Health Insurance Waiting Periods

What are health insurance waiting periods?

Put simply, a waiting period is how long you need to wait before you can claim for certain conditions on your policy¹. 

Waiting periods start ticking down the moment you take out a policy. Different conditions and treatments typically have different waiting periods. For example, some might apply for two months, others some might apply for twelve months and so on. 

For example, let’s say you take out hospital cover and the policy places a two month waiting period on dental surgery. That means your policy won’t cover the costs of dental surgery for the first two months you hold it. Additionally, you might have to wait even longer for other treatments – especially if they’re for pre-existing conditions. But we’ll dive into this a little more detail later. 

Can I get health insurance with no waiting periods?

Unfortunately, finding hospital cover where no waiting periods apply can be rare.  

That being said, there are maximum waiting periods for all hospital cover policies². Insurers legally aren’t allowed to make you wait any longer than the Maximum Waiting Period stated below for the following: 

Now, when it comes to extras cover, the rules aren’t so hard and fast. These policies are for medical services like physio or check-ups at the dentists, and insurers can set their own waiting periods here⁴. 

While it’s not across the board, some typical waiting periods for extras cover might look like the following: 

In truth, the waiting periods for extras cover generally stretch from anywhere from 2 months to 3 years.  Sometimes funds waive extras waiting periods for new customers, while others offer policies that don’t have waiting periods for certain services⁵ (such as routine dental treatments). However, you should always carefully your document to find out when waiting periods apply. 

What are the waiting periods for pre-existing conditions?

A “pre-existing condition” is any health problem that you had before you took out your insurance policy. More specifically, it’s a health problem where any symptoms were showing 6 months before it started⁶.  

When it comes to hospital cover, there will usually be a 12 month waiting period for pre-existing conditions. The good news? This doesn’t apply for palliative care, rehabilitation or psychiatric treatment, where the waiting period can’t be more than 2 months⁷. 

If waiting periods didn’t exist, there would basically be no reason for anyone to take out or maintain actually need medical treatment. This would essentially have a knock-on effect, driving up the premiums for everyone⁸. 

Do I always have to serve waiting periods?

In short, no.  There are exceptions which mean you don’t always have to serve waiting periods.  

The first relates to hospital cover. ⁹If you are switching to an equal or lower level of hospital cover, even with a different insurer, you won’t have to re -serve waiting periods. However, if you’re upgrading your policy – whether with the same or a new insurer – you will need to serve waiting periods for any new or higher hospital benefits.   For example, if you switch from a bronze level of hospital cover to silver, you can claim straight away for any of the services that were already covered under your previous bronze hospital policy but you’ll need to serve waiting periods for any new or upgraded services such as heart and vascular.  

For extras cover, many insurers will choose to honour your old waiting periods, even though they’re not required to do so by law¹⁰. But if you’ve accrued benefits or loyalty limits, those usually do not transfer over to your new policy. However, it can be worth asking if this can be done. 

You might also be able to avoid extras waiting periods by keeping an eye out for insurers who offer to waive waiting periods on extras products for new customers. Keep in mind these types of promotions and incentives may be limited time offers.

Helpful Tip: Many policy holders stick with an outdated or expensive policy because they mistakenly believe they’ll need to re-serve any hospital benefit waiting periods if they switch to a different fund. The good news is that this simply isn’t true. Any hospital waiting periods you’ve already served will be protected by law as long as you switch to any equal or lower level of cover, and funds generally honour extras waiting periods too. If you are a new customer or upgrading your level, keep an eye out for special offers from funds to waive waiting periods. Remember, if you want to be covered for a private birth (which may also include wanting a private room and better accommodation and facilities), make sure that you are covered for a full 12 months before the baby is born. Sarah McKay, Neuroscientist, author, speaker, & media personality.

What if I go to the hospital before my waiting period is up?

n a perfect world, you would never need to visit the hospital before your pre-existing condition waiting period was up. But if you do need to go to hospital, contact your health insurance provider straight away to check if you are entitled to hospital benefits. As a minimum, you’ll generally need to have been with your insurer for at least two months before any benefits can be paid. 

To determine whether or not your condition was pre-existing, your insurer should¹¹: 

• Give you some information about the pre-existing conditions that apply to your policy. 
• Get their health fund doctors to look at the information provided by your specialist to deem whether the condition is pre-existing.¹² 
• Contact you within five days with a decision on whether the condition is deemed a new condition where benefits are payable or advise that you will not be covered for the admission and treatment if the condition is pre-existing.

It is worth noting that if you need to receive urgent care, you might not hear back from your insurer before you are admitted for treatment.  

What happens if I suspend my policy?

For care that falls under extras cover, like dental care or visits to the physio, waiting periods are decided by health insurance providers. These are some typical waiting periods for extras cover²:

• 2 months for general dental benefits and physiotherapy
• 6 months for optical items, like glasses or contact lenses
• 12 months for major dental procedures, like crowns or bridges
• Up to 3 years for some high cost procedures such as braces and other orthodontics

Some providers will even have no waiting periods for certain treatments, which means you can start using your benefits straight away. For example, some insurers won’t make you wait for treatments like a dental checkup.

What if I go to the hospital before my waiting period is up?

In a perfect world, you might never need to visit the hospital before your waiting period was up. But if you do need to go to hospital, the Private Health Insurance Ombudsman recommends that you contact your health insurance provider straight away to check if you are entitled to hospital benefits². Your insurer should:

• Give you some information about the pre-existing conditions that apply to your policy.
• Send you documentation to the hospital that doctors will complete and return.
• Get their health fund doctors to look at the information provided by your specialist to deem whether the condition is pre-existing.
• Contact you within five days with a decision on whether the condition is deemed a new condition where benefits are payable or advise that you will not be covered for the admission and treatment if the condition is pre existing.

It is worth noting that if you need to receive urgent care, you might not hear back from your insurer before you are admitted for treatment. 

What happens if I suspend my policy?

You may be able to suspend your Aussie health insurance if you’re travelling overseas. This might be appealing to those looking to save money while outside of Australia, but keep in mind that the days you suspend your cover won’t be counted toward your waiting period¹³. Once you resume your policy in Australia, the waiting period clock continues. 

How can I find a fund with the shortest waiting periods?

The best way to find a new health insurance provider with a shorter waiting period is to compare your options. Use our online Comparison Tool to see how our range of providers* stack up when it comes to waiting periods, plus other key features and benefits that are important to you. 

Endorsed by:
Sarah McKay

Neuroscientist and author

Dr Sarah McKay is a neuroscientist, speaker, author, and media personality. She is the founder of Think Brain and the Neuroscience Academy suite of training programs, which provide professional development training in applied neuroscience and developing a healthy brain.

Learn more

Sources:
1. Commonwealth Ombudsman | Private Health Insurance Ombudsman - Waiting periods for private health insurance, p2
2. As above, p2
3. *You can upgrade your hospital cover for psychiatric care without a further waiting period if you have finished a 2 month waiting period for limited psychiatric benefits.  Note you can only do this once in your lifetime.  Terms and conditions apply, for more information
4. As above, p4
5. ahm - Super Extras Cover Product Guide, p2
6. Commonwealth Ombudsman - What is the Waiting Period for Pre-Existing Conditions?
7. As above. 
8. Australian Government | Department of Health and Aged Care - Waiting periods and exemptions
9. Commonwealth Ombudsman | Private Health Insurance Ombudsman - Waiting periods for private health insurance, p4
10. As above, p6
11. Commonwealth Ombudsman | Private Health Insurance Ombudsman - The Pre-Existing Conditions Rule 
12. Australian Government | Department of Health and Aged Care - Getting the best from your private health insurance