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A pre-existing condition is a medical issue that existed before you joined a health fund, or upgraded to a new health insurance policy. Australian health funds generally impose a 12 month waiting period before you can claim on a pre-existing condition, except for psychiatric, rehabilitative or palliative care, which only require a two-month wait.

Are you covered for a pre-existing health condition?

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

  1. You do not pay more for health insurance because of pre-existing conditions.
  2. Conditions do not need to have been previously diagnosed to be considered ‘pre-existing’.
  3. You can seek private treatment for your pre-existing condition following the waiting period without penalty.

What is considered a pre existing condition?

A pre-existing condition is defined as any illness, ailment or condition that existed in the six months prior to joining a health insurance policy.

It is not necessary for a condition to have been diagnosed in order to be considered pre-existing. You and your doctor may not have even been aware of the condition, but if it was there prior to joining your health insurance policy, it will be classified as pre-existing.

However, signs or symptoms should have been reasonably evident in order for this to be considered (i.eevident to you, or to your doctor if you had been medically examined in this 6 month period).

Your health fund will determine whether your condition is pre-existing by appointing a medical practitioner to examine you. They are also required to take into account information provided by your doctor.

How is a pre-existing condition defined?

A pre-existing condition is defined as any illness, ailment or condition that existed in the six months prior to joining a health insurance policy.

It is not necessary for a condition to have been diagnosed in order to be considered pre-existing. You and your doctor may not have even been aware of the condition, but if it was there prior to joining your health insurance policy, it will be classified as pre-existing.

However, signs or symptoms should have been reasonably evident in order for this to be considered.

Your health fund will determine whether your condition is pre-existing by appointing a medical practitioner to examine you. They are also required to take into account information provided by your doctor.

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

If your condition is considered to be pre-existing, your health fund will impose a 12 month waiting period before you will be covered for benefits relating to that condition – simple as that. This 12 month waiting period for pre-existing conditions only applies to hospital coverage and not extras.

If you need to be admitted to hospital for a condition you think may 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, you can still seek treatment through Medicare, if you think it’s medically urgent.

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

No, you won’t. Even if you have a pre-existing condition, you can purchase any health insurance policy at the same price as anyone else, and you can claim as soon as your waiting periods are served.

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

Because anyone who’s fallen ill could sign up for health insurance, claim on this cover immediately, and then leave. Insurers would have to shoulder the costs, and then these costs would be passed on to others who hold health insurance policies…in the form of more expensive premiums. It’s essentially for the same reasons why health funds impose waiting periods.

Frequently asked questions about pre-existing conditions

Is mental illness a medical condition?

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

Mental illness can be broken into different types and varying degrees of severity, with major types including depression, anxiety, bipolar mood disorder, personality disorders, schizophrenia, and eating disorders. With this pre-existing medical condition, you are required to wait a two-month period for psychiatric care and rehabilitation.

Is pregnancy a pre-existing condition?

Pregnancy is not considered a pre-existing condition in health insurance policies, but you still need to serve a 12 month waiting period to be covered for pregnancy and birth-related services and admissions.

In order for this kind of cover to take effect, it must be included on your health insurance policy’s Product Disclosure Statement (PDS) 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 wait period, your fund may not cover pregnancy services.

As such, it’s important you always check to see, and understand, what is actually covered in your policy regarding obstetrics; some insurance providers do not cover pregnancy, while others restrict benefits (meaning you may only be covered as a private patient in a public hospital).

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 have to re-serve any waiting periods for the services you were covered for. However, a 12-month waiting period can apply to pre-existing medical conditions if you transfer to a higher level of cover.

For example, if you are adding on cover for a service that wasn’t covered on your previous policy, you won’t be able to claim on that new benefit for the first 12 months if it is deemed a pre-existing condition; psychiatric, palliative care, and rehabilitation are the exception here, where you are only required to serve a two-month waiting period.

Are conditions in my family history considered pre-existing?

Conditions running through your family are not considered signs or symptoms of pre-existing medical conditions.

Which health funds cover pre-existing conditions?

By law, all health funds are required to provide cover to those with pre-existing conditions. It’s vital you don’t let medical checkups, questions pertaining to your medical history, or waiting periods deter you from taking out the right level of cover for your healthcare needs. Chat to our experts today on 1800 456 981 so you can find the right policy for your healthcare needs.

Do pre-existing conditions affect other types of insurance?

Pre-existing conditions can affect your life insurance and travel insurance policies as well.

  • Life insurance: You are required to pay a higher premium to cover pre-existing health conditions. Certain cover exclusions for life insurance include suicide within an early specified period of a policy, like 13 months, as well as cancers, heart attacks, and strokes for an early specific period, like 90 days of a trauma policy. Conditions like post-natal depression are usually not covered if the person is not incapacitated for more than three months.
  • Travel insurance: As touched on previously, travel insurance can be tricky when it comes to seeking cover for pre-existing health conditions – but this doesn’t mean you won’t find coverage. As with all insurers, you must disclose any known conditions before taking out your policy, or you may find yourself without cover during your travels.

To ensure you’re choosing the right policy for your needs, compare health insurance for free with us today.

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