Waiting periods and health insurance
In this guide, we’ll break down what waiting periods are in health insurance, why they exist to protect Australians, and how you can manage them to make the most out of your health insurance. We also discuss some nuances in waiting times that will give you an advantage when using your insurance. Understanding these conditions and their associated waiting periods enables policyholders to make better decisions and avoid unexpected out-of-pocket expenses.
Why do waiting periods exist?
Waiting periods play a crucial role in safeguarding the community of insured members by preventing scenarios where individuals abuse the insurance system. Without waiting periods, Australians would rapidly file a high-cost claim and drop their membership soon after.
This kind of strategy, if left unchecked, would lead to higher premiums for everyone who genuinely needs to be insured. Remember, it is called insurance for a reason, not a “guarantee-acne.”
Impact of Waiting Periods on Policyholders
Specific clinical categories, like pregnancy and birth, often have waiting periods more significant than the term of the pregnancy, which means planning becomes essential. Others, like cataracts, are generally diagnosed before they become urgent to remove.
For more information about clinical categories, read our article: What are the differences in hospital coverage tiers?
By thinking through what conditions will likely happen for you within the next 2 to 3 years, you lower your chances of financial risk in the long term and your risk of needing to use the public system because you aren’t appropriately covered. If you are having difficulty deciding what level of insurance is appropriate, give us a call.
What Exactly Are Waiting Periods in Health Insurance?
Upon signing up for a new private health insurance plan or enhancing your coverage with clinical categories you have not previously insured, you must navigate waiting periods before claiming benefits at your updated coverage level. There are several types of waiting periods, including Pre-Existing conditions, New Conditions, and Specific treatments.
Pre-existing Conditions Explained
According to the Private Health Insurance Act 2007, a pre-existing condition is defined by law as any ailment, illness, or condition that you had signs or symptoms of during the six months before you joined a hospital cover or upgraded to a higher hospital policy.
It is unnecessary for you or your doctor to know what your condition was or for it to have been diagnosed. There are no exceptions whatsoever to the Waiting Period Rule. However, it’s worth noting that your insurer is the final authority in determining whether or not you will be privately covered, even if your clinical category is not insured.
Portability
Don’t re-serve waiting periods when you switch to a new health fund or policy
“John was immediately covered for a hip replacement in private hospital because he had already served his waiting periods for joint replacements on his old policy”
New Conditions Waiting Period
If you have had no signs or symptoms of a condition in the six months before taking out an insurance policy, it would classify as a new condition. These are insured two months after the cover is taken.
Please be aware that your health insurer will need time to decide if your condition is considered pre-existing, so check with your insurer well before you go to the hospital to ensure you are covered.
Other Waiting Periods
1. Mental Health
Mental health services have a waiting period exemption since April 1st, 2018, you can upgrade to higher psychiatric benefits without serving the two-month waiting period, once per lifetime, if you have completed an initial two months on any hospital cover level. Contact your insurer for details.
2. General Treatment Waiting Periods
Your health fund is the final authority over what waiting periods you must serve for extras. Waiting periods for general treatments like dental, optical, and physiotherapy vary by insurer but are usually between two and six months. Major items like orthodontics or hearing aids can have waiting periods of twelve months or more.
3. Health Fund Discretion
- Some funds choose to waive extras waiting periods at any given time or don’t have waiting periods at all on some selected services. Funds all have different rules regarding waiting periods on extras and can classify specific therapies or dental procedures differently than others.
- For example, some funds have wisdom teeth, periodontal and veneers under General Dental, while others classify them under Major Dental. Some funds would classify Myotherapy as a Physio claim, while some consider it a natural therapy and add it to Remedial Massage limits.
If you are struggling to find a fund that will give you the best waiting periods for services you need, you’ll benefit from a chat with one of our expert policy advisors at Fair Health Care Alliance. While extra policies can vary with waiting periods between health funds, all funds come together and have the same standard waiting periods applied to hospital cover.
Navigating Waiting Periods: Tips and Strategies
A few things are essential to know when looking for a better health insurance plan.
- Many Australians are worried that leaving their current insurer will result in re-serving waiting periods. This is a very big misconception that we see every single day, when in fact, switching health funds is not going to impact your current cover, as long as your new policy contains the items you previously insured.
- If you currently have private health insurance, you do not need to re-serve waiting periods for the clinical categories you already cover if you move to equivalent or lower coverage.
- Don’t overpay for a clinical category you don’t need.
- If you have a family history of some sort of illness, like kidney stones, cancer, or heart problems, you may want to consider adding these things to your policy. Knowing it could be twelve months before you can claim certain services privately can be scary.
- Keep your cover continuous. If you have something covered, ensure it isn’t lost in the transition to a new level of cover. It’s often easy to lose something important when evaluating your cover. Talk to your health insurance broker if you have one, or contact us at Fair Health Care Alliance for a consultation regarding your options in private health.
Conclusion
Navigating the health insurance landscape can be a challenge, but with the proper knowledge, you can make more informed decisions. Stay proactive, plan accordingly, and choose a plan that suits your needs. Remember, understanding waiting periods in private health insurance is essential for making informed decisions about your coverage. Whether you’re considering new insurance or planning to switch or upgrade your plan, being aware of the various waiting periods for pre-existing conditions, new conditions, and specific treatments will help you navigate the complexities of health insurance effectively.
By planning ahead and consulting with your insurer, you can ensure that you and your family are adequately covered without facing unexpected out-of-pocket expenses. Remember, insurance is about safeguarding your future, and with the right knowledge, you can make the most out of your health insurance plan. If there are any doubts at all, talk to a Fair Health Care Alliance advisor to easily ensure you get the best value for money and proper coverage.
