A waiting period is the time you’ll need to wait after joining or changing level of cover, before you can claim a benefit.
Waiting periods exist to protect our current members and to ensure that we are able to keep premiums as low as we possibly can. If you could join private health or change your level of cover just to claim something and then cancel straight away, premiums would inevitably increase making health insurance unaffordable.
Waiting periods for Hospital Cover
Waiting periods for Extras Cover
Waiting periods for Ambulance
Waiting periods for new members transferring from another fund
When you switch to Phoenix Health from another Australian health fund, any waiting periods you’ve served with your previous insurer will switch with you, so there’s no starting again!
There may be times though where you’ll be required to serve waiting periods:
- Where there’s been a gap in cover of 30 days or more between cancelling with your previous fund and joining Phoenix Health.
- Where services or benefits were not covered, excluded or restricted under your previous cover, waiting periods will apply to these services.
- Where you join Phoenix Heath on a level that is considered an upgrade in cover from your previous fund- waiting periods will apply to the upgrade in any benefits, limits or excess amounts.
- Where you haven’t fully served your waiting periods with your previous fund, you’ll need to complete the remainder of your waiting periods before you can claim on your Phoenix Health cover.
Waiting periods for new members to private health insurance
New to private health or been without cover for more than 30 days when you join Phoenix Health? Full waiting periods will apply before you’re able to claim on your membership.
Waiting periods for existing Phoenix Health members changing their level of cover
As a Phoenix Health member, when you make a change to your level of cover, waiting periods will apply only to any upgrades to benefits, limits or excess that occur as a result of the upgrade.
It’s also important to remember that if you downgrade your cover, in the future if you decide to upgrade again (and it’s been more than 30 days since you held the higher cover), waiting periods will apply to the upgrade in cover, as detailed above.
Waiting periods for existing Phoenix Health members moving between memberships
Where you join a new (or existing) Phoenix Health policy within 30 days of being removed from your previous policy, you won’t need to re-serve waiting periods for equivalent cover.
Waiting periods will still apply where:
- a gap in cover of more than 30 days
- for any services or benefits that were not covered
- for any excluded or restricted services under your previous cover
- for any any upgrades in cover – including benefits, limits or excess amounts
- where you haven’t fully served your waiting periods with Phoenix Health.
Any limits you have accessed on your previous Phoenix Health membership will count towards your limits used on your new policy, for that calendar year.
As long as you add your baby to your Phoenix Health membership within 60 days of their birth, they won’t have any waiting periods – you don’t need to worry about doing this before baby arrives!
|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 guide here.
Adopted or Foster Children
Adopted or foster children can be added to a family or single parent family membership by supplying us with supporting documentation that shows the member’s parental responsibility for the child and what date this came into effect. Supporting documentation must show what date the child came into the member’s care or was legally adopted and can be in the form of:
- a letter from the Department of Family and Community Services confirming the member has parental responsibility for the child and has been recognised as an approved carer of the child
- a copy of the court order from the Children’s or Family Court
- confirmation from Centrelink that the member receives support payments for the child and what date this commenced
When the child is added within 60 days of their legal guardianship date, we’ll waive the child’s waiting periods in the following instances:
- Hospital only policies – we’ll waive the standard 2 month hospital waiting period, which means that if the child needs in-hospital treatment for a condition that is not considered pre-existing conditions, they’ll be covered straight away. Pre-existing conditions will still have the standard 12 month waiting period applied.
- Combined Hospital and Extras policies – we’ll waive the standard 2 month hospital and extras waiting periods. Benefits will be available straight away for things like general dental, physiotherapy and chiropractic as well as in-hospital treatment for a conditions that aren’t considered pre-existing. 6 and 12 month waiting periods will still apply on the extras and for hospital, the standard 12 month waits will still apply to pre-existing conditions.
- Extras only policies – all waiting periods will apply when you add an adopted or foster child on to an Extras only policy.
What is a Pre-Existing Condition?
A Pre-Existing Condition (PEC) is any illness, ailment or condition that existed or showed any signs or symptoms at any point in the 6 months prior to taking out or upgrading your hospital cover. PECs have a 12-month waiting period starting from the date you commenced or upgraded your hospital cover.
Health insurers do not charge you any extra fees if you do have a pre-existing condition.
I think I have a pre-existing condition – what happens now?
Once you’ve served your 2-month general hospital waiting period, if you’re going to need a hospital admission within the first 12-months of holding or upgrading your cover you’ll need to give us a call on 1800 028 817 so we can start the PEC assessment process for you.
How does the Pre-Existing Condition assessment work?
We’ll send you a copy of the Pre-Existing Condition: Medical Assessment Form which will need to be completed in full by you, your GP, and your treating Specialist. The form will then be assessed by an independent Medical Practitioner who will determine whether the condition is pre-existing or not.
How long will the Pre-Existing Condition Assessment take?
The PEC process can take up to 10 business days once we have received your completed paperwork. If you’re admitted to hospital before the PEC assessment is completed and your condition is deemed as pre-existing, no benefits will be payable by Phoenix Health for your admission, and you will be responsible for all hospital and medical charges not covered by Medicare.
My PEC assessment has deemed by condition not pre-existing
This means we can pay a benefit towards your hospital admission as per your level of cover only for the condition that has been assessed.
My PEC assessment has deemed the condition as pre-existing – what now?
This means we are unable to pay a benefit for the condition until you have served your 12-month waiting period. However, you do have some options; you could self-fund your hospital admission or you could speak with your treating specialist about having the procedure done as a public patient in the public system.
An accident is an unplanned or unforeseen event, occurring by chance and caused by an unintentional and external source, resulting in bodily injury that requires immediate hospital treatment. An accident is not a condition that can be attributed to medical causes. There are no waiting periods for hospital treatment received as the result of an accident.
Where a member is within waiting periods or holds a level of hospital cover that has exclusions and needs to go to hospital as a result of an accident, the mandatory waiting period for that condition will be waived and benefits payable for a private hospital admission, regardless of whether the service is excluded on the member’s level of cover or not.
How are Accident Cover benefits assessed?
For accident benefits to be assessed, you must report to an emergency facility within 24 hours of the injury and a Doctor’s report of this visit must be submitted to Phoenix Health along with any other supporting documentation as requested. All treatment relating to the injury must be initiated within 30 days and completed within 90 days of the accident.
Please contact the Phoenix Health Team as soon as you are able, and we can guide you through the Accident Cover claiming process.
Is there anything Accident Cover won’t cover?
Accident Cover benefits are not payable where:
- Your hospital cover has an excess – you’ll still need to pay this for an Accident Cover admission.
- The condition is related to a pre-existing condition, pregnancy and birth, drug and alcohol use, illegal activities or resulting from a surgical procedure;
- The condition is claimable through compensation or damages, or through another third-party insurance policy.
- The admission is to a public hospital.
- The accident occurred outside of Australia.
To improve access to mental health treatment in Australia, the Government introduced mandatory Psychiatric Hospital upgrade waiver rules.
Where a hospital cover has restrictions for Hospital Psychiatric services, as long as the general 2 month waiting period has been served, a member can transfer to a policy that provides cover for full Hospital Psychiatric services, without having to serve any waiting periods on the upgrade for that treatment.
All other waiting periods will still apply, and the waiver does not apply to any other services or any excess or co-payments that may apply on upgrading cover.
The Psychiatric Upgrade Waiver is available once per person, per insured lifetime and is transferrable between funds, as detailed on a Transfer Certificate.