Last Updated on 3 July 2020

Why is there a Waiting Period for Health Insurance?


Before you can make a claim through your private health insurer, you need to make sure your waiting period is over.

Most funds have waiting periods to start off with, and some may be longer than others. However, the government has enforced legal limits to waiting periods for all hospital cover policies to ensure you won’t be waiting forever.

Taking out general (or ‘extras’ cover) is a different story. There are no legal limits to these waiting periods so each fund will vary.

It’s important to shop carefully to find a health insurance policy that offers minimal waiting periods, not only if you require prompt treatment, but also for peace of mind. You want to feel secure from the moment you purchase your policy.

Key Points
  • Waiting periods exist to protect all members of health funds from people who want to join and immediately make large claims – which would force up premiums for all.
  • Some health insurers will advertise no waiting periods for General (extras) cover. This doesn’t necessarily mean you are free of all restrictions. You may find certain treatments can be claimed straight away while others do have a wait time involved.
  • You will not have to re-serve waiting periods when switching hospital cover policies, provided you purchase the same or a lower level of coverage.

What are Standard Waiting Periods?

After taking out a private health insurance policy for the first time, there is a set amount of time known as a waiting period, where you’ll be unable to make any claims. It is not only applied when you take out a new policy but also if you decide to increase your level of cover on a current policy.

When this set amount of time is up, your policy will kick in and allow you to make claims and receive the full benefits of your insurance.

The government sets maximum waiting periods for all private health funds when it comes to hospital cover only. The waiting periods for general cover (also known as ancillary or extras cover) are set by each individual health fund, and are not influenced by the government in any way.

Here’s a quick look at the current maximum waiting periods for hospital treatment:

  • For all pre-existing illnesses or health conditions; that is, in the opinion of a medical adviser appointed by the health insurer, the signs or symptoms of that illness, ailment or condition existed at any time in the period of 6 months ending on the day on which you became insured under the policy , you must wait a maximum of 12 months before making a claim.
  • For obstetrics benefits, you must wait a maximum of 12 months before claiming any pregnancy-related services.
  • For psychiatric, palliative or rehabilitation care, needed for both new and pre-existing conditions, the maximum waiting time is 2 months.
  • In all other circumstances, the waiting period is 2 months.

Private Health Insurance Waiting Periods

Why Do Waiting Periods Exist?

Waiting periods may seem like a nuisance, but they are necessary. Here’s why:

  • They protect all members of the fund by ensuring that people cannot join a fund, make a large claim immediately and then leave the fund. That type of ‘hit and run’ behaviour would force premiums up for the many loyal and long term health fund members. in case of an emergency.
  • It allows private health insurance to do what it’s meant to. That is, cover members for unforeseeable health conditions or illnesses. After all, insurance exists to protect people in case of an emergency.
  • Insurance companies rely on healthy people taking out cover to help pay for those who end up needing medical services covered.
  • If waiting periods ceased to exist, the price of your premium would soar, and potentially become unaffordable.

Can I Avoid Waiting Periods?

You may be able to avoid some waiting periods with General (extras) Insurance cover depending on the health insurer you go with. Some funds will advertise no waiting periods. However, even if the waiting period is waived, this doesn’t mean you’ll be free of all restrictions. For example, you may find that coverage is readily available for routine optical or dental care, but if you require further treatment, you may not be covered until the waiting period is over.

Check with the health fund you are considering purchasing from to see whether there are any fineprint details you should be aware of in regards to waiting periods.

So, you’re thinking of upgrading your private health insurance to a higher level of hospital coverage or a new extras policy. Have you checked the following:

  • Your policy terms. Know and understand your fund’s rules around waiting periods.
  • Which treatments you get immediate access to, if any, and which ones you must wait for.
  • How long you will have to wait for these treatments before you can make a claim.

How long do I have to wait for health insurance?

Waiting periods are compulsory lengths of time. You must honour these before claiming health insurance benefits. They do not apply if you have already served them or are downgrading your policy.

Standard waiting periods for health insurance vary depending on the procedure and your chosen health fund. It also depends on the type of cover involved, for example extras cover or hospital cover.

You might be in need of a dental check-up. You should expect to have to wait an average of around 2 months from when you join to when your extras cover actually begins. If you’re in need of dental surgery, then you should expect to have to wait a lot longer before being able to make a claim.

With extras cover, health insurers call the shots when it comes to waiting periods. The best advice would be to do your research carefully so you’re prepared and know what to expect.

How do waiting periods for extras cover work?

Health insurance waiting periods for extras will depend on your specific fund. Generally speaking, waiting periods for extras can vary from 2 to 12 months. Everything is going to depend on the complexity and cost of the treatment involved.

Typical waiting periods for extras include 2 months for dental checkups and physiotherapy. They can be 6 months for glasses and contact lenses and 12 months for big dental procedures such as orthodontics.

Can health funds waive waiting periods?

There are some conditions under which health funds may offer reduced or no waiting period health insurance. This would normally be for a particular promotion to attract new members.

It could be that there’s a particular element of your health insurance policy that you know you’ll want to claim on frequently. You should check out the waiting periods before you join up. This way you’ll be sure the waiting periods are going to suit your needs.

Some insurers will have special offers from time to time. When these are on, they may waive some extras cover waiting periods on combined hospital policies. They do this to tempt new customers to join up. Even so, it is unusual for insurers to waive12 month waiting periods.

With some special deals, it could be that your insurer won’t expect you to serve waiting periods for preventative or general treatments. This might include things like a routine check-up at the dentist. You would still need to wait before claiming for major dental treatment, such as root canals.

What happens if I have a pre-existing condition?

The government always determines the maximum waiting periods for all types of hospital cover.

When you’ve got a pre-existing condition you should still be able to claim for treatment as long as you serve the 12 month waiting period. Some examples of pre-existing conditions are high blood pressure and heart disease. They could also include cancer, and diabetes. Other conditions would be those that have been showing signs or symptoms during the previous six months.

Pregnancy and obstetrics cover also have a waiting period of 12 months. Psychiatric treatment, rehabilitation and palliative care have a 2 month waiting period.

Will Waiting Periods Apply When Switching Policies?

You will not have to re-serve waiting periods if you switch funds, provided you are taking out coverage of the same level, or of a lower level. On the other hand, if you wish to upgrade your policy, you will have to wait for new, higher benefits to kick in. Your fund will be able to provide you with further information on how long this wait will be.

Use our calculator below to find out what your waiting periods might look like should you wish to upgrade or purchase a new policy.

Health Insurance Waiting Period Estimator

You will have to serve a waiting period when you start a new private health insurance policy or increase your level of cover. A waiting period protects members of the fund by ensuring that individuals aren't able to make a large claim shortly after joining and then cancelling their membership. This kind of behaviour would result in increased premiums for all members.

Use this calculator to choose a hypothetical date in the future (or leave it on the default setting, which is today's date) to determine when you will be covered for various types of coverage.


Months Standard Waiting Period
0
  • Accidents
  • Ambulance
2
  • Chiropractic/Osteopathic
  • Alternate/Natural Therapies
  • Dietetics
  • Eye Therapy
  • Hospital Treatment
  • Occupational Therapy
  • Pharmaceutical Perscriptions
  • Physiotherapy
  • Podiatry
  • Speech Therapy
  • General Dental
6
  • Optical
12
  • Orthotics
  • Major Dental
  • Pre-Existing Conditions
  • Pregnancy Related Services

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