When you start a new private health insurance policy or increase your level of cover, you have to complete waiting periods before you can claim benefits under your new level of cover. 

The maximum hospital waiting periods are 12 months for pre-existing conditions and pregnancy, 2 months for psychiatric care, rehabilitation or palliative care (even for a pre-existing condition), and 2 months for all other circumstances. 

When you start a new private health insurance policy or increase your level of cover, you have to complete waiting periods before you can claim benefits under your new level of cover. A waiting period protects members of the insurer by ensuring that individuals are not 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 policy holders.

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 start your policy.

Hospital treatment waiting periods

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

• 12 months for pre-existing conditions,
• 12 months for pregnancy and birth (obstetrics),
• two months for psychiatric treatments, rehabilitation or palliative care, even for a pre-existing condition,
• two months in all other circumstances.
  

Pre-existing conditions

Under the Private Health Insurance Act 2007, a health insurer may impose a 12 month waiting period on benefits for hospital treatment for a pre-existing condition. Some important facts to remember about this rule:

• A pre-existing condition is defined by law as any ailment, illness, or condition that you had signs or symptoms of during the six months before you joined a hospital cover or upgraded to a higher hospital policy. 
• 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 starting the hospital cover or upgrading to a higher hospital policy.
• The decision is made by a medical practitioner appointed by your insurer.
  
• In forming an opinion about whether or not an illness was pre-existing, the medical practitioner must take into account information provided by your own doctor.
• Your health insurer will need time to advise you if your condition is pre-existing, so check with your insurer well before you go to hospital to make sure you are covered.
• Even if you have a pre-existing condition, health insurer must allow you to purchase any type of cover, at the same price as any other person. Once you have served any waiting periods, you will be entitled to claim.

The exceptions to the 12 month waiting period for pre-existing conditions are psychiatric treatment, rehabilitation and palliative care. These services have a two month waiting period, even if the condition pre-existing. 

In some cases, you may be able to access an exemption to the two month waiting period for upgrading psychiatric benefits - see Mental health - waiting period exemption.

For more information, see the Ombudsman's factsheet on the pre-existing conditions rule.

Pregnancy and birth (obstetrics)

The maximum waiting period for pregnancy and birth 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 child well in advance (before you become pregnant). Some important facts to remember: 

• If you have a single membership or you are a dependent on a family policy and you are expecting a child, you will need to transfer to a family membership or single parent membership if you would like your newborn child to be covered. If you would like your child to be insured from the time of birth, without waiting periods, you may have to transfer to the new policy several months before your child is born. Health insurers have different rules about how far in advance you need to make changes to your cover to insure your newborn baby, so you should contact your insurer for more details.
• The entitlement to pregnancy 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. 

Mental Health – waiting period exemption for higher benefits

If you are on a hospital policy which provides restricted benefits for psychiatric care, then to access higher benefits you usually upgrade and complete a two month waiting period.

However, from 1 April 2018, you can upgrade without having to serve this waiting period to access higher benefits for psychiatric care in a hospital or hospital substitute treatment.

This exemption applies only once per lifetime and can only be accessed if you have already completed an initial two months of membership on any level of hospital cover. For more information about accessing the exemption, please contact your health insurer.

For general information about the exemption, see the Department of Health and Aged Care website: waiting periods and exemptions.

General treatment waiting periods

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

Generally, waiting periods vary from two to six months for items such as general dental, optical and physiotherapy, and up to 12 months or more for major items such as orthodontics or hearing aids.