Waiting periods

You will have to serve a waiting period when you start a new private health insurance policy or increase your level of cover. A waiting period protects members of the fund by ensuring that individuals aren't able to make a large claim shortly after joining and then cancelling their membership. This kind of behaviour would result in increased premiums for all members.

The government sets the maximum waiting periods that funds can impose for hospital treatment:

The waiting periods for general treatment (ancillary or extras) cover are set by individual health funds.

When purchasing health insurance make sure you are fully aware of any waiting period you may have to serve. There is usually no waiting period if you need hospital or medical treatment because of an accident that happens after you join the fund.

Pre-existing conditions

Under the Private Health Insurance Act 2007, a health fund may impose a 12 month waiting period on benefits for hospital treatment for a pre-existing condition.

A pre-existing condition is defined by law as any ailment, illness, or condition that you had signs or symptoms of during the 6 months before you joined a hospital table or upgraded to a higher hospital table. It is not necessary that you or your doctor knew what your condition was or that the condition had been diagnosed. A condition can still be classed as pre-existing even if you hadn’t seen your doctor about it before joining the hospital table or upgrading to a higher hospital table.

In forming an opinion about whether or not an illness was pre-existing, the health insurer appointed medical practitioner who makes the decision, must take into account information provided by your own doctor.

Your health fund will need time to advise you if your condition is pre-existing so be sure to check with your fund well before you go to hospital to make sure you are covered.

Even if you have a pre-existing condition, health funds must allow you to purchase any type of cover, at the same price as every other person. Once you have served any waiting periods, you will be entitled to claim.

Obstetrics (Pregnancy)

The maximum waiting period for obstetrics benefits is 12 months - if you are planning to become pregnant and wish to be covered, you will need to organise appropriate health insurance for both yourself and your newborn well in advance (before you become pregnant).

Entitlement to obstetrics benefits rests with the mother. She needs to have served the full waiting period before being admitted to hospital to be able to claim benefits.

Many less expensive hospital covers do not include obstetrics, or pay restricted benefits that only cover you for obstetrics as a private patient in a public hospital, not in a private hospital.

Health funds have different rules about how far in advance you need to make changes to your cover to insure your newborn baby. Some funds may require you to add your baby to your cover several months before his or her birth, so make sure you check with your fund as soon as possible.