periods for
private health
insurance
A guide for consumers about how and
why waing periods operate, including
the rules on pre-exisng condions.
WAITING PERIODS
A waing period is an inial period of health insurer
membership during which no benet is payable for certain
procedures or services. Waing periods can also apply to
any addional benets when you change (upgrade) your
health insurance policy.
In Australia, all health insurers are required by law
to provide health insurance for Australian residents
regardless of their health status and cannot charge
higher premiums based on whether a person is more
likely to require treatment.
If there were no waing periods, people could take out
hospital insurance or upgrade to a higher policy only
when they knew or suspected they might need hospital
treatment. This would lead to much higher premiums for
all exisng contributors to health insurance.
WAITING PERIODS FOR HOSPITAL COVER
The maximum hospital waing periods that health insurers
can apply are set down in the Private Health Insurance
Act 2007:
• 12 months for pre-exisng condions—this is dened as
any condion, illness, or ailment that you had signs or
symptoms of during the six months before you joined a
hospital policy or upgraded to a higher hospital policy.
• 12 months for obstetrics (pregnancy)—to be covered,
the mother’s hospital admission needs to take place
aer the 12 month waing period has been completed.
• Two months for psychiatric care, rehabilitaon, and
palliave care, even for a pre-exisng condion—this
can include treatment of post-natal depression, eang
disorders, and drug and alcohol rehabilitaon, amongst
other treatments.
• Two months in all other circumstances.
If you transfer from one health insurer to another without a
break in cover, you do not need to re-serve hospital waing
periods you have previously completed. However, if you are
adding or upgrading your hospital cover, you do need to
complete waing periods for the new or upgraded items.
WAITING PERIODS FOR
The waing periods for general treatment, also known
as extras or ancillary cover, are set by individual health
insurers are not subject to the same laws as hospital cover.
They vary signicantly from two months to three years,
so to nd out the waing periods that apply to you please
contact your health insurer. Some examples of typical
waing periods are:
• Two months for benets for general dental services
and physiotherapy
• Six months for benets for opcal items (glasses or
contact lenses)
• 12 months for benets for major dental procedures
such as crowns or bridges
• One, two or three years for some high cost procedures
such as orthodoncs.
If you transfer from one health insurer to another, most
health insurers will not require you to re-serve many waing
periods again. However, loyalty limits and accrued benets
don’t necessarily transfer between insurers so check with
the individual insurer.
Holding a general treatment (extras) policy does not count
towards waing periods for a hospital policy.
WAIVERS FOR HEALTH INSURANCE
WAITING PERIODS
Somemes insurers will waive some waing periods as
part of a promoon to aract new members. Usually,
they only waive or some of the waing periods for general
treatment services. Always check which waing periods
will sll apply. It is very rare for insurers to waive the
twelve month waing periods for pre-exisng condions,
obstetrics, or major dental.
THE OBSTETRIC
If possible, it is best to plan health insurance for private
obstetric treatment early because insurers are usually
strict in applying a 12 month waing period to this service.
Almost all insurers apply a 12 month waing period to
hospital benets for pregnancy services.
You will receive advice on an ’expected delivery’ date
from your doctor; but if your baby arrives earlier than
ancipated and you have not served the 12 month waing
period, health insurers are not required to pay a benet.
Choose an appropriate policy–many less expensive
hospital policy do not cover obstetrics, or pay restricted
benets that only cover you for obstetrics as a private
paent in a public hospital.
You will also need to upgrade from a single policy to family
policy if you want to ensure your baby is covered at birth
in a private facility. Insurers have dierent rules about
when you need to do this, so make sure you check with
your insurer as soon as possible.
CONDITIONS WAITING PERIOD
A pre-exisng condion is dened by law as any condion,
illness, or ailment that in the opinion of the health
insurer’s doctor (not you, or your doctor), you had signs
or symptoms of during the six months before you joined a
hospital policy, or upgraded to a higher hospital policy.
It is not necessary that you or your doctor knew what your
condion was or that the condion had been diagnosed.
A condion can sll be classed as pre-exisng even if
you hadn’t seen your doctor about it before joining the
hospital policy or upgrading to a higher hospital policy.
Risk factors, including family history of a condion, are not
signs or symptoms of a pre-exisng condion.
If you are a new holder of a hospital policy, you will not be
entled to any benets for a pre-exisng condion in the
rst 12 months of membership.
If you already have a hospital policy but have transferred
to a higher level of cover, you may only receive the
(lower) benets that you had on your previous level of
cover for a pre-exisng condion in the rst 12 months on
your new policy.
WHAT HAPPENS IF I NEED TO GO TO HOSPITAL
WAITING PERIOD?
If you need to be admied to hospital during your waing
period, you should contact your health insurer straight
away to check if you will be entled to hospital benets.
Your health insurer should:
• Give you some general advice about the pre-exisng
condion rule but, at this stage, they cannot tell you
whether or not your condion is pre-exisng.
• Send you documentaon for your doctors to complete
and return to the insurer.
• Contact you within ve working days of sending them
the informaon, if not contact the insurer and ask if
they have made a decision.
If you need to go to hospital urgently, your health insurer
might not have enough me before you are admied to
decide whether your condion is pre-exisng. This means
that you may not know, before you are admied, whether
you will receive any health insurer benets.
If you proceed with your admission before the health
associated with the admission.
If you are concerned that you may be liable for your own
private hospital treatment and want to look at other
opons, it is a good idea to check with your doctor for
advice. Your doctor is in the best posion to advise you if
delaying treatment is medically advisable or whether you
can opt to use the public system instead.
• Pam was experiencing nausea and abdominal pain one
month before she took out hospital insurance with a
health insurer.
• She consulted her GP about the problem shortly aer
joining the insurer. Her GP referred her to a specialist,
who diagnosed gallstones and recommended surgery.
• The doctor appointed by the health insurer determined
that symptoms of Pam’s condion were in existence in
the six months before she joined the insurer. Although
Pam’s GP had not diagnosed gallstones inially, the
symptoms of nausea and pain had been present for
some me before Pam saw him or joined the health
insurer.
• The insurer advised Pam she would not be eligible for
benets for treatment of the gallstones for the rst 12
months of her membership.
• Warren had held his hospital policy for three months
when he suered a stroke and was rushed to hospital.
• Warren’s treang doctor indicated he had a number of
risk factors for stroke, including high blood pressure, but
had no signs or symptoms of a condion that lead to the
stroke prior to joining the insurer.
• The doctor appointed by the health insurer determined
that Warren was eligible to receive benets for his
treatment, because he did not have any signs or
symptoms of the stroke prior to joining the insurer.
(Please note that these examples are intended as a guide
only. Each case will depend on the individual’s parcular
circumstances.)
MORE INFORMATION AND
HOW TO MAKE A COMPLAINT
The Private Health Insurance Ombudsman has a number
of other brochures and publicaons on our websites that
may help you to beer understand your health insurance.
If you need our help with private health insurance
arrangements or have a complaint please refer to our
contact informaon on the back page.
CONTACT US
ONLINE
Visit ombudsman.gov.au and privatehealth.gov.au
EMAIL
IN WRITING
GPO Box 442, Canberra ACT 2601
PHONE
Call 1300 362 072 between 9am and 5pm (AEDT)
Monday to Friday.
SERVICES AVAILABLE TO HELP YOU MAKE A COMPLAINT
If you are a non-English speaking person, we can help
through the Translang and Interpreng Service (TIS) on
131 450. If you are hearing, sight or speech impaired, a
TTY Service is available through the Naonal Relay Service
on 133 677.
THE OMBUDSMAN’S SERVICES ARE FREE
