Finding Health Insurance with Pre-existing Conditions

Published: July 15, 2019

Australian law states that no one may be refused access to private health insurance because of their health status or medical history. However, according to the Private Health Insurance Act 2007, health funds may impose a 12-month waiting period. Meaning, you must wait 12 months before you can claim any benefits relating to your pre-existing condition.

Once you've served your waiting period, you can generally claim benefits.

You might want to compare major health insurance brands to help you find a company offering shorter waiting periods for your specific pre-existing condition.

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What is considered a pre-existing medical condition in health insurance?

Under current health insurance law, a pre-existing condition is defined as an ailment, illness or condition for which there were signs or symptoms 6 months before purchasing or upgrading your policy. Such signs and symptoms as are the opinion of the insurer's appointed medical practitioner.

Before getting health insurance with a pre-existing condition, you should know:

  • Even if your condition has not been diagnosed, it may still be viewed as pre-existing.
  • Generally, signs and symptoms of the ailment, illness or condition should have been reasonably evident for it to be considered pre-existing.
  • Your health insurer might request a medical certificate from your doctor, stating your medical condition over the past six months.
  • Any persisting symptoms noted during this period are assessed, whether your doctor made a diagnosis or not.
  • The health fund will determine whether your medical condition is pre-existing by appointing a medical practitioner to examine you.

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Does private health insurance cover pre-existing conditions?

Yes, all health funds must provide private health insurance, regardless of your past or present health. However, you can generally expect to wait up to 12 months before you can claim benefits associated with your condition, depending on your chosen health fund.

Take note: After serving the health fund's waiting period, you are free to claim benefits. The cost of your premium will not increase because of a pre-existing condition.

Examples of pre-existing medical conditions in Australia

According to the Australian Institute of Health and Welfare, in 2018, the top diseases leading to people dying early or living the remainder of their lives affected by ill health, include:

  • Coronary heart disease
  • Cancer, specifically lunch cancer in males
  • Arthritis
  • Musculoskeletal condition, like back pain and osteoporosis
  • Asthma in children between the ages of 5 and 14
  • Anxiety disorders
  • Dementia

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Can you get private health insurance with no waiting period for pre-existing conditions?

No, all health funds generally adhere to the pre-existing waiting period rules. However, private health insurance companies will analyse policies on a case-by-case basis. Sometimes health funds may waive waiting periods associated with general treatments, but this is extremely rare, especially with regards to pre-existing conditions.

Why is there a waiting period of pre-existing conditions?

Waiting periods help create fairness between health insurance customers. If health funds were to remove waiting periods, people might take out a policy to immediately claim a benefit and then cancel. If there were no waiting periods, premiums would skyrocket to compensate for these frequent payouts.

Frequently asked questions and answers

Which health insurance companies cover pre-existing conditions?

All Australian private health funds cover pre-existing conditions. Typically, you’ll be able to claim benefits for pre-existing conditions after a 12-month waiting period, beginning on the day you join a health fund or upgrade your cover. However, this varies from fund to fund.

Because of this, you might want to request quotes and compare major brands when searching for a policy suited to your requirements.

Is pregnancy a pre-existing condition?

As with pre-existing health conditions, you’ll typically have to wait a maximum of 12 months before you can claim any pregnancy or birth-related benefits.

If you want the ability to choose your obstetrician and give birth in a private hospital, you'll need to apply for a family policy as soon as you're considering getting pregnant.

Will mental illness be classified as a pre-existing condition?

According to the Commonwealth Ombudsman, a mental health problem is seen as a pre-existing condition. However, you only need to serve a 2-month waiting period before being covered as a private patient for psychiatric treatment or drug and alcohol rehabilitation.

How to change policies when you have a pre-existing condition?

If you have a pre-existing medical condition and want to switch health insurance policies, your waiting period will carry over to the new fund. So, you'll continue to serve the time you've not yet completed. However, if you've already completed the waiting period before switching to a new fund, you won't have to re-serve your waiting period.

Take note: When switching to a higher level of cover or to a policy that includes benefits not previously listed, you’ll have to serve the waiting period for the difference in the cover amount or for that specific benefit type.

Before you change health insurance providers:

  • Get a detailed quote from the fund you are planning to switch to.
  • Apply for cover from the new fund.
  • Request that your old fund sends a clearance certificate to your new fund.
  • Cancel your old cover and make sure your old fund is no longer deducting premiums from your bank account.
  • Give your new health fund permission to start deducting premiums.

What happens if you need to go to the hospital during the pre-existing waiting period?

If you need treatment for your condition before your 12-month waiting period ends, you should contact your health fund immediately to check if you are entitled to hospital benefits. Alternatively, you can go to a public hospital under Medicare.

How much is health insurance with a pre-existing condition?

A private health insurance policy that covers pre-existing medical conditions will not cost you more than if you had no prior illnesses, ailments or conditions. Your past and current medical history do not influence your health insurance premium.

Where can you find pre-existing health insurance?

You can find pre-existing health insurance by comparing quotes from some of Australia’s major health insurance brands.

Request health insurance quotes with pre-existing conditions

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  • Dan Savage

    Hey Guys!
    I am moving to Australia for work in the next few months. I live in the U.S. and have good health insurance with my current employer. I am trying to find good health insurance for my wife and me – A requirement for our work VISAs.

    Are there health plans out there that do not have a pre-existing clause or ones even that are less than 12 months? I have Crohn’s Disease and take a once-weekly injection from Humaria that does an outstanding job controlling/treating the condition.

    I was hoping to not have to absorb those prescription costs for a full year before health insurance kicks in. Any thoughts, insights, or plans you can suggest would be greatly appreciated.

    • Specialist
      Anneke Van Aswegen

      Hello Dan.

      Thanks for your question. Generally, the 12-month waiting period for pre-existing conditions are pretty standard for all health insurance providers. However, because you currently have health insurance your waiting period could be reduced, depending on the insurer you choose.

      Feel free to give us a call or fill in the quote form above and a specialist will assist you finding the right cover for you and your wife.

  • Karen

    I have Crohn’s Disease and I’m wondering if it is possible to get Income Protection Insurance

    • Specialist
      Anneke Van Aswegen

      Hi Karen.

      Depending on a few variables regarding your pre-existing condition, for example, date of diagnosis, current medication, your age and general health, you could get income protection insurance. Every insurer has their own underwriting rules, so while one might offer you cover but exclude Crohn’s disease, another might provide comprehensive cover at an increased premium or even standard rates depending on your personal information. It’s best to shop around and see which one offers you the best cover at the best price.

      Please give us a call on 1300 743 254 and request a pre-assessment be done – this is when we send your details on an anonymous basis to companies to see what coverage and premium you can expect.

      Hope to hear from you soon.