PrivateHealth.gov.au

Waiting periods

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When you join a health insurer or increase your level of cover, you may have to wait some time before your insurance becomes effective. This protects you and others in your fund by ensuring no contributor makes a large claim shortly after joining a fund, and then drops their membership. Such 'hit and run' behaviour would result in increased premiums for all policy holders. There is usually no waiting period if you need hospital or medical treatment because of an accident that happens after you join the insurer.

The Government sets the maximum time that health insurers are able to make members wait until they can claim benefits for hospital treatment. These maximums are:

• 12 months for pre-existing conditions,
• 12 months for obstetrics (pregnancy) cases (see below for more information),
• two months for psychiatric care, rehabilitation or palliative care, even for a pre-existing condition,
• two months in all other circumstances.

The Government does not regulate waiting periods for benefits payable under general treatment cover (extras or ancillary services). These waiting periods are set by individual health insurers and you should make sure you are aware of benefit waiting periods that apply to your policy.

Waiting periods are listed on the Standard Information Statement (SIS) provided on this site for every health insurance product. If you are unsure how the waiting periods in your policy work, ask your health insurer.

New-born children

If you have a single membership and are expecting a child, you will need to transfer to a family membership or a single parent family membership if you want your new-born to be covered.

If you want your child to be insured from the time of birth, you may have to transfer to the new policy several months before your child is born. Health insurers have different rules about when you need to do this, so make sure you check with your insurer as soon as possible.

Obstetrics (pregnancy)

Most insurers apply a 12-month waiting period to hospital benefits for pregnancy services. Insurers are usually strict in applying this waiting period and you may not be covered if your baby comes early and you have not served the waiting period.

If you think you will need cover for pregnancy services, you need to take out or upgrade to appropriate cover well before you fall pregnant. Entitlement to obstetrics benefits rests with the mother. She needs to have served the full waiting period 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. If you want to be covered for your baby's birth in a private hospital, you need to take out a hospital treatment cover well before you fall pregnant that allows you to do this.

Pre-existing conditions

You may already be unwell when you to take out or upgrade a private health insurance policy. This is referred to as a pre-existing ailment or illness.

A pre-existing ailment is an ailment, illness or condition, the signs or symptoms of which, in the opinion of a medical practitioner appointed by the health insurer, existed at any time during the six months prior to taking out hospital cover or upgrading to a higher level of cover.

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.

Under the Private Health Insurance Act 2007, a health insurer may impose a 12-month waiting period on benefits for hospital treatment where it should have been reasonably apparent to either the contributor or a medical practitioner who conducts an examination, that there was a pre-existing ailment in the six months prior to taking out hospital cover or upgrading to a higher level of cover. For psychiatric care, rehabilitation and palliative care, the maximum waiting period is two months, even for a pre-existing condition.

Even if you are already insured, if you require hospital treatment, but you have less than 12 months membership on your current insurance, a 12-month waiting period could apply if your condition was determined to be pre-existing.

It is very important to check this with your health insurer prior to your admission to hospital if possible. Remember, your health insurer will need to have time to advise you about whether the pre-existing ailment 12-month waiting period applies.

Even if you are already ill, health insurers must allow you to purchase any type of cover, at the same price as every other person and once you have served any waiting periods, you will be entitled to claim.

More information

• Waiting Periods Brochure (PDF 215 KB)