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Health Insurance Waiting Periods

Even if you are already ill, all health funds will allow you to purchase health insurance. However, standard waiting periods may apply before benefits are payable. If a fund refuses you membership, you may appeal to the Minister for Health and Ageing.

Waiting Periods

When a member joins a health fund or increases their level of cover, they may have to wait some time before their health insurance becomes effective. This protects members already in the fund by making sure no contributor makes a large claim shortly after joining a fund, and then drops their membership. This 'hit and run' behavior results in increased premiums for everyone.

The Government sets the maximum time that health funds are able to make members wait until they can claim benefits for hospital treatment.

These maximums are:

  • 12 months for pre existing ailments;

  • 12 months for obstetrics services; and

  • 2 months in all other cases.

The Government does not regulate waiting periods for benefits payable under dental/ancillary (extras) cover. These waiting periods are set by individual health funds and members should make sure they are aware of the dental/ancillary (extras) benefit waiting periods that apply to their fund.

There is usually no waiting period if an insured person needs hospital or medical treatment because of an accident that happens after they join the fund.

Pre-existing ailment or condition

When a member decides to take out or upgrade their health insurance, they may already be ill and have what is referred to as a pre-existing condition or ailment.

Under the National Health Act 1953, a health fund may impose a 12 month waiting period on benefits for hospital treatment where it should have been reasonably apparent to either the member or a medical practitioner that there was a pre-existing ailment in the six months prior to joining a hospital table or upgrading to a higher level of cover.

What is the definition of a pre-existing ailment?

A pre-existing ailment is an ailment, illness or condition, the signs or symptoms of which, in the opinion of a medical practitioner appointed by the health fund, existed at any time during the 6 months prior to the member joining a hospital table or upgrading to a higher level of health insurance cover.

What this means in real terms is that the signs or symptoms of the pre-existing illness, ailment or condition should have been reasonably apparent or reasonably evident to the contributor; or there must be something that would have been apparent to a reasonable general practitioner on a routine external examination if the contributor had been examined.

In forming an opinion about whether or not an illness was pre existing, the health fund appointed medical practitioner who makes the decision must take into account information provided by the members own doctor.

If a member requires hospital treatment, but has less than 12 months membership on their current hospital table, a 12-month waiting period could apply if the condition was pre-existing. The decision about whether the condition is pre-existing is made by the health fund. It is important to check this with the health fund prior to admission to hospital. Remember, the health fund will need at least a week or so to advise about whether the pre-existing ailment 12 month waiting period applies.