Private Health Insurance and Pre-Existing Conditions


In Australia, although pre-existing conditions are referred to in the policy literature of all private health insurers, the exact details could vary from one insurer to the other. A waiting period, which is not more than 12 months, can be executed by health insurers before the insured person is able to access hospital benefits for certain pre-existing conditions.

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What is a pre-existing condition?

Pre-existing conditions are medical conditions, ailments, or illnesses for which the insured person exhibits symptoms or signs at any stage in the preceding six months, calculated to the day the policy becomes active. There is no need for a diagnosis. Moreover, the insured people are not expected to know about the pre-existing condition. It could rely on the opinion of a medical adviser designated by the health insurer, considering the presence of any symptoms and signs and/or information given by the doctor treating the insured person.

When can hospital benefits for pre-existing conditions be accessed?

The waiting period for any pre-existing conditions should not be more than 12 months, and once the insured person can access the complete benefits of the policy they have continuous hospital cover for 12 months. This waiting period is applicable to persons choosing the private health insurance offered by iSelect in Australia for the first time, or at the time of upgrades to a new policy that offers better benefits or a higher level of cover.

What is the purpose of a waiting period for pre-existing conditions?

The waiting period is not for denying access to healthcare for individuals; in contrast, it protects the insurer as well as other members of private health insurance. It prevents individuals from taking up hospital cover, or a higher level of cover, only when the need for a particular treatment arises, and then canceling it once the required treatment is over, which would result in the insurer and other members taking up the financial burden. Individuals who have a pre-existing condition, but no private health insurance, can still access public hospital treatment under Medicare.

Important points to remember

The Private Health Insurance Act 2007 legislates that private health insurers can implement a 12 month waiting period for benefits in the case of pregnancy and childbirth, apart from a two-month waiting period for palliative care, psychiatric care, and other services.

Each health insurer can decide whether these additional waiting periods are applicable, and the duration. Comparison of various insurance products and their terms and conditions is simplified by iSelect–Health Insurance Australia.

However, it must be noted that although individuals are expected to declare any pre-existing conditions known to them, decisions regarding pre-existing conditions are taken based on the opinion of a medical adviser designated by the insurer, in which case family history of any conditions and/or risk factors are not taken into account.

About iSelect

As Australia’s Life Admin Store™, iSelect helps customers take care of some of life’s most important purchase decisions. They are proud of the service they provide to the millions of Australians who seek expert advice each year. With plenty of partners and hundreds of policies, plans and products, iSelect gives customers the confidence to make the right call on the things that matter most.

Their dedicated departments cover all of life’s essentials, from choosing the right health insurance, life insurance, obtaining a car insurance quote to a home loan comparison. iSelect can help customers with electricity providers, broadband connections, and even take care of travel insurance.  

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Last updated: Nov 19, 2018 at 10:58 AM

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