Health insurance waiting periods and pre-existing conditions in Australia
The maximum hospital waiting periods, how the 12-month pre-existing condition rule is decided, the mental health waiver, extras waits and upgrades.
When you take out private hospital cover or upgrade it, you usually cannot claim straight away. The government sets the maximum waiting periods: 12 months for pre-existing conditions and for pregnancy and birth, 2 months for psychiatric, rehabilitation and palliative care even if the condition is pre-existing, and 2 months for all other hospital treatment. There is usually no waiting period for an accident that happens after the policy starts. Extras waiting periods are set by each insurer and are often 2 to 6 months for common services and 12 months or more for major dental, orthodontics or hearing aids.
This guide is part of private health insurance and Medicare explained.
Hospital waiting periods at a glance
| Treatment | Maximum waiting period |
|---|---|
| Pre-existing conditions (other than psychiatric, rehabilitation or palliative care) | 12 months |
| Pregnancy and birth | 12 months |
| Psychiatric care, rehabilitation, palliative care | 2 months, including when pre-existing |
| All other hospital treatment | 2 months |
| Accident occurring after cover starts | Usually none |
Insurers can set shorter waiting periods or waive them as a promotion, but not longer ones for hospital cover. Check the Private Health Information Statement for the exact periods.
What counts as pre-existing
A pre-existing condition is any ailment, illness or condition that you had signs or symptoms of in the six months before you joined or upgraded. It does not matter whether you had seen a doctor or knew what it was. The decision is made by a medical practitioner appointed by the insurer, who must consider information from your own treating doctors.
Example. Jess notices recurring knee pain and swelling in May. She takes out Bronze cover on 1 July. In October her GP refers her to a surgeon, who recommends an arthroscopy. Because she had symptoms in the six months before joining, the insurer's medical adviser is likely to rule the condition pre-existing, and the 12-month wait applies until 1 July next year. If she had been injured playing netball in August, after joining, it would usually be treated as an accident or a new condition.
Insurers cannot refuse to sell you cover because of your health; Australian private health insurance is community rated, so everyone pays the same premium for the same policy regardless of health, claims or age (apart from the Lifetime Health Cover loading and age-based discounts). The waiting period is how insurers manage the risk instead.
The mental health waiver
Since 1 April 2018 you can upgrade your hospital cover once in your life to get higher benefits for in-hospital psychiatric treatment without serving the 2-month waiting period, provided you have already served the initial 2 months on your current policy. Ask the insurer to apply the waiver when you upgrade.
Upgrades and switching
- Switching to the same or lower cover: waiting periods you have already served carry over, so you do not start again.
- Upgrading: you can claim at the old level straight away, but you serve new waiting periods on the higher benefits or new categories.
- A break in cover: a gap between policies can mean starting waiting periods again. Insurers set how long a break they will accept; confirm it before cancelling anything.
The switching checklist and the switching guide cover the steps.
Pregnancy and babies
The 12-month wait for pregnancy and birth means hospital cover that includes it must normally start before conception. Pregnancy and birth is guaranteed only in Gold hospital cover, although some Silver Plus policies include it. To have a newborn covered from birth, you usually need to move to a single parent or family policy before the birth; insurers set their own rules on how far in advance. If you are already pregnant without suitable cover, the public hospital system provides maternity care for Medicare-eligible residents.
Extras waiting periods
Extras waiting periods are not capped by the hospital rules. Typical structures (illustrative):
| Service | Common waiting period |
|---|---|
| Dental check-up and clean | 2 months |
| Physio, chiro, podiatry | 2 months |
| Optical | 6 months |
| Major dental, such as crowns | 12 months |
| Orthodontics, hearing aids | 12 months or more |
Many insurers also apply waiting periods again if you upgrade extras limits.
When to see a doctor
Waiting periods should never stop you getting care you need. If you have symptoms, see your GP; if the condition is urgent, public hospital emergency departments treat everyone at no cost to Medicare-eligible patients. Call 000 in an emergency or healthdirect on 1800 022 222 for advice. Your GP can also tell you whether planned treatment can wait until a waiting period ends.
FAQ
Can I be a private patient while serving a waiting period?
You can, but the insurer will not pay benefits for that treatment. You would pay the hospital and doctors yourself, apart from Medicare's 75% of the schedule fee for doctors.
Who decides if something is pre-existing?
A medical practitioner appointed by the insurer, using information from your doctors. You can ask the insurer to review the decision and complain to the Ombudsman if you disagree.
Is there a waiting period for ambulance cover?
Insurers set ambulance waiting periods; many have none or a short one. Check the policy.
Does the accident rule cover sports injuries?
Usually, if the injury happens after cover starts, but definitions of "accident" vary. Read the policy statement.
Sources
- PrivateHealth.gov.au — waiting periods and the pre-existing condition definition
- Commonwealth Ombudsman — complaints about pre-existing condition decisions
- healthdirect — free health advice line and symptom information
