While you may consider private hospital cover a useful buffer 'just in case' you ever experience any health ailments, those with pre-existing conditions can also benefit from a health insurance plan, too.
However, the process of obtaining hospital cover – and gaining those benefits – may be a little more complicated than for those who have no existing health issues. However, don't let this put you off making the effort to get health insurance – it could definitely pay off in the long run!
If you're an Australian with a pre-existing ailment or health condition, here are the facts you need to know before picking out an insurer:
What counts as an existing condition?
Ahh – specifics. What really counts as an issue with your health? An allergy to peanuts? Obesity? Or diabetes? The Private Health Insurance Ombudsman (PHIO) defines a pre-existing condition as any ailment, illness or condition which is deemed by a medical professional (appointed by the insurer) to have existed in the six months before the date obtaining their particular policy.
These symptoms could be associated with conditions such as a heart attack, gallstones or stroke, as well as smaller conditions.
The medical practitioner chosen by the insurer must also take into account information and records from the patients' usual doctor, and a diagnosis is not necessary for an individual to be subject to the conditions for pre-existing conditions. Symptoms and signs of an illness or ailment are enough to determine someone as having a pre-existing condition – however, risk factors, such as genetic predisposition or a family history of a certain illness, are not, and should not be a factor.
What's different to normal private health insurance?
Those determined as having a pre-existing condition are still able to obtain private health insurance – however, the main difference is that they will be subject to certain waiting periods before they can reap the benefits of their particular policy.
The PHIO states that benefits for hospital treatment may have a maximum 12 month waiting period imposed under the Private Health Insurance Act 2007, during which full benefits of the hospital policy may be unavailable. After 12 months continuous membership, the individual is entitled to the same benefits as an individual without a pre-existing condition.
If a patient requires hospital treatment for an illness during the 12 month waiting period, they will be eligible to be covered by their fund if the chosen medical practitioner determines they displayed no associated symptoms in the six months prior to taking out hospital cover.
Some health conditions have differing waiting periods, all of which can be applied to new members and those wishing to upgrade their policy. These include two months for psychiatric, rehabilitation and palliative care, and all other services, and 12 months for obstetric services.
What's the reason for a waiting period?
It may seem a little unfair that those without pre-existing conditions can immediately claim on their hospital cover. However, waiting periods exist for a reason. According to the PHIO, this is to protect against the risk of those who are aware of their health issues taking out private hospital cover close to the time when they feel they need to visit the hospital. They may then cancel their cover after having reaped the benefits, which would result in their hospital costs being paid by long-term members.
Therefore, the waiting periods are essentially there to protect you in the future – once you're a long-term member, there's no need to pay unnecessary expense caused by those opting in and out of hospital cover at their leisure. It also reduces the need for excessively high premiums.
What about for general cover?
The waiting periods outlined above all apply to hospital cover, however, insurers may also apply waiting periods to other forms of cover at their discretion. If you need advice on which insurers do and do not apply such waiting periods, it could be helpful to speak with the professionals at HICA to help you decide which is right for you.