Health insurers paid out a record $9.4 billion in 'high claims' for hospital treatment exceeding $10,000 in 2024, a new analysis of health fund data shows.
The 2025 Annual Hospital High Claims Report shows health funds paid for 453,259 'high' claims in 2024 - 10% more (40,771 more) than the previous year. These high claims accounted for more than half (50.4%) of all hospital benefits paid by health insurers in 2024.
This includes a 13% increase in mental health hospital high claims for members aged 65 and older (6,816 claims), for which funds paid $147.7 million in benefits. Of the 6,816 hospital high claims in this category, 35% were for depressive (mood/affective) disorders, followed by delirium, substance abuse disorders, and dementia.
For members aged under 30, there were 22,032 hospital claims with benefits exceeding $10,000 in 2024. This was a 3.4% increase on 2023, and 13% more than before the pandemic in 2019. Neonatal care remains a significant contributor to high claims, with $43.3 million in benefits paid during the 12-month period.
One-in-three hospital high claims for health fund members aged 18 to 30 were for mental health treatment, of which 70% were for female patients. The average length of stay in hospital for their episode of care was 26 days. The data shows more than 1,000 people were hospitalised with serious conditions that resulted in payments of more than $100,000 each. Their conditions included coronary artery disease, severe infections, cancers, diabetes and schizophrenia as well as complications from spinal fusions. Many spent months in hospital.
The highest benefit paid was $697,267 for treatment of severe mitral valve disease with a heart valve replacement that ended with complications. The patient remained in hospital for 2.7 months and required a tracheostomy with ventilation support as part of the treatment received.
Other notable cases, include:
- An extremely premature baby who spent 133 days in hospital costing $486,000.
- A teenager with schizophrenia who needed two years of hospital treatment costing $259,000.
- A person in their 20s who spent 222 days in hospital due to a stroke costing $123,000.
- A woman in her 30s who required two years of hospital treatment for anorexia, costing $272,000.
- A man who needed a leg amputation for diabetes, costing $231,000.
PHA CEO Dr Rachel David said the record payout by health funds confirmed the critical role of private health insurance for all Australians, including infants who spent months in hospital following birth and young people receiving mental health treatment, among other hospital care.
"The record amount paid out for members' hospital high claims highlights the real and tangible value members are receiving from their private health cover when they or their loved ones need it most," Dr David said.
"It is also taking enormous pressure off the public health system and ensuring more Australians can get the care they need, when they need it, and why health fund membership continues to grow in this country."
Hospital claims fall into the 'high' category if the total insurer benefit for the hospital episode of care exceeds $10,000. The 2025 Annual Hospital High Claims Report uses anonymised data from PHA member funds about hospital claims paid for Australians with health cover. It describes the claimants' gender, age group, number of days spent in hospital and whether the stay was in a public or private hospital.
