What is a waiting period for health insurance?

How waiting periods work

When you buy health insurance, there are some things you'll be able to claim almost immediately, such as the cost of an emergency ambulance trip. But there are other services you can't access until you've held your policy for a while.

Waiting periods vary depending on the treatment. In most cases, you'll need to serve a 2-month waiting period before you're covered, with a few exceptions. For example, you have to hold a gold-standard hospital policy for at least 12 months before you can claim for pregnancy or childbirth benefits.

Waiting periods were put in place to keep people from signing up only when they need treatment and then cancelling afterwards. If you were allowed to do this, insurance premiums would go up for all policyholders because there would be so much pressure on the health funds.

Switching health funds?

Once you've served your waiting periods with 1 health fund, you won't have to serve them again if you switch unless there's a break in cover.

Hospital waiting periods

With hospital cover, the Private Health Insurance Ombudsman sets the maximum possible waiting periods for every circumstance and insurers have to stick to them. This means the same waiting periods will apply no matter what hospital policy you get.

Extras waiting periods

Extras waiting periods are set by individual health funds so unlike hospital cover, they can vary. However, due to competition between insurers, you'll find that they are typically the same across the majority of health funds. In some cases, health insurers will let you skip waiting periods for certain treatments such as general dental, optical and physiotherapy.

Private health insurance waiting periods and pre-existing conditions

Hospital

You'll have to wait 12 months before pre-existing medical conditions are covered by your hospital insurance policy. That includes any illnesses you showed symptoms of in the 6 months prior to taking out a hospital policy. The only exception is if your pre-existing medical condition falls under psychiatric care, rehabilitation or palliative care – in which case, you'll only need to serve a 2-month waiting period.

Extras

There are no pre-existing condition waiting periods with extras health insurance. That means if you've already got bad eyesight, you won't have to wait any longer to claim benefits. You'll just have the standard waiting period.

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Frequently asked questions about waiting periods

• What happens to waiting periods if I switch funds?

  If you've already served a waiting period with one fund, you shouldn't have to serve it again if you decide to switch. The new insurance company will recognise the time you've waited.

  Even if you've only waited out part of the period, that should still apply. For example, if you served 6 months of your 12-month waiting period with 1 fund, your new fund will only require you to serve 6 months.

  Be careful though, insurers won't recognise the time served if there is a significant break in cover. So when switching, try and get the company to start your cover from the day after your old policy ends.

  For this to work, your old health insurance history needs to be sent to your new insurer. According to the Private Health Insurance Ombudsman, you can ask your new insurer to do this for you or handle it yourself.

• Why do I have to serve a waiting period?

  Waiting periods can be frustrating, but health insurance wouldn't work without them. If they didn't exist, people might buy cover just to lodge a big claim then cancel shortly after. If too many people did that, there wouldn't be enough money in the health insurance pot to cover claims anymore and nobody would benefit.

• What happens if I go to hospital before I've served my waiting period?

  Get in touch with your insurer as soon as possible to find out if you'll receive hospital benefits. For example, you may have served the 2-month waiting period for the kidney and bladder, but not pre-existing conditions.

  At this stage, your health insurer should give you some general advice about the pre-existing condition rule, send you forms that your doctor needs to fill out and return, then contact you within 5 working days with a decision.

  If you need to go to hospital urgently, your insurer might not have enough time before you are admitted to decide whether your condition is pre-existing. This means that you may not know before you are admitted whether you'll receive any benefits.

  If you haven't served the waiting period for the specific medical category, you won't be covered by your policy. You may want to consider the public system at this point.

• Do health funds all have the same waiting period?

  All hospital policies have the same waiting periods, although you may be able to skip some if you take advantage of sign-up offers. For extras, there are sometimes differences between funds.

• What is the waiting period for major dental?

  Major dental typically has a 12 month waiting period. It covers more complex treatments such as crowns and dentures.