Waiting periods

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Waiting Periods

A “waiting period” is the period of time a person must have health cover before benefits are paid.

Applicable Waiting Periods

What are waiting periods?

A waiting period is an initial period of health insurer membership during which no benefit is payable for certain procedures or services. Waiting periods can also apply to any additional benefits when you change (upgrade) your health insurance policy.

 

Why do waiting periods apply? 

In Australia, all health insurers are required by law to provide health insurance for Australian residents regardless of their health status and cannot charge higher premiums based on whether a person is more likely to require treatment. If there were no waiting periods, people could take out hospital insurance or upgrade to a higher policy only when they knew or suspected they might need hospital treatment. Their hospital costs would then have to be paid by the long-term members of the insurer. This would lead to much higher premiums for all insurer members and would not be fair.

 

Do all health insurers apply the same waiting periods?

Most insurers apply the same waiting periods for hospital policies, but waiting periods do differ between insurers for general treatment (extras).

 

Benefit limitation periods

Some insurers also apply Benefit Limitation Periods for some types of treatment on some of their hospital policies. These are initial periods of membership during which only a minimal benefit is paid for some types of treatment. HCI does not have any Benefit Limitation Periods included in its hospital products.

 

First-time health cover

If you are taking out private health insurance for the first time, you will be required to serve full waiting periods before benefits can be paid.

 

Transferring from another health fund (portability)

If you already have health cover with another health fund, you can transfer to HCI at any time.

If you join within 2 months of the expiration of your cover with your previous fund, you will not have to serve any new waiting periods for the same or lower level of cover with HCI.

HCI’s normal waiting periods will be applied, including the pre-existing ailments rule, to benefits not covered by your previous fund cover. Under the Federal Government’s Lifetime Health Cover initiative, your “certified age at entry” with your previous fund will be recognised by HCI if you join immediately after the expiration of your cover with your previous fund.

 

Accidents

There is no waiting period for treatment as a result of an accident sustained after joining us. An accident is categorised as an unforeseen event or incident which results in an injury and requires immediate treatment.

 

Changing your HCI cover

You can vary  your  level  of  cover  to  meet  your  changing  needs at any time. If you increase your level of cover by adding a new benefit type, or by increasing your benefit level, or moving from an excess product to a lower or excess free product, waiting periods will apply to the higher benefits of your new cover. You will, however, be entitled to the benefit levels of your previous cover.

 

Psychiatric services and rehabilitation

Psychiatric services and rehabilitation only  require  a  2  month waiting period, even if the condition is pre-existing. This means you can be covered 2 months after commencing a policy.

 

Pre-existing conditions

If you have less than 12 months membership on your current level of cover, you should contact us on 1800 804 950 before arranging hospital treatment to find out whether the pre-existing condition rule applies to you.

A pre-existing condition is defined as any ailment, illness, or condition where, in the opinion of a medical adviser appointed by the health insurer, the signs or symptoms of that illness, ailment or condition existed at any time in the period of 6 months ending on the day on which the person became insured under the policy. The pre-existing condition waiting period applies to new members and members upgrading their policy to any higher level benefits under the new policy.

The test applied under the law relies on the presence of signs or symptoms of the illness, ailment or condition; not on a diagnosis. It is not necessary for the member or their doctor to know what their condition is, or for it to be diagnosed. In forming an opinion about whether or not an illness is a pre-existing condition, the health insurer appointed medical practitioner who makes the decision must take into account information provided by the member’s treating doctor.


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

If there were no waiting period for pre-existing conditions, people could take out hospital cover or upgrade to comprehensive cover only when they knew or suspected that they might need hospital treatment and immediately make a hospital claim. If these new members then ceased their membership or downgraded to a lower level policy, their hospital costs would have to be paid for by the long-term members who remain on their previous hospital policy. This would not be fair to long-term members.

New and upgrading members who do have pre-existing conditions can still seek treatment for these conditions in a public hospital under Medicare.

 

Key Points for pre-existing conditions

  • Only applies to hospital tables.
  • It is the health insurer’s medical practitioner who decides if an ailment, illness or condition is pre-existing, NOT the member’s treating doctor. The insurer’s medical practitioner must also consider any information regarding signs and symptoms provided by the treating medical practitioner(s).
  • Whether or not a member has a pre-existing condition must always be assessed in relation to that person’s individual circumstance. It is not allowable to say that certain conditions are always pre-existing.
  • The medical practitioner appointed by the health insurer must be satisfied that there is a direct link between the ailment, illness or condition that requires hospital treatment and the signs and symptoms that existed in the 6 month period prior to the member joining or upgrading hospital cover.
  • It is not necessary for the ailment, illness or condition, to have been diagnosed in the 6 month period – only that signs or symptoms were, or would have been, evident.
  • These signs and symptoms should have been reasonably apparent to either the member, or a reasonable general practitioner had the member been examined in this 6 month period.

 

First-time health cover

If you are taking out private health insurance for the first time, you will be required to serve full waiting periods before benefits can be paid.

Waiting periods for new born babies

Waiting periods for new born babies

When a newborn child is added to a family or single parent policy, the child is deemed to have served the same waiting periods as the policy holder, providing that:

-     the  child  is  added  to  the  policy  within  2  months  of  their date of birth; and

-     all contributions with respect to that policy are paid up-to-date and effective from the date of birth.

Note: Where the policy is a single or couples policy prior to the birth, the addition of the newborn child will require the policy to be upgraded to a family or single parent policy from the date of birth.

If you haven’t been covered by family hospital cover for 12 months prior to becoming pregnant, we suggest you give us  a  call  on 1800 804 950 to check you and your baby’s benefit entitlements.

Changing your HCI cover

You can vary your level of cover to meet your changing needs at any time. If you increase your level of cover by adding a new benefit type, or by increasing your benefit level, or moving from an excess product to a lower or excess free product, waiting periods will apply to the higher benefits of your new cover. You will, however, be entitled to the benefit levels of your previous cover.

Transferring from another health fund (portability)

If you already have health cover with another health fund, you can transfer to HCI at any time.

If you join within 2 months of the expiration of your cover with your previous fund, you will not have to serve any new waiting periods for the same or lower level of cover with HCI.

HCI’s normal waiting periods will be applied, including the pre-existing ailments rule, to benefits not covered by your previous fund cover. Under the Federal Government’s Lifetime Health Cover initiative, your “certified age at entry” with your previous fund will be recognised by HCI if you join immediately after the expiration of your cover with your previous fund.

Pre-existing conditions

If you have less than 12 months membership on your current level of cover, you should contact us on Freecall 1800 804 950 before arranging hospital treatment to find out whether the pre-existing condition rule applies to you.

A pre-existing condition is defined as any ailment, illness, or condition where, in the opinion of a medical adviser appointed by the health insurer, the signs or symptoms of that illness, ailment or condition existed at any time in the period of 6 months ending on the day on which the person became insured under the policy. The pre-existing condition waiting period applies to new members and members upgrading their policy to any higher level benefits under the new policy.

The test applied under the law relies on the presence of signs or symptoms of the illness, ailment or condition; not on a diagnosis. It is not necessary for the member or their doctor to know what their condition is, or for it to be diagnosed. In forming an opinion about whether or not an illness is a pre-existing condition, the health insurer appointed medical practitioner who makes the decision must take into account information provided by the member’s treating doctor.

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

If there were no waiting period for pre-existing conditions, people could take out hospital cover or upgrade to comprehensive cover only when they knew or suspected that they might need hospital treatment and immediately make a hospital claim. If these new members then ceased their membership or downgraded to a lower level policy, their hospital costs would have to be paid for by the long-term members who remain on their previous hospital policy. This would not be fair to long-term members.

New and upgrading members who do have pre-existing conditions can still seek treatment for these conditions in a public hospital under Medicare.

Key Points for pre-existing conditions

  • Only applies to hospital tables.
  • It is the health insurer’s medical practitioner who decides if an ailment, illness or condition is pre-existing, NOT the member’s treating doctor. The insurer’s medical practitioner must also consider any information regarding signs and symptoms provided by the treating medical practitioner(s);
  • Whether or not a member has a pre-existing condition must always be assessed in relation to that person’s individual circumstance. It is not allowable to say that certain conditions are always pre-existing;
  • The medical practitioner appointed by the health insurer must be satisfied that there is a direct link between the ailment, illness or condition that requires hospital treatment and the signs and symptoms that existed in the 6 month period prior to the member joining or upgrading hospital cover;
  • It is not necessary for the ailment, illness or condition, to have been diagnosed in the 6 month period – only that signs or symptoms were, or would have been, evident;
  • These signs and symptoms should have been reasonably apparent to either the member, or a reasonable general practitioner had the member been examined in this 6 month period.

Obstetrics (pregnancy and birth related services - including IVF and assisted reproductive services)

Obstetrics (pregnancy and birth related services - including IVF and assisted reproductive services). 

A 12 month wait applies to any obstetric related services.

  • Services    which    occur    outside    of    a    hospital    admission, including consultations and tests, may be claimable on Medicare or paid out of your own pocket.
  • A person with single membership is eligible for obstetric benefits provided she has been a member of a hospital table for 12 months or more.

Always check with the hospital, HCI and your doctor before proceeding with a hospital booking to ensure you will be covered and to discuss what costs you may incur.

 

IVF and assisted reproductive technology

In vitro fertilisation (IVF) treatment is a process to treat infertility. IVF and other assisted reproductive services aren’t automatically covered on policies that cover natural births and obstetrics. Even on policies which include IVF, the treatment has several steps and only the component which involves an admission to hospital can be covered under private hospital insurance.

Check with HCI before proceeding with IVF or similar treatments to confirm what services you will be required to pay for and that you have completed any required waiting periods. The standard waiting period of IVF treatment is 12 months. Check with your doctor and IVF clinic for more information and quotes.

IVF and assisted reproductive technology

In vitro fertilisation (IVF) treatment is a process to treat infertility. IVF and other assisted reproductive services aren’t automatically covered on policies that cover natural births and obstetrics. Even on policies which include IVF, the treatment has several steps and only the component which involves an admission to hospital can be covered under private hospital insurance. Services which occur outside of a hospital admission, including consultations and tests, may be claimable on Medicare or paid out of your own pocket.

Check with HCI before proceeding with IVF or similar treatments to confirm what services you will be required to pay for and that you have completed any required waiting periods. The standard waiting period of IVF treatment is 12 months. Check with your doctor and IVF clinic for more information and quotes.

Psychiatric services and rehabilitation

Hospital insurance covers the cost of hospital accommodation and a portion of the medical fees. Hospital admission may be for an extended period but it can also be overnight or for a day admission only (where you are treated and discharged on the same day).

Psychiatric services and rehabilitation only require a 2 month waiting period, even if the condition is pre-existing. This means you can be covered 2 months after commencing a policy.

Accidents

There is no waiting period for treatment as a result of an accident sustained after joining us. An accident is categorised as an unforseen event or incident which results in an injury and requires immediate treatment.