Private health insurance with pre-existing conditions
How health insurance works when you have pre-existing medical conditions
A guide to pre-existing conditions
Updated 26 March, 2024
Pre-existing conditions explained
Pre-existing conditions explained by Dr Ginni Mansberg.
Dr. Ginni Mansberg
Health
Video Transcript
Hi, it’s Dr. Ginni Mansberg, GP and health commentator in the media.
I’m here to chat about preexisting conditions.
Australia is lucky enough to have an excellent public health care system.
It helps you access treatment for many medical conditions, but that system won’t cover you for everything.
So lots of people choose to top up their support with private health insurance, but they’re worried about their pre-existing conditions.
A pre-existing condition is one that gave you symptoms as determined by the fund’s appointed medical practitioner in the six months
before you took out your health insurance policy or upgraded to a higher level of cover.
We’re talking about things like endometriosis, hip arthritis, heart disease, a knee injury or depression.
If you have a pre-existing condition, your health insurer can impose a waiting period of up to 12 months on benefits for hospital treatment for that condition.
But once you’ve had your policy for a continuous period of 2 or 12 months, the waiting period is over.
You’ll be eligible to receive all the benefits available under your hospital insurance policy.
Chat to the experts about waiting periods and which private health insurance policy best suits your needs.
What is a pre-existing condition?
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.
Expert tips for pre-existing conditions
Our health insurance expert, Steven Spicer, has some tips on taking out health insurance with a pre-existing condition.
Steven Spicer
Executive General Manager – Health, Life & Energy
Look for a policy with accident cover
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.
Consider health insurance for rehabilitation
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.
Get cover for your condition as early as possible
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.
Health insurance with pre-existing conditions
How pre-existing conditions affect health insurance
Here are the most important things you need to know about pre-existing conditions regarding your health insurance policy.
- Legally, all health funds are required to provide cover to those with pre-existing conditions.
- You do not pay more for private health insurance because of pre-existing conditions.
- A condition doesn’t have to be previously diagnosed to be considered ‘pre-existing’.
- If you have a pre-existing condition, you will typically have a longer waiting period before you can claim on hospital treatment for your condition through the private healthcare system.
- You can receive private treatment for your pre-existing condition and claim through your policy for it once you’ve served your waiting period.
Can you get health insurance with a pre-existing condition?
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.
Why health insurers impose waiting periods for pre-existing conditions
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.
Types of pre-existing conditions
Is mental illness a pre-existing condition?
Mental health issues come in many forms and vary in severity. Common types of mental illness include:
- Depression
- Anxiety
- Bipolar mood disorder
- Personality disorders
- Schizophrenia
- Eating disorders.
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.
Is pregnancy a pre-existing 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.
Are conditions in my family considered pre-existing?
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.
More information
Will I pay more if I have a pre-existing condition?
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.
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 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).
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.
Meet our health insurance expert, Steven Spicer
As the Executive General Manager of Health, Life and Energy, Steven Spicer is a strong believer in the benefits of private cover and knows just how valuable the peace of mind that comes with cover can be. He is passionate about demystifying the health insurance industry and advocates for the benefits of comparison when it comes to saving money on your premiums.