Article was originally published by TJ Ryan January 30, 2017.
Does health insurance cover pre-existing conditions?
Yes, you can get health insurance to cover your pre-existing health conditions, but a waiting period of up to 12 months may apply before you are able to claim benefits on that cover.
The Private Health Insurance Ombudsman (PHIO) defines a pre-existing condition as any ailment, illness or condition where the medical adviser appointed by the health insurer declares that symptoms of that condition existed any time within the past six months leading up to the person becoming insured.
It is up to the health fund’s appointed doctor, not your own doctor, to decide whether the condition was pre-existing. However, the health fund’s appointed doctor must take into account any information given to them by your own doctor. This usually means getting a medical certificate from your doctor and sending it to your health fund.
The person does not have to have been diagnosed, as long as symptoms were present and would have been reasonably clear to the person or their GP if they had been examined. Each case is assessed on its merits but even the patient’s own medical history may not be enough to definitively say that a condition was pre-existing.
The table below features a snapshot of hospital & extras policies on Canstar’s database with pregnancy cover and links to providers’ websites, sorted by provider name (alphabetically). Please note the results are based on a couple aged under 35 in NSW with pregnancy cover.
The pre-existing condition waiting period rule
Under the Private Health Insurance Act 2007, a health insurer can impose a waiting period of up to 12 months on benefits for hospital treatment for pre-existing conditions. Once a person has been insured for the condition for the 12-month waiting period, they are covered to make claims for benefits relating to that condition.
This rule applies to all hospital cover, and some insurers also apply this rule to their extras cover.
If you need to get treatment for a condition that you suspect is a pre-existing condition, the Private Health Insurance Ombudsman (PHIO) advises that you should contact your insurer first. This gives them time to assess your medical history and decide whether or not it is a pre-existing condition. It’s always better to check beforehand and serve a waiting period if you have to, than to try to claim your treatment afterwards and have your claim rejected.
Patients should remember that if their health condition requires urgent treatment, they can get free treatment through the public health system (Medicare). Waiting lists for surgeries can be quite long in the public health system, but you are able to serve the 12-month waiting period for private insurance for a pre-existing condition while you are on public waiting lists. So you can always sign up for private insurance and see which system can treat your condition first.
Health insurers do not apply the 12-month pre-existing condition waiting period to the following conditions, because these conditions have their own prescribed waiting periods for new members or members who are upgrading their cover:
- Obstetric services (pregnancy and childbirth): 12 months
- Psychiatric care: 2 months
- Rehabilitation treatment: 2 months
- Palliative care (end of life care): 2 months
- Other services that are not pre-existing conditions: 2 months
Why should I have to serve a waiting period?
The government in creating the pre-existing condition rule reasoned that if there was no waiting period, someone could avoid paying for health insurance until they found out something was wrong. They could sign up for insurance, get treatment, claim the benefits, and then immediately cancel their policy again to avoid paying more premiums. The cost of all this essentially not-paid-for treatment would likely fall on the long-term health insurance customers who have been paying their premiums, and their premiums may consequently become too expensive to afford. That’s why the current pre-existing waiting period rule applies.
Do you pay more to get health insurance for pre-existing conditions?
No, pre-existing conditions do not increase the cost of your insurance premiums. You will pay the same premium for cover as any person without that pre-existing condition would pay. Once you have served the 12-month waiting period with a health fund for a pre-existing condition, you can start claiming benefits for that condition.
I switched health funds, do I have to serve the waiting period?
If your previous health policy covered your health condition and you had cover for at least 12 months, then you will likely be covered for that pre-existing condition under your new policy and you may not have to serve the usual 12-month waiting period. This applies whether or not you served a pre-existing condition waiting period under your old policy, because you had cover for at least 12 months.
Common pre-existing conditions for health insurance
A few of the common pre-existing conditions that people may encounter when looking for health insurance include the following, although this list is by no means exhaustive:
- Heart attack
- Diabetes Type 2
- High blood pressure
- High cholesterol
- Organ transplant
But as we said above, the law defines a pre-existing condition for health insurance as any kind of health condition that you would be seeking to claim treatment for. It doesn’t have to be one of these common conditions.
I have a family history of something, is that a pre-existing condition?
If you have risk factors such as a family history (a family member has or had that condition), this is not considered to be a sign or symptom of you having a pre-existing condition.
Which health funds accept pre-existing conditions?
All health funds are required by law to provide cover to patients who have pre-existing conditions. You cannot be refused health insurance because of a pre-existing condition. However, you will have to serve the 12-month waiting period before you can claim benefits related to a pre-existing condition.
Don’t let the waiting periods or the extra questions about your medical history put you off from getting an adequate level of private health insurance. Having cover for a pre-existing condition can make a significant difference in the long run if your condition requires expensive treatment or has a long waiting list in the public health system.
What if I disagree with the health fund about a condition?
If you do not agree with your health fund that a condition was pre-existing, you should ask your health fund to review their decision in the first instance. You can also discuss the health fund’s decision with your own doctor. If your health fund does not change their decision, you can make a complaint to the Private Health Insurance Ombudsman (PHIO):
- Phone: Hotline 1300 362 072, open 9am-5pm, Monday-Friday
- Online complaint form: http://www.ombudsman.gov.au/making-a-complaint/contact-us
- Email: email@example.com
What else do I need to know about my pre-existing conditions?
When it comes to life insurance for pre-existing conditions, where the definition of a pre-existing condition varies and you may or may not be covered depending on your choice of insurer.
As for travel insurance, pre-existing conditions are a common exclusion unless you have arranged with the insurer to specifically include these under the policy. If you are travelling with a known health condition, it is especially important to check your product disclosure statement (PDS) for what your policy covers.