Private Health Insurance Cover for Pre-Existing Conditions

This guide covers the ins and outs of pre-existing conditions including how insurers define them, waiting periods, switching and more.

by Gary Andrews

Last update 15 Apr 2021

Overview

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.

Key Points

Pre-existing conditions are medical conditions that are present prior to upgrading your health cover or buying health insurance for the first time.
If you have a pre-existing condition when purchasing your first policy, you will face a waiting period of up to 12 months for hospital cover.
When switching to a policy with an equal or lesser level of cover, you will not have to re-serve waiting periods for hospital cover.
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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.

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.

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.

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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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This guide is opinion only and should not be taken as medical or financial advice. Check with a financial professional before making any decisions.