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Understanding Private Health Insurance: Waiting Periods, Pre Existing Conditions, Exclusions and Restrictions
Navy Health understands that Private Health Insurance can be quite confusing for our members with various impositions on your cover that may impact you using it when you need it.
To assist our members, we have created Be Informed, an online resource to provide you with information relating to the Private Health Insurance industry and to provide you with resources to make better informed decisions relating to your health needs.
What are waiting periods?
Waiting periods are placed on policies in the following scenarios:
|•||New to Navy Health and have not had private health insurance in the past year.|
|•||New to Navy Health and are transferring from another fund from a lower cover i.e. from Bronze to Gold.|
|•||A current member of Navy Health who is upgrading to a higher level of cover i.e. from Bronze to Gold.|
|•||A previous member of Navy Health who is returning after not having had private health insurance for 12 months.|
|•||A person joining an existing Navy Health membership that falls into the above points.|
Why do waiting periods exist?
In Australia, all health insurers are required by law to provide health insurance for Australian residents regardless of their health status and cannot charge higher premiums based on whether a person is more likely to require treatment.
If there were no waiting periods, people could take out hospital insurance or upgrade to a higher policy only when they knew or suspected they might need hospital treatment. This would lead to much higher premiums for all existing contributors to health insurance.
Ref: Private Health Insurance Ombudsman.
How long are the waiting periods?
|•||12 months for pre-existing conditions – this is defined as any conditions, illness, or ailment that you had signs or symptoms of during the six months before you joined a hospital policy or upgraded to a higher hospital policy.|
|•||12 months for obstetrics (pregnancy) – to be covered, the mother’s hospital admission needs to take place after the 12 month waiting period has been completed.|
|•||Two months for psychiatric care, rehabilitation, and palliative care, even for a pre-existing condition – this can include treatment of post-natal depression, eating disorders, and drug and alcohol rehabilitation, amongst other treatments.|
|•||Two months in all other circumstances.|
General Treatment (Extras Cover):
General treatment or extras cover are set by Navy Health and they are not subject to the same laws as hospital cover, however there are rules surrounding waiting to ensure all of our members have a fair and equitable experience.
Examples of the wait periods on extras covers are below; however to view your product waits please go to our website.
|General Dental||2 months|
|Major Dental||12 months|
If you have transferred from another funds and have served similar waits, you will not need to re-serve any waits when you join Navy Health.
What is the pre-existing condition waiting period?
A pre-existing condition is defined by law as any condition, illness, or ailment that in the opinion of the health insurers doctor (not you, or your doctor), you had signs or symptoms of during the six months before you joined a hospital policy, or upgraded to a higher hospital policy. Navy Health utilise an independent doctor to make these impartial determinations on our behalf.
Under Navy Health fund rules, we will not pay for hospital admissions within the first 12 months of joining or upgrading your level of cover.
If you require a hospital admission within your waiting periods, Please contact our member’s services team on 1300 306 289 to discuss the process and the options that may be available to you.
Pre-existing conditions example
Example 1: Pre-existing rule applies:
|•||Nick has experienced reoccurring chronic sore throats before he took out hospital cover for the first time with Navy Health.|
|•||During his last sickness, Nick consulted his doctor shortly after joining Navy Health and his doctor diagnosed him with chronic tonsillitis and referred him to a specialist who recommended surgery to remove his tonsils.|
|•||Nick contacted Navy Health to discuss his options and was provided with documentation for his doctor to fill out about his condition, which was then passed through, confidentially, to Navy Health’s independent doctor.|
|•||The doctor appointed by Navy Health determined that symptoms of Nick’s condition were in existence in the six months before he joined. Although Nick’s doctor had not diagnosed tonsillitis initially, the symptoms had been present for some time before Nick saw his doctor or joined Navy Health.|
|•||Navy Health advised Nick that his surgery would not be covered by private health insurance as it was deemed pre-existing. Nick will need to serve the remaining months before his surgery will be covered.|
Example 2: Pre-existing rule does not apply:
|•||Rebecca has been a member of Navy Health for 2 months when she was rushed to hospital by ambulance.|
|•||Rebecca’s treating doctor diagnosed that a heart attack had occurred.|
|•||The treating doctor/hospital submitted the claim for services to Navy Health and we submitted the information to our independent doctor for evaluation.|
|•||Whilst the doctor highlighted numerous risk factors for the heart attack i.e. smoking and high blood pressure, there were no signs or symptoms leading up to joining Navy Health that would indicate a heart attack was about to occur.|
|•||Navy Health’s doctor deemed the claim ok to pay as there were no signs or symptoms leading up to the heart attack.|
|•||Navy Health paid the claim in full.|
Exclusions and restrictions?
Some of Navy Health’s hospital policies contain exclusions and restrictions i.e. silver or bronze policies. Exclusions and restrictions exist to provide our members with varying levels of cover and varying premium prices and allow members to choose a policy suited to their health needs.
If your policy contains exclusions for specific categories/conditions, Navy Health will not pay for that treatment in either a private or public hospital if you are admitted.
For example, if you are admitted into hospital for a heart attack (cardiac), Navy Health will not pay any benefits toward your hospital or medical costs that are incurred if the policy you have purchased has cardiac excluded.
If your policy contains restrictions for specific categories/conditions, Navy Health will pay for treatment, but only as a private patient in a public hospital.
For example, if your policy contains restrictions for pregnancy and birth related services, you will only be covered in full if you are admitted to public hospital as a private patient to give birth.
It is important for all members to regularly review their policy to ensure that it is suited to their health needs now and into the future. If you would like to discuss your policy options please contact Navy Health on 1300 306 289.
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