Member Insider: make sense of waiting periods

You might already know this, but when you first join CBHS or upgrade your level of health cover, you'll need to serve a 'waiting period'. This is the period of time you'll have to wait before you can start claiming any benefits for services or items covered by your policy, even if you’re transferring from another fund. All health funds have waiting periods. 

If you transfer from another fund, you don’t start from scratch! Any waiting period you've already served carries over to your new fund. If you upgrade your level of cover, waiting periods may apply to benefits that weren't included in your original cover.

Waiting periods are in place at all Australian health funds to help keep the system fair for all health fund members. Waiting periods prevent people from being able to join and make a high-cost claim straight away, then cancel their cover after receiving the benefit. This would drive up premiums.

What are the standard waiting periods?

Hospital waiting periods:

These waiting periods apply to Hospital cover and packaged cover. However, not all services listed below are included in all level of covers. You can check your level of cover by logging into the CBHS app or Member Service Centre.

All waiting periods displayed are in calendar months.

^* If you have a pre-existing condition, a waiting period of 12 months will apply before we will pay hospital or medical benefits towards any treatment for that condition.
^** If you don’t have Gold level cover, but need a mental health admission, you can utilise a once-in-a lifetime waiver to upgrade your cover after the two-month waiting period. For more details contact us on 1300 654 123 or email help@cbhs.com.au.
^*** 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.

Extras waiting periods:

These waiting periods apply to Extras cover and packaged cover. However, not all services listed below are included in all level of covers. You can check your level of cover by logging into the CBHS app or Member Service Centre.

Pre-existing conditions and how they affect waiting periods

A pre-existing condition is any ailment, illness, or condition that you had signs or symptoms of during the six months before you joined the fund or upgraded to a higher level of cover. It doesn’t matter if you or your doctor knew the nature of the condition or if it had been diagnosed.

A doctor appointed by CBHS will be consulted as to whether your condition is pre-existing or not. This appointed doctor will consider the opinions of your treating doctors regarding the signs and symptoms but is not required to agree with them.

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

If your condition is deemed pre-existing, you’ll have to wait 12 months to be covered for any treatment linked to that condition. This also applies to cover upgrades as well as changes to excess or co-payments.

CBHS cannot immediately tell you whether your medical condition is pre-existing or not. You’ll need to complete a consent form for CBHS to access your medical history and have the doctors treating your condition complete a medical report.

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. 
 
If you decide to go to hospital before CBHS has been able determine whether your condition is pre-existing, 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’ll be able to recoup those costs from CBHS. If you’re 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. 

Of course, if your situation is deemed an emergency, you will be covered by CBHS.

Planning for a baby

If you’re planning to start a family, check whether your current level of cover includes pregnancy and birth. For CBHS members, these services are covered on our Gold tier products. Keep in mind that there’s a 12-month waiting period for these services. So, it’s best to plan ahead to avoid any surprises.

Newborns don’t need to serve waiting periods, as long as your little one is added to your policy within two calendar months of the birth.

Emergency vs. non-emergency ambulance services

Emergency ambulance

An emergency ambulance service means you’re transported to a hospital urgently because of a serious, unexpected illness or injury, such as a heart attack, stroke, or an accident. This type of service is provided by a State Government ambulance service or one recognised by CBHS, like the Royal Flying Doctor Service.

If your policy includes ambulance cover, there is only a one-day waiting period on emergency ambulance cover. We get that you can’t plan for emergencies, so your cover will be ready to use almost straight away. And, for your peace of mind, if you hold any level of Hospital cover with CBHS, emergency ambulance cover is included.

Non-emergency ambulance

CBHS Ambulance cover doesn’t include non-emergency ambulance services like planned transportation when immediate treatment isn’t needed, such as moving between hospitals or from hospital to home for ongoing treatment (for example dialysis or chemotherapy). So, if you’d like cover for non-emergency services, the best thing to do is contact your state ambulance scheme for details.

Costs for ambulance services can vary based on the state you’re living in. For residents of WA, CBHS Hospital and package policy covers non-emergency ambulance services up to $5,000 per person per year when approved. A one-day waiting period applies to non-emergency ambulance services on eligible products. Residents of QLD and TAS are covered under their state-based ambulance schemes.

Accidental injuries

It’s important to understand the different categories when it comes to waiting periods and hospital treatment:  Accident related treatment, treatment for a medical emergencies and the 'usual' circumstances – like explained above, in which waiting periods would apply.

Accidents happen unexpectedly, which is why CBHS covers treatments for accidents occurring after immediately joining or upgrading your policy (subject to your policy’s inclusions).

For an injury to be considered an accident:

• It must be an unforeseen and unexpected event
• It must result from an external force or object and not be intentional
• The event must result in an injury to the body which requires treatment by a medical practitioner, hospital or dentist (as the context requires) but excludes pregnancy
• You must seek treatment within seven days of injury.

What isn’t considered an accident?

• Sudden illness
• Elective surgical procedures
• Pregnancy and birth
• Aggravation of existing conditions.^*

^*Subject to each individual condition

What is covered if you have an accident?

If you have an accident, here’s what your cover includes:

• Treatment after an accident: any Hospital treatment you need due to an accident is covered under accidental injuries, as long as the accident happened after you joined CBHS, fulfilled your one-day waiting period, and seek treatment from a health care provider within seven days of the accident.
• Hospital stays: if you need to be admitted to a hospital, this must happen within 180 days of the accident for cover under accidental injuries.
• Ongoing hospital care: if you need more hospital treatment after 180 days, it will be covered according to your policy’s specific benefits.
• Emergency room fees: any fees charged for using the hospital’s accident and emergency facilities are also included.

What to do if you have an accident

If you need treatment due to an accident:

• You must receive medical advice or treatment from a registered medical practitioner within seven days of the accident
• You must complete all required hospital treatments within 180 days of the accident
• We recommend you call CBHS as soon as possible to determine if you’ll need to submit an accident form.

Make the most of your cover

Understanding waiting periods is key to maximising the value of your health insurance. Whether you're planning for a major life event or dealing with unforeseen health issues, being aware of your coverage helps you stay prepared and make informed decisions.

For more information on waiting periods, refer to our Health Benefit Fund Rules. If you have any questions, reach out to our helpful Member Services team on 1300 654 123 for support - we're here to help.

This articles is current as at 28 January 2025 and provides general information and guidance about our policies and is intended as a summary only. This information should be read in conjunction with the CBHS Health Benefit Fund Rules and is subject to change from time to time.