A waiting period is the amount of time you need to wait after joining private health insurance or changing your level of cover before you can claim certain benefits.
Waiting periods help protect existing members and keep health insurance sustainable. Without them, someone could join or upgrade their cover simply to make a claim and then cancel or reduce their cover straight afterwards, increasing costs for everyone.
Learn more about how waiting periods work, including when they apply, switching health funds and changing your cover.
Waiting periods for Hospital Cover
Waiting periods for Extras Cover
Waiting periods for Ambulance
Transferring from another health fund
When you switch to Phoenix Health from another Australian health fund, any waiting periods you’ve already served on an equivalent level of cover will transfer with you — so there’s no starting again!
There are some situations where you may still need to serve waiting periods:
- If there’s been a gap in cover of 30 days or more between leaving your previous fund and joining Phoenix Health.
- If a service was excluded, restricted or not covered under your previous cover.
- If your Phoenix Health cover provides a higher level of cover or benefits than your previous policy. Waiting periods may apply to the upgraded benefits, limits or excess.
- If you hadn’t finished serving a waiting period with your previous fund. You’ll need to serve the remaining period before you can claim that benefit with Phoenix Health.
New to private health insurance
If you’re new to private health insurance, or you’ve been without cover for 30 days or more before joining Phoenix Health, full waiting periods will generally apply before you can claim benefits under your new cover.
Changing your level of cover
If you’re an existing Phoenix Health member and change your level of cover, waiting periods will only apply to any upgraded benefits, limits or excess as a result of the change.
If you downgrade your cover and later decide to upgrade again, waiting periods may apply to the upgraded cover if it’s been more than 30 days since you held the higher level of cover.
Moving between Phoenix Health memberships
If you join a new or existing Phoenix Health membership within 30 days of being removed from your previous Phoenix Health membership, you won’t need to re-serve waiting periods for an equivalent level of cover.
Waiting periods may still apply:
- If there’s a gap in cover of more than 30 days.
- For services or benefits that weren’t covered under your previous cover.
- For services that were excluded or restricted under your previous cover.
- For any upgrade in benefits, limits or excess.
- If you hadn’t finished serving an existing waiting period with Phoenix Health.
Any benefits you’ve already claimed on your previous Phoenix Health membership will count towards the applicable limits on your new policy for that calendar year.
Newborns
As long as you add your baby to your Phoenix Health membership within 60 days of their birth, they won’t need to serve any waiting periods — so you don’t need to worry about adding them before they arrive!
Pregnant or planning to start a family? For everything you need to know about having a baby and your Phoenix Health membership, check out our Having a Baby guide.
Adopted or foster children
Adopted or foster children can be added to a Family or Single Parent Family membership by providing documentation that confirms your parental responsibility for the child and the date this came into effect.
Supporting documentation needs to show the date the child came into your care or was legally adopted and can include:
- A letter from the relevant state or territory department confirming you have parental responsibility for the child and are an approved carer.
- A copy of a court order from the Children’s Court or Family Court.
- Confirmation from Centrelink that you receive support payments for the child and the date those payments commenced.
If the child is added within 60 days of their legal guardianship date, the following waiting period rules apply:
- Hospital only policies — we’ll waive the standard 2-month Hospital waiting period. This means the child can receive benefits straight away for eligible hospital treatment that isn’t for a pre-existing condition. The standard 12-month waiting period will still apply to pre-existing conditions.
- Combined Hospital and Extras policies — we’ll waive the standard 2-month Hospital and Extras waiting periods. This means benefits can be available straight away for eligible services such as general dental, physiotherapy and chiropractic, as well as eligible hospital treatment that isn’t for a pre-existing condition. The applicable 6 and 12-month Extras waiting periods will still apply, along with the 12-month Hospital waiting period for pre-existing conditions.
- Extras only policies — all applicable waiting periods will apply when an adopted or foster child is added to an Extras only policy.
What is a Pre-Existing Condition?
A Pre-Existing Condition (PEC) is an illness, ailment or condition where signs or symptoms existed at any time during the 6 months before you joined or upgraded your Hospital Cover. A 12-month waiting period applies to treatment for a Pre-Existing Condition from the date you joined or upgraded your cover.
Having a Pre-Existing Condition doesn’t mean you’ll pay more for your health insurance.
I think I have a Pre-Existing Condition — what happens now?
If you need a hospital admission within the first 12 months of joining or upgrading your Hospital Cover, give the Phoenix Health team a call on 1800 028 817 so we can determine whether a Pre-Existing Condition assessment is required.
How does the Pre-Existing Condition assessment work?
We’ll send you a Pre-Existing Condition Medical Assessment Form, which will need to be completed by you and your treating medical practitioners. Once we receive the completed paperwork, an independent medical practitioner will assess the information and determine whether your condition is pre-existing.
How long does the assessment take?
The Pre-Existing Condition assessment can take up to 10 business days once we’ve received all of the completed paperwork.
Planning a hospital admission? It’s important to allow enough time for your assessment to be completed before you’re admitted. If you’re admitted before the assessment is complete and your condition is later determined to be pre-existing, Phoenix Health won’t be able to pay benefits towards that admission and you’ll be responsible for hospital and medical costs not covered by Medicare.
What if my condition is not considered pre-existing?
If your assessment determines that the condition isn’t pre-existing, we can pay benefits towards eligible treatment for that condition in line with your level of cover, provided any other applicable waiting periods have been served.
What if my condition is considered pre-existing?
If your assessment determines that the condition is pre-existing, we won’t be able to pay benefits towards treatment for that condition until you’ve served the 12-month waiting period.
If you need treatment before then, you can speak with your treating specialist about your options, which may include self-funding your private hospital treatment or receiving treatment as a public patient in the public hospital system.
An accident is an unplanned or unforeseen event that occurs by chance and is caused by an unintentional and external source, resulting in bodily injury that requires immediate hospital treatment. An accident isn’t a condition that can be attributed to medical causes.
There are no waiting periods for eligible hospital treatment received as the result of an accident.
If you’re serving waiting periods or your Hospital Cover excludes the treatment you need as the result of an accident, the applicable waiting period or exclusion may be waived and benefits paid towards an eligible private hospital admission.
How are Accident Cover benefits assessed?
To be eligible for Accident Cover benefits, you must attend an emergency facility within 24 hours of the injury. Treatment relating to the injury must begin within 30 days of the accident and be completed within 90 days.
We’ll need a doctor’s report from your visit to the emergency facility, along with any other supporting information we request to assess your claim.
Contact the Phoenix Health team as soon as you’re able on 1800 028 817 and we can guide you through the Accident Cover claiming process.
Is there anything Accident Cover won’t cover?
Accident Cover benefits aren’t payable where:
- The condition is related to a pre-existing condition, pregnancy and birth, drug or alcohol use, illegal activity or a surgical procedure.
- The condition can be claimed through compensation or damages, or another third-party insurance policy.
- The admission is to a public hospital.
- The accident occurred outside Australia.
If your Hospital Cover has an excess, you’ll still need to pay the applicable excess for an Accident Cover admission.
To improve access to mental health treatment, the Australian Government introduced the Psychiatric Upgrade Waiver for private Hospital Cover.
If your Hospital Cover has restricted benefits for Hospital Psychiatric services and you’ve served the general 2-month Hospital waiting period, you can upgrade to a policy that provides full cover for Hospital Psychiatric services without serving the usual waiting period on the upgraded psychiatric benefits.
The waiver only applies to Hospital Psychiatric services. Any waiting periods that apply to other services will still need to be served, and any excess or co-payment that applies to your upgraded cover will still apply.
Important to know
The Psychiatric Upgrade Waiver can only be used once per person during their insured lifetime. If you’ve previously used the waiver with another Australian health fund, you can’t use it again after transferring to Phoenix Health.
Information about whether you’ve previously used the Psychiatric Upgrade Waiver is transferred between Australian health funds as part of your transfer information.
