What Is a Health Insurance Waiting Period?
After purchasing health insurance, it is easy to assume that every benefit becomes available as soon as the policy starts. However, some benefits may be subject to a waiting period.
What is a waiting period?
A waiting period is the specified time between the commencement of a policy or benefit and the date from which an eligible claim may be made.
During this period, the policy may already be active and premiums remain payable, but claims under the affected benefit may not yet be eligible.
Waiting periods help manage the risk of someone purchasing insurance only after becoming aware that treatment is required and then cancelling the policy shortly after claiming.
Does every benefit have a waiting period?
No.
Waiting periods vary between insurance products, benefits and individual policy terms. Some core medical benefits may apply from the policy’s commencement date, while certain optional or specialised benefits may require a period of continuous cover.
Benefits that may have a waiting or qualifying period include:
Dental and optical care
Health checks and screening
Obstetric or maternity allowances
Specified procedures or treatments
Serious-condition lump-sum benefits
Newly added or upgraded benefits
These are general examples only. The applicable waiting period should always be confirmed in the current Policy Document, Acceptance Certificate or Renewal Certificate.
Waiting periods and pre-existing conditions are different
A waiting period determines when a benefit may become available.
A pre-existing condition assessment determines whether an illness, injury, symptom, investigation, treatment or surgery that existed before cover began is eligible.
Completing a waiting period does not automatically make every pre-existing condition eligible. A condition may be covered, subject to special terms, temporarily excluded or permanently excluded, depending on the policy and underwriting decision.
When does a waiting period begin?
Depending on the policy, the waiting period may begin from:
The policy commencement date
The date a new member joins the policy
The start date of an optional benefit
The effective date of an upgrade
The date cover is reinstated or reassessed
If a policy is cancelled, allowed to lapse or replaced, a previously completed waiting period may not automatically be recognised.
Can an upgrade create a new waiting period?
Potentially, yes.
Adding specialist, everyday healthcare, screening or other optional benefits may create a waiting period for the new or increased portion of cover.
Before upgrading, confirm:
Which new benefits have waiting periods?
When does each waiting period begin?
Will the existing cover continue without interruption?
Does the waiting period apply only to the increased benefit?
How will symptoms arising during the waiting period be assessed?
What if symptoms begin during the waiting period?
If symptoms arise during the waiting period but diagnosis or treatment occurs after it ends, the insurer may review when the symptoms first appeared and apply the relevant pre-existing condition definitions and policy terms.
Waiting until the period ends before visiting a doctor does not necessarily make the treatment eligible. Medical advice should be obtained when needed, and all information supplied to the insurer should be complete and accurate.
Does completing the waiting period guarantee payment?
No.
Completing the waiting period satisfies only one possible requirement. A claim must still comply with the policy’s:
Benefit definitions
Medical-necessity requirements
Exclusions and special terms
Annual or lifetime limits
Provider and referral requirements
Prior-approval procedures
Reasonable-charge provisions
Written pre-approval should be obtained before expensive surgery, specialist treatment or diagnostic testing.
Conclusion
There is no single waiting period that applies to every health insurance policy or benefit. Different benefits within the same policy may have different requirements.
Before purchasing, upgrading or replacing cover, review the waiting periods, pre-existing condition provisions, exclusions and continuity rules. Written pre-approval is also recommended before costly treatment.
This article provides general information only and does not constitute personalised financial advice. Cover remains subject to the individual policy documents and the insurer’s written decision.