Written by Joshua Malin
Reviewed by Lana Hambilton
Last updated 21/09/2023
Health insurance in Australia is community-rated, meaning you’ll never be denied cover or pay more because you have a pre-existing condition. However, there are a few things you’ll need to understand about pre-existing conditions before taking out cover:
A pre-existing condition is a medical issue that you had before you joined a health fund or upgraded to a higher level of cover. A pre-existing condition is defined as any illness, ailment or condition which, in the opinion of a health fund’s appointed health professional, 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 may not have even been aware of the condition, but if it was there before purchasing your private health insurance policy, it may 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 consider information provided by your treating doctor, so they may ask you to provide a medical report by your doctor (for example) from when you were first assessed for your pre-existing condition.
Our health insurance expert, Lana Hambilton, has some tips on taking out health insurance with a pre-existing condition.
Even if you’re serving waiting periods for a pre-existing condition, you may be glad to know that many health funds cover ambulance services and hospital treatment as the result of an accident with little to no waiting period after taking out hospital cover. It’s always a good idea to check the fund’s policy brochure for more details around coverage and waiting periods.
Private hospital cover could be a suitable solution for those with a pre-existing condition that requires in-hospital rehabilitation after a surgery. If you’re able to get the surgery through the public system or fund a private surgery yourself, cover for rehabilitation could be accessed after only a two-month waiting period (regardless of pre-existing conditions). This will allow those who are upgrading or new to cover (as long as they’ve served the two-month waiting period) to seek more personalised treatment or treatment in a quicker timeframe.
At a time of need, the last thing you will want to do is worry about whether a surgery is covered or if there’ll be a waiting period for pre-existing conditions. It’s important to make sure you’ve got the right policy for your needs; it pays to compare your health insurance on a regular basis or as your circumstances change.
Here are the most important things you need to know about pre-existing conditions regarding your health insurance policy.
Yes, you can still get private health cover if you have a pre-existing condition. However, Australian health funds will impose pre-existing condition waiting periods before you can claim policy benefits for hospital treatment related to your condition. You’ll only be paid a benefit towards your condition through hospital insurance if the procedure is included in your policy, medically necessary, listed on the Medicare Benefits Schedule (MBS) and you’re admitted as an inpatient.
When you take out private health insurance with a pre-existing condition, you’ll typically have a 12-month waiting period before being 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 only apply to hospital cover, not to extras cover – although health funds might still impose general waiting periods for particular extras services (e.g. 12 months for major dental).
If you need to be admitted to hospital for a condition that 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 note that even if you need to serve this waiting period to access private health insurance, Medicare will still cover you for treatment in the public healthcare system.
Health funds impose waiting periods for pre-existing conditions so new members can’t make expensive health insurance claims shortly after joining. If health insurance for pre-existing conditions had no waiting periods, anyone who is 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, leading to more expensive premiums for others who hold health insurance policies long term.
Mental health issues come in many forms and vary in severity. Common types of mental illness include:
Unlike the typical 12-month waiting period for pre-existing conditions, you’re usually only required to wait two months to claim for in-hospital psychiatric care and rehabilitation if you suffer from a mental health condition.
Health funds don’t classify pregnancy as a pre-existing condition. However, in most instances, you still need to serve a 12-month waiting period to be covered for pregnancy and birth-related services. So, if you want to give birth in a private hospital, you’ll need to purchase your policy before falling pregnant. If your baby arrives early or you haven’t served the full waiting period before/during your pregnancy, your fund may not cover your admission and care.
As such, it’s important to check and understand what is covered in your policy regarding obstetrics. 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 Plus policies.
When you take out private health insurance, your family’s medical history isn’t considered a sign of pre-existing medical conditions. This means that even if your family has a history of a congenital condition, it won’t be considered a pre-existing condition unless you’ve shown some signs or symptoms in the past six months.
No, you won’t. Health insurance is ‘community rated’, which means you will purchase any health insurance policy at the same base premium as anyone else with that exact policy (even if you have a pre-existing condition), and you can claim as soon as you’ve finished serving your waiting periods.
The good news is that if you were already covered for the services relating to your condition on your previous policy, you won’t be required to re-serve the waiting periods when you switch to the same or lower level of cover with a new health fund.
However, if you’re transferring to a higher level of hospital cover or adding on cover for a new service, you won’t be able to claim on your new benefits for the first 12 months if it’s deemed for your pre-existing condition (excluding psychiatric, rehabilitative or palliative care).
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.
As Head of Health, Life, and Income Protection Insurance at Compare the Market, Lana Hambilton is passionate about simplifying the comparison process and educating Australians about the value and benefits Private Health Insurance can offer and the critical role it plays in our medical system. She firmly believes that health insurance provides choice in one of the most important aspects of life – our health – and has experienced countless cases over the years where peace of mind comes through the ability to choose when, where, and who will treat you.
Lana has 15 years’ experience in the health insurance and insurance comparison industries. She’s also a Board Member of the Private Health Insurance Intermediaries Association.
