A GUIDE TO WAITING PERIODS
A health insurance waiting period is the initial phase of your membership, during which no benefit is payable for certain procedures or services. Waiting periods can also apply to any additional benefits you may now have access to when you change your policy.
WHAT ARE WAITING PERIODS?
Health insurance waiting periods are mandatory time periods you have to honour before you can claim health insurance benefits. The standard waiting period for health insurance depends on the procedure, type of cover (e.g. extras cover or hospital cover) and health fund.
The Australian Government sets the health insurance waiting periods for all services that fall under hospital cover (those in-hospital fees such as surgery and accommodation), while your health insurer will have their own waiting periods for services under extras cover (such as dental, optical, and physiotherapy).
Health insurers are strict on enforcing waiting periods, so it’s important to do your research before committing to a fund.
WHY DO HEALTH INSURERS HAVE WAITING PERIODS?
Health insurance waiting periods exist so that providers can keep premiums lower. It prevents customers from joining for a particular service and claiming immediately.
A waiting period protects members of a health fund by ensuring that people don’t join up, make an expensive claim, then cancel their membership – resulting in increased premiums for all members of that fund.
WHEN DO WAITING PERIODS APPLY?
Health insurance waiting periods apply in a number of situations. If you’re new to health insurance, have recently re-joined health insurance after cancelling, or have upgraded your health insurance policy, you’ll need to serve a waiting period.
If you are switching to a health insurance provider or a policy that has the equivalent or fewer benefits, the waiting period you’ve already served will be protected by the law for hospital related treatments.
Most funds won’t apply waiting periods for dental and other general treatments you’ve already served with another health fund.
ARE THERE DIFFERENT WAITING PERIODS FOR HOSPITAL COVER?
Hospital cover relates to any in-hospital fees including accommodation, operations, nursing care, and medication taken while you’re in hospital. The Australian Government determines the maximum health insurance waiting periods that you need to serve in regards to hospital cover.
If you have a ‘pre-existing condition’, you’ll still be able to claim for your treatment provided you serve the 12-month waiting period.
‘Pre-existing condition’ examples include heart disease, high blood pressure, cancer, and diabetes or any other conditions that have been showing signs or symptoms during the past six months.
Pregnancy and obstetrics cover also requires a waiting period of 12-months.
Psychiatric care, rehabilitation, palliative care (even for a pre-existing condition) and hospital admission only require a two-month waiting period.
WHAT ARE THE WAITING PERIODS FOR HOSPITAL COVER?
Every health insurance policy includes waiting periods that you need to serve before you can claim benefits. The waiting periods for hospital cover are enforced by the Australian Government.
If you have a pre-existing condition that has shown signs or symptoms during the past six months – such as heart disease, high blood pressure, or diabetes – you’ll be able to make a claim under hospital cover once you serve the initial 12-month waiting period.
Pregnancy similarly requires you to wait a period of 12-months. Psychiatric care, rehabilitation, palliative care (even for a pre-existing condition), and hospital admissions for new conditions only require a 2-month waiting period.
If you have held a health insurance policy, with hospital psychiatric services covered as a restricted service for a minimum of 2 months, you will be entitled to upgrade once in your lifetime and waiver the waiting periods. You also have the ability to backdate this waiver for up to 5 days.
If you are transferring from another health fund, the waiting periods you have served will transfer with you. You will only need to serve a waiting period for services that you were not previously covered for.
AM I ELIGIBLE FOR A WAITING PERIOD EXEMPTION FOR MENTAL HEALTH?
From 1 April 2018, you can upgrade your hospital cover to a higher level of hospital cover without having to serve the two-month waiting period to access higher benefits for psychiatric care in a private hospital.
This exemption applies only once per lifetime and can only be accessed if you have already completed an initial two months of membership on any level of hospital cover.
For more information about accessing the exemption, please contact your health fund.
For general information about the exemption, see the Department of Health website: Supporting mental health – waiting period exemption for higher benefits
ARE THERE DIFFERENT WAITING PERIODS FOR EXTRAS COVER?
Unlike hospital cover waiting periods that are protected by law, health insurance waiting periods for extras depend on your specific fund.
In general, waiting periods for extras can range from two to 12 months depending on the complexity and cost of your treatment.
Typical examples of waiting periods for extras include two months for dental check-ups and physiotherapy, six months for optical and 12-months for major dental procedures such as orthodontics.
WHAT HAPPENS TO MY WAITING PERIODS IF I SUSPEND MY POLICY?
In certain cases, you’ll be able to suspend your local health insurance when you travel overseas for work or play.
This can be helpful if you want to save money, but it’s super important to remember that the days you suspend your cover won’t be counted towards your health insurance waiting periods.
HOW DO I FIND A FUND WITH THE SHORTEST WAITING PERIODS?
Comparing health insurance providers is one of the best ways to find a provider with suitable health insurance waiting periods and great value.