Understanding Your Health Insurance Cover Percentage and True Payout Value
Published December 9, 2025
Whatever amount you spend on health insurance, you naturally want to get good value for your money. If you’re looking at the cash you get back when claiming and wondering whether it’s enough, here’s what you need to know. One of the most important factors is your Health Insurance Cover Percentage, which shows how much of your medical costs your policy will actually cover.
Like any form of insurance, health insurance is there to help you financially when you need healthcare. But what makes health insurance different is the amount of events you can claim for. For example, with home insurance, you generally only claim if there is an unlikely but costly event like a fire, flood or damage.
With health insurance, what you claim depends on the type of cover you buy Hospital Extras and/or Ambulance. There’s a range of reasons you might need to claim – everything from an ambulance call-out to a cataract surgery, fertility treatments to rehabilitation, weight loss programs to hearing aids, and more. You can’t expect to claim back more on health insurance than you pay in premiums.
How much money should you get back on health insurance?
According to data from Private Healthcare Australia-the peak body for the health insurance industry-for every dollar Australians spend on health insurance premiums they get back around 84 cents. That’s only an average-some years you might get back more, while other years you might claim back nothing at all, depending on your level of cover and health requirements. And the older you get, the more likely you are to claim. But unless you have a very expensive form of surgery, the amount you spend on health insurance over your lifetime will generally be more than you get back in claims.
How much should you get back from Hospital Cover?
Hospital Cover is for hospital procedures where you’re admitted to hospital as a private patient-in a private or public hospital. Most healthy people won’t claim on their Hospital Cover very often, so instead of looking at how much money you’re getting back, think about how valuable it would be to have private hospital treatment if you needed elective surgery, such as a knee replacement or tonsillectomy. If you’re willing to wait a long time in the public hospital system, Hospital Cover might not be as valuable to you.
According to health economist, Professor Luke Connelly from the University of Queensland, Hospital Cover provides the best value on average when you’re in your mid-50s and older, and therefore more likely to claim-but there are no guarantees. Healthy young people can, and do, still get hospitalised.
How to switch health insurance policies
If you have worked out that your health insurance isn’t providing good return relative to your premiums and claims, it’s time to look for a better policy. At Utility Market, we have made this quick & easy. Our calculator make it a point to search every insurer in Australia in a matter of seconds, giving you all of your options, so you can make the right choice. Look for a new health insurance policy or compare your current policy to others available. So, find a policy that gives you the best value for your budget, lifestyle and health care needs.
For tips on Health Insurance Cover Percentage and smart ways to save, follow Utility Market on LinkedIn for the latest guides and updates.
