Diabetes and Insulin Pumps
If you have diabetes, your doctor, endocrinologist or diabetes educator may recommend the use of an insulin pump.
An insulin pump is a small portable medical device used by people with diabetes that delivers insulin constantly and is worn 24 hours a day. The insulin pump helps to reduce fluctuations in blood glucose levels.
Does private health insurance cover insulin pumps?
Under the Private Health Insurance Act 2007, private health insurers can cover the cost of insulin pumps under their Hospital or General Treatment policies. If an insulin pump is provided as part of an episode of hospital treatment and you have an appropriate Hospital policy, private health insurers are required to pay benefits towards the cost of the pump, as well as the hospital accommodation fees and the doctor’s fee.
In many instances, however, the provision of an insulin pump does not require the patient to be admitted to hospital. Some insurers choose to cover the cost of insulin pumps in cases where hospitalisation is not required. The benefits available and the terms and conditions for the provision of benefits for insulin pumps where hospitalisation is not required will vary between insurers and benefits may be restricted for a specified period of time.
What do private health insurers cover if I need an insulin pump?
If you already have private health insurance and have served your waiting periods, contact your insurer as soon as possible to confirm whether you are covered for an insulin pump, what benefits will be paid, if you will have any out-of-pocket expenses to pay (such as the ‘medical gap’ on doctors’ fees), and whether your health insurer requires you to apply for pre-approval.
If you do not currently have health insurance, have only recently taken it out, or if your current policy does not cover insulin pumps, it is important to know that waiting periods will apply before you will be eligible to claim. As an insulin pump is required for treatment of a pre-existing condition, a health insurer can apply a 12 month waiting period after joining or upgrading your cover. We recommend you discuss waiting periods with your health insurer for more information about which policy you should purchase and what waiting periods will apply to you.
Generally, most health insurers require pre-approval for an insulin pump benefit. This means that you will need to apply to the insurer for approval of a benefit before you are provided with a pump. It is recommended that you do this before admission to hospital, to ensure that you will be eligible for benefits for the service.
Contact your health insurer for advice on how to apply for a benefit towards your insulin pump. The insurer will confirm what information is required from you, your doctor and the hospital so your request for a benefit can be assessed.
You can ask your health professional for assistance in applying to your insurer for a benefit, and the hospital may also offer assistance by providing you with all necessary documentation that your insurer may require, such as the type of insulin pump you will be provided with and the cost of the pump.
I need an insulin pump but will not be admitted to hospital
Health insurers are not required to provide a benefit towards an insulin pump when the pump is provided as an out-patient (out of hospital) service, or if you are admitted to hospital but the hospitalisation is not considered medically necessary.
Some insurers, however, choose to provide benefits for insulin pumps where hospitalisation is not required. In these circumstances, you should contact your insurer directly to ask if your insurer will consider providing a benefit towards the cost of your insulin pump.
I have an insulin pump that needs to be replaced or repaired
Most insurers will only allow you to claim on an insulin pump replacement after you have used your existing pump for a set period of time. The time limits will vary between insurers; however, they are most commonly between 4 and 5 years. Always check with your insurer prior to having an insulin pump fitted, to ensure your eligibility for benefits.
If you require a repair to your insulin pump and the pump is still under warranty, contact the manufacturer to see if the repair is covered. If the repair is not covered by warranty, please check with your insurer to confirm if a benefit is payable toward the cost of the repair, as not all health insurers will provide this benefit.
To check or upgrade your cover, contact your health insurer.
To obtain quotes and find out your out-of-pocket expenses, contact your health insurer and your health professional.
Your health insurer should be able to advise you of what benefit is payable toward your insulin pump and what documentation is necessary if pre-approval of a benefit is required.
If you require assistance in applying for an insulin pump benefit, please contact us
For general information about private health insurance and to compare health insurance policies, contact the Private Health Insurance Ombudsman at:
- 1300 737 299
If you have a complaint about your health fund, you may wish to contact the Private Health Insurance Ombudsman on 1300 362 072 or www.ombudsman.gov.au.