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An independent guide to private health cover in Australia. Not an insurer, broker or comparison service.

The guide · card 3 of 6

Waiting periods: how long before you can claim

A waiting period is the time after you take out a policy, or move to a higher level of cover, before you can claim the new benefits. For hospital cover the government caps it at 12 months for pre-existing conditions and for pregnancy and birth, and 2 months for everything else.

General informationThis page explains how the rules work in general. It is not financial, tax or medical advice, and it does not recommend any fund or policy. The rules are on privatehealth.gov.au and the Department of Health’s waiting periods page; your policy lists the waits that apply to you.

The hospital clock, from the day cover starts

These are maximums: the government sets the longest waiting periods insurers can impose for hospital treatment.

  1. Day 1accident

    An accident after you join

    There is usually no waiting period for hospital or medical treatment needed because of an accident that happens after your policy starts.

  2. 2months

    Most hospital treatment

    Two months in all circumstances not listed below.

  3. 2months

    Psychiatric care, rehabilitation, palliative care

    Two months, even when the condition is pre-existing.

  4. 12months

    Pre-existing conditions

    Up to twelve months for hospital treatment of a pre-existing condition, under the Private Health Insurance Act 2007.

  5. 12months

    Pregnancy and birth

    Up to twelve months for obstetrics.

The same clock starts again for the higher benefits whenever you increase your level of cover: you serve the waiting periods for the new benefits before you can claim them.

Why waiting periods exist

The official explanation is protection for other members. Without them, a person could join, make a large claim and then cancel, and the cost would push up premiums for everyone.

What counts as ‘pre-existing’

The rule has five parts, and each one is set out on the official page.

  • A pre-existing condition is defined by law as any ailment, illness or condition you had signs or symptoms of in the six months before you joined hospital cover or upgraded to a higher policy.
  • Neither you nor your doctor needs to have known what it was. It can be pre-existing even if you had not seen a doctor about it.
  • The decision is made by a medical practitioner appointed by your insurer, who must take into account information from your own doctor.
  • Your insurer needs time to tell you whether a condition is pre-existing, so the official advice is to check well before you go to hospital.
  • A pre-existing condition never stops you joining. The insurer must let you take out any type of cover at the same price as anyone else; once you have served the waiting periods, you can claim.

The Ombudsman publishes a factsheet on the pre-existing conditions rule, linked from the waiting periods page on privatehealth.gov.au.

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Photo by Sasun Bughdaryan on Unsplash

Pregnancy and birth

Because the waiting period can be twelve months, the official advice for anyone planning a pregnancy who wants to be covered is to arrange suitable cover for themselves and the baby well before becoming pregnant. Three details matter:

  • The entitlement to pregnancy benefits rests with the mother, who must have served the full waiting period before being admitted.
  • For the newborn to be covered, someone on a single membership, or covered as a dependant on a family policy, needs to move to a family or single parent membership. Insurers have different rules about how far ahead that change must be made.
  • Many less expensive hospital policies do not include pregnancy and birth, or restrict it to cover as a private patient in a public hospital. On the tier table, pregnancy and birth is a requirement only for Gold.

The once-only mental health exemption

If your hospital policy pays restricted benefits for psychiatric care, moving to higher benefits would normally mean a two-month wait. Since 1 April 2018 you can instead upgrade without serving that waiting period, for psychiatric care in hospital or hospital substitute treatment.

  • It can be used once in your lifetime, and only after you have completed an initial two months on any level of hospital cover.
  • It applies to everyone on the policy, each person once.
  • If you upgrade within 5 days of going into hospital, you may be covered for treatment from before the upgrade; after more than 5 days, cover runs from the date you upgraded.
  • Upgrading does not use it up. You use the exemption when you claim higher benefits for mental health treatment within 2 months of upgrading.
  • Any higher excess or co-payment on your old policy may still apply until the standard 2 months is over.

Extras run on the insurer’s clock

There is no government cap for extras. Insurers can apply any waiting period, and your policy lists the ones that apply to you. The Ombudsman’s site says they generally range from two to six months for items such as general dental, optical and physiotherapy, and twelve months or more for major items such as orthodontics or hearing aids.

When you already have cover

Health insurers must not give you extra waiting periods if you move to a new policy with the same level of benefits, even with a different insurer. The details of changing funds are on the Department of Health’s waiting periods page. A break in your hospital cover is different: you may need to serve waiting periods again, so the official advice is to check with your insurer before letting cover lapse.