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Health insurance WA: who are the best performing health funds?


We compare health funds in Western Australia to see who best performed overall using most recent data from the Ombudsman.
best health insurance WA

Western Australia is the biggest Australian state by land size with a measured area of 2.6 million square kilometers, and is home to almost just as many Australian residents and citizens. Despite the sheer size, almost all of the private hospitals in WA are in Perth, if not close to it.

Western Australia can also be tricky when it comes to what products and policies are prominent and well-recognized by local health providers. Many east coast health insurance funds have very little foothold way over in Perth, which certainly begs the question: who does the best health insurance in WA?

Of course, there is no such thing as a best health insurance fund and you should be careful heeding any advice that declares any one fund as being the “best”. This article does, however, seek to compare the key performance indicators that might demonstrate holistically the health insurance funds that stand above the rest in WA.

We will measure and compare the overall percentage of hospital related charges, the percentage of doctors gaps that were covered, and the benefits paid by funds compared to contributions paid into the fund by members. We will also take a look at which health funds hold the most market share in WA and who have most of their member-base in WA.

All the data used to share this information is taken from the most recent State of the Health Funds Report from the Commonwealth Ombudsman, which is updated each year on April 1st with data from the year prior. It’s important to understand that the following figures and comparisons will have changed slightly and will be updated when the new report comes out later this year.

The following tables only display the top 15 results. Please be aware that there are many more health insurers available in Western Australia. If you would like to compare health insurance in WA, get in touch with us for some advice.

Western Australia market share
Health FundMarket
Share in
Defence Health0.7%
Teachers Health0.5%
Australian Unity0.5%
GU Health Corporate0.4%
Navy Health0.2%
Total members held in WA
Health Fund % total
in WA
Police Health13.5%
GU Health Corporate12.2%
CBHS Corporate8.4%
Navy Health7.2%
MO Health5.8%
Emergency Services5.2%

Important: This list is restricted to the top 15 results.

It’s no surprise that HBF (Hospital Benefit Fund) sits at the top of both tables. HBF have been Western Australia’s own health fund for more than 75 years, home-based in Perth. HBF hold just over half of the total Australian market share in WA with Medibank – Australia’s largest health insurer – only holding 20 percent in second place. Just under 90 percent of HBF members are based in WA proper, so it would appear that HBF are happy focusing their attention in their home state.

HIF (Health Insurance Fund of Australia) are another health insurance company based in Perth, WA. Originally established in 1954 as the Western Australian Government Railways Employees Hospital and Medical Benefits Fund Inc, HIF appears to have a much smaller market share (3.7%) in Western Australia. HIF sit in second place for % total members based in WA with just under sixty percent of their members calling WA home.

It makes sense that Australia’s bigger health insurance players sit at the top of market share in WA, with Medibank/AHM, BUPA, HCF, NIB and GMHBA, however, it would appear that Western Australia accounts for only 5-10% of their total membership base. These health insurance companies seem to be much more prominent in the east coast states where they are based (makes sense).

Health Fund performance in WA
Health Fund Benefits as % contributions in WAHospital Related Charges covered in WA% of Services with no gap in WA% of Services with Known gap in WA
Nurses and Midwives104.2%90.8%86.9%95.4%
Defence Health94.1%93.1%88.0%96.3%
Police Health91.1%93.7%81.7%94.4%
Navy Health91.0%94.7%88.3%97.2%
St Lukes89.7%86.3%79.7%88.1%
Teachers Health88.3%91.6%86.1%95.9%
Health Partners87.6%89.9%83.7%92.2%
Transport Health87.2%95.0%90.6%98.4%
Reserve Bank85.4%97.1%90.2%98.5%
RT Health Fund83.8%93.8%87.3%96.0%
CUA Health83.5%89.0%88.7%96.1%
Doctors’ Health82.9%90.9%90.8%97.7%
Australian Unity81.5%88.8%88.5%95.7%
GU Health Corporate78.1%88.6%83.4%94.2%
CBHS CorporateTBA96.6%89.7%92.6%
Emergency ServicesTBA94.4%81.5%100.0%
MO HealthTBA83.7%75.8%93.7%
Bigger isn’t always better.

An interesting outcome of reviewing this data is that some of the health insurers listed earlier as having the most market share in WA are not necessarily topping the charts for performance in the listed categories. We wrote an article about how the size of a health fund is not an indication for how they might perform.

Benefits as % contributions in WA

We have ranked the table above by benefits as a percent of contributions by members. This figure basically shows how much each health insurer pays back to their members in the way of benefits and payouts as a percentage of premiums contributed by members. Whether it’s in-patient or out-patient medical bills, doctors gaps, extras payouts or any health perk or benefit paid for by the fund, this figure demonstrates the overall value of the health fund in Western Australia.

It comes as no surprise that the results for benefits as a percentage of contributions is top-heavy with not-for-profit health funds, after all, there are no share-holders to consider and all profits go back into members, often in the form of benefits.

That being said, it does not necessarily demonstrate the value of any one policy with any health fund listed above. Each fund has a multitude of products and policies, each with it’s own inherent value rating. The ratings above are strictly universal and are being referenced as a point of overall health fund performance.

These figures pertain to the amount that each health insurer paid on average of the total cost for in-patient treatments, where 100% is the total cost for the medical treatment. The Commonwealth Ombudsman describes it as:
“…charges for hospital accommodation, theatre costs, prostheses and specialist fees (not including the Medicare benefit) and associated benefits (after any excesses and co-payments are deducted). ” (Private Health Insurance Ombudsman State of the Health Funds Report 2018).
The industry average for hospital related charges covered in Western Australia is 93.8%.

% of Services with no gap or Known gap in WA

The number of in-patient health services where no gap was charged to the patient. The ‘gap’ is the out-of-pocket expense charged by the operating doctor and specialist, as well as the operating Anesthetist. The gap amount is the difference between the Medicare Benefit Schedule fee (what Medicare pays) for the procedure and the doctors’ fee (what the doctor/s are charging). Of course, the gap is payable by the member.

No Gap‘ means the procedure was performed and there was no gap fee charged to the patient. This is often the case if the doctor chose to participate in a gap-cover scheme with the patients health insurer. All that said, the figures above represent how many of the total private procedures performed in WA were with no gap.

Known gap‘ is similar to no gap, however the fee is not entirely waived. A known gap arrangement is where the doctors’ gap fee is reduced but not eliminated. The figures above under this column represent how many of the total private procedures done in Western Australia for the year were with a reduced gap or no gap.



Don’t re-serve waiting periods when you switch to a new health fund or policy *

“John was immediately covered for a hip replacement in private hospital because he had already served his waiting periods for joint replacements on his old policy”

* Read more about how portability works.

In conclusion, it’s hard to say to who is the best health fund in WA. There are numerous ways that we can measure a health fund in addition to what we have listed in the tables of this article. One important factor to consider is that all the night and day private hospitals in WA are centered around Perth. This makes health insurance tricky for any rural Western Australians who may not have easy access to Perth without a great or difficult journey.

There are some health funds who have greater benefits for Travel and Accommodation – an amount claimable by the member for costs association with long-distance travel for some medical services. Some funds are cheaper at insuring someone as a private patient in a public hospital, which is often beneficial to people who only have access to a public hospital.

Health insurance in WA is complex and multi-faceted. Different health funds are going to suit people of different health needs. Get in touch with us for some helpful health insurance advice. We can help you access some of the best health funds as per the performance tables listed above.

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