Can-Do-Ability: Answers and Solutions from my personal experiences of living with a disability

I DON'T Feel Better Now Thank You Medibank Private!

3 Feb 2012Once again, my own life has led to a blog…. As some of my regular readers may remember, last year I began walking on some Canadian crutches, to build up the strength in my legs, however, after just a few short months of doing so, and loving it, I felt a kind of crackle in my ankle, which was followed by a lot of pain, and limited movement in my ankle.

After many different doctor appointments, tests, specialist and hospital visits, where I was told that there was nothing wrong with my ankle and was advised to ‘just rest it'(although I wasn't aware of occasionally walking on it and transferring to and from my wheelchair constituted as anything else), I was finally given the diagnosis that I had a piece of bone in my ankle, that was floating around, that had been there for possibly ten years or more, which had now decided to lodge itself into my ankle joint, causing pain, and restricted mobility.

I was advised that I would require an ankle arthroscopy, to remove the irritating piece of bone that has been bothering me. So last year, I found myself a surgeon who had been recommended to me, by a fellow OI (brittle bones) patient of his. I saw the specialist last November, and he sent me for more tests, to confirm what I had already been told (that there was loose bone in my ankle joint), and at the follow up appointment, I would find out when surgery could be done. However, the earliest available appointment wasn't for three months! Although far away, I thought I'd waited this long, what's another three months?

Yesterday was my follow up appointment. I organised to leave work at 1:30pm (three hours earlier than normal), for my appointment at 2:45pm. I arrived a little bit early, just to give myself time, and allow for traffic etc., only to be told that the doctor was running 45 minutes late, which I usually expect at doctor's offices anyway. Except, I wasn't seen until more than TWO HOURS LATER!!! I was so mad, but being something that I need sorted, I was at the mercy of the doctor's surgery, and kept my boiling disposition to myself.

I was given all of my forms and important information for the surgery that was scheduled for March, when I was advised of the amount of money that I would have to fork out to cover the specialist's surgery fees. It was at this point that I thought to myself, why in the world, do I bother paying for private health insurance?!!

I pay around $60 per month for the lowest type of hospital cover, which doesn't sound too bad, but when you add that up, for every month, for the past six years, it works out to be $4,320! And I've NEVER needed to use it, EVER! But anyway, one would assume that when health insurance is taken out, the hospital fees etc. would be covered by private insurance. I was under the impression, that if I required surgery ever, I would pay my excess, which is a one off payment of $250 for a whole year, then, I would be covered for all the other fees charged, but NO, that is not the case at all!

I called my health insurer up yesterday to find out what it is, exactly, that they would be contributing towards my scheduled surgery. I discovered, to my disgust, that they are covering $150 towards the operation, Medicare pays $350, and I am left with $970 for the specialists fees, $250 excess, plus an unknown amount for the cost of the anaesthetist, which will not be disclosed, until after the operation is over.

I thought this may have just been an exception because I am on the lowest level of hospital cover, but after a discussion with my friends, some of who also have OI, I was advised that this is quite a common occurrence in the health care system. And we were all left to wonder, why we bother taking out costly insurance, when the cost outweighs the benefits.

The simplest way that it was explained to me, is that a private doctor can charge whatever they feel like for surgery, this fee is called the ‘gap', which is not covered by health insurance. Some anaesthetists charge their own fees, and some can be covered under insurance, but if they aren't, you are left with their fees as well.

So for me, for surgery on something that quite honestly isn't ‘life altering', I will be out of pocket by almost $2000, which I would quite frankly, rather put towards saving for a house. My health insurer suggested that I can request weather or not the doctor would be willing to contribute to the gap, which I have now done, and am waiting on a response. But if he refuses, or doesn't contribute a reasonable amount, I will be asking to go onto a public waiting list, to have my surgery done in a public hospital, whenever I can be fit in.

I'm not sure if I'm being naïve, but I always thought, covering my butt with private health insurance would pay off in the end. But, honestly, if I ended up in hospital with an emergency, because of my disability, and the complications that could arise from it, I wouldn't be handed over to an intern to look after me, my case would be given to a doctor who has experience in dealing with OI, so basically, private health insurance for me is a waste of money, and I want out!

After this debacle is over and done with, I will be cancelling my insurance, and going through the public system from now on, which by the way, I hear is much better in Australia than some countries, so it really isn't that bad at all compared to some.

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Previous Comments

P Leslie from Lennox Head posted on 16 Jun 2016
My daughter has had a claim refused by Medibank because their doctor (who has never seen her) disagrees with two of her doctors (who have) who say she did not have a pre-existing condition. One of her doctors is the leading professor in the field but apparently an unknown doctor who has never seen her is right. They're happy to take your money, not so happy to pay out.

Unimpressed from Melbourne posted on 2 Sep 2015
Yeah Look. Your feigned outrage is a joke at best. You pay the minimum cover so don't expect the maximum payout. Most people are paying around $200 a week in top cover. That's $10,000 a year. What that DOES get you is choice of hospital, choice of Doctor, choice of surgeon, it doesn't pay for the surgeon unless you go public. The downside going public is that you could wait on a waiting list for years.Your one visit eats up half what you have already paid in premiums. By the way, it's about $1000 a day in a hospital that is being picked up by your fund, so you are still way ahead.

Sydneygirl from Sydney posted on 28 Jul 2015
I have just been qouted 3340AUD for a laparoscopy by a surgeon PLUS 3391 AUD by the hospital as a day surgery. The AL-TERnative is to wait 12months on the public list - now given I have been admitted to ER with severe abdominal pain 3x in 1 month and discharged with treatment - my GP is begging ER to take my appendix out yet they will not- I am not going to wait 12months. Putting the cost into perspective, I am paying my taxes, my Medicare and have been paying 120AUD private health insurance for the last 8years - claimed approx 150AUD in the same amount of time. Now I am getting told that "gyno laparoscopy" is not covered (for the amount of 120AUD per month!)so I either wait for the public list or wait 12moths as "pre-existing" condition or pay my own way. Well, I am paying my own way - and once I am recovered I am getting a one way first-class plane ticket out of Australia - what a joke this system is.

Margaret from Melbourne posted on 24 Nov 2014
I work in the private medical sector and can confirm that MOST surgeons will have a gap for surgery. It does seem unfair that we pay for private health insurance and then have to pay extra when we need surgery. However, it seems that a lot of people when taking out private health insurance DO NOT read the fine print; i.e., that they are only covered as a private patient in a public hospital (cover which is nicknamed "nothing cover" in the industry). Also, many people think that private health insurance will cover them for a visit to a surgeon or physician. It doesn't. Private health insurance covers you as an inpatient in hospital only. Before cancelling private health insurance read into any information regarding public waiting lists. The Australian Public Health System may seem comparatively better than other countries, but waiting lists are still long, with many patients with debilitating and painful conditions waiting years for their surgery.PS: Doctors NEVER run on time. Don't expect it, just take a book!

Michelle from Brsbane posted on 25 Sep 2014 check product review before join in and wasting $$$$$

Anonymous from Qld posted on 24 Sep 2014
Unfortunately most people are grossly uninformed about what their hospital cover is for, I would hope not to ever have to use my own however I have had two twice and was thankful to have a small portion of the doctors fees paid which is the smallest part of the cost and not what your 'hospital' insurance is for. Nb 'hospital' insurance not 'doctors fees' insurance as this does not exists. Please be very careful with the information you read as a lot of the comments here are incorrect. I agree that your insurers should have explained better firstly when selling you the insurance and secondly what it covered of the bills. Medibank is in my opinion one of the better health insurers, there are many choices but the scenarios here would have turned out the same or worse, they have the largest group of hospitals covered. Hospital fees could be around three grand a day. The doctors fee 'gap' of the Medicare schedule fee or if your insurer has a gap cover scheme a little higher only covers the 25% that Medicare doesn't cover. We are very fortunate to have the health system available to the public. What your health insurance will give you is access to services without having to wait in the public system depending on how many people are ahead of you and the choices of doctor. I work in the industry and have seen hundred thousand dollar bills for expensive hip replacements, rehab etc. I'll stay insured myself.

Mick from QLD posted on 14 Mar 2014
I'm glad that in the last paragraph you've said you're cancelling your private health insurance because you don't think you're getting good value for money, because that is one of the few sensible things you have written in this piece. You blame your predicament on rip-off health insurers and greedy doctors when the truth is you didn't read your policy before you took out your cover. Your ignorance is what's really to blame. The health insurers do not hide anything - that would be illegal - but they do present their products in the best possible light while hiding the less good bits. That is called marketing and it is not illegal (unless they lie or mislead). It is up to consumers themselves to work out the truth about products instead of relying on what advertising tells them. The reality is that private health insurance should in my opinion be called "private hospital insurance" because it is designed to cover your hospital expenses - which constitute a great portion of your treatment costs - and not your doctor's fees. Most people have no clue of the true cost of health care and hospital stays. Also, if you have a complication and have to stay in hospital longer or require intensive care, again this is all covered. Remember, it's called INSURANCE; no one expects to get back their house insurance premiums because no one wants their house destroyed. Likewise you shouldn't expect to get you health insurance premiums back or else it wouldn't be insurance, it would be a savings fund. I pay $1500 a year for income protection insurance and I hope I never see a cent of it, because I don't want to be sick or injured. But I don't go around saying it's bad value for money because one day I'll have paid $50,000 in preimums and never got anything back from them. You pay $720 a year and you complain you don't get value for money because it doesn't cover everything bar your excess, even though it still covers a sizeable portion of the total cost of your surgery. Find out how much your hospital fees were (ask the hospital and say you have no insurance) and you'll see how much you're insurance has really covered. Finally, don't blame doctors because of the so called "gap payment". Doctors are professionals just like lawyers and accountants, and they can charge what they like in our free, capitalist country. In our country it is market forces that control prices of goods and services. If you think your accountant charges too much you can go to a cheaper one. Likewise your surgeon. What Medicare and the health funds choose to reimburse patients towards their doctor's fees is not based on the true cost of providing medical services, but is based instead on politics. It is a wise doctor that chooses to ignore what the politicians decide they should be remunerated for their services and makes this decision for him/herself. The sad fact is that the semi-nationalised health system in this country called Medicare has succeeded in convincing most people that medical services are worth a fraction of their true value, and that medical service providers are just greedy, all because they have over-promised the delivery of health services to the public which we simply can't afford.

Morgan Robertson from Brisbane posted on 28 Nov 2013
I empathise with you buddy! Medibank are horrible.My dentist recommended I get all 4 wisdom teeth taken out. This came to a total of $1600 for the procedures and $600 for the anaesthetist. Guess how much medibank want to cover? About $950 dollars for everything. That's not so bad right? But I also have to pay an excess ($250). This leaves me $1500 to pay. Guess how much I pay medibank per month (for my small family)? ~$360 for top hospital and 'top extras 85' which is one of the top covers. I've only used some optical and basic dental. So here is how they fuck you, on a fairly common procedure (75% of the pop can't maintain wisdom teeth and need them removed apparently). Medibank will cover for 'major dental', 'dental prosthetics' but wisdom teeth extraction is not covered unless it's in hospital and if it is, they only cover 45% of the surgery (but less than 1/3 of the anaesthetist, and you also have an excess to pay). If I used a 'members choice' provider, I can get 85% back but there are no 'member's choice' maxillofacial surgeons! When I called up to inquire and question, they recommended investigating providers that allow 'gap cover'. You can find anethatists that will do gap cover, but all the surgeon's offices have told me that gap cover does not apply to wisdom teeth extraction - it's for stuff like ulcers.I've been with medibank with this cover for 2.5 years (~10K$) and this will be my last month. They've just cost me money and time with little peace of mind.

Ken from Gold Coast posted on 18 Sep 2012
Good article & so true, i just had to claim off Medystank only to find that the cost of the anaesthetist was not covered in my level of cover, aaand yet strangly the cost of the surgury was, I asked the please explain how you can be covered for an operation & yet the cost of getting knocked out was not, no real answer, so we have changed insurers.... they totally suck after years of payment, to find that they do not cover much at all

Jade from Melbourne posted on 9 Feb 2012
Good article and I hear what your saying. I also think that there should be some limit to what a surgeon/specialist should be able to charge. I saw a gynaecologist who quoted me over $2000 for a day procedure for a laparoscopy and would there be out of pocket $2000 for the anaesthetist and assistant. What an absolute joke. As im a nurse I was absolutely ddisguted with the surgeons quote and no she would use the gap cover either just money hungry. A collegue dr saw the quote and said it was outrageous and he could perform 3 operations for that amount il definately be shopping around for a discount might even try the option of being a private pt in a public hospital at least id get my choice of surgeon but without all the added expense. At least I managed to scab a couple of boxes of the pill from the greedy dr

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