A pre-existing condition has a specific meaning when it comes to private health insurance, and it works differently to the way pre-existing conditions can be treated by other types of insurance.
Having a pre-existing condition doesn’t mean a health fund can permanently exclude that condition from your Hospital cover. Instead, a 12-month waiting period can apply before you can claim benefits for hospital treatment related to the condition. This waiting period doesn’t apply if you’ve already served the waiting period for the level of cover that includes the treatment you need.
Whether a condition is considered pre-existing depends on whether signs or symptoms existed during the six months before you joined or upgraded your Hospital cover, even if the condition hadn’t been diagnosed at the time.
This article explains how pre-existing conditions work in private health insurance, who determines whether a condition is pre-existing and what it means for your cover.
Key Points
- Pre-existing conditions aren’t permanently excluded from private health insurance.
- A condition can be considered pre-existing even if it hadn’t been diagnosed before you joined or upgraded your Hospital cover.
- A 12-month waiting period can apply to hospital treatment for a pre-existing condition when you join or upgrade your Hospital cover.
- If you’ve already served the waiting period for the level of cover that includes the treatment you need, the pre-existing condition waiting period doesn’t apply.
What is a pre-existing condition?
For private health insurance, a pre-existing condition is an ailment, illness or condition where signs or symptoms existed during the six months before you joined or upgraded your Hospital cover.
It doesn’t matter whether you or your doctor knew about those signs or symptoms at the time, or whether the condition had been diagnosed. What matters is whether signs or symptoms of the condition existed during that six-month period.
This works differently to some other types of insurance, where a pre-existing medical condition may be excluded from cover or affect whether you’re able to take out a policy.
Australian private health insurance operates under community rating. This means a health fund can’t refuse to insure you, charge you more or permanently exclude you from Hospital cover because of your health or medical history.
If you’re still serving the relevant waiting period after joining or upgrading your Hospital cover, a 12-month waiting period applies to hospital treatment for a condition determined to be pre-existing. If you’ve already served that waiting period, the pre-existing condition rule won’t prevent you from claiming benefits for treatment included under your cover.
Who decides if a condition is pre-existing?
A health fund can’t simply decide that a condition is pre-existing. The assessment must be based on medical information about the signs and symptoms that existed during the six months before you joined or upgraded your Hospital cover.
A medical practitioner appointed by your health fund will consider information provided by the doctors who treated you and determine whether, in their opinion, signs or symptoms of the condition existed during that six-month period.
Your treating doctor provides important medical information as part of this process, but they don’t make the final decision about whether the pre-existing condition waiting period applies.
This is why your health fund may need to request medical information from your treating doctors before it can confirm whether you’re eligible to receive benefits for the treatment.
How does Phoenix Health assess a pre-existing condition?
If Phoenix Health needs to determine whether a condition is pre-existing, we’ll send you a pre-existing condition assessment form. The form needs to be completed by you, your GP and your treating specialist.
Once we receive the completed form and all supporting information, it’s provided to a medical practitioner appointed by Phoenix Health. The medical practitioner reviews the information and determines whether the condition meets the definition of a pre-existing condition.
The assessment can take up to 10 working days from the date we receive all of the required information, so it’s important to return the completed form and supporting documents as soon as possible.
Does it matter if I hadn’t been diagnosed before joining?
No. A condition doesn’t need to have been diagnosed before you joined or upgraded your Hospital cover for it to be considered pre-existing.
The assessment looks at whether signs or symptoms of the condition existed during the six months before you joined or upgraded your cover. Those signs or symptoms can still be relevant even if you didn’t know what was causing them or hadn’t sought medical treatment for them at the time.
For example, you might develop ongoing knee pain before taking out Hospital cover but not see a doctor or receive a diagnosis until several months later. If medical information shows the knee pain was a sign or symptom of the condition you now need hospital treatment for, the condition could be determined to be pre-existing.
Likewise, receiving a diagnosis after you joined doesn’t automatically mean the condition is pre-existing. The assessment is based on when the signs or symptoms existed, not simply the date you were diagnosed.
What waiting period applies to a pre-existing condition?
A 12-month waiting period applies to hospital treatment for a pre-existing condition when you take out Hospital cover for the first time or upgrade to a higher level of cover that includes the treatment you need.
However, new or upgraded Hospital cover has waiting periods that apply regardless of whether a condition is pre-existing. This means the timing of when you need treatment matters.
| Time since joining or upgrading | What applies? |
|---|---|
| First 2 months | The standard Hospital waiting period applies, so you won’t be covered for treatment subject to this waiting period regardless of whether the condition is pre-existing. |
| 2 to 12 months | If you’ve served the standard waiting period but need treatment for a condition that may be pre-existing, a pre-existing condition assessment is required to determine whether the 12-month waiting period applies. |
| After 12 months | If you’ve served the relevant waiting periods for your level of cover, the pre-existing condition waiting period no longer prevents you from claiming benefits for treatment included under your cover. |
Worth knowing: changing your Hospital excess
Reducing your Hospital excess is considered an upgrade to your cover. For example, if you change your excess from $750 to $0 and need hospital treatment within the following 12 months, a pre-existing condition assessment may be required before the $0 excess can apply.
If the condition is determined to be pre-existing, you can still receive benefits towards the treatment if you’ve already served the waiting periods that applied under your previous cover. You’ll simply need to pay your previous $750 excess until you’ve served the 12-month waiting period for the upgraded $0 excess.
Can a health fund permanently exclude a pre-existing condition?
No. Unlike some other types of insurance, Australian private health insurance doesn’t permanently exclude you from Hospital cover because you have a pre-existing medical condition.
If your policy includes the hospital treatment you need, a pre-existing condition affects the waiting period that applies, not whether you’ll ever be covered for that condition.
Once you’ve served the relevant 12-month waiting period, you can claim benefits towards hospital treatment for the pre-existing condition in accordance with your level of cover.
What happens if I need treatment during the waiting period?
You can still have hospital treatment while you’re serving a pre-existing condition waiting period, but your health fund won’t pay benefits towards treatment for the pre-existing condition until you’ve served the 12-month waiting period.
If you choose to have the treatment during this time as a private patient, you’ll be responsible for the costs that would otherwise have been covered by your health fund.
Depending on the treatment you need, you may also be able to receive treatment through the public hospital system as a public patient.
If you’re unsure whether a waiting period applies to treatment you’re planning, contact your health fund before you’re admitted to hospital so you understand how your cover will apply.
Does the pre-existing condition rule apply to Extras?
No. The pre-existing condition rule applies to Hospital cover, not Extras cover.
Extras cover can still have waiting periods for services such as dental, optical and physiotherapy, but these waiting periods apply regardless of whether you have a pre-existing condition.
Once you’ve served the waiting period for an Extras service, you can claim benefits in accordance with your level of cover. You won’t be required to complete a pre-existing condition assessment before claiming.
What happens if I switch health funds?
Switching health funds doesn’t mean you’ll have to re-serve a pre-existing condition waiting period you’ve already completed.
If you transfer to the same or a lower level of Hospital cover and have already served your waiting periods, you can continue to receive benefits for treatment included under your new cover, including treatment for pre-existing conditions.
If you’re partway through a pre-existing condition waiting period when you switch, the time you’ve already served will count towards the 12-month waiting period with your new health fund.
If you upgrade your Hospital cover when you switch, a new waiting period can apply to the higher or additional benefits. The pre-existing condition rules can then apply to treatment covered by that upgrade.
What information is needed for a pre-existing condition assessment?
A pre-existing condition assessment requires medical information to determine whether signs or symptoms of the condition existed during the six months before you joined or upgraded your Hospital cover.
This can include information from your GP and treating specialist about your medical history, when signs or symptoms first appeared, when you first sought treatment and when the condition was diagnosed.
Information about the treatment you’re planning and the condition the treatment relates to may also be required.
This information is reviewed by the medical practitioner appointed by your health fund, who determines whether the condition meets the definition of a pre-existing condition.
Not sure if a pre-existing condition waiting period applies?
If you’re a Phoenix Health member and you’re planning hospital treatment, contact us before your admission. We can check your cover and waiting periods and let you know if a pre-existing condition assessment is required.
Call our team on 1800 028 817 and we’ll help you understand what you need to do before your treatment.
