What are private health insurance waiting periods?

Published November 2024 | 5 min read
Words by Andrea Downey

Confused about waiting periods? Here’s what you need to know about hospital cover, extras cover and how long you may have to wait before claiming.

You might think that because you’ve paid for private health insurance you can claim immediately, but it doesn’t work like that. And there’s a good reason behind it.  

Waiting periods protect existing members from paying higher premiums. If health funds didn’t have waiting periods, people could take out private health insurance, make a high-cost claim, then cancel their insurance, meaning people who regularly pay their premiums bear the cost of that claim.

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

When do waiting periods apply? 

Waiting periods apply if: 

• you’re a new member 
• you rejoin after having a break in private health cover 
• you’re an existing member and upgrade to a higher policy. For example, if you increase your cover from HCF's Silver Hospital cover to Premium Gold Hospital cover, there’s a waiting period for new included services not covered in your previous policy or services with a higher level of benefits.   
• you reduce your excess – this is considered an increase in your cover as you’re lowering the amount you pay if you go into hospital. If you do go to hospital during the waiting period, you’ll pay the old, higher excess amount.
  

Do waiting periods apply when you switch private health cover?

If you transfer from another fund, you generally don’t need to re-serve waiting periods you have already completed for benefits previously covered. 

For example, if your new HCF cover includes the same benefits as your previous cover, such as major dental, and you’ve already served the waiting periods with your previous policy provider, then the waiting periods you served will be recognised. 

Even if your previous cover has lapsed, you may still be eligible to skip waiting periods if it lapsed within 30 to 60 days of your new cover. Different health funds have different rules, so check with your new policy provider. 

If you’re upgrading your benefits, for example switching your hospital cover from a silver policy to gold, you’ll need to serve the relevant waiting periods for your higher entitlements.

How long are waiting periods? 

The maximum length of hospital cover waiting periods are set by the Australian Government. Currently, they can be no more than:  

• 12 months for pre-existing conditions 
• 12 months for pregnancy and birth-related services 
• two months for psychiatric care, rehabilitation or palliative care (even if it's for a pre-existing condition) 
• two months for all other services. 

What about extras and ambulance cover?

Most HCF extras like dentures, hearing aids, orthodontics and major dental have a 12-month waiting period; minor treatments have a two-month waiting period. Most HCF members can access hospital cover after just two months and emergency ambulance cover* after just one day. 

What if you have a pre-existing condition? 

A pre-existing condition is an illness or other condition that you had symptoms of in the six months before a health insurance policy started. This applies even if the condition wasn’t diagnosed by a doctor or specialist in that time.  

If you’re upgrading your health insurance policy or switching to a new provider, you will most likely have to serve a 12-month waiting period to access cover for that condition. 

Health funds won’t generally pay for treatments not previously covered until you serve your waiting period and will only pay at the previous cover level if you've upgraded your cover.

Making the most of mental health cover 

To support quicker access to mental health services, patients with limited cover for psychiatric care could be eligible to upgrade their hospital cover to access higher benefits without serving the two-month waiting period. 

However, policy holders are only able to use this exemption once. 

Eligible HCF members can also access an annual HealthyMinds Check-in^{^} with a PSYCH2U psychologist at no cost.

What if you’re visiting Australia?

If you’re living in Australia on a visitor’s visa, you may be eligible for overseas visitors cover.  

Some visas require you to have private health cover, but even if that’s not the case, it’s often a good idea to get health cover as medical treatment can be expensive, especially if you're not covered by a Reciprocal Health Care Agreement. 

Depending on the level of cover you choose, your HCF policy can cover you when you’re in hospital and for other services, like doctor visits, blood tests and X-rays. You can also get cover for extras like dental treatment, glasses and physiotherapy.  

All levels of HCF overseas visitors cover also include emergency ambulance services^*.

Can health cover have no waiting periods? 

Generally, health funds keep to established waiting periods to ensure fairness for all members, but occasionally they may waive waiting periods for some extras cover services. 

You might also see promotions waiving waiting periods from time to time.

Do private patients have to go on waiting lists for surgery? 

Elective surgery is non-urgent surgery like knee replacements, cataract extractions and tonsillectomies.  

Elective surgery waiting lists in the public system tend to be longer than in the private system. When opting for private treatment, you’re also able to choose your doctor and where you’re treated. 

Find a participating hospital to lower your out-of-pocket hospital costs.  

How to get the most from your private health cover  

When taking out health insurance, make sure you’re covered for the things you think you’ll need. 

If your policy doesn’t cover treatments you’re likely to need in the future, it’s a good idea to upgrade or switch policies, being sure to take waiting periods into account. 

For example, if you’re planning a family and want to be covered for the pregnancy and birth, make sure you consider the 12-month waiting period.  

Before booking a hospital procedure, contact your health fund to confirm if you’ve served the relevant waiting periods to avoid unexpected costs. 

A reminder of when waiting periods might apply 

• When you’re a brand-new member. 
• When you’re switching from a different fund. 
• When you’re reducing your excess. 
• When you’re increasing your cover on your current policy. 

Need to review your cover?   

If you’re considering upgrading to a higher or lower level of health cover, adding a dependent or child to your policy or encouraging a friend to get health cover for the first time, we're here to help. Give us a call on 13 13 34, chat to us online or find your nearest branch.