Private health insurance waiting periods: your questions answered

Confused about waiting periods with private health funds? Get the lowdown on how they work and why they exist.

When you pay for a service, you generally want it to kick in immediately – like with internet, water and electricity. However, private health insurance works a little differently.

Serving waiting periods before you start claiming on private health insurance is common in Australia. Why? As it turns out, there’s a really important reason.

Why do private health funds have waiting periods?

Having to wait to use some parts of your private health cover – like major dental – can be frustrating, but the reason could save you money.

If health funds don’t have waiting periods, people could join the fund and take out private health insurance, make a high-cost claim, then cancel their insurance. What this means is that people who are regularly paying their premiums bear the cost of that claim.

In short, waiting periods protect existing members and reduce the rate of premium increases in the long run.

How long are waiting periods for health insurance?

The Australian Government sets the maximum hospital cover waiting periods. Here’s what the government has decided are the maximum lengths:

• Two-month wait for psychiatric care, rehabilitation and palliative care, plus all other circumstances (any new health conditions that require hospitalisation).
• 12-month waiting period for treatment of pre-existing conditions. ‘Pre-existing’ means any condition, illness or ailment you had signs or symptoms of in the six months before you joined a hospital policy or changed your cover to a higher hospital policy – even if it wasn’t officially diagnosed.
• 12-month wait for pregnancy and birth-related services.
• 12-month wait to access HCF No-Gap Joints Program*.

There is great news, as well, for HCF members when it comes to emergency ambulance cover.

It’s good to know that with HCF, there’s a waiting period of two months for hospital cover, but your emergency ambulance cover kicks in after only one day.

When do waiting periods apply to hospital or extras cover?

When it comes to extras waiting periods for cover like dental, optical, physiotherapy and remedial massage, these are set by individual private health insurers. Wait times vary between insurers depending on the service.

Waiting periods apply if:

• you’re a new member
• you rejoin after having a break in private health cover
• you’re an existing member and change your cover to a higher policy e.g. if you increase your cover from HCF's Silver Hospital cover to Premium Gold Hospital, there’s a waiting period for new included services not previously covered
• you reduce your excess because this is considered an increase in your cover as you’re lowering the amount to pay if you go into hospital. If you do go to hospital during this waiting period, you’ll pay the old, higher excess amount, rather than the excess you’re changing to.

Are there waiting periods for mental health hospital treatment?

The waiting period to access hospital treatment for any mental health issue is usually two months, including psychiatric care.

But if you’re moving from a policy with restricted benefits for psychiatric care to a higher graded policy, you may be exempt from any waiting period if you have already served at least two months on your previous policy.

Eligible members⁺ can also access a HealthyMinds Check-in with a PSYCH2U psychologist at no cost. 

Do waiting periods apply when you switch private health cover?

If you transfer from another fund, without a break in cover, you generally don’t need to re-serve waiting periods you have previously completed.

For example, if your new HCF cover includes the same benefits and services as your previous cover, and you’ve already served the equivalent waiting periods, then the HCF waiting periods may be waived.

Some timeframes and exceptions may apply so it’s best to speak to an expert by calling us on 13 13 34 to find out.

Can health insurance have no waiting periods?

Generally, health funds keep to established waiting periods to ensure fairness for all members, but occasionally they may waive waiting periods for extras cover items like general dental services (not the more complex treatment), some optical treatments, and therapies like remedial massage.

You might also see promotions [waiving waiting periods] from time to time.

Do private patients have to go on waiting lists for surgery?

While waiting periods refer to accessing your health fund benefits, waiting lists usually refer to elective surgery.

Elective surgery is non-urgent surgery that has been recommended to you by a medical professional. This includes knee replacements, cataract extractions and tonsillectomies.

Elective surgery waiting lists in the public system tend to be much longer than in the private system. With private health insurance, you are also able to choose your doctor and where you are treated and may be able to access further benefits like a private room.

Find a HCF Participating Hospital to lower your out-of-pocket hospital costs for elective surgery.

How to get the most from your private health cover

• Be sure to contact your health fund before you have any health treatment or before going to hospital as a private patient, to check whether you’ve served any relevant waiting periods.
• Be as prepared as you can be. If you’re planning a family and would like to be covered for the pregnancy and birth, make sure you arrange private health cover with enough time, taking into account a 9 month pregnancy and the 12 month waiting period. If you want your baby covered from birth, let your private health insurer know within two months of their arrival.
• For unexpected situations, like emergency hospitalisation where you haven’t served out the two-month waiting period for new conditions, you can access the public health system.

For more information on waiting periods, call on 13 13 34, or log in to online member services.

A reminder of when waiting periods might apply?

• When you’re a brand-new member
• When you’re swapping over from a different fund
• When you’re reducing your excess
• When you’re increasing your cover on your current policy
• When accessing HCF No-Gap Programs.

Words by Bonnie Bayley and Angela Tufvesson
Updated August 22