Private health insurance cover is divided into two categories: hospital cover and general treatment cover, also known as ‘extras’ cover. These covers can be purchased separately or as combined policies by most health funds, depending on your individual requirements. In some states, a third category known as ambulance cover is also available, although this is sometimes included in hospital cover or extras depending on your policy.
As private health insurance is not risk rated, providers can’t refuse to insure any eligible person. They must also charge everyone the same base premium for the same level of cover. Therefore, to help mitigate some of the risk for health fund providers, some treatments may incur a waiting period. This is typically served when you first purchase private health insurance, or when you upgrade your policy to include services and treatments not previously covered.
The government sets the maximum waiting periods that health funds can impose for hospital treatment, which are:
- 12 months for pre-existing conditions
- 12 months for obstetrics and IVF
- 2 months for psychiatric care, rehabilitation or palliative care, even for a pre-existing condition
- 2 months in all other circumstances
For extras insurance, waiting periods are determined by your individual health fund provider, and the length can vary depending on the treatment and your level of cover. If you’ve already served a waiting period for a specific service and switch providers without cancelling your cover in between, you generally don’t have to serve a new period unless you are increasing your benefits, although it’s best to verify this with your new provider.
To receive benefits, you must have a policy that covers the treatment you’re receiving and have served your waiting period. Some clinics and hospitals will be able to automatically apply your benefit by scanning your health fund membership card during the payment transaction. In some cases, you may need to make the benefit claim after paying up front, which you can do by contacting your health fund provider directly. How much you pay, ultimately depends upon your policy and level of cover.