Health cover explained: What is a pre-existing condition?

Updated July 2024 | 5 min read
Words by the Health Agenda team

What is a pre-existing condition? And how can it affect your private health insurance? Let’s find out. 

When quizzed about our health, most Aussies think we’re doing pretty well. According to the latest Australian Institute of Health and Welfare report, more than 80% of us aged 15 to 64 believed our own health was ‘excellent’, ‘very good’ or ‘good’.

However, almost 50% of us are probably living with at least one of these chronic conditions:

• cancer
• heart disease
• mental health problems
• arthritis
• back pain and back issues
• asthma
• diabetes
• chronic obstructive pulmonary disease.

And almost a quarter of us are likely to have two of these conditions.

The disconnect between how healthy we think we are and how well we actually are is a challenge for many health campaigns and programs, but when it comes to private health insurance, it pays to be realistic and self-aware to get a jump on waiting periods for pre-existing conditions.

What is a pre-existing condition?

Planning for the illnesses and conditions that might hit us out of the blue is one of the chief reasons many of us invest in good health cover, but what about the health problems we may already have?

A pre-existing condition is an ailment, illness or condition that you had at any time in the six months before a health insurance policy started. The condition may not have been diagnosed by a doctor or specialist, and you may not have even realised what the problem was, but if signs and symptoms were present in those six months, the condition will likely be considered ‘pre-existing’ by a health fund.

This matters if you’re upgrading to a higher level of health cover, adding a dependent or child to your policy, or if you’re new to private health insurance.

A waiting period of up to 12 months will be applied on claims for treatments of a pre-existing condition, if the condition wasn’t covered previously or for the higher entitlement. Your health fund won’t pay for treatments not previously covered during your waiting period time and will only pay at the previous cover level, if you've since upgraded your cover.

Why is there a waiting period for health insurance?

Waiting periods for pre-existing conditions are common to all private health insurers. Waiting periods protect regular fee-paying members against inheriting the cost of other people with serious conditions who might otherwise join, incur large medical bills, then quickly leave the fund.

The waiting period on pre-existing conditions and pregnancy-related conditions is usually 12 months but they’re shorter for psychiatric, rehabilitation and palliative care hospital treatments, which generally only have a two-month waiting period, regardless of pre-existing signs and symptoms. If you’re not covered for mental health treatments in hospital, you may also use a once in a lifetime option to upgrade your cover and access benefits without any waiting period.

If you switch from a fund where you’ve already served waiting periods for treatment for a pre-existing condition, you won’t serve waiting periods again at HCF or any other fund.

As always, you can access treatment in the public system under Medicare during private cover waiting periods, but you’ll have to join the public wait list for your treatment in the public system.

Who assesses pre-existing conditions for insurance purposes?

If your condition or illness is being assessed as possibly pre-existing, HCF will have a medical professional look at information from your doctor and specialists, as well as any other relevant claim details. The decision of whether you had signs of your condition in the six months before your cover started is in the hands of the fund-appointed medical professional, not your own doctor, and takes about five days to complete.

My condition is considered pre-existing. What does this mean for me?

If your condition has been deemed as pre-existing by our medical practitioner, you’ll need to serve the 12-month waiting period (or the remaining part of the period if you have served some of it with your previous fund) before you can claim for the service or treatment. HCF won’t pay benefits if you decide to go ahead with the service or treatment before the waiting period has been served. This also means that you can’t lodge a claim after the waiting period has ended for a service that was provided within the waiting period.

Keeping on top of health risk factors like smoking and being overweight are just as important as your pre-existing conditions when making health cover decisions.

Need more coverage?  

If you’re considering upgrading to a higher level of health cover, adding a dependent or child to your insurance policy or encouraging a friend to get health cover for the first time, don’t wait too long to ask about pre-existing conditions.