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Other things you need to know

Waiting periods 

  • Waiting periods can apply before you are entitled to benefits can be imposed when you first join a health fund or change to a new level of cover which provides greater benefits than your previous level of cover. Maximum waiting periods for hospital cover are 
    • 12 months for pre-existing conditions
    • 12 months for obstetrics
    • 2 months for all other circumstances 
    • There is usually no waiting period for accidents 
  • Waiting periods may also apply when you change to a cover with a lower excess or no excess. If a waiting period applies to your situation, you will need to pay the higher excess applicable to your previous cover. The Private Health Insurance Ombudsman provides more information on upgrading in this brochure
  • Waiting periods for ancillary or extras cover are not regulated
  • If you want your new born child to be insured from the time of birth,all you need to do is to add them to your membership within two months from the date of their birth. This means moving to a family membership if you are not already on that level of cover. This will ensure your child does not serve any additional waiting periods
  • When you transfer from one fund to another your new fund must give you credit for the waiting periods you have already served. The new fund may ask you to serve waiting periods where the benefits are greater than your previous cover

Pre-existing conditions 

  • A pre-existing ailment, illness or condition, the signs of which in the opinion of a medical practitioner appointed by the health fund, is one that existed at any time during the 6 months prior to the member joining a health fund or upgrading their cover. A waiting period of 12 months can apply to payment of benefits for the treatment of a pre-existing condition.
  • For emergency admissions within the waiting period, private hospitals will usually require the Fund's confirmation that the admission is not in respect of a pre-existing condition, and that the patient is therefore covered by the Fund. Such confirmation cannot be provided immediately and will be dependent on receipt and review by the Fund, of information from the member's Medical Practitioner or Specialist.  In such circumstances, the hospital may request a security deposit from the member pending confirmation from the Fund that the member is covered.

Portability or transferring from one fund to another 

  • A clearance certificate from your current fund will allow you to have continuity of cover when transferring to another fund. You may authorize your new fund to obtain the clearance certificate or you can request it from your old fund
  • When transferring you will get credit for waiting periods you have already served. Where you have greater benefits on specific services you may have to serve waiting periods for those services. However, funds are not obliged by law to recognise waiting periods served for ancillary or extras services, but many do
  • Your new fund may also take into account benefits paid by the previous fund in determining your annual benefit limits

Continuity of membership 

  • You can suspend your fund membership while you are overseas, and suspension may be allowed under other circumstances. During suspension claims cannot be made and time towards waiting periods is not counted
  • It is important to keep your contributions up to date. When you are more than 2 months behind in paying your insurance it will lapse. Some funds may not accept payments in arrears after 2 months and waiting periods may be imposed when you resume contributing

Claiming benefits

  • Claims must be lodged within two years of the date of the service
  • When you cannot claim 
    • If you will be paid compensation by a third party 
    • If you provide false or inaccurate information on your claim form
    • If you are more than 2 months behind with your contributions 
    • If the service was provided while your membership was suspended 
    • If the service provider is directly related to you 
    • If the service provider is not qualified under the fund rules 
    • If the claim is made more than 2 years after the date of the service

Community rating 

  • Private health insurance is ‘community rated’ unlike other types of insurance which are ‘risk rated’. Under community rating factors such as age, gender, your state of health or size of your family cannot be used to vary the amount charged to individuals for the same health cover product

Acute care patients 

  • If you are in hospital for more than 35 days in succession, unless your doctor specifies you are an acute care patient, you can expect to pay part of the cost of your hospital accommodation. Private health insurers are not allowed to cover the costs of non-acute nursing home type care.

The information on this page has been prepared from a number of sources including the documents listed below. Other sources informing this material include the Commonwealth Dept of Health & Ageing website www.health.gov.au, the Private Health Insurance Administration Council materials www.phiac.gov.au, the Private Health Insurance Ombudsman materials www.phio.org.au, The Key Features Guide and product information from a number of health funds.

Doctors Bills – from PHIO