Stethoscope sitting on table next to medication

Health Insurance and Pre Existing Medical Conditions

Looking to join or upgrade your current hospital cover? Find out how pre existing medical conditions are assessed.

A pre-existing condition is an ailment, illness or condition where signs or symptoms existed within a six-month period, prior to you joining your hospital cover, or upgrading to a higher policy. A health condition can still be considered pre-existing, even if your illness wasn’t formally diagnosed before your decision to switch or increase your level of cover. Your health funds medical practitioner will assess whether there have been any signs or symptoms of the condition were evident in the months leading up to your application. This article will explore how pre-existing medical conditions are treated by medical practitioners and how waiting periods are applied if you suffer from an existing condition.

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What waiting periods apply to pre-existing conditions?

The pre-existing condition waiting period applies to new members and members upgrading their policy to any higher level benefits under the new policy. Strict waiting periods apply before benefits start for sufferers and patients who’ve received treatment for a pre-existing condition. There is a twelve-month waiting period for pre-existing illnesses. Health funds are also allowed to apply the following waiting periods to new and upgrading members:

  • 12 months for obstetric services
  • Two months for psychiatric care, rehabilitation and palliative care
  • Two months for all other services

It is important to note that those who join a new private health fund, or upgrade their policies can still seek treatment in a public hospital under Medicare.

When do pre-existing condition waiting periods apply?

If you're going to hospital and have less than 12 months’ membership on your current level of hospital cover, or you have recently resumed your cover after suspending it, the pre-existing condition waiting period applies to you. The standard 12-month waiting period may also apply if you have decreased your level of hospital excess in the last year. Funds may waive some waiting periods as part of a promotion to attract new members, but this is rare.

Why do waiting periods apply?

Waiting periods apply to stop people cheating the system. In the past funds have seen consumers taking out a new form of cover, or switch private health funds before cancelling, soon after joining. This raises the cost for the long-term members of that fund. If you are changing your insurance to another fund, most funds won’t make you serve waiting periods for benefits you had on your previous policy. However, you will have to wait for any benefits to do with add-ons or changes to your old policy.


What are the standard waiting periods for hospital and extras?

If you’re seeking treatment for a pre-existing condition, you have two options that will provide you with adequate cover. The issue is that you will have to wait for a certain period of time before you receive any benefits. These fall into the following categories:

  • Hospital Cover. You may not receive any benefits for a pre-existing condition in the first 12 months of membership. If you already have a hospital policy but have transferred to a higher level of cover, you may only receive the benefits you had on your previous level of cover in the first 12 months on your new policy. Most funds apply a two-month waiting period before benefits start under your hospital policy. Some funds do payout benefits immediately after an accident within this time, but it’s up to you to find out if this is the case.
  • General Treatment (Extras) cover. This form of insurance varies for the different type of services you’re seeking. Membership of a general treatment policy doesn’t cover you for a hospital stay, and it doesn’t count towards waiting periods on a hospital policy.

Here are the industry standard waiting times until you receive your benefits:

  • Two months for benefits for general dental services and physiotherapy
  • Six months for benefits for optical items (glasses or contact lenses)
  • 12 months for benefits for major dental procedures such as crowns or bridges
  • One, two or three years for some high cost procedures such as orthodontics

Some funds may apply additional waiting periods for extra services – if the condition that is being treated is considered to be pre-existing.


What you need to know about waiting periods

If you’re looking for adequate insurance for a pre-existing condition, consider the following:

  • A pre-existing condition only applies to hospital tables. Some funds apply these rules to their General Treatment (Extras) cover, so you must understand what you’re covered for
  • The health fund’s GP decides if your illness or condition is pre-existing
  • A pre-existing condition is determined by your individual circumstance
  • The medical practitioner appointed by your health fund must be satisfied that there is a direct link between your ailment, illness or condition that requires hospital treatment and the signs and symptoms that existed in the 6 month period prior joining or upgrading hospital cover
  • Your ailment, illness or condition doesn’t have to be diagnosed in the six-month period. Only signs or symptoms are required to have been evident
  • Risk factors, including family history of a pre-existing condition, are not used as signs or symptoms
  • The waiting period for pre-existing ailments cannot exceed 12 months from your date of joining or upgrading hospital tables

Read the guide to health insurance and waiting periods


Is my family medical history relevant?

Both your own and your family’s medical history are not relevant when being assessed for a pre-existing condition. Ultimately, this is up to your health fund’s general practitioner to decide. It’s important to note that each case is assessed on its own individual merit.

Who decides if I have a pre-existing condition?

Irrespective of how long your doctor says you’ve had your condition for, your fund will provide its own medical practitioner to determine whether this is true. Your health fund pays a medical practitioner to make this informed decision about whether or not you had your illness, before switching funds or choosing to purchase add-on policies to cover treatment costs. In doing this, your fund’s chosen GP must also take into account information given by your own doctor.

What if I need hospital treatment in my first year of joining?

You have limited options if you need treatment in your first year of changing funds, or adding extra policies. If you make the switch to a new hospital policy, you’re likely to miss out on any benefits for the first year of your membership change. If you have changed your policy to include a higher level of cover, you may only receive the benefits you already had on your previous level of cover in the first 12 months. If you need urgent hospital treatment in your first year, you need to get in touch with your fund immediately. This can verify if you qualify for any hospital treatment benefits. Staff working for the fund can give you some general advice about the pre-existing condition rule, but they can’t tell you whether or not your condition is pre-existing. You’ll have to wait until your fund sends a letter with all the information surrounding the policy, and medical certificates for your own GP to fill out and return to your fund.

What can I do if I disagree with the fund’s decision that my condition is pre-existing?

If you’re concerned the decision surrounding your fund’s medical practitioner’s assessment of your pre-existing condition is not right, you can request your fund to review it. You can also talk about the decision with your own doctor. Take your pre-existing conditions rule book so he or she can have a thorough read through your policy, and how you’re covered, or not. The next step is to contact the Private Health Insurance Ombudsman. Here staff can help your organise an independent investigation into your fund’s decision. If you feel like you need to contact the ombudsman’s department, here are the contact details:

Private Health Ombudsman

It’s a difficult process to determine whether your ailment, illness or condition had been pre-existing prior to you switching health funds or raising to a higher level of cover. This is because every fund has unique rules and regulations related to when benefits will kick-in. Given your fund provides assessment through a third party medical practitioner, there’s no assurance they will listen to the advice of your own doctor. This means you must be fully aware of how you’re covered, and any waiting period restrictions that are imposed.

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