Will health insurance cover tonsillectomy costs? 

Tonsillectomy is among the most common elective surgeries performed in Australia and there can be a long wait for public hospital treatment – up to 185 days (which is more than 6 months), Australian Institute of Health and Welfare data shows. You might choose to use health insurance and get treated at a private hospital, which is generally much faster, and you’ll be able to choose your own specialist (and get a private room if it’s available). Here’s what you need to know about using health insurance for tonsillectomy costs. 

What is a tonsillectomy? 

A tonsillectomy is an operation to remove your tonsils, the 2 small glands at the back of your throat. It’s often done in children who have problems with frequent infections or inflammation, but is sometimes done in adults, particularly for breathing or sleeping problems. An adenoidectomy (to remove the adenoids, soft tissue at the back of the nose) might be done at the same time. The operation is done under general anaesthetic, and can involve an overnight stay in hospital.  

Tonsillectomies and adenoidectomies are both covered under the Tonsils, Adenoids and Grommets clinical category of Hospital Cover – not Ear, Nose and Throat, as you could have assumed. Tonsils, Adenoids and Grommets treatments are generally not included on Basic tier policies, so you’d need at least Bronze level of cover or higher. Check your policy carefully to make sure you’re covered.

What do the different tiers of Hospital Cover mean?

Paying a Gap for tonsillectomy 

If you or your child needs a tonsillectomy and you want to have it done in a private hospital, make sure you get a full rundown of tonsillectomy costs from all doctors first (including anaesthetists), so you know whether you’ll have to pay a Medical Gap. Gaps exist because some doctors charge more than the Medicare Benefits Schedule Fee (MBS Fee). Health insurers and Medicare combined only pay up to the MBS Fee amount for a procedure – so if your doctor charges more, that means out-of-pocket costs for you (unless your insurer has a ‘no Gap’ or ‘known Gap’ arrangement with your doctors). Check the government’s Medical Costs Finder to find out the average Gap for a tonsillectomy. At the time of publication, a tonsillectomy for someone aged 12 and over involved an average Gap of $700. 

You might have a Hospital Gap to pay too, if your policy doesn’t cover all the private hospital’s costs for the procedure (such as theatre costs and accommodation). If so, find out whether your insurer has Agreement Hospitals where you could have the treatment for a lower or no Gap. If you have a tonsillectomy at a public hospital, your costs will be covered by Medicare with no Gaps. 

How can I reduce my out-of-pocket costs?

Can I claim tonsillectomy costs on health insurance? 

First things first, check your policy covers you for a tonsillectomy (it’ll be listed under Tonsils, Adenoids and Grommets). Read the conditions thoroughly, especially regarding the excess and co-payments.  

If you’ve recently taken out the policy, or just upgraded your tier of Hospital Cover, there might be a waiting period before you can claim. If your tonsil issues existed in the 6 months before you bought the policy, it’ll be considered a pre-existing condition, which means you can’t claim for 12 months from the date you bought (or upgraded) your policy. If you’re unsure, contact your insurer to find out if waiting periods apply for your tonsillectomy. 

What are the waiting periods for pre-existing conditions?

What’s the best health insurance for tonsillectomy costs? 

To find the best health insurance for tonsillectomy costs, use the healthslips.com.au Calculator, and search for Bronze tier Hospital Cover or higher. Our Calculator is a free, quick and easy way to search every policy in Australia to see all your options without any bias – and you don’t need to sign up to get your results. Search for a new policy or compare your existing policy with others, and find the best policy for your needs at the best price.  

Trudie McConnochie

Writer and Researcher

Knowledge is power – that’s the guiding principle behind everything Trudie writes, and it’s a philosophy she brings to her work at healthslips.com.au. By breaking down complex information into easy-to-understand blogs and stories, she aims to empower Australians to make the best choices and an informed decision around private health insurance.

Trudie understands firsthand some of the complexity of private health insurance having moved to Australia from New Zealand and having to navigate a vastly different public healthcare system and health insurance structure.

Trudie holds a Bachelor of Communication Studies (journalism major) from the Auckland University of Technology.

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