Finding Health Insurance When You Have A Pre-existing Condition

All private health insurance companies must cover treatment for pre-existing medical conditions as stipulated by Australia’s pre-existing health condition health insurance law. However, while it won’t be difficult to find health insurance with pre-existing conditions, you can generally expect to wait up to 12 months before you can start claiming any benefits associated with your condition.

It might be best to compare top health insurance companies to help you find cover for pre-existing medical conditions. When comparing be sure to review which health funds offer the shortest waiting periods.

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Does private health insurance cover pre-existing conditions?

Yes, private health insurance companies in Australia do cover pre-existing conditions. Australian law requires that no one may be refused access to private health cover because of their health status or claim history.  However, according to the Private Health Insurance Act 2007, health funds may impose a 12-month waiting period on benefits for hospital treatment for pre-existing conditions. Once you’ve served this waiting period, you may claim benefits.

When searching for pre-existing health insurance, take note that:

• Even if your condition has not been diagnosed, it may still be considered pre-existing if signs and symptoms have been reasonably evident.
• The health fund will determine whether your medical condition is pre-existing by appointing a medical practitioner to examine you.
• The cost of your premium will not increase because of a pre-existing condition.
• After serving the health fund’s waiting period, you are free to seek private treatment for your condition.

What is considered a pre-existing medical condition?

A pre-existing medical condition is a chronic ailment, illness or disorder that has existed at least six months prior to purchasing or upgrading your health insurance policy. This may be any medical complaint like a joint injury, asthma, or diabetes. The existence of a pre-existing condition is based on information from your doctor, and then diagnosed by a medical practitioner appointed by your health insurer.

How do private health insurers define pre-existing medical conditions?

According to the Private Health Insurance Ombudsman (PHIO), a pre-existing medical condition is any ailment, illness or condition that has existed within the six months prior to the date of obtaining your policy. Symptoms and signs of an ailment may be enough to determine whether you have a pre-existing condition, for example, a hernia, gall stones, diabetes, etc.

Your health insurer might request a medical certificate from your doctor, stating your medical condition over the past six months. Any persisting symptoms noted during this period are assessed, whether your doctor made a diagnosis or not.

Every private health insurer will analyse a person’s application on a case-by-case basis. However, pre-existing conditions are commonly linked to waiting periods of 12 months.

Is pregnancy a pre-existing condition?

While pregnancy isn’t generally defined as a pre-existing medical condition, you’ll typically still have to wait 12 months before you’re able to claim any pregnancy related benefits. As soon as you’re thinking of starting a family, you need to apply for private health insurance if you want to be able to choose your obstetrician and whether you want to give birth in a private hospital.

Will mental illness be classified as a pre-existing condition?

A mental illness or disorder is seen as a health problem that significantly affects how a person feels, thinks and behaves (ombudsman.gov.au). Unlike other pre-existing conditions, psychiatric services and rehabilitation usually only requires a 2-month waiting period.

Which health insurance companies cover pre-existing conditions?

All Australian private health funds cover pre-existing conditions. Typically, you’ll be able to claim benefits for pre-existing conditions after a 12-month waiting period, beginning on the day you join or upgrade to a higher level. However, this varies from fund to fund. Which is why requesting quotes and comparing leading health insurance companies can help you find the best cover for your requirements.

Your health insurance provider will appoint a medical practitioner to assess whether symptoms or signs of your condition were evident in the six months prior to your joining or upgrading your level of hospital cover. If they were, these will be classified as pre-existing conditions.

Most common pre-existing medical conditions that are covered by health funds

Signs and symptoms should have been reasonably evident for the below conditions to be considered pre-existing. The most common pre-existing conditions people want health insurance cover for, include:

• Heart attack
• Cancer
• Angina
• Diabetes type 2
• High blood pressure
• High cholesterol
• Stroke
• Depression
• Organ transplant

Can I get private health insurance with no waiting period when I have pre-existing conditions?

No, all health funds in Australia applies to the pre-existing waiting periods rule. Waiting periods help create a fair playing field for private health insurance customers. Essentially, they protect you from additional premium increases. If health funds were to remove waiting periods for pre-existent medical conditions, people might take out health cover, lodge a claim and then cancel as soon as their benefit gets paid.

If there were no waiting periods, premiums would have to increase to cover the cost of health funds regularly paying so many claims.  

However, there are always exceptions to any rule. Sometimes private health insurers may waive waiting periods associated with general treatments. These are waived on a case-by-case basis and are extremely rare, especially for pre-existing conditions.

How can I change policies when I have a pre-existing condition?

If you have a pre-existing medical condition and want to switch health insurance policies, your waiting period will carry over to the new fund and you won’t have to re-serve your waiting period. However, if you’re switching to a higher-level of cover, you’ll have to serve the waiting period before claiming on benefits your old policy did not provide.

Before you change health insurance providers:

1. Get a detailed quote from the fund you are planning to switch to.
2. Apply for cover for cover from the new fund.
3. Request that your old fund send a clearance certificate to your new fund.
4. Cancel your old cover and make sure your old fund is no longer deducting premiums from your bank account.
5. Give your new health fund permission to start deducting premiums.

If you need treatment for your condition before your 12-month waiting period is up, you should contact your health insurer immediately to check if you are entitled to hospital benefits. Alternatively, you can go to a public hospital under Medicare.

Where can I find pre-existing health insurance?

You can find pre-existing health insurance by comparing quotes from some of Australia’s top health insurance companies.

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