Finding Health Insurance with Pre-existing Conditions
Australian law states that no one may be refused access to private health insurance because of their health status or medical history. However, according to the Private Health Insurance Act 2007, health funds may impose a 12-month waiting period. Meaning, you must wait 12 months before you can claim any benefits relating to your pre-existing condition.
Once you've served your waiting period, you can generally claim benefits.
You might want to compare major health insurance brands to help you find a company offering shorter waiting periods for your specific pre-existing condition.
What is considered a pre-existing medical condition in health insurance?
Under current health insurance law, a pre-existing condition is defined as an ailment, illness or condition for which there were signs or symptoms 6 months before purchasing or upgrading your policy. Such signs and symptoms as are the opinion of the insurer's appointed medical practitioner.
Before getting health insurance with a pre-existing condition, you should know:
- Even if your condition has not been diagnosed, it may still be viewed as pre-existing.
- Generally, signs and symptoms of the ailment, illness or condition should have been reasonably evident for it to be considered pre-existing.
- 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.
- The health fund will determine whether your medical condition is pre-existing by appointing a medical practitioner to examine you.
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Does private health insurance cover pre-existing conditions?
Yes, all health funds must provide private health insurance, regardless of your past or present health. However, you can generally expect to wait up to 12 months before you can claim benefits associated with your condition, depending on your chosen health fund.
Examples of pre-existing medical conditions in Australia
According to the Australian Institute of Health and Welfare, in 2018, the top diseases leading to people dying early or living the remainder of their lives affected by ill health, include:
- Coronary heart disease
- Cancer, specifically lunch cancer in males
- Musculoskeletal condition, like back pain and osteoporosis
- Asthma in children between the ages of 5 and 14
- Anxiety disorders
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Can you get private health insurance with no waiting period for pre-existing conditions?
No, all health funds generally adhere to the pre-existing waiting period rules. However, private health insurance companies will analyse policies on a case-by-case basis. Sometimes health funds may waive waiting periods associated with general treatments, but this is extremely rare, especially with regards to pre-existing conditions.
Why is there a waiting period of pre-existing conditions?
Waiting periods help create fairness between health insurance customers. If health funds were to remove waiting periods, people might take out a policy to immediately claim a benefit and then cancel. If there were no waiting periods, premiums would skyrocket to compensate for these frequent payouts.
Frequently asked questions and answers
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 a health fund or upgrade your cover. However, this varies from fund to fund.
Because of this, you might want to request quotes and compare major brands when searching for a policy suited to your requirements.
As with pre-existing health conditions, you’ll typically have to wait a maximum of 12 months before you can claim any pregnancy or birth-related benefits.
If you want the ability to choose your obstetrician and give birth in a private hospital, you'll need to apply for a family policy as soon as you're considering getting pregnant.
According to the Commonwealth Ombudsman, a mental health problem is seen as a pre-existing condition. However, you only need to serve a 2-month waiting period before being covered as a private patient for psychiatric treatment or drug and alcohol rehabilitation.
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. So, you'll continue to serve the time you've not yet completed. However, if you've already completed the waiting period before switching to a new fund, you won't have to re-serve your waiting period.
Take note: When switching to a higher level of cover or to a policy that includes benefits not previously listed, you’ll have to serve the waiting period for the difference in the cover amount or for that specific benefit type.
Before you change health insurance providers:
- Get a detailed quote from the fund you are planning to switch to.
- Apply for cover from the new fund.
- Request that your old fund sends a clearance certificate to your new fund.
- Cancel your old cover and make sure your old fund is no longer deducting premiums from your bank account.
- Give your new health fund permission to start deducting premiums.
If you need treatment for your condition before your 12-month waiting period ends, you should contact your health fund immediately to check if you are entitled to hospital benefits. Alternatively, you can go to a public hospital under Medicare.
A private health insurance policy that covers pre-existing medical conditions will not cost you more than if you had no prior illnesses, ailments or conditions. Your past and current medical history do not influence your health insurance premium.
You can find pre-existing health insurance by comparing quotes from some of Australia’s major health insurance brands.
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