Pre-existing Conditions Explained

Pre existing Conditions

In health insurance, you will come across the terms pre-existing and new conditions and its waiting periods. You might be wondering why you need to wait these periods for medical services before your health fund will pay a benefit towards your fee. Health Deal explains:

Why do waiting periods exist?

The Private Health Insurance Act 2007 allows insurers to place a 12 month waiting period on medical services before a member can begin claiming benefits on pre-existing conditions. Without waiting periods, most people would only take up health insurance when they needed medical attention and then drop their cover after treatment. If this occurred, health insurance fees would skyrocket, making it difficult for those who are health insured for the long term. Allowing people to drop or lower their level of cover places the financial strain on long-term members and eventually health insurance would be too costly for most people to afford.

Health insurers are also entitled to apply the following waiting periods on these hospital covers:

  • Obstetric services 12 months
  • Psychiatric, rehabilitation, and palliative care 2 months
  • All other conditions 2 months

Pre-existing Conditions

Pre-existing conditions, as defined by the Private Health Insurance Ombudsman, is any ailment, condition or illness that you had 6 months prior to taking up or upgrading hospital cover.

A medical professional chosen by the health insurer will determine whether a condition is new or pre-existing. Irrespective of whether the patient is aware of their condition or not, the chosen health personnel will use your previous medical records to assess your condition.

Once your health fund receives medical confirmation that your ailment existed 6 months before you purchased or upgraded hospital cover, a waiting period of 12 months will be placed on the treatment of the associated condition.

Your health fund will not pay any benefit towards treatment of the identified condition, however, always remember that you can still choose to be treated through the public healthcare system (Medicare) while waiting out the 12 months.

Here is a list of some common pre-existing conditions:

  • Heart disease
  • High cholesterol
  • Stroke
  • Cancer
  • High-blood pressure
  • Asthma
  • Hip and Knee replacement
  • Diabetes
  • Cancer
  • Arthritis
❝Can waiting periods exceed 12 months? No, that is the maximum timeframe for pre-existing conditions❞

Waiting periods FAQ

  • Is my family history taken into account? No, it does not impact the medical professional’s determination.
  • What if I need immediate medical attention for a pre-existing condition? Even if you’re privately insured, you can still be treated under Medicare.
  • Are there waiting periods for extras or ancillary services? Yes, some common extras waiting periods are:
    • 12 months for major dental orthodontics
    • 2-6 months for optical services
    • 2 months for general dental, physiotherapy and other common extras services
    • Up to 36 months for hearing aids
  • Can my family doctor determine if my condition is pre-existing or new? No, it has to be a medical practitioner chosen by your health fund.
  • What if I haven’t been diagnosed for the condition? It won’t matter. The doctor can determine whether your condition is new or pre-existing based on signs and symptoms that occurred 6 months before becoming insured.
  • Can waiting periods exceed 12 months? No, that is the maximum timeframe for pre-existing conditions.
  • If I lower my level of cover and then take it up again, will I have to re-serve my waiting periods? If people could lower their premiums and then pick up higher cover when they needed it, private health insurance would become very unstable and costly.
  • Are there any exceptions? There is a once-in-a-lifetime waiver for psychiatric services. This means that anyone is allowed to upgrade or pick up cover for immediate psychiatric treatment once in their lives. Some health funds may offer lowered waiting periods as a special month-by-month incentive but this is rare.
  • Can I dispute the health fund’s decision about my pre-existing condition? If you disagree that your ailment or illness is pre-existing, you can ask for a second opinion. If you still disagree with the second opinion, you can lodge a complaint through the Private Health Insurance Ombudsman.

How to get private health insurance

If you have been thinking of starting a family, are intent on taking control of your health, or if you simply want to avoid the Lifetime Health Cover Loading (LHC), you would then be considering private health insurance.

Health Deal agents are ready to assist you with finding the best policy to suit your needs. Our highly trained representatives can help you review your cover and ascertain whether you are under or over-accommodated in your current policy.

New to cover? If you plan on having a baby, for example, you’ll want to take up health cover at least 5-6 months before conceiving. This way you’ll have completed your 12 month waiting period by the time your baby arrives. If pregnancy insurance is for you, Health Deal can help you get the most out of your obstetrics cover.

If you want to know that you’re getting the best deal out there, for any of your health insurance policies, call 1300 369 399 for a free comparison today.

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