Private health insurance and endometriosis

Gaby D'Souza
6 min readMar 23, 2018

Endometriosis is a condition that affects 1 in 10 women. It occurs when endometriosis cells that line the uterus start to grow in other parts of the body (including ovaries, bladder, bowel). The symptoms include pain, particularly during ovulation and menstruation, during bowel movements, and heavy and irregular menstruation. The intensity of these symptoms varies from person to person. There’s no cure, and while surgery (laparoscopy with lasering to remove endo cells) can stymie its growth, some endo sufferers may continue to experience symptoms after surgery.

My GP suggested that I look into hospital cover because of the recurring nature of my endometriosis and so I’ve been canvassing insurance options (a rather unenviable task made all the more awful by having a specific condition that I’m concerned about). I was rather frustrated by the lack of information available so I’ve made my findings public. These are presented below.

What you need to look for

Please note that the health insurance markets is a helluva messy area and if you’re incorporating any of the information your read here into your purchase decision, you should also definitely ring up your (potential) health insurance provider and make them tell you whether or not you’ll be covered for the procedure you have to undergo, and exactly how much out of pocket you’ll be. In order to do this you will need to get an item list from your specialist to identify precisely what item numbers from the Medicare benefits Schedule (MBS) you require coverage for. The summaries I have posted here and in my spreadsheet assume the following item numbers (this information is from when I had the same procedure through the public system): 30390, 35630, 35640, and 35713. (If you’re thinking about getting an IUD inserted during your procedure, the item number for that is 35503).

Do not listen to any bull$#!t a salesperson will spout about not being able to tell you this until you join (this happened to me). To make matters worse some insurers will claim that they cover endometriosis-related procedures but but might not cover that specific item number so make sure you find out the item numbers and ask if those are covered.
Also, note that almost all insurers (in fact every single one that I looked at) had a 12 month waiting period before they would cover you for your procedure (for pre-existing ailments; it’s usually 2–6 months for new conditions). If you already have hospital cover with another provider, some insurers will waive (some part of/) your waiting period.
Something else to add into the mix — insurance companies review their premiums (either increase or decrease) on April 1 every year. I’ve done my best to capture this difference in the spreadsheet.

I’ve been with BUPA for a couple of years however the recent furore and my own health needs means that it’s no longer an appropriate cover for me. The good news is that their lowest level of cover does insure the item numbers associated with laparoscopy to detect endometriosis. However you are restricted to a list of BUPA approved health providers, available here.
Cost — $41.3 per fortnight (p.f.) (hospital only)

AHM does cover the procedures on the MBS associated with detecting and removing endometriosis under their Boost Cover however they too also restrict you to a specific list of providers. You can find out if you’re preferred provider is on their list here
Cost — $40.9 p.f. (hospital only)

There’s a bit of confusion about this one. Their website advertises that they cover endometriosis related procedures but when I quoted my laparoscopy item number (30390) that I’d received from the RWH they said that it fell under their fertility related treatments so would not be covered under their base cover ($31.64 p.f.). I would instead have to switch to their top level cover which is $84.25 p.f. (more than double). Credit to them, they are investigating this further and I will update this post and the spreadsheet when I have more information.
Edit: NIB have got back to me and informed me that they do cover endometriosis under their base cover. The person who I spoke to was misinformed.
Cost— 31.64 p.f (hospital only)

I would be avoiding these guys at all costs for health insurance.
Not unlike NIB and Medibank, while Suncorp advises that they cover “gynaecological procedures like endometriosis” under their basic cover ($31.64 p.f.). However what they actually mean is that they don’t. Confusing right? Turns out that they only cover laparoscopy under their basic hospital plus cover which is $ 40.06 a fortnight (hospital cover only); about $10 more a fortnight than their basic cover.
Their customer service is also the worst I’ve ever experienced. Their salesperson told me that they wouldn’t be able to let me know if I’d be covered for any of the item numbers I was enquiring about until I signed up, which was a blatant lie. And then when I tried to resolve the issue of their misleading statement about coverage of endo, my knowledge about laparoscopy and its efficacy in treating endometriosis was questioned. I have lodged a formal complaint and will be taking this to the Private Health Insurance Ombudsman.
Cost — $40.06 p.f. (hospital only)

Perhaps the least informative website in terms of what’s actually covered, but really good sales reps (which is saying something in this industry). After a bit of back and forth on MBS item numbers I found out that the Basic hospital cover does cover for laparoscopy procedure for endometriosis as does the mid level cover).
Cost — 41.2 p.f. (hospital only)

Medibank’s lowest level of cover, Hospital Essentials ($32 .88 p.f.) appears to cover endometriosis related procedures (under minor gynaecological procedures) however when I contacted them to give them my item numbers, they informed me that the level of cover than I would need would be core Hospital which is $35.72 p.f. They have informed me that they are looking into this issue. I will update the post and spreadsheet with more information when I receive it.
Cost — $35.72 p.f. (hospital only)

Saved the best for last — this is the one I’ll be going with. Special thanks to my friend Cat for alerting me to it. The second lowest level of cover — GoldStarter — covers laparoscopy to detect endometriosis and their extras are really good value for money. They also don’t put much by way of restrictions on providers (hear that, BUPA?), with their coverage extending to 96 % of private hospitals.
Cost— 28.8 p.f. (hospital only)

Final thoughts
This started off as being a relatively innocuous search to inform those that suffer from endo about the options available to them in the private health insurance system. But the more I spoke to insurance companies about this, the more disheartened and frustrated I became. One dude questioned my knowledge about endometriosis and the efficacy of laparoscopy as treatment. Apparently, because I was not a medical professional I wasn’t in a position to suggest whether or not a laparoscopy was a definitive way of identifying endometriosis.
There were a number of insurance products that claimed to cover endometriosis, yet wouldn’t cover a laparoscopy — which is at present the only definitive way to detect endometriosis — because it can be used for infertility investigations. This is a bad argument for a few reasons
1) By the system’s own description the diagnostic laparoscopy procedure is for persons aged 10 years or over. Nowhere does it say anything about being fertility related in the MBS description. Insurance companies have clearly had to draw a line in the sand around procedures that are fertility related, and some have decided to put the MBS item number relating to laparoscopy in the infertility investigation section so they can effectively price discriminate.
2) It’s really interesting to think about how we got to a situation where the same procedure, that would cost the same amount, but investigated different things would have a much higher cover and price attached to it, once it had a hint of “infertility investigation”.
3)It’s so frustrating how many people in the health insurance market seem to conflate uterus with fertility problems. But this isn’t news, doctors until recently were still telling endo sufferers that getting pregnant would get rid of endo (FALSE).
Newsflash: there are things that can (and do) go wrong with your reproductive system that happen way before the decision to have children, that are != fertility-related.



Gaby D'Souza

Econo nerd. Kitten-obsessed but it's validated by my other occupation - one of the editors-in-chief @econlolcats. Also tweets from @act_yen. Usual disclaimers