Private Health Insurance Cover For Pre-existing Conditions

Millions of Australians are covered by private health insurance.

According to recent APRA figures, over 11 million Australians have hospital cover and over 13.5 million Australians have extras cover.

Private health insurance can provide benefits for services that Medicare doesn't, and it also gives you more control over your health decisions, such as choosing your doctor and hospital.

However, it's critical to be aware of restrictions on cover due to pre-existing conditions.

If you're buying insurance for the first time or are upgrading to a higher level of cover, be aware that you may not be immediately covered for all existing medical conditions.

What are pre-existing conditions?

Pre-existing conditions are medical conditions that were present prior to taking up private health insurance.

If your health insurance policy lapses and you develop a medical condition, it will be considered a pre-existing condition when you take up your next policy.

The Department of Health use the following criteria to identify a pre-existing condition:

• The signs or symptoms of the medical condition must have been "reasonably apparent" or "reasonably evident" in the six months before signing up for insurance OR

• You have some symptom, sign or impairment that would have been apparent to a reasonable GP conducting a routine external examination if you had sought a medical exam.

How do insurers define pre-existing conditions?

Your insurer may determine that you have a pre-existing condition even if you do not have a previous diagnosis.

As explained by the Private Health Insurance Ombudsman, it is up to the medical adviser appointed by the health insurer to decide if your existing health conditions qualify as pre-existing .

If the signs or symptoms of a condition were present 6 months prior to becoming insured (or anytime within those 6 months), it may be considered a pre-existing condition.

This is true even if you were not previously aware of the condition.

For example, if you have a lump in your breast before you sign up for insurance and are diagnosed with breast cancer afterwards, the cancer would likely be considered a pre-existing condition.

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)

I have a pre-existing condition, can I still get insured?

Yes, you can get health insurance even with a pre-existing condition.

There are no limits or restrictions on the type of cover you can buy, but waiting periods will likely apply.

Insurers usually impose a waiting period on pre-existing conditions, which means you'll have to serve the waiting period before you can make claims.

Waiting periods apply to new policyholders and when you upgrade to a higher level of benefits.

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.

Waiting periods for pre-existing conditions

The Private Health Insurance Act 2007 permits health insurers to impose a maximum 12-month waiting period on hospital cover for pre-existing conditions.

Maximum waiting periods are as follows:

• 12 months for hospital treatment for pre-existing conditions

• 12 months for hospital-substitute treatments for pre-existing conditions

• Two months for hospital or hospital substitute treatments for psychiatric care, whether or not you had a pre-existing condition

• Two months for rehabilitation or palliative care, whether or not you had a pre-existing condition

Waiting periods for extras (also called general) cover is at the discretion of the insurer.

Legally, there are no restrictions on waiting periods for pre-existing conditions when it comes to extras cover.

This means the insurer can decide if and how long the waiting periods are for this type of cover.

Switching insurers when you have a pre-existing condition

The good news is that you don't have to sit the same waiting periods twice; they usually only apply when you buy insurance for the first time or if you are moving to a higher level of cover.

Portability laws are in place to ensure that you don't have to re-serve waiting periods for the same level of cover when switching plans without an extended gap in your cover.

However, it's important to note that these laws only apply to hospital cover.

If you switch your extras policy, your new fund can impose a new waiting period if they so desire.

Fortunately, pre-existing conditions will not disqualify you from coverage with most insurers.

Be sure to check with your new fund about any waiting periods that apply before committing to a switch.

If I have a pre-existing condition, is it too late to get health insurance?

Insurance was developed to protect you against life's unexpected events, like an accident or unforeseen illness.

If you have a pre-existing condition but don't yet have health insurance, that doesn't mean it's too late.

Health insurance may still cover you for things unrelated to your condition.

However, it is still best to have your insurance in place before a medical condition arises.

If you don't have any pre-existing conditions, securing your health insurance now is a smart move.

Depending on your level of cover, you'll already be covered should you be diagnosed with a medical condition down the line.

Otherwise, you may be faced with the difficult decision of paying out-of-pocket, foregoing a much-needed treatment or relying on the public health system ---and that's a decision no one should have to make.

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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).