How we review health insurance policies


Understanding the scores in our health insurance comparison tool.

panel of judges holding up scores


Health insurance is a complicated product, so unfortunately there's no simple way to show you the "best" policy, but this will help you understand what we consider when calculating the scores you see on the results page.

Unlike our other product and service reviews where we come up with an overall score before publishing the results, our health insurance comparison tool scores policies in real time, or dynamically, in response to your inputs.

It starts by filtering out policies that don't match the selections you've made – for example, the number of people covered, the state you live in or the treatments you want cover for. 

Then the tool takes into account all the items you do want covered, plus other criteria you've entered, and returns an overall score matched expressly to you and your needs. 

The finer details of our scoring are a little different for the three different types of cover:

Scoring extras policies

The Overall Score is dynamically calculated and ranks results from four weighted components.

In calculating the Overall Score, the Extras Match Score (which considers only product features) and the Price Score are balanced against each other according to how much you say you claim on your extras.

1. Extras Match Score for the services selected by the user

We score a policy's individual service categories (e.g. General Dental, Optical, etc.) against other policies to come up with a range of category scores. These are aggregated into the Extras Match Score, which describes how well a policy's features meet your stated needs compared to other policies.

The features used to calculate the category scores include:

  • item benefits (e.g. how much is paid for an individual physiotherapy session)
  • annual maximum benefits (e.g. the total amount that can be claimed for physiotherapy per person, per year)
  • waiting periods
  • services limits (e.g. where you can only claim for a hearing aid device once every three years)
  • lifetime limits (commonly found in Orthodontic).

Items that offer a percentage of the bill back are given a scoring preference over those that offer a set dollar benefit.

2. Price Score

The Price Score is a rating of how expensive a policy is compared to other policies which meet the user's needs. In the pool of relevant policies, the most expensive product will score 0 and the least expensive will score 100. Other policies will be scored depending on where they fall between the highest and lowest prices.

The Price Score for an individual policy will change if the user's selections are changed. For example, if you go back to the decision tree and select more services, some policies will now be excluded from scoring (as they don't offer these new services). This might change the lowest and highest premiums, which in turn will change each policy's Price Score.

3. Fund Complaints Score

This is an indirect measure of a fund's internal dispute resolution process. It's calculated using the number of customer complaints and disputes handled by the Private Health Insurance Ombudsman over the previous four quarters as a proportion of the fund's membership size. The Complaints Score is always worth 5% of the Overall Score.

4. How much you use extras

If you describe yourself as a low extras user, the Price Score is given greater weight, and generally speaking cheaper policies are preferenced in the results. The reverse is the case for high extras users, who are generally shown policies with higher Extras Match Scores.

Scoring hospital policies

The Overall Score is calculated using four weighted components. Before scoring, hospital policies are filtered so that only those that, at a minimum, meet the user's stated needs are included.

1. Hospital Cover Score

The Hospital Cover Score assigns points according to the level of cover offered for all hospital services covered by Medicare, with particular attention given to the following 12 commonly restricted or excluded services:

  • Pregnancy and birth-related services
  • Fertility treatment such as IVF
  • Heart surgery
  • Rehabilitation
  • Joint replacement e.g. knee and hip replacements
  • Major eye surgery e.g. cataracts
  • Palliative care
  • In-hospital psychiatric care
  • Non-cosmetic plastic surgery
  • Renal dialysis
  • Sterilisation (includes vasectomies and tube tying)
  • Obesity surgery

If a policy offers full cover in a private hospital (after any waiting periods) for a particular service, it is awarded full points for that service. Points are deducted for benefit limitation periods, where cover is only available in a public hospital and if a service is not covered at all.

The Hospital Cover Score is calculated non-dynamically, meaning that top cover policies with no exclusions will always score 100.

2. Out of Pocket Score

The Out of Pocket Score takes into account potential charges incurred by the patient in the event of a hospital claim. These include:

  • excesses for hospital admission
  • co-payments for hospital accommodation
  • gap fees where insurance does not cover the full cost of treatment.

Generally speaking, a co-payment may be charged for four types of accommodation: shared or single rooms in either public or private hospitals. Points are allocated for the range of accommodations for which no co-payment is charged.

In assessing the likelihood of a health fund member facing an out-of-pocket cost, the Out of Pocket Score also takes into account the percentage of services covered by a fund where the patient paid either no gap fee, or where the gap was "known" due to an agreement between the fund and the service provider. These figures are compared against the industry average in each state to position the fund's gap performance in each market.

The Out of Pocket Score takes into account the number of hospital agreements in each state, as a percentage of the total number of hospitals.

3. Price Score

The Price Score is a rating of how expensive a policy is compared to other policies which meet the user's needs. In the pool of relevant policies, the most expensive product will score 0, and the least expensive will score 100. Other policies will be scored depending on where they fall between the highest and lowest prices.

The Price Score for an individual policy will change if the user's selections are changed. For example, if you go back to the decision tree and select more services, some policies will now be excluded from scoring (as they don't offer these new services). This might change the lowest and highest premiums, which in turn will change each policy's Price Score.

4. Fund Complaints Score

This is an indirect measure of a fund's internal dispute resolution process. It's calculated using the number of customer complaints and disputes handled by the Private Health Insurance Ombudsman over the previous four quarters as a proportion of the fund's membership size. The Complaints Score is always worth 5% of the Overall Score.

Scoring combined policies

Combined policies are scored using the methods applied above for hospital and extras policies. The Overall Score for combined policies includes:

  • Hospital Score (comprising a Hospital Cover Score and an Out Of Pocket Score)
  • Extras Match Score
  • Price Score
  • Complaints Score

Before scoring, filters are applied which remove products that don't meet the user's needs. The individual hospital and extras components are scored separately. Because extras cover is more variable, the Extras Match Score is given greater weight in the Overall Score than Hospital Score. As with extras, the relative weight given to the Extras Match Score and the Price Score is determined according to the user's stated level of extras use.

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