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A pre-existing condition is a medical issue that you had before you joined a health fund or upgraded to a new health insurance policy.

Let’s find out how private health insurance policies are affected by pre-existing conditions.

What is a pre-existing condition?

A pre-existing condition is defined as any illness, ailment or condition which, in the opinion of a health insurer’s appointed medical adviser, showed associated signs or symptoms of the condition’s existence at any time in the six months prior to purchasing a private health insurance policy.

Essentially, conditions don’t need to be diagnosed beforehand to be considered pre-existing.

You and your doctor may not have even been aware of the condition, but if it was there before purchasing your private health insurance policy, it will be classified as pre-existing.

However, for a condition to be considered a pre-existing condition, signs or symptoms should have been reasonably evident to you or a medical practitioner (had you been examined in the prior six months).

Your health fund can determine whether your condition is pre-existing by appointing a medical practitioner to examine you. Your health fund is also required to take into account information provided by your doctor; for example, they may ask you to provide a medical report by your doctor from when you were first assessed for your pre-existing condition.

How will a pre-existing condition affect my health insurance policy?

Here are the most important things you need to know about pre-existing conditions in regards to your health insurance policy.

  1. By law, all health funds are required to provide cover to those with pre-existing conditions.
  2. You do not pay more for private health insurance because of pre-existing conditions.
  3. A condition doesn’t have to be previously diagnosed to be considered ‘pre-existing’.
  4. If you have a pre-existing condition you will typically have a longer waiting period before you can claim hospital treatment on private health cover than a person would typically have for that condition if it were not pre-existing.
  5. You can seek private treatment for your pre-existing condition and claim under your policy for such treatment following the waiting period.

Can I get health insurance with a pre-existing condition?

Yes, you can still get health cover if you have a pre-existing condition. However, in Australia, health funds will impose waiting periods before you can claim policy benefits on pre-existing conditions. You will only be covered for pre-existing conditions through health insurance if the procedure is covered in your policy.

How soon after getting health insurance can you use it for a pre-existing condition?

When you take out private health insurance with a pre-existing condition, you will have a 12 month waiting period before you will be covered for hospital treatments or services relating to that condition. However, cover for psychiatric, rehabilitative or palliative care can be accessed after waiting just two months.

Pre-existing conditions generally only apply to hospital cover, not to extras cover – although health funds might still impose general waiting periods to cover anyone for particular extras services (e.g. 12 months for major dental).

If you need to admit yourself to a hospital for a condition you think could be pre-existing, check with your health fund in advance to ensure you’ll be covered for your medical treatment.

It’s important to realise that even if you need to sit through this waiting period to access private health insurance, you can still seek treatment in the public health system.

older couple testing blood pressure at home wondering if their private health insurance covers pre-existing conditions

Will I pay more for health insurance if I have a pre-existing condition?

No, you won’t. Because health insurance is ‘community rated’, you can purchase any health insurance policy at the same price as anyone else – even if you have a pre-existing condition – and you can claim as soon as you’ve finished serving your waiting periods.

Community rated means that everyone is charged the same base premium (i.e. price) for any health insurance policy, regardless of their age, gender or health status. This is something you don’t need to worry about when shopping for cover.

Why do health insurers impose waiting periods for pre-existing conditions?

Health funds impose waiting periods for pre-existing conditions so people can’t make expensive health insurance claims shortly after joining the health fund. If health insurance for pre-existing conditions had no waiting periods, anyone who’s ill could sign up and claim health insurance cover immediately, then leave the health fund once they receive treatment.

Health funds would then have to shoulder the costs, and these costs would be passed on through more expensive premiums to others who hold health insurance policies long term.

Frequently asked questions about pre-existing conditions

Is mental illness treated as a pre-existing medical condition by health funds?

According to the Commonwealth Ombudsman, mental illness or mental disorder can be defined as a health problem which affects feelings, thoughts, behaviours, and interactions between the person suffering and other people.

Mental illnesses come in many forms and vary in severity. Common types of mental illness include:

  • depression
  • anxiety
  • bipolar mood disorder
  • personality disorders
  • schizophrenia
  • eating disorders.

However, unlike the typical twelve month waiting period for pre-existing conditions, if you suffer from mental illness you’re generally only required to wait two months to claim psychiatric care and rehabilitation after purchasing your policy – even if your mental illness was pre-existing.

Is pregnancy a pre-existing condition?

Health funds don’t classify pregnancy as a pre-existing condition. However, you still need to serve a 12 month waiting period to be covered for pregnancy and birth-related services and admissions. So, if you want to give birth in a private hospital, you’ll need to purchase your policy before falling pregnant.

For this kind of cover to take effect, it must be included on your hospital insurance policy, and the mother’s hospital admission must take place after this waiting period is served. If your baby arrives early, or you haven’t served the full waiting period, your fund may not cover your admission.

As such, it’s important to check and understand what is covered in your policy regarding obstetrics. Some health funds do not cover pregnancy on all products, while others restrict benefits, which means you may only be covered as a private patient in a public hospital. If you’re looking for suitable cover, Gold-tier health insurance policies are required to cover pregnancy and birth, although some health funds may include pregnancy cover in Silver+ policies.

What are some common examples of pre-existing conditions?

When applying for health insurance or upgrading your policy, some of the most common pre-existing conditions that may incur a longer waiting period include being currently affected by or having a history of:

  • angina
  • cancer
  • depression
  • diabetes type 2
  • heart attack
  • high blood pressure
  • high cholesterol
  • organ transplant

However, this list of common pre-existing conditions isn’t exhaustive. Even if you have a different condition to those mentioned above, your health fund may still consider it a pre-existing condition.

Make sure you check your Product Disclosure Statement (PDS) or contact your health fund for further details.

How are pre-existing conditions affected when switching health insurance?

The good news is that if you were already covered for the services relating to your condition on your previous policy, you’ll have no waiting period to re-serve for your new health fund again when you switch.

However, if you are transferring to a higher level of health cover or adding on cover for a new service, you won’t be able to claim on those new benefits for the first 12 months if it is deemed a pre-existing condition.

Are conditions in my family history considered pre-existing?

When considering private health insurance, a history of family conditions isn’t considered a sign of pre-existing medical conditions. This means waiting periods for pre-existing conditions won’t apply to health care, and you can still get private cover for health care if you have a history of conditions in your family.

What if I don’t agree with my health fund’s decision about my pre-existing condition?

If you don’t agree with your health fund’s decision regarding your pre-existing condition, you can request a re-assessment or discuss the decision with your doctor. If you still aren’t satisfied with the health fund’s ruling on your pre-existing condition, you can lodge a complaint with the Commonwealth Ombudsman.

To help you choose a policy that covers what you need, you can easily compare health insurance for free with us today. Our health insurance comparison service will show you a variety of options side-by-side, to help you find a policy that is within your budget and has great-value features.

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