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Here’s what you need to know about your waiting periods

27 July, 2018
Woman using the CBHS app

What is a waiting period?

A health insurance waiting period is the initial phase of your membership, during which no benefit is payable for certain procedures or services. Waiting periods can also apply to any additional benefits gained when you change your policy.

Why do we have to serve waiting periods?

In Australia, all health insurers are required by law to provide health insurance for Australian residents regardless of their health status and cannot charge higher contributions based on whether a person is more likely to require treatment. If there were no waiting periods, people could take out hospital insurance or upgrade to a higher policy only when they knew or suspected they might need hospital treatment. This would lead to much higher premiums for all existing members, potentially making health insurance unaffordable for many.

What are the different waiting periods?

Hospital Treatment Waiting Periods

The Government sets the maximum waiting periods that funds can impose for hospital treatment. CBHS applies these maximum waiting periods to all hospital treatments:

  • 12 months for pre-existing conditions
  • 12 months for obstetrics/pregnancy
  • 2 months for psychiatric care, rehabilitation or palliative care (even for a pre-existing condition)
  • 2 months in all other circumstances.

In addition to the above waiting periods, CBHS applies the following waiting periods to Hospital Treatment.

  • 1 day for Accidents (Accident means an unexpected or unforeseen event caused by an external force or object resulting in an injury to the body which requires treatment by a medical practitioner, Hospital or dentist (as the context requires) but excludes pregnancy).
  • 1 day for Emergency Ambulance services

Extras services waiting periods

The waiting periods for extras cover are set by individual health funds and not set by Government Legislation. This means they may vary from Fund to Fund.

CBHS applies the following waiting periods on Extras Services

  • 12 months for crowns, bridges and orthodontia
  • 12 months for artificial aids, health care appliances, oxygen apparatus and hearing aids
  • 6 months for prescribed optical appliances
  • 6 months for periodontics, endodontics, facings and dentures
  • 2 months all other services

Do waiting periods apply on upgrades?

Yes - Waiting periods will also apply to any additional benefits when you upgrade your health insurance policy. This may also apply if you have joined from another fund but joined CBHS on a higher level of cover.

For current members upgrading their cover, waiting periods will only apply for the additional benefits on the higher level of cover. If you need to claim during the waiting period, you will receive the same benefits as your previous level of cover, provided you have served all waiting periods on the previous level of cover. Your new, higher benefits/limits will commence after the waiting period ends.

How do I prove I have served my waiting periods?

If you are thinking about transferring between funds, then you will need to request a transfer from your current fund to prove you have served your waiting periods.

A transfer certificate serves as a record of your health insurance cover. The transfer certificate confirms the details such as type of cover, level of cover, join date, cancellation date, lifetime health cover (LHC) certified age of entry.

If a transfer certificate is not available, you will have to complete waiting periods as though you were taking health insurance for the first time.

What is a pre-existing condition?

Under the Private Health Insurance Act 2007, a health fund may impose a 12-month waiting period on benefits for hospital treatment for a pre-existing condition.

A pre-existing condition is defined by the CBHS Health Benefit Fund Rules as an ailment or illness,  the signs or symptoms of which in the opinion of a Medical Adviser appointed by CBHS existed in the period six months before a person became insured under the policy or upgraded to a higher hospital cover. It is not necessary that you or your doctor knew what your condition was or that the condition had been diagnosed. A condition can still be classed as pre-existing even if you had not seen your doctor about it before joining CBHS or upgrading to a higher level of hospital cover.

What happens if I need hospital treatment during the initial 12 months of my policy?

You should always contact CBHS as soon as you know you will need to be admitted to hospital. CBHS will need your help to determine if the condition you wish to claim for is a pre-existing condition.

CBHS cannot tell you on the spot whether your medical condition is pre-existing or not.

You will need to complete a consent form for CBHS to access your medical history and have the doctors treating your condition complete a medical report.

Once the consent form and medical reports are completed, send them directly to CBHS. Once CBHS has the required documentation, we will refer them to an independent medical advisor to determine if the condition is subject to the pre-existing condition waiting period.

In forming an opinion about whether an illness was pre-existing, the CBHS appointed medical advisor who makes the decision, must consider information provided by your own doctor.

What if I decide to go ahead with hospital treatment anyway?

The important thing to remember is that if you go ahead with your hospital admission before CBHS has advised you if you are entitled to benefits, you may become responsible for all admission costs.

In an urgent situation where you must go to hospital immediately, there might not be sufficient pre-admission time for CBHS to determine whether your condition is pre-existing. In this case you won’t know before your admission if any health fund benefits will be forthcoming, so you have the following options: (a) seek treatment in a public hospital as a public patient or (b) decide to go ahead and be treated as a private patient.

If you go the private route, the hospital will inform you of your out-of-pocket costs should it be decided you have a pre-existing condition that makes you ineligible for benefits. If you must pay part or all your treatment costs upon admission and CBHS concludes you are entitled to benefits, you will be able to recoup those costs from CBHS. If you are still in the hospital and it is determined you’re not eligible for benefits, you can discuss your next steps with hospital personnel, including the option of being transferred to a public hospital for any further treatment.

 

Haven’t there been some changes to waiting periods for a mental health admission?

Yes - If you are on a hospital policy which provides restricted benefits for psychiatric care, then to access higher benefits you usually upgrade and complete a two-month waiting period.

However, from 1 April 2018, you can upgrade without having to serve this waiting period to access higher benefits for psychiatric care in a private hospital.

This exemption applies only once per lifetime and can only be accessed if you have already completed an initial two months of membership on any level of hospital cover.

For more information about accessing the exemption, please contact CBHS.

Can CBHS waive a waiting period?

From time to time, health funds will waive the waiting periods as a promotion offer to attract new members to the fund. New members help grow the fund and assist in keeping CBHS financially viable and competitive.

Usually it’s just the 2 & 6 month waiting period on extras only.

How can I protect the waiting periods I have already served with my previous fund?

If you are switching health insurance to a policy with CBHS that includes services comparable to your old cover, the waiting periods you’ve already completed are waived if you have maintained continuity of cover or apply to join CBHS within one month of leaving your old fund.

This is known as “portability” and is a rule set down by the Australian Government in the Private Health Insurance Act 2007. The portability rule only applies to hospital cover, but CBHS will usually waive the extras cover waiting period also.

Sources

http://www.ombudsman.gov.au/__data/assets/pdf_file/0017/35612/Waiting-periods-DL-Fyler-Web.pdf

http://www.ombudsman.gov.au/publications/brochures-and-fact-sheets/phio/the-pre-existing-conditions-rule

https://www.legislation.gov.au/Details/C2007A00031

http://www.health.gov.au/internet/main/publishing.nsf/Content/health-privatehealth-supporting-mental-health

https://www.ombudsman.gov.au/__data/assets/pdf_file/0020/29423/Right-to-Change-DL-Fyler-Web.pdf

All information contained in this article is intended for general information purposes only. The information provided should not be relied upon as medical advice and does not supersede or replace a consultation with a suitably qualified medical practitioner. CBHS endeavours to provide independent and complete information, and content may include information regarding services, products and procedures not covered by CBHS Health Cover policies.
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