Private Health Insurance Waiting Periods

What are waiting periods?

Understanding your private health waiting period doesn't need to be complicated. A waiting period is the length of time you need to hold your cover before you can claim benefits for certain treatments under your health insurance policy. Waiting periods are set under the Australian Government's private health insurance rules, and as South Australia's own not-for-profit health fund, we want ours to be as easy to understand as possible.

Waiting periods help keep things fair for everyone. Without them, people could take out cover, claim for expensive medical treatment straight away, and then cancel, which would mean higher premiums for existing members. The waiting period that applies depends on the type of treatment, your level of cover and your cover history.

In short, the waiting period for most Extras and hospital treatment is 2 months. This rises to 12 months for major dental, orthodontics, aids & appliances. On hospital 12 month waits apply for pre-existing conditions, pregnancy and birth-related services, while hospital psychiatric services, rehabilitation and palliative care stay at two months.

When you join without current health cover

As a new member taking out private health cover for the first time, or if you've been without private health cover for more than 30 days, you'll generally need to serve waiting periods for the services included in your level of cover. Most waiting periods are two months, though some take longer, like major dental, orthodontics, aids and appliances, and pregnancy.

Extras waiting periods

After two months, you can access benefits for most Extras services included on your cover, such as general dental. Some services have a longer wait, including aids and appliances such as blood pressure monitors, blood glucose monitoring machines and hearing aids, which have a 12-month waiting period.

The dental waiting period is a good example. Major dental work like crowns and bridges and dentures has a 12-month waiting period, while everyday dental treatment is covered after your standard two-month wait. Check your Individual Cover Details for how specific treatments, including extractions, are classified on your cover.

Orthotics have a 12-month waiting period on on Active Family, Growing Family, Best and Better Extras, and a two-month waiting period on other covers. Refer to your Individual Cover Details to see what waiting periods apply to your chosen cover. Not all benefits are available on all covers.

Hospital waiting periods

After two months, you can access benefits for most hospital treatment on your chosen cover, except for pre-existing conditions, pregnancy and birth-related services, and the other items listed below.

This includes home nursing and home sleep studies, which carry a 12-month wait. Outpatient loyalty benefits for insulin pumps and replacement hearing devices build over time, with 50% of the benefit available after three years, 70% after four years and 100% after five years. Palliative care, rehabilitation and hospital psychiatric services carry a shorter two-month wait.

If you've held hospital cover with us for at least two months and upgrade to a cover with higher benefits for hospital psychiatric services, you may be able to access those higher benefits without serving a further wait. This exemption is available once in your lifetime. See our pre-existing conditions guide for more details.

+ Waiting periods do not apply to benefits for treatment provided immediately after and related to an accident. Accidents must not have occurred within 1 day of membership commencement. When an accident has occurred within 1 day of membership commencing the accident rule does not apply and waiting periods apply.

Refer to your Individual Cover Details to see what waiting periods apply to your chosen cover. Not all benefits are available on all covers. Terms and Conditions Apply, see below for details.

Accidental Injury

If you need hospital treatment immediately after an accident, from a registered medical practitioner and unrelated to a pre-existing condition, waiting periods won't apply to your hospital benefits. This means you can still receive benefits for that treatment even if you haven't yet served your standard waiting periods.

This doesn't apply if the accident happened within 1 day of your membership starting, in which case standard waiting periods apply. The accident waiver doesn't extend to Extras benefits. Refer to our Member Guide for the full accident definition and conditions.

When you transfer from another fund

If you've held cover with another Australian health fund and served the waiting periods for an equivalent level of cover, meaning a policy with the same inclusions and limits, you generally won't need to re-serve those waiting periods when you switch to us. To keep your served waiting periods, you'll need to transfer within 30 days of your previous cover ending.

Waiting periods will apply for:

• Any additional services, treatments, goods and any higher limits. During this time you will receive the same benefits you received on your previous cover
• If you have only partially served waiting periods with your previous fund, the remainder of the waiting period will be served with us.
  Refer to our Member Guide for full conditions.
• If more than 30 days have passed since your previous cover ended, in which case full waiting periods apply.

Benefits you've already claimed with your previous fund count towards your yearly and lifetime limits with us, and loyalty bonuses don't transfer between funds. Refer to our Member Guide for full conditions.

When you upgrade your cover

If you're an existing member and you change to a different hospital or extras cover, waiting periods may apply for any increased benefits, new services and higher limits. During this time, you'll still receive the same benefits as before, and for hospital cover, you'll pay the same excess and co-payment as your previous level of cover, where applicable.

When you change cover, we'll explain exactly which benefits you can claim straight away, and which waiting periods apply. This applies whether you're increasing your hospital cover level, adding Extras, or moving to a higher cover tier for the first time.

Pregnancy and Birth

A 12-month waiting period applies to hospital benefits for pregnancy, birth and other birth-related and reproductive services, so it's worth taking out hospital cover that includes these services well before you plan to claim. Twelve months is the maximum waiting period insurers can apply to these services under the Australian Government's private health insurance rules.

For more on pregnancy and hospital cover, read our Having a Baby flyer.

Pre-existing conditions

A pre-existing condition is any ailment, illness or condition where signs or symptoms existed at any time in the six months before you joined, or before you upgraded to a higher level of hospital cover. The condition doesn't need to have been diagnosed. An independent medical practitioner appointed by Health Partners will determine whether your treatment relates to a pre-existing condition.

Pre-existing conditions carry a 12-month waiting period for hospital treatment, except for hospital psychiatric services, rehabilitation and palliative care, which have a two-month waiting period, as outlined above. Refer to our Member Guide for full conditions, or see our pre-existing conditions guide for more on how this works.

When waiting periods may not apply

In some situations, waiting periods can be reduced or waived, subject to eligibility and our Fund Rules:

• Newborns added within 90 days of birth, or within 12 months if you're on a family-type cover that allows dependants, provided any required premiums are paid.
• Adopted or fostered children added within 90 days of obtaining legal guardianship, though pre-existing condition waiting periods still apply. Children adopted from overseas must be eligible for full Medicare benefits before hospital benefits can be paid.
• Eligible Gold Card holders (Veteran Card - All conditions) who apply within two months of ceasing to hold a Gold Card.
• Australian Defence Force personnel who join within 30 days of discharge, for both hospital and Extras.
• Members transferring from another Australian health fund who have already served waiting periods for an equivalent cover.
• Eligible accident-related hospital treatment, subject to the conditions above.

If a newborn, adopted or fostered child isn't added within the allowed period, full waiting periods apply from the date their cover starts.

Some covers and promotional offers may also include waiting period waivers. Check the terms that apply to your cover, or ask our team.

Whatever stage of life you're at, we're here to help make sense of your waiting periods and your health needs, as South Australia's own health fund. New and existing members alike can call our local Member Care team on 1300 113 113 during business hours for help understanding which waiting periods apply to their cover.