Private health insurance with pre-existing conditions

Here are some of the most important things you need to know about pre-existing conditions and health insurance.

1. Legally, all health funds are required to cover people with pre-existing conditions.
2. You do not pay more for private health insurance because of pre-existing conditions.
3. A condition doesn’t have to be previously diagnosed to be considered ‘pre-existing’.
4. If you have a pre-existing condition, you’ll typically have a longer waiting period before you can claim on hospital treatment for your condition through the private healthcare system.
5. You can receive private inpatient treatment for your pre-existing condition and claim through your policy provided you hold an appropriate level of cover and have served your waiting period.

Yes, you can still get private health cover if you have a pre-existing condition. However, Australian health funds will impose pre-existing condition waiting periods before you can claim for hospital treatments related to your condition.

You’ll only be paid a benefit towards your condition through hospital insurance if the procedure is included in your policy, medically necessary, listed on the Medicare Benefits Schedule (MBS) and you’re admitted as an inpatient.

When you take out private health insurance with a pre-existing condition, you’ll typically have a 12-month waiting period before being covered for hospital treatments or services relating to that condition. However, cover for psychiatric, rehabilitative or palliative care can be accessed after waiting just two months.

Pre-existing conditions only apply to hospital cover, not to extras cover – although health funds might still impose general waiting periods for particular extras services (e.g. 12 months for major dental).

If you need to be admitted to hospital for a condition that could be pre-existing, check with your health fund in advance for further information on whether you can make a claim.

It’s important to note that even if you need to serve this waiting period to access private health insurance, Medicare will still cover you for treatment in a public hospital.

Health funds impose waiting periods for pre-existing conditions so new members can’t make expensive health insurance claims shortly after joining. Without waiting periods, anyone who’s ill could sign up and claim on their health insurance cover immediately, then leave the health fund once they receive treatment.

Health funds would then have to shoulder the costs, leading to more expensive premiums for others who hold health insurance policies long term.

Mental health issues come in many forms and vary in severity. Common types of mental illness include:

• Depression
• Anxiety
• Bipolar mood disorder
• Personality disorders
• Schizophrenia
• Eating disorders.

Unlike the typical 12-month waiting period for pre-existing conditions, you’re usually only required to wait two months to claim for in-hospital psychiatric care if you suffer from a mental health condition.

Health funds don’t classify pregnancy as a pre-existing condition. However, in most instances, you still need to serve a 12-month waiting period to be covered for pregnancy and birth-related services. So, if you want to give birth in a private hospital, you’ll need to purchase your policy before falling pregnant.

If your baby arrives early or you haven’t served the full waiting period before/during your pregnancy, your fund may not cover your admission and care. As such, it’s important to check and understand what is covered in your policy regarding obstetrics. If you’re looking for suitable cover, Gold-tier health insurance policies are required to cover pregnancy and birth, although some health funds may include pregnancy cover in Silver Plus policies.

When you take out private health insurance, your family’s medical history isn’t considered a sign of pre-existing medical conditions. This means that even if your family has a history of a congenital condition, it won’t be considered a pre-existing condition unless you’ve shown signs or symptoms in the past six months.

No, you won’t. Health insurance is ‘community rated’, which means you will purchase any health insurance policy at the same base premium as anyone else with that exact policy in your state of residence (even if you have a pre-existing condition), and you can claim as soon as you’ve finished serving your waiting periods.

The good news is that if you were already covered for the services relating to your condition on your previous policy, you won’t be required to re-serve the waiting periods when you switch to the same or a lower level of cover with a new health fund.

However, if you’re transferring to a higher level of hospital cover or adding on cover for a new service, you won’t be able to claim on your new or higher benefits for the first 12 months if it relates to your pre-existing condition (excluding psychiatric, rehabilitative or palliative care).

If you don’t agree with your health fund’s decision regarding your pre-existing condition, you can request a re-assessment or discuss the decision with your doctor. If you still aren’t satisfied with the health fund’s ruling on your pre-existing condition, you can lodge a complaint with the Commonwealth Ombudsman.