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Navigating private health insurance in Australia can be complex. The government-mandated Standard Information Statement (SIS) is your key tool for comparing policies “apples to apples.” Whether you’re looking at a combined (Hospital + Extras) or standalone policy, this guide will walk you through how to decode your SIS and make an informed choice.

What is the SIS?

The Standard Information Statement (SIS) is a standardized summary document that every private health insurer must provide for every policy they sell. Its purpose is to present complex information in a clear, consistent format so you can easily compare different policies from different funds. Remember: It is a summary only. Always contact the insurer for full details.

Step 1: Start with the Policy Header (The Basics)

The top of the SIS contains the fundamental facts. Check this first to see if the policy is even a candidate for you.

• Health Insurer & Product Name: Who is providing the cover and what they call it (e.g., “Gold Hospital,” “Basic Extras”).
• Product Code & Date: Note the unique code and the “Date this Statement was last updated.” Policies can change; this ensures you have the latest version.
• Who is Covered: Is this a Singles, Couple, or Family policy? Always check with the insurer for specific dependency requirements (e.g., student age limits).
• Monthly Premium: This is an indicative fee. Your final premium may include a government rebate, Lifetime Health Cover (LHC) loading, or insurer discounts. You must check with the insurer for your exact price.
• Availability: Is the policy available in your state? Some are state-specific.
• Medicare Levy Surcharge (MLS): A crucial line. It tells you if this policy provides “an approved level of cover” to exempt you from the MLS tax.

Step 2: Decode the Hospital Cover Section

This section details what happens if you need hospital treatment. Don’t just look at what is covered; pay close attention to what isn’t.

1. What’s Covered?
   • Read the summary of treatments, accommodation, and ambulance.
   • Red Flag: If you see “A limited number of services are covered, see below,” this is a low coverage policy (e.g., Basic or Bronze). It only covers a select few categories.
2. What Services Are NOT Covered At All? (Exclusions)
   • This is a list of treatments for which you will receive $0 from your insurer. You will be 100% out-of-pocket.
   • If the list includes “other services,” contact the insurer immediately for the full exclusion list.
   • “No exclusions” means no exclusions on Medicare Benefits Schedule (MBS) items, but cosmetic or non-MBS services may still not be covered.
3. What Services Are Only Covered to a Limited Extent? (Restrictions)
   • These are services where your benefits are capped or limited (e.g., joint replacements only covered in public hospitals, or limits on pregnancy services).
   • “No restrictions” is what you want to see for full cover in a treatment category.
4. Waiting Periods
   • Standard is 2 months for general, 12 months for pre-existing conditions & obstetrics. Any longer periods should be noted.
5. What Will I Have to Pay?
   • Excess/Co-payment: This is the amount you agree to pay per admission (excess) or per night (co-payment) to lower your premium. Higher excess = lower premium.
   • Medical Gaps: The most critical part. Look for the phrase: “ out of 10 medical services…” This shows the insurer’s performance. E.g., “9 out of 10” means that, on average, 90% of their members had no out-of-pocket gap for medical services in hospital.

Step 3: Analyse the General Treatment (Extras) Cover Section

This uses a standard table to compare ancillary services like dental and physio.

• Column 1: Services Covered: The SIS lists common services. Important: Your policy may cover many more (e.g., dietetics, speech therapy) not shown here. Check the “Other Features” box or contact the insurer.
• Column 2: Waiting Period (Months): How long you must wait before claiming. Common: 2 months for general (dental, physio), 12 months for major (orthodontics, hearing aids).
• Column 3: Benefit Limits (Per 12 Months): This is your annual spending cap.
  • Key Term: “Combined Limit.” This is a pooled limit shared across multiple services (e.g., a $1,000 limit shared between dental, physio, chiro, etc.). It offers flexibility but requires budgeting.
  • Sub-limits: There may be smaller caps within a combined limit (e.g., a $200 sub-limit for massage within a $1,000 pool).
• Column 4: Examples of Maximum Benefits: Shows what the insurer will pay for common treatments, either as a percentage (e.g., 70% of charge) or a dollar amount (up to $50). This is for comparison only.

Preferred Provider Arrangements:

• Most funds have networks (e.g., Members First, MemberPlus). Using these providers almost always results in lower or no out-of-pocket costs. Always check your insurer’s provider finder tool.

Step 4: Look for “Other Features” & Notes

• Hospital & General Treatment “Other Features”: This is where insurers list unique perks: health management programs, gym discounts, online doctor services, loyalty bonuses, etc.
• Notes (marked with ¬ or *): Always read these. They contain critical conditions, like “Hearing aids payable once every 5 years” or “Preventative dental only covered every 6 months.”

Final Checklist Before You Decide

1. Compare Using www.PrivateHealth.gov.au: Use the government website to generate and compare SIS documents side-by-side.
2. Contact the Insurer: Use the phone number on the SIS to confirm premiums, clarify exclusions, and ask about any services important to you that aren’t clearly listed.
3. Match to Your Life Stage: Do you need pregnancy cover? Are you planning major dental work? Ensure the policy’s restrictions, limits, and waiting periods align with your expected needs.
4. Look Beyond Price: The cheapest premium might have high exclusions, a massive excess, or poor gap cover. The SIS helps you see the true value.

By using this guide to systematically work through your Standard Information Statement, you move from being confused by jargon to being an informed consumer, ready to choose the right cover for your health and financial needs.

For the official SIS page and to compare policies, visit: www.PrivateHealth.gov.au