A Guide to Health Insurance & Pre-Existing Conditions

If you have any signs or symptoms of pre-existing illnesses, conditions or ailments in the six months before you get private health insurance – or upgrade to a higher level of hospital cover – this could affect your cover.

This guide will examine how health funds generally define pre-existing conditions, what it means for your coverage, and how to find the right private health insurance for your particular needs.

What is considered a pre-existing medical condition in private health insurance?

Across the vast majority of health funds in Australia, a ‘pre-existing condition’ simply refers to any illness or condition that you showed symptoms or signs of, in the six months prior to purchasing private health cover (or upgrading to a higher tier of cover).

This is all determined by the specific health fund’s chosen medical advisor. What is very important to note – and what is often misunderstood by people looking for private cover – is that these illnesses and conditions don’t need to be diagnosed beforehand to be considered pre-existing.

Even if you and your medical practitioner were unaware of the condition or illness, they may be classified as pre-existing if symptoms were evident before the purchase of the health cover. The classification period for pre-existing conditions is usually six months prior to the purchase of hospital cover.

What are some common pre-existing conditions in Australia?

Despite more than 80% of Australians aged 15 and over saying they believe they are in good health, the truth is that around half may be living with chronic conditions that a private health fund may consider as ‘pre-existing’*.

These conditions can vary, but some of the most common ones include:

• Cancer

• Heart disease

• Mental health problems

• Arthritis

• Back pain

• Asthma

• Diabetes

• Lung disease (e.g. chronic obstructive pulmonary disease – COPD)

Is pregnancy considered a pre-existing condition?

No – the good news is that health insurance policies don’t consider pregnancy a pre-existing condition.

However, there’s an important caveat. The majority of private health insurance funds require that you serve a minimum 12 month waiting period to take advantage of pregnancy, obstetrics and birth-related coverage.

This means that if you or your partner fall pregnant and you aren’t already covered by a private health insurance policy, then you may not have served out your waiting period by the time you give birth.

It’s important to compare private health funds well before you start trying for a baby so you can ensure you’ll be adequately covered for pre-natal, natal, and post-natal care.

Health cover from private health insurers can be helpful whether you are giving birth at a public hospital or a private hospital.

Does family history impact pre-existing conditions?

You won’t be penalised for having a family history of chronic conditions. If, for example, one parent has had cancer and a sibling has heart disease, these won’t be factored into your eligibility when applying for private health insurance. As the Commonwealth Ombudsman outlines:

“Risk factors, including family history of a pre-existing condition, are not signs or symptoms of a pre-existing condition. The health insurer’s medical practitioner should not consider these risk factors when deciding whether a condition is pre-existing.”

However, if you have a personal history of chronic illness or conditions yourself, then that illness or condition will likely be regarded as a pre-existing condition for health insurance purposes.

Can I be denied health insurance because of a pre-existing condition?

No – a health fund cannot legally refuse to grant you private health cover if you have pre-existing conditions.

However, under the Private Health Insurance Act 2007, they are allowed to impose a 12 month waiting period on any hospital treatment for pre-existing ailments, illness, or conditions, such as treatment for diabetes or mental health treatment.

Once you’ve served that waiting period, you will be covered for treatments concerning your pre-existing conditions.

What if your pre-existing condition wasn’t diagnosed when you joined your health fund?

A medical practitioner doesn’t have to have diagnosed the condition at the time of joining or upgrading your private health cover.

Instead, ‘pre-existing’ relates to any ailment, illness, or condition where you showed signs or symptoms in the six months prior to getting private health insurance.

So, if you were experiencing symptoms of heart disease in the months before joining a new private health fund but you weren’t diagnosed with this condition until after you joined your policy, the health fund can attribute your heart disease as a pre-existing condition because you were showing signs of the illness even though you didn’t know you had it.

Can you change policies if you have a pre-existing condition?

In Australia, you have the right to change health funds whenever you want to – without being unreasonably penalised for doing so. Regularly comparing private health cover is the best way to ensure you’re getting good value for your health insurance dollar.

However, switching funds with a pre-existing condition means you may have to serve a new 12-month waiting period if you upgrade your cover.

However, there are no new waiting periods when you switch to an equivalent hospital cover. Make sure you’re aware of any relevant waiting periods for your ailments, illnesses, or conditions before making the switch from one health insurer to another.

How do waiting periods work with pre-existing conditions?

Some health insurers try to be more competitive by offering reduced waiting periods in their policies for certain services.

For all Australian health funds, the maximum waiting period you will have to serve for any illnesses, ailments, or conditions that are considered pre-existing is 12 months.

Make sure you read the insurer's product information and speak to your chosen provider to understand exactly how long the waiting period is before you will be fully covered for any relevant hospital treatments.

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

No. Just like a health fund cannot legally refuse to grant you private health cover based on any pre-existing conditions you may have, they can’t raise the price of your premiums simply because you have an ailment, illness, or condition that is pre-existing.

You can rest easy knowing that once you’ve served your waiting period (typically 12 months for pre-existing conditions), you’ll be covered for relevant hospital treatments included in your policy.

Having a pre-existing condition doesn’t exclude you from getting the level of private health insurance you want.

You don’t have to pay more just because you have a chronic condition or illness. You can start comparing private health insurance* for pre-existing conditions today with Compare Club.

Chris Stanley is the sales & operations manager of health insurance at Compare Club. With extensive experience and expertise, Chris is a trusted leader known for his deep understanding of health insurance markets, policies, and coverage options. As the sales & operations manager of health insurance, Chris leads a team of dedicated professionals committed to helping individuals and families make informed decisions about their health insurance needs.

Meet our health insurance expert, Chris Stanley

Chris's top health insurance tips

• 1

  Australia’s public health system is world-class, but wait times for public hospitals can be long, inconvenient - and leave you living in constant pain while you wait.

• 2

  An appropriate private health insurance policy can speed up your surgery, relieving your pain sooner.

• 3

  Family health cover means your children are covered under the same policy as you.

• 4

  Many health insurance policies come with a 12-month waiting period for pregnancy-related cover, so it’s a good idea to get a family policy organized well before starting your family. This means your child will be covered from birth until at least their early twenties (depending on which health fund you select).