Pre-existing conditions FAQs

In health insurance, a pre-existing condition is defined as any ailment, illness or condition (diagnosed or not) where you have had signs or symptoms at any time in the six months before you commence hospital cover or upgrade to a higher level of cover.

A 12-month waiting period applies for pre-existing conditions. Any hospital claims made within that 12-month waiting period will, in most cases, be subject to a pre-existing condition assessment. This is conducted by an independent medical professional arranged by Police Health.

After you’ve served your 12-month waiting period, your claim will not be considered a pre-existing condition. Please note that a 2 month waiting period applies before a pre-existing condition assessment can be undertaken.

If you’ve upgraded to our Gold Hospital or Gold Combined cover, we’ll always confirm your waiting periods once we receive a transfer certificate from your previous fund (usually within 2-3 weeks of joining or upgrading).

These waiting periods help protect our existing members from additional costs.

If there were no waiting periods for pre-existing conditions, people could take out our hospital cover only when they knew or suspected that they might need hospital treatment and immediately make a hospital claim.

If these new members then cancelled their membership, their hospital costs would have to be paid for by the remaining Police Health members. This would not be fair to long-term members, and is common to all private health insurers.

Pre-existing condition waiting periods apply to hospital cover,claims for hospital admissions and other benefits such as any Excess you may have had with a previous health fund.

If you've upgraded your level of cover, a waiting period will apply to the upgraded benefits.

During that waiting period, if you're admitted to hospital for a treatment related to the upgrade, you may be covered at your previous level cof cover, which can include an excess if your old policy had one.

With Police Health's Gold Hospital cover, some of the most common claims that trigger pre-existing condition assessments include (but are not limited to);

Weight loss surgery
Joint replacements
Heart surgery

The above list are examples only. If you're unsure about how pre-existing conditions work, please call us 1800 603 603.

Like all insurers, Police Health's waiting period for pre-existing conditions is 12 months.

Please note that a 2 month waiting period applies before a pre-existing condition assessment can be undertaken.

Contact Police Health as soon as possible to discuss your individual circumstances. Pre-existing conditions assessments can take 10 days or longer from the time all paperwork is submitted to us, which must include supporting documentation from your treating doctor. If you don’t have this information already, you will need to factor in time to make an appointment with your doctor to collect this information.

You can contact us by calling 1800 603 603 or emailing enquiries@policehealth.com.au.

A medical practitioner appointed by Police Health is the only person authorised to decide that a condition is pre-existing.

Your own doctor is not authorised to decide if a condition is pre-existing.

However, the practitioner appointed by Police Health must consider any information regarding signs and symptoms provided by your own treating doctor or specialist.

This is a requirement for all health insurers, not just Police Health.

This process can take at least 10 days after all paperwork is submitted to us, and may be longer if further information is required. You should also factor in the time it will take for you to collect the relevant information from your treating doctor or specialist.

This is because you'll need to take pre-existing condition forms to your specialist, and they may ask your GP or another specialist to complete part of the form if they've been involved in your care. Also, multiple doctors or specialists may be required to provide information.

After that, the information you provide has to go to a Police Health appointed medical practitioner to review the information.

While the assessment itself does not carry a fee, you may need to pay for any doctor or specialist appointments needed to collect the appropriate paperwork if these are not bulk billed.

These are the two most common scenarios where you've either never had private health insurance before, or you've upgraded your level of cover when you've joined Police Health.

If you've never had private health insurance before and the independent appointed medical practitioner decides your condition is pre-existing, you’ll need to serve the full 12-month waiting period before you can claim that service or treatment.

If you've upgraded your level of cover, a waiting period will apply to the upgraded benefits.

During that waiting period, if you're admitted to hospital for a treatment related to the upgrade, you may be covered at your previous level cof cover, which can include an excess if your old policy had one.

You also can’t claim after the waiting period has ended for any treatment you received during the waiting period. However, once you've served your waiting period, you can claim benefits for eligible treatment going forward (subject to the terms and conditions of your policy and other requirements).

That's because a condition doesn't have to be previously diagnosed to be considered pre-existing.

Under Australian Private Health Insurance Act (2007), a condition may be considered pre-existing if signs or symptoms existed in the six months before you joined or upgraded your hospital cover — even if you didn’t know what the condition was at the time.

Also, these signs and symptoms should have been reasonably apparent to either the member, or a reasonable general practitioner had the member been examined in this 6 month period;

Because of this, insurers are required to assess medical information to determine whether those signs or symptoms were present before your cover started and whether the pre-existing waiting period applies.

No, if the treatment or surgery you need is related to a pre-existing condition, you’ll have to wait 12 months before you can use your Gold Hospital cover for it.

If you've upgraded your level of cover, a waiting period will apply to the upgraded benefits.

During that waiting period, if you're admitted to hospital for a treatment related to the upgrade, you may be covered at your previous level cf cover, which can include an excess if your old policy had one.

Please note, any services related to the pre-existing condition with a date of service prior to the 12 months waiting period being served will not be able to be claimed after you have served your waiting periods.

No, in-hospital psychiatric care does not have the 12-month waiting period like other hospital service categories.

Police Health only requires you to wait 2 months to claim in-hospital psychiatric care for mental health conditions. These include, but are not limited to;

Depression
Anxiety
Bipolar mood disorder

If you are transferring from another fund and have hospital cover which provides psychiatric care with restrictions, you can upgrade without having to serve the 2-month 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.

Also, like all health insurers Police Health requires you to serve a 2 month waiting period for rehabilitation and palliative care, even if pre-existing.

if you previously held Gold level hospital cover with another health fund and then joined Police Health, an excess may still apply in the first 12 months of membership, if the services are deemed as pre-existing.

When you upgraded your hospital cover, a waiting period will apply to the upgraded benefits.

During that waiting period, if you're admitted to hospital for a treatment related to the upgrade, you may be covered at your previous level cf cover, which can include an excess if your old policy had one. This can apply to when you're upgrading to gold level hospital cover from basic, bronze or silver level of cover.

Once the waiting period for the upgrade is complete, Police Health's hospital cover applies and you won't have to pay an a excess.

No, but you do have to serve a 12-month waiting period for pregnancy cover.

Interested in pregnancy cover? Learn more with our helpful guide.

Yes, you can keep your Police Health cover or join us. However, you will have to serve our 12 month pre-existing waiting periods under the terms of our policy before you can claim treatment or surgeries related to that condition.

No, Police Health and all health insurers don't consider this a pre-existing condition.

Even if your family has a history of a congenital condition, it won't be considered a pre-existing condition unless you've shown signs or symptoms in the six months before you joined Police Health or before you upgraded your existing Police Health policy to include Gold Hospital cover.

No, Police Health doesn't charge you higher premiums because you have a pre-existing condition.

Health insurance is ‘community rated’, so you'll pay the same base premium as anyone else with the same cover in your state of residence.

However, if you join Police Health with a pre-existing condition you will need to serve our 12 months waiting periods under the terms of our policy before claiming for that condition.

Given Police Health only provides a gold level of hospital cover, Gold Hospital, you'll most likely be upgrading your health insurance when you join us from another fund.

This means you'll most likely have to serve the 12-month pre-existing condition waiting period for any clinical categories that you weren't covered for before. The exceptions to the 12 month waiting period for pre-existing conditions are psychiatric care, rehabilitation and palliative care.