Pre-existing conditions and what they mean for your private health cover

Have you ever wondered how private health insurance handles pre-existing conditions? What even defines a pre-existing condition? No matter the reason why you are trying to navigate the world of healthcare, our guide will shed light on what pre-existing conditions are, their relevant waiting periods and how certain conditions might impact your health cover.

No jargon, no mysteries – just the facts to empower your decisions about health cover. So let’s get to the bottom of how pre-existing conditions relate to private health insurance.

A pre-existing condition, in the context of private health insurance, refers to any ailment, illness or medical condition where you exhibited signs or symptoms within the six months before your enrolment in a health insurance policy, or before upgrading to a higher tier of cover.

What’s most important for you to know is that these conditions don’t necessarily need to have been formally diagnosed – neither do you have to be aware of them. They are considered pre-existing if signs or symptoms were reasonably evident to you or a medical practitioner during the six-month period before joining or upgrading your insurance.

Pre-existing conditions cover all sorts of medical issues. Some of the most common pre-existing conditions include:

• Diabetes: Both Type 1 and Type 2 diabetes, which involve issues with blood sugar levels.
• Hypertension: High blood pressure is often a pre-existing condition that may require management and treatment.
• Asthma: If you have a history of asthma and its associated symptoms, it may be referred to as a pre-existing condition by your insurer.
• Arthritis: Whether osteoarthritis or rheumatoid arthritis.
• Mental health conditions: Conditions like depression and anxiety are also considered pre-existing, with their own specific waiting periods.

These are just a few examples, and the list of pre-existing conditions for your chosen policy can vary widely. It's not a one-size-fits-all scenario, and how pre-existing conditions are assessed will depend on your provider.

Health funds tend to take a meticulous approach to this, as they want to ensure fairness and accuracy when assessing specific pre-existing conditions.

First, when a policyholder like yourself wants to see whether a particular condition qualifies as pre-existing, your health fund will appoint a medical practitioner. This practitioner must be independent and not have any affiliations with the insured individual, as they will be the one to evaluate the status of the condition (if it’s present at all).

Then it comes down to assessing signs and symptoms. This evaluation is used to determine whether you were showing signs of an ailment, illness or condition within the six months preceding the policy’s commencement or an upgrade. These signs and symptoms are not necessarily dependent on a formal diagnosis. Instead, they should have been reasonably apparent either to you or a competent GP if an examination had taken place during the six-month period.

Health funds might also request information from your treating doctors. The views of these doctors, who have direct knowledge of your medical history and condition, are considered alongside the assessment made by the fund-appointed medical practitioner. Having multiple perspectives can make the evaluation more accurate overall.

While health funds in Australia provide cover for a broad range of medical needs, not all conditions are covered under their private health policies. The list below outlines some of the most common pre-existing conditions that are generally not covered by health insurers.

• Pregnancy: Most insurers impose a 12-month waiting period for pregnancy-related services, so it’s crucial to plan ahead. In other words, you won’t be able to jump on a new policy and expect pregnancy cover if you are already with child.
• Chronic illness: Some insurers may not cover the ongoing management of chronic conditions. This includes, but is not limited to:
  • Many forms of cancer
  • Diabetes
  • Lupus
  • Epilepsy
  • Asthma
  • Sleep apnoea
  • Anxiety
  • Acne
• Psychiatric conditions: Cover for pre-existing mental health conditions is often subject to waiting periods.

Waiting periods for pre-existing conditions are in place to ensure the private health system remains fair for all members, and that long-term members aren’t financially burdened by those seeking immediate treatment for existing conditions. Here’s a breakdown of the typical waiting periods.

• General waiting period (2 months): This is a standard waiting period for most hospital treatments and services. It applies to new members and those upgrading their policies to a higher hospital tier. During this time, you generally won’t be covered for hospital treatment, including procedures related to pre-existing conditions.
• Waiting period for pre-existing conditions (12 months): New members, or those upgrading to a higher tier of private cover, will typically have to serve a 12-month waiting period before being able to make a claim for benefits on hospital treatments related to pre-existing conditions. During this period, you won’t receive coverage for any treatments connected to these conditions.
• Exceptions (2 months): There are exceptions to the 12-month rule. Psychiatric care, rehabilitation and palliative care all have a shorter two-month waiting periods (maximum), even if related to pre-existing conditions.

Switching insurers – even if you have pre-existing conditions – is open to all Australians, but it does require careful consideration and understanding of how the process works. Here are some tips to guide you along the way:

• Compare policies: Start by researching and comparing different health insurance policies. Look for one that covers your specific pre-existing condition and includes the benefits you need. Most importantly, make sure any waiting periods align with your health needs.
• Don't let your old policy lapse: Hold onto your existing policy until you have confirmed the start date of your new one. This will ensure you have continuous cover – and you won’t need to re-serve waiting periods.
• Contact your new insurer: Get in touch with your new insurer and chat about your situation. They can guide you through the process and provide relevant information about specific waiting periods.
• Seamless switch: Some insurers require a seamless switch, meaning there should be no gap between the end of your old policy and the start of the new one. Check with your new insurer about their specific requirements.
• Waiting periods: Be aware that if you’re switching to a policy with extra benefits not included in your previous policy, additional waiting periods will most likely apply for those benefits.
• Consult your doctor: Keep your regular doctor informed about the change and make sure they provide any necessary documentation or medical reports to your new insurer regarding your pre-existing condition.

While waiting periods for pre-existing conditions are a common part of private health insurance, it’s important to remember that they are safeguards to protect the stability of the system and fair treatment for all policyholders.

By researching policies and staying informed, you can navigate pre-existing conditions and maintain the best possible health cover for your needs.