Pre-Existing Conditions and Health Insurance

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What is a pre-existing medical condition?

Do health insurance policies cover pre-existing conditions?

Types of pre-existing conditions

What are the most common types of chronic conditions?

Does a pre-existing condition mean I’ll pay more for health insurance?

Can a health insurer refuse to provide cover if I have a pre-existing condition?

Are there any exemptions on the waiting period for pre-existing conditions?

Do the waiting periods start again if I switch policies?

Frequently asked questions

Looking for health insurance with a pre-existing condition?

Long story short

What counts as pre-existing?

If you’ve had signs or symptoms in the six months before joining a health policy, they count as pre-existing, even if they’re undiagnosed.

Guaranteed health coverage

Australian law makes sure that all health funds cover pre-existing conditions.

No extra costs for your condition

Your health history doesn’t impact your policy premium because of Australia’s community-rated system.

Mental health waiting time waiver

If you’re upgrading your cover for a mental health condition, you can use a once-in-a-lifetime exemption to skip the two-month wait.

What is a pre-existing medical condition?

A pre-existing medical condition is an ailment, illness or condition you showed signs or symptoms of in the six months before you joined or upgraded your health insurance. Even if you didn’t know you had the condition beforehand, if there were signs, then it could be considered as pre-existing.  

Do health insurance policies cover pre-existing conditions?

All health funds must cover pre-existing conditions under Australian law to provide fair health coverage. But if you’re one of the 49.9% of Australians managing a long-term health condition,¹Australian Bureau of Statistics – Health conditions prevalence you might face a longer wait compared to others.

This waiting period is capped at 12 months under the Private Health Insurance Act 2007, so you won’t have to worry about waiting more than a year for treatment. Once you’ve covered this waiting period, you’ll be able to claim treatments to help manage and ease your condition.  

Types of pre-existing conditions

What illnesses are considered pre-existing conditions?

With around eight in 10 Australians (or 20.7 million people) managing at least one chronic condition in their lifetime, pre-existing conditions are quite common.²As above They can range from everyday issues like asthma, diabetes, or arthritis and extend to conditions like osteoporosis, vascular disease, cancer, and mental health conditions.  

Is pregnancy treated as a pre-existing condition?

While pregnancy obviously isn’t a pre-existing condition, it is treated similarly. Most insurers apply a 12-month waiting period for pregnancy and birth-related claims. So, if you’re planning to grow your family and want to give birth privately, it’s a good idea to take out or upgrade to pregnancy cover before you start trying.  

Is mental illness treated as a pre-existing condition?

Mental health conditions like bipolar affective disorder, eating disorders, OCD (obsessive compulsive disorder), and PTSD (post-traumatic stress disorder) are treated as pre-existing conditions, but with a shorter waiting period of only two months.  

There is an exemption to these waiting periods, but it can only be used once in your lifetime. If you’re upgrading to a higher level for psychiatric care, you can skip the two-month period. But only if you’ve already completed an initial two-month membership on any hospital policy. 

Is my family history treated as a pre-existing condition?

No, your family’s medical history doesn’t count as a pre-existing condition. Assessments are based on your personal medical history, including recent hospital treatments and doctor’s notes about specific symptoms.  

What are the most common types of chronic conditions?

Did you know one in two Australians will face at least one chronic condition in their lifetime?³As above That makes finding the right care to manage your health more important than ever. If you’re not sure if your condition is considered pre-existing, it’s worth checking with your health insurer.  

In the meantime, here are some common chronic conditions impacting Australians (data from 2022). You can also read through iSelect’s health risk report to get the bigger picture when it comes to Australia’s health.  

Does a pre-existing condition mean I’ll pay more for health insurance?

No. Australia’s community-rated private health system means that your premiums aren’t influenced by your health history. This means that health funds can’t charge you more based on your health status or claims history. So if you have a pre-existing condition, you’ll pay the same as anyone else for the same cover, although those pesky waiting periods will still apply.  

Can a health insurer refuse to provide cover if I have a pre-existing condition?

In short, no. Australian law makes sure that health funds can’t refuse hospital cover, even if you have a pre-existing condition. Once you’ve served all your required waiting periods, you can claim for treatments under your policy. 

But just because you identify a pre-existing condition with your insurer, it doesn’t mean your policy will cover treatment for it. For example, you might have basic hospital cover, which doesn’t include treatment for the heart or vascular system. If you claim for a pre-existing heart condition or one that develops later, you won’t be covered unless you upgrade your policy.  

That’s why it’s always a good idea to read your policy brochure to see what kind of conditions and clinical treatments are included in your coverage.  

Helpful tip:

Researching your insurer’s network of preferred providers can help you find specialists who are experts in treating your condition. Some health fund networks include medical specialists with extensive experience in specific areas. Choosing these specialists can offer tailored care that better suits your needs while potentially lowering out-of-pocket costs, especially if they have ‘no-gap’ agreements with your insurer. 

Dr. Jill Gamberg

GP, Coach and Lifestyle Medicine Physician

Are there any exemptions on the waiting period for pre-existing conditions?

There are some exceptions to the 12-month waiting period for pre-existing conditions. All of the following exceptions have a maximum waiting period of two months, even with a pre-existing condition.

• Psychiatric care: Hospital treatment for patients with psychiatric, mental, addiction or behavioural disorders
• Rehabilitation: Physical rehabilitation from surgery or illness (such as stroke recovery or cardiac rehabilitation)
• Palliative care: Treatments to manage pain and provide quality of life for people with a terminal illness

Do the waiting periods start again if I switch policies?

The good news is that, by law, you won’t have to re-serve hospital waiting periods you’ve already done if you switch insurers or choose a new policy. 

But there are still some rules that you’ll need to follow to skip the waiting periods. You’ll need to make sure that your old policy is paid up to the date you switch. You also need to find out whether your new insurer allows short breaks in between coverage changes or insists on a seamless transition from old to new. If there’s a gap, you might need to re-serve some of those waiting periods, so it’s important to check this beforehand.  

Important 

The rules can also be a little different if you’re switching to a policy with extra benefits that weren’t included under your previous policy. In these cases, the insurer might get you to serve an additional waiting period before the extra benefits take effect. 

Frequently asked questions

Looking for health insurance with a pre-existing condition?

Having a pre-existing condition doesn’t mean you’re left out in the cold. You can still find hospital cover, you’ll just need to wait a little longer before receiving the benefits of your policy. iSelect can help you compare a range of health insurance policies and providers to find a health policy for your needs, no matter your health history. Call our team of comparison experts on 1800 784 772 for more information.