What is a pre-existing condition?

A pre-existing condition is any illness, ailment or condition where, in the opinion of a medical advisor appointed by Australian Unity, the signs or symptoms have existed at any time during the six months up to and including the day on which you became insured under the policy—regardless of whether you were aware of it.

Like most health insurers, Australian Unity’s hospital covers have a 12-month waiting period on the treatment of pre-existing conditions. This waiting period applies to new members and members upgrading their existing policy to a higher level.

If you’ve got Overseas Visitors Cover, you can find out about pre-existing conditions here.

If you are switching to Australian Unity within 30 days of leaving your previous health fund, and you have chosen a level of cover that is similar or lower than your previous cover, you won’t have to re-serve the 12-month pre-existing condition waiting period if you have already completed it.

If you are upgrading your cover, you will be required to wait 12 months before receiving the higher benefits. Rest assured that you will still be entitled to the benefits payable under your previous level of cover while you are serving the waiting period for higher benefits.

After you have held hospital cover for a continuous period of 12 months, the pre-existing condition waiting period no longer applies and you are entitled to the full benefits under the policy.

New and upgrading members who have pre-existing conditions and are affected by the waiting period can still seek treatment for these conditions in a public hospital under Medicare.

Why is there a waiting period for pre-existing conditions?

If this waiting period didn’t exist, people could take out hospital cover or upgrade to comprehensive 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 (or downgraded) their membership, their hospital costs would have to be paid for by the fund’s long-term members. Not only is this unfair to existing members, it could also lead a fund having to increase premiums.

Going to hospital during the first 12 months?

For any hospital claim during this 12-month waiting period that might be related to a pre-existing condition, we may ask you to have a medical report completed by the first doctor you saw about the condition, such as your GP or specialist. We will then review the information and assess whether the treatment relates to a pre-existing condition.

To ensure you are not faced with any unexpected costs, you should always check that you will be covered before seeking hospital treatment. We recommend you download the Medical Report Form as soon as you know you need hospital treatment, and ask your doctor to complete it and return it to us ASAP. We need up to five working days to carry out the initial pre-existing condition assessment after receiving the report form.

To find out more about the pre-existing condition waiting period, call us on 13 29 39 or visit the Commonwealth Ombudsman website.