to helping individuals and families make informed decisions about their health insurance needs.

Meet our health insurance expert, Chris Stanley

Chris's top health insurance tips

• 1

  Australia’s public health system is world-class, but wait times for public hospitals can be long, inconvenient - and leave you living in constant pain while you wait.

• 2

  An appropriate private health insurance policy can speed up your surgery, relieving your pain sooner.

• 3

  Family health cover means your children are covered under the same policy as you.

• 4

  Many health insurance policies come with a 12-month waiting period for pregnancy-related cover, so it’s a good idea to get a family policy organized well before starting your family. This means your child will be covered from birth until at least their early twenties (depending on which health fund you select).