Things you need to know about a pre-existing condition.

OSHCglobal - If you’ve got OSHC, OVHC, you can find out about pre-existing conditions

The Private Health Insurance Act 2007 says that a person has a pre-existing condition if:

• In the opinion of a medical practitioner appointed by your health insurer, you had signs or symptoms of an illness or condition, at any time in the six months before you took out your policy (ending on the day you took it out)

Who decides whether a condition is pre-existing?

A doctor appointed by your insurer decides whether your condition is pre-existing, not you or your doctor. The insurer’s doctor must consider your treating doctors’ opinions on the signs and symptoms of your condition, but doesn’t have to agree with them.

If you’re unhappy with your health insurer’s decision, or how they have handled your assessment, it’s always best to contact them, and follow any complaints handling processes that they have. If you can’t resolve it, you can discuss your complaint with the Private Health Insurance Ombudsman.

What happens if my condition is pre-existing?

If your insurer’s doctor has assessed your condition and decides it was pre-existing, generally you won’t be covered for any treatment for it for the first twelve months of starting, or upgrading your policy. The exceptions to this are if it’s for psychiatric treatment, rehabilitation or palliative care, which you’ll generally wait two months before being covered for.

If you need psychiatric services, in certain circumstances, you might be able to upgrade your cover without a waiting period, once in your whole lifetime.

OSHCglobal (source: Bupa)