Research & Insights

Private health insurance waiting periods: Your questions answered

Confused about waiting periods with private health funds? Get the lowdown on how they work and why they exist in this blog from HCF health insurance.

Bonnie Bayley
Nov 2019

When you pay for a service, you want it to kick in immediately, right? It’s true for your internet and electricity, but private health insurance is a bit different. You usually serve a waiting period before you can start claiming on your private health cover.

Here’s why waiting periods exist and how they work regardless of your level of cover.

Why do private health funds have waiting periods?

Having to wait to use some parts of your private health cover, like major dental, can be frustrating – particularly if you’ve been a member for a while – but there’s solid reasoning behind this, says HCF team member Caeden Kalen Zaine.

“If we didn’t have waiting periods, someone could join private health insurance, make a high-cost claim, and then cancel their insurance,” he says. “Then the ones who’d have to bear the cost of that claim would be all the other people who were consistently paying towards their insurance.”

In short, waiting periods protect existing members and reduce the rate of premium increases in the long run.

How long are waiting periods for health insurance?

The Australian Government sets the maximum hospital cover waiting periods.

Here’s what the government decided is the maximum length:

  • A 12-month waiting period for treatment of pre-existing conditions. ‘Pre-existing’ means any condition, illness or ailment that you had signs or symptoms of in the six months before you joined a hospital policy or upgraded to a higher hospital policy – even if it wasn’t officially diagnosed.
  • A 12-month wait for pregnancy and birth related services.
  • A 2-month wait for psychiatric care, rehabilitation and palliative care, plus all other circumstances (any new health conditions that require hospitalisation).

“With HCF, although there’s a waiting period of two months for hospital cover, your emergency ambulance cover kicks in after only one day,” adds Caeden.

When do waiting periods apply to hospital or extras cover?

When it comes to extras waiting periods for cover like dental, optical, physiotherapy and remedial massage, these are set by individual private health insurers. Wait times vary significantly between insurers, from two months to three years, depending on the service.

Waiting periods apply if:

  • you’re a new member
  • you re-join after having a break in private health cover
  • you’re an existing member and change your cover or upgrade your cover to a higher policy e.g. if you upgraded from HCF's Silver Hospital cover to Premium Gold Hospital, there’s a waiting period for joint replacement surgery
  • you reduce your excess: “Reducing your excess is considered an upgrade, because you’re lowering the amount you have to pay if you go into hospital,” explains Caeden. If you do go to hospital during this waiting period, you’ll pay the old, higher excess amount, rather than the excess you’re changing to.

Do waiting periods apply when you switch private health cover?

If you switch between private health funds, you may not need to re-serve waiting periods.

For example, if your new HCF cover includes the same benefits and services as your previous cover, and you’ve already served the equivalent waiting periods, then the HCF waiting periods may be waived. Some timeframes and exceptions may apply so it’s best to speak to an expert by calling us on 13 13 34 to find out.

Can health funds waive your waiting periods?

Generally, health funds keep to established waiting periods to ensure fairness for all members, but occasionally they may waive waiting periods for extras cover items such as general dental services (not the more complex treatment), some optical treatments, and therapies such as remedial massage. “You might also see promotions from time to time,” explains Caeden.

How to get the most from your private health cover

  • Be sure to contact your health fund before you have any health treatment or before going to hospital as a private patient, to check whether you’ve served any relevant waiting periods.
  • Be as prepared as you can be. If you’re planning a family and would like to be covered for the pregnancy and birth, make sure you arrange private health cover with enough time, taking into account a nine month pregnancy and the 12 month waiting period. If you want your baby covered from birth, let your private health insurer know within two months of their arrival.
  • For unexpected situations, like emergency hospitalisation where you haven’t served out the two month waiting period for new conditions, you can access the public health system.

For more information on waiting periods, call on 13 13 34, or log in to online member services.

A reminder of when might waiting periods apply?

  • When you’re a brand-new member
  • When you’re swapping over from a different fund
  • When you’re reducing your excess
  • When you’re upgrading your current policy. 

Source: Commonwealth Ombudsman

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