Waiting Period Over? Cover Isn’t Automatic
Many people closely track the waiting period on their health insurance policy. Once that period has passed, they may assume that future consultations, diagnostic tests and treatments will automatically be covered.
That is not necessarily the case.
Completing a waiting period satisfies only one possible policy condition. A claim may still depend on the history of the medical condition, the policy’s benefits and exclusions, medical necessity, referral requirements, prior approval, benefit limits and the insurer’s assessment.
What is a waiting period?
A waiting period is a specified period that generally begins when a policy starts or when cover is added or upgraded. Certain conditions, services or treatments may not be claimable during that period.
Waiting periods help prevent someone from purchasing or increasing insurance only after becoming aware that treatment is likely to be required.
The applicable period can vary between insurers, products and benefits. Some services may have no standard waiting period, while other benefits may have separate or longer restrictions. Passing one date therefore does not mean every part of a policy becomes unrestricted.
Waiting periods and pre-existing conditions are different
This is one of the most important distinctions to understand.
A waiting period is a time-based restriction. A pre-existing condition assessment considers whether a condition, symptom or relevant health circumstance existed before cover began.
An insurer may look beyond the date of formal diagnosis. Symptoms, consultations, medication, previous investigations, recommendations for testing and treatment received before the policy started may all be relevant.
For example, a condition may be diagnosed after the waiting period ends, but the medical records might show that related symptoms existed before the policy began. The claim could still be affected by a pre-existing-condition provision or a specific exclusion.
A specific exclusion included in the underwriting terms will not usually disappear simply because a general waiting period has ended. Any opportunity to reconsider that exclusion will depend on the insurer’s rules and the medical evidence available.
The treatment must be covered by the policy
Health insurance is not a general account that reimburses every healthcare expense.
Some policies focus on eligible surgery and hospital treatment. Others may also provide benefits for specialist consultations, diagnostic tests, GP services, physiotherapy, dental care, optical care or non-government-funded medicines.
Two policies with similar names can provide substantially different benefits. A treatment recommended by a doctor may be clinically appropriate but still fall outside the policy’s covered benefits.
Medical advice and insurance eligibility are separate decisions.
The treatment may need to be medically necessary
An insurer may require evidence that the proposed treatment is medically necessary, appropriate and consistent with the applicable policy definition.
Supporting information may include:
• A GP or specialist referral
• Clinical notes and symptom history
• Diagnostic test results
• A confirmed diagnosis
• The clinical reason for the proposed treatment
• A treatment plan and cost estimate
A claim may be delayed or declined if the information is insufficient, the treatment is considered experimental, or the policy’s eligibility requirements are not met.
Prior approval may be required
Surgery, hospital treatment, expensive diagnostic procedures, specialised medicines and overseas treatment may require written approval before treatment begins.
Prior approval can help confirm:
• Whether the condition is eligible
• Whether the treatment falls under an insured benefit
• Whether the provider meets the policy requirements
• How much the insurer expects to pay
• Whether further medical evidence is required
A verbal discussion or an estimate from a healthcare provider may not amount to a formal commitment from the insurer. Written confirmation is particularly important before proceeding with expensive treatment.
An eligible claim may not be paid in full
Even when treatment is approved, the amount payable may be affected by:
• The policy excess
• A co-payment percentage
• Annual or per-treatment benefit limits
• Approved-provider or network requirements
• Reasonable and customary charge provisions
• Non-covered associated costs
• Benefits already used during the policy year
“Eligible to claim” and “fully reimbursed” do not mean the same thing.
What should you confirm before treatment?
Before arranging treatment, consider asking the insurer or your insurance adviser:
Is the condition affected by a pre-existing-condition provision or specific exclusion?
Which policy benefit applies to the proposed treatment?
Is a GP or specialist referral required?
Do I need written prior approval?
Will an excess or co-payment apply?
What is the maximum amount payable?
What medical records and cost information are required?
Can the decision be confirmed in writing?
Final thoughts
The end of a health insurance waiting period does not create automatic cover for every illness, investigation or treatment.
Claim eligibility depends on the medical history, underwriting decision, policy wording, nature of the treatment, supporting evidence and claim process.
Before proceeding with surgery, costly testing or other significant treatment, check the applicable benefits and obtain written confirmation where required. This can reduce the risk of discovering after treatment that some or all of the cost is not covered.
This article provides general information and is not personalised financial or insurance advice. Cover depends on the individual policy wording, underwriting terms and the insurer’s assessment.