Applying for private health insurance with a pre-existing condition? This guide will explain how your condition will affect your cover and the waiting periods.

If you’re looking to join a health fund or upgrade your policy and have an existing medical condition, you may have to endure a waiting period. But what really counts as a pre-existing health condition? Eczema? A food allergy? Diabetes? High Blood Pressure?

A health condition can be considered pre-existing if you’ve been experiencing signs or symptoms within the six-month period prior to buying or upgrading your hospital cover. It also doesn’t have to be formally diagnosed to be deemed a pre-existing condition and you may not even be aware of it.

This guide will explore what pre-existing conditions are and the waiting periods you may have to serve before you can take advantage of your health cover.

If you think you’ve got a good handle on the basics, you can always begin the hunt for a suitable private health cover right now using our online comparison tool.

The Members Own comparison tool allows you to compare a range of options from 20 not-for-profit health funds in just a few minutes.

Our funds exist solely to give members more benefits and better coverage, while investing a higher percentage of your premiums to improve services and keep you happy. In fact, over one million Australians are already with one of our not-for-profit or mutual funds.

What are pre-existing conditions in relation to health insurance?

When it comes to health insurance, the definition of a pre-existing condition is defined by the Private Health Insurance Ombudsman.

The term “pre-existing condition” refers to an illness, ailment or condition which a medical professional states has existed in the six months before you’re obtaining a particular policy or upgrading the cover. This is irrespective of whether you are aware of the condition.

The medical practitioner responsible for assessing the condition is appointed by the individual health fund. During the assessment, they must take into account all of the information and records from your usual doctor or specialist.

A medical diagnosis of a condition, illness or ailment is not necessary for it to be deemed a pre-existing condition. Associated signs and symptoms can be adequate for the medical practitioner to determine whether you have a pre-existing condition. However, risk factors such as family history or genetic predisposition are not a factor in most cases.

What are the most common pre-existing conditions?

Some of the most common pre-existing conditions that people applying or upgrading their health insurance may encounter are:

  • Cancer

  • Heart Attack

  • Angina

  • Diabetes Type 2

  • High Blood
    Pressure

  • High Cholesterol

  • Stroke

  • Depression

  • Organ Transplant

It’s important to note this list is just some of the pre-existing conditions and while your condition may not be one of the common illnesses, it may still be deemed pre-existing.

How do pre-existing conditions affect your cover?

If your symptoms, illness or ailment is determined to have met the definition of a pre-existing condition, a 12-month waiting period is applied to your hospital cover. This period begins from the date you joined the fund or upgraded your level of cover, and applies to all health insurers.

If you have resumed your hospital cover after suspending it for a period of time, the pre-existing waiting period applies. You’ll also have to wait the 12 months if you have decreased your level of hospital cover in the last year.

This means, your insurer may not pay any hospital benefits for the treatment of the identified condition during the 12-month waiting period. If you have upgraded your cover, your chosen fund may pay benefits that are in line with the level of your previous policy.

While pre-existing conditions affect your ability to access benefits and treatments through the private system, it’s important to keep in mind you can still seek treatment using Medicare during this waiting period.

Why do waiting periods exist with private health insurance?

Health funds impose waiting periods for pre-existing conditions to create a fair playing field. Without this, anyone who has fallen ill could sign up for a private health insurance policy, claim on the cover after receiving treatment and then leave.

How does that affect you? This form of behaviour impacts the cost of health insurance premiums, making private cover more expensive for everyone.

The majority of people don’t take out health insurance knowing they are unwell or have pre-planned a medical procedure with the intention to leave straight after claiming. Unfortunately there’s no way for health insurers to know who is genuinely looking for cover for the long haul and who is trying to take advantage of the system.

That’s why the pre-existing waiting period rule applies to everyone who wants to enjoy the benefits of private health cover.

Do you pay more in premiums if you have a pre-existing condition?

The cost of your premium will not increase if you’ve been found to have a pre-existing condition. You are able to purchase any private health insurance policy that suits your needs at the same price as anyone else. You can also claim as soon as you have served your waiting periods on any of the policy benefits.

If you’re worried you’re paying too much for your health insurance, it’s worth comparing your policy. With plenty of options out there, there’s no need for you to be paying an overpriced policy and missing out on the benefits.

Let’s take a look at some of the most common questions with pre-existing conditions?

I have a family history of a condition, will that affect my policy?

If a member of your family has or had a condition such as Diabetes Type 2, it does not affect your health insurance policy. A family history may increase your risk of developing the condition, but it is not considered a sign or symptom of you having a specific pre-existing condition.

However, each case is assessed on its own individual merit and it’s ultimately up to the medical practitioner assigned by your health fund to decide.

Are there any other waiting periods to be aware of?

Although funds may run a promotion for private health insurance with no waiting period for pre-existing conditions to attract new members, this is extremely rare. Most private health funds will impose the 12 month pre-existing waiting period at all times.

The maximum limits of waiting periods for private hospital cover are regulated by the Australian Government. Besides pre-existing conditions, there are a range of other waiting periods imposed by the funds to be aware of. These include:

  • Pre-existing conditions – 12 months
  • Obstetrics services – 12 months
  • Specific conditions such as rehabilitation and palliative care – 2 months
  • All other hospital treatments and services – 2 months

What about extras cover and a condition I currently have?

The pre-existing condition rule applies to hospital cover. But before you can take advantage of the benefits on your extras cover, you may be required to serve a waiting period for some services, even if you’re suffering from a current condition.

The general waiting periods for extras cover includes:

  • Two months – most extras services including general dental, physiotherapy and chiropractic treatment.
  • Six months – optical services including glasses and contact lenses.
  • 12 months – major dental, orthotic appliances and psychology consultations.
  • 12-36 months – orthodontics, assisted reproductive medications and hearing aids.

What if I need treatment in my first 12 months of joining?

In the event you need urgent hospital treatment and you’re in your first year of joining the fund, you can receive treatment through the public hospital system using Medicare. You can also get in touch with your fund immediately to confirm whether you qualify for any of the hospital treatment benefits under your policy.

It’s important to remember your potential new fund can provide you with general advice about the pre-existing condition rule, but they’re not going to determine whether or not your specific condition or illness is per-existing.

If you are upgrading to a higher level of cover, you may only receive the benefits that you already had on your previous policy.

What happens if I disagree with the fund’s decision about my pre-existing condition?

If you disagree with the health fund’s decision that your condition, illness or ailment is pre-existing, you can always request your fund to review the assessment again.

You can also choose to discuss your policy and the terms with your own doctor to seek their advice on how you’re covered.

In the event you’re still concerned about the decision surrounding the assessment, you can contact the Private Health Insurance Ombudsman and lodge a complaint. The Ombudsman’s department can help organise an independent investigation into your health fund’s decision.

Key points to consider with waiting periods and pre-existing conditions

If you have a pre-existing condition and are looking for adequate health insurance that meets your needs, it’s important to consider the following:

  • The pre-existing condition definition only applies to hospital cover, however some funds stipulate these rules under their extras cover.
  • It is the fund’s GP / medical examiner, not your own, that decides whether or not you have a pre-existing condition.
  • A pre-existing condition is determined based on your individual circumstances.
  • The condition must have existed in the 6 months prior to joining or upgrading your hospital cover to be deemed pre-existing.
  • A diagnosis is not required. Signs and symptoms may be enough to decide you have a pre-existing condition.
  • Risk factors such as genetics and family history are not considered signs and symptoms.
  • The pre-existing waiting period cannot exceed 12 months.

What’s next with your decision about private health cover?

Determining whether your illness, ailment or condition was pre-existing before you joined a fund, switched insurers or raised your level of cover can be difficult. That’s because health funds all have their own unique rules and regulations. And as the fund uses a third party medical professional to assess your condition, there isn’t any assurance they’ll listen to the recommendations from your own doctor.

This means it’s absolutely critical that you’re aware of how you’re covered and any waiting periods your health fund imposes.

With that in mind, finding the best private health insurance that meets your health needs can ensure you’re getting the most value out of your cover. You can easily compare policies by using the Members Own comparison service.

This online tool takes out all the the stress of comparing insurance policies. Within minutes, you’ll be able to compare the policies of 20 not-for-profit health funds and find out which offer the best value for your individual needs and budget.

All you need to do is jump onto the Members Own online comparison site and you’ll be presented with a range of policies that could see you enjoying the benefits of private health insurance in no time!

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If you have any questions or queries with your health cover or pre-existing condition, we have friendly staff who are all health insurance experts. You can call one of our team on 13 10 66.

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