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 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.
The government sets the maximum waiting periods that funds can impose for hospital treatment:
- 12 months for pre-existing conditions,
- 12 months for obstetrics (pregnancy),
- two months for psychiatric care, rehabilitation or palliative care, even for a pre-existing condition,
- two months in all other circumstances.
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.
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 six 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.
The exceptions to the 12 month waiting period for pre-existing conditions are psychiatric care, rehabilitation and palliative care. These services have a two month waiting period, even if pre-existing.
In some cases, you may be able to access an exemption to the two month waiting period for upgrading psychiatric benefits - see below for more information.
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).
If you have a single membership and are expecting a child, you will need to transfer to a family membership or single parent membership oif 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 funds 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.
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.
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 private hospital.
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 fund.
For general information about the exemption, see the Department of Health website: Supporting mental health - waiting period exemption for higher benefits.
Benefit Limitation Periods
Before 1 July 2018 some private health insurers imposed benefit limitation periods (BLPs) of up to 24 months for some categories of hospital treatment. During a BLP, you are only entitled to restricted benefits for a particular condition or treatment for a set period of time. Insurers have now ceased this practice.
For more information, see the Department of Health website: Private Health Insurance Benefit Limitation Periods – Changes to improve information for private health insurance members
- Waiting Periods
- Factsheet: The Pre-Existing Conditions Rule
- Factsheet: Obstetrics and Private Health Insurance