Health Insurance Waiting Periods | Review & Compare

Published: July 12, 2017

Waiting is a necessary part of life. We wait in lines at the bank and grocery stores, we wait at the airport and in doctors’ rooms, and we eagerly await payday. At some point, we all have to wait for something we need.

The amount of time you have to wait before claiming on your insurance could have a significant impact on your health and bank account. All health cover policies have specific waiting periods applicable after joining; the time you have to wait before you’re able to claim any benefit.

Waiting periods

  • What are they
  • How do they work
  • When do they apply

Waiting for treatment

  • Hospital
  • Pre-existing
  • Pregnancy

Waiting for Extras

  • Dental
  • Optical
  • Medication

We want to help you choose the right health plan with the shortest waiting period. Use our comparison tool to find private health insurance that suits your unique requirements. In this article, we’ll look at what waiting periods are and when they apply, as well as periods associated with pre-existing conditions.

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What are waiting periods and how do they work?

Generally, a waiting period refers to a stretch of time that needs to pass before you can start utilising and claiming health services and treatments. There are different waiting times associated with different treatments, so it’s crucial you know the length of time you’ll need to wait before lodging a claim, or you risk having to pay from your own pocket.

The Federal Government requires health funds to provide all Australian residents with cover, regardless of their health status and prohibits them from charging higher premiums based on whether a person is more likely to require treatment.

However, the Federal Government have set maximum limits for certain hospital benefits, as per the Private Health Insurance Act 2007. This is because people could take advantage of the system by applying for hospital insurance or upgrading cover only when they need medical attention, and then cancelling once their claim has successfully been processed, which means insurers would have to charge higher premiums to offset increased claims payouts.

Because these periods can differ between health funds, it’s an important consideration when comparing health insurance policies.

The 3 Instances when waiting periods will apply:

When you have joined a health fund, and your policy starts.

When you’ve increased your cover amount or upgraded to a higher cover policy.

When you have re-joined a health fund after your cover has lapsed due to premium payments missed.

The maximum waiting period’s health insurers can apply:

  • 2 months from the start of your policy for psychiatric care, rehabilitation and palliative care.
  • 12 months from the start of your policy for pre-existing conditions, pregnancy and birth related services, including IVF, labour ward fees, and private obstetricians.

General waiting periods for extras treatments:

  • 2 months for general dental and physiotherapy.
  • 6 months for optometry, including prescription glasses.
  • 12 months for any major dental procedures, including crowns.
  • 1 year plus for orthodontics and other high-cost

Is there health insurance with no waiting period?

No, private health insurance with no waiting periods do not exist. No matter what plan you choose, whether it’s hospital or extras cover, or a combination of the two, you will still have to serve the waiting periods associated with the treatments and services included in your policy.

If you have a family history of a certain medical condition or are planning to start a family but you’re not sure when then it is better to be prepared and get the appropriate level of cover now. Not only will you have served the waiting periods when the time comes to claim, but you’ll also have peace of mind that you’ll have the necessary cover when you need it.

Waivers for health insurance waiting periods

No waiting period health insurance is not available, however there are special circumstances under which private health insurers will waive waiting periods associated with general treatments. However, these are waived on a ‘case-by-case’ basis and are extremely rare, especially for pre-existing medical conditions.

Examples of when a health fund might waive your waiting period:

  • As part of a promotion to attract new members. However, it’s important that you always check which waiting periods will still apply.
  • Under certain medical emergency conditions, if for example you’ve been in an accident and require immediate assistance.

Waiting periods for hospital treatments and services

Hospital waiting periods are set by the Federal Government and thus strictly enforced. However, if you transfer from one health insurer to another without a break in cover, you do not need to re-serve the waiting period. Here’s what you need to know about hospital treatment waiting periods:

  • Psychiatric and rehabilitation: If psychiatric illness or drug addiction is pre-existing you don’t have to wait the regular 12 months. You only need to wait 2
  • Pregnancy: Almost all health funds enforce a 12-month waiting period, so if you’re planning to have children, you should buy obstetrics cover a minimum of 3 months before falling pregnant.
  • Pre-existing conditions: If your health fund’s appointed medical expert determines that you have had a condition for a maximum of 6 months before buying your policy, it is considered a pre-existing condition and you will need to wait the mandatory 12 months before claiming any benefits.
  • For all other general hospital treatments, there is a 2-month waiting period.

Compare waiting periods for hospital procedures

Hospital Procedures nib Hospital Bupa Hospital GMHBA Medibank
Accidents: For example, a heart attack or car accident. 1 day 0 0 0
Ambulance services: Depending on your level of cover, this could include emergency air, road, and sea transport to the hospital, transport between hospitals, and paramedic attendance. 1 day 0 For emergency services 0 7 days
Hospital treatments: Including hernia repair, minor gynaecological surgery, and appendicitis. Excluding pre-existing conditions. 2 months 2 months 2 months 2 months
Pregnancy-related services 12 months 12 months 12 months 12 months
Pre-existing conditions: Illness or condition evident at any time during the 6 months before joining the health fund. 12 months 12 months 12 months 12 months
Rehabilitation, psychiatric services, and palliative care (caring for the terminally ill). 2 months 2 months 2 months 2 months

What is a benefit limitation period?

A benefit limitation period is a set amount of time during which you will only receive a restricted benefit (amount of money) paid back to you when you claim for certain treatments. This period is usually within one to three years.

Some health funds impose a benefit limitation period, but by law, it will not be applied if you are transferring from an existing hospital policy to one that has the same waiting period, or to another insurer with the same level of cover and the same waiting period.

You also have the option to select a hospital cover policy with one (or more if you choose) benefit limitation periods in exchange for a lower premium. Consider this decision very carefully, because you will be subject to increased risk. For example, if you choose lower benefits on pregnancy-related services and then fall pregnant within the benefit limitation period, you could jeopardize your personal finances by receiving less money back and therefore paying more out of pocket.

Be aware that when a waiting time applies for a particular condition or treatment, then the healthcare fund might only kick the benefit limitation period into gear from the end of the initial waiting period. For example, if the period is 12 months and your benefit limitation period is two years, then you will NOT receive full benefits for three years from when your membership commences. That’s three years of paying premiums without being able to claim a full benefit back.

Check with your insurer and make sure you are aware of the implications of benefit limitation periods in your health cover policy before deciding to go with this option.

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Compare private health insurance extras waiting periods

Each private health insurance fund is free to set their own waiting periods for the extras healthcare services that they offer. Examples of typical waiting periods are:

  • General dental services and physiotherapy: 2 months from the start of your policy.
  • Eye care, like prescription glasses or contact lenses: 6 months from the start of your policy.
  • Major dental procedures, like crowns or bridges: 12 months from the start of your policy.
  • Certain high-cost procedures, like orthodontics: 1, 2 or 3 years from the start of your policy.

If you transfer from one health insurer to another, most health insurers will not require you to re-serve many waiting periods. However, loyalty limits and accrued benefits don’t necessarily transfer between insurers. This is something that you must check with your insurer.

Because waiting periods vary significantly between insurers it’s important you compare the different health funds to see which one suits you best.

Extras Treatments nib Hospital Bupa Hospital GMHBA Extras Medibank Extras
Major dental: Periodontics, crowns and bridges, dentures, root canal therapy, orthodontics, wisdom teeth removal. 12 months 12 months 12 months 12 months
Optical: Glasses or contact lenses. 6 months 2 months 6 months 6 months
Physiotherapy, chiropractic, and osteopathy services 2 months 2 months 2 months 2 months
Podiatry:Treatment of the lower extremities, like feet and ankles. 2 months 2 months 2 months 2 months
Speech therapy 2 months 2 months 2 months 2 months
Pharmacy: Medication given to members when admitted to hospital and medication purchased by a member while not in the hospital. 2 months 2 months 2 months 2 months
Health Management:Including preventative services like weight loss programs and stress management programs. 6 months 6 months 2 months Check your cover summary
Hearing aids 12 months 12 months 12 months 36 months

Waiting periods for pre-existing conditions

A pre-existing condition is an illness or medical condition that has existed a minimum of six months before your purchasing or upgrading your policy. These conditions are linked to waiting periods of around 12 months.

These pre-existing conditions don’t need to have been diagnosed in the six months before you joined the health fund, but signs or symptoms are counted as evidence that it existed. It’s important to note that a pre-existing condition is NOT determined by yourself or your GP; it is the health insurer’s appointed medical practitioner that determines whether an ailment, illness or condition is pre-existing.

A condition, like cancer, obesity, and diabetes can still be classified as pre-existing even if you weren’t aware you had it before joining or upgrading to a higher policy.

New policyholders aren’t entitled to any benefits for a pre-existing condition during the first 12 months of membership. If you have upgraded to a higher level of cover, you will receive the lower benefits you had previously during the first 12 months upgrade.

Yes, even if you’ve previously been diagnosed with a condition, you can still qualify for private health insurance. The Australian Federal Government has prohibited private health insurers from refusing health cover or to even charge a higher premium because of your health status or claim history. However, the relevant waiting period will apply.

Once you’ve waited to required amount of time, you will be eligible to claim benefits.

Waiting periods stop people from taking out cover, claiming, and then cancelling their policy without contributing any premiums to the fund. Without them, health fund members who do regularly pay their premiums end up covering the cost of those that claim and leave. This results in higher premiums for all members.

Steps to follow when you need to go to the hospital during your pre-existing waiting period:

  1. Contact your health insurer straight away.
  2. Check with your insurer if you are entitled to hospital benefits.
  3. If you proceed with your admission before speaking to your health insurer, you run the risk of having to pay all the costs associated with your admission.
  4. Ask your doctor for advice before proceeding, he/she might delay treatment or opt to use the public system instead.

Cover for psychiatric and rehabilitative care is included in almost every hospital plan, however you will usually have to wait 2 months before claiming on treatment and medication when applying for a new policy. If you have already served the whole waiting period with one health insurer and are transferring to another you won’t need to re-serve these periods.

Can you get health insurance while pregnant?

Yes, you can get health insurance while pregnant, but you’ll be bound to a 12-month waiting period. For example, if you fall and break your leg, then treatment to heal your leg is covered, however, if you then visit your obstetrician to check on your unborn baby, you’ll pay out of pocket if the waiting period has not yet ended.

That is why it’s important to invest in a health insurance plan that includes cover for obstetric treatment and services before you become pregnant. Take the time to compare and review health funds and choose the right policy for you and your growing family.

Waiting periods for pregnancy cover

The general waiting period for pregnancy cover is12 months. Pregnancy treatments excluded during this period are:

  • In vitro fertilisation (IVF) treatment and other reproductive services.
  • Hospital accommodation.
  • Theatre/labour ward fees.
  • Intensive care relating to the birth, or post-birth for the mother
  • Pharmacy services administered in hospital.
  • 100% of the Medicare Benefits Schedule fee for doctor fees (75% Medicare + 25% fund)

Unplanned pregnancy

Even in the case of an unplanned pregnancy, the 12-month waiting period will still apply. Therefore, it is really important to consider getting health insurance that includes cover for pregnancy if there is even the slightest chance that you could become pregnant.

IVF and assisted reproductive services

In vitro fertilisation (IVF) treatment and other reproductive services have a standard waiting period of 12 months. However, there are some policies that restrict benefits for these services for up to three years. Make sure your policy covers IVF and other assisted reproductive services before signing. If you do have cover, check with your fund to confirm which services you will need to pay for and if there are any required waiting periods.

Dental Waiting Periods

Dental insurance is important for oral health. You need a trusted dental practitioner so that you can go for check-ups, have regular cleanings, and tend to any issues before they become more serious.

What is the waiting period for dental insurance?

The dental insurance waiting periods include:

  • 2 months for general dental services.
  • 12 months for major dental procedures, like crowns or bridges.
  • 1, 2, or 3 years depending on the insurer for certain high-cost procedures, like orthodontics.

Frequently asked questions and answers

When transferring from one health insurer to another after having served the full or part of the waiting periods, you won’t necessarily have to re-serve those periods. However, you will need to confirm this with the health fund you’re switching to.

If you go overseas and continue to pay your health insurance premiums, you will continue to serve these waiting periods as per normal. You can, however, suspend your cover for the duration of your trip. You will remain a member, but you won’t have to pay premiums for the time that you are away and your waiting periods will be preserved. The time you have already waited will not be affected, and you will carry on serving the waiting period when you return home and remove the suspension of cover. All that you need to do is give your insurer proof of your re-entry into Australia.

Before choosing a policy, shop around and read company reviews to know exactly what they’re offering. If you already have a policy, make sure you know what you’re covered for and whether you’re receiving true value for money.

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4 Comments

  • manda beaton |

    l require ankle surgery but have never had private health insurance cover. Now I am over 40 and considering getting some cover for myself. l know I’d still have to wait to have the surgery on my ankle, but just wanting to know if you can still get full cover knowing l have this condition?

    • SPECIALIST
      Anneke Van Aswegen |

      Hi Manda,
      Yes, you can usually still get coverage for pre-existing conditions, such as surgery for your ankle. However, you will have to serve a predetermined waiting period. Typically, 12 months, depending on your insurer, before claiming for this benefit and you’ll need a health insurance policy that provides coverage for podiatric surgery.

      Be sure to ask your surgeon, hospital and health insurer about any out-of-pocket costs that may apply, before you go to the hospital as health funds are only required to pay the minimum benefit toward hospital costs for foot and ankle surgeries.

      Another cost you’ll have to consider is the Lifetime Health Cover (LHC) loading. Because you’ve never had private health insurance you’ll have to a pay an additional 2% loading on top of your premium for every year after your age 31.

  • daniel |

    Can I back pay for the cover for an unplanned pregnancy?

    • SPECIALIST
      Anneke Van Aswegen |

      Hi Daniel,
      Interesting question. However, you generally have to hold pregnancy cover for 12 months after starting a policy, before you can claim benefits.