Waiting periods and exemptions

If you take out private health insurance or increase your cover, you may have to wait for a while before you can claim costs. Waiting periods can vary for different services.

Waiting periods

When you take out private health insurance or increase your cover you may have to wait some time before you can claim a benefit.

Waiting periods vary for different services. Waiting periods for hospital services must be no more than:

  • 12 months for pre-existing conditions
  • 12 months for pregnancy and birth-related services
  • 2 months for psychiatric care, rehabilitation or palliative care (even if it’s for a pre-existing condition)
  • 2 months for all other services

Insurers can apply any waiting period for extras cover.

Your policy will list the waiting periods that apply to you.

If you change policies or insurers

Health insurers must not give you extra waiting periods if you switch to a new policy that offers the same level of benefits as your old policy.

This applies even if you change insurer.

Find out more about your right to change.

Pre-existing conditions

If you already have a health condition or you are sick when you take out private health insurance, you may not be able to claim benefits straight away. Having a waiting period like this helps stop people making a claim and then dropping their cover. This would lead to higher premiums for everyone.

Your insurer can’t make you wait more than 12 months to claim a benefit for a pre-existing condition.

Find out more about waiting periods.

Mental health waiting period exemptions

You can upgrade your hospital cover for psychiatric care without a further waiting period. This is only if you have finished a 2 month waiting period for limited psychiatric benefits.

You can do this at any time but only once in your lifetime.

This exemption applies to hospital, or hospital-substitute, care for:

  • mental health services
  • drug and alcohol treatment 

Usually you will be eligible for higher benefits as soon as you upgrade. If you haven’t served the full 2 month waiting period when you upgrade, your health insurer may not provide higher benefits until you have served the full 2 months.

Cover for treatment you had before upgrading

You may be able to get cover for treatment you had before upgrading, if you upgrade within 5 days of going into hospital.

If you upgrade more than 5 days after going into hospital, you will be eligible for cover only from the date you upgraded.

Using your exemption

You don’t have to use the once-only exemption if you upgrade your cover.

You can choose to:

  • use the once-only exemption and claim higher benefits for the treatment, or
  • not use the exemption and claim only the lower benefits you were entitled to before upgrading

If, after you upgrade, you don’t claim higher benefits for your treatment, the exemption is still available to you. You will have used your exemption if you claim higher benefits for mental health treatment within 2 months of upgrading your policy.

Because you can only use the mental health exemption once in your lifetime, if you upgrade your cover again, you have wait 2 months before you can claim higher benefits.

Premiums for higher cover

Your new premiums are payable from the date you upgrade your cover.

You can go back to a lower level of cover at a later time if you want. You can only get higher benefits for mental health care while you have higher cover.

Excess, co-payments and other out of pocket costs for mental health treatment

The reduced waiting period only applies to the higher benefits paid when you claim on your upgraded cover.

If your old policy had a higher excess or co-payment, you may still have to pay this until the standard waiting period of 2 months is over.

Your hospital may charge an upfront fee if they can’t confirm your cover while you are upgrading. It’s up to the hospital whether they refund this later.

You might also have to pay other out of pocket costs depending on what your doctor charges for services.

Talk to your doctor and hospital about their charges and refund policies.

Changing health insurers for higher cover

You can choose to upgrade to higher cover with your current insurer or any other private health insurer.

As long as you have finished the 2 month waiting period with your current insurer, you can access higher benefits for mental health. This can be with any insurer you decide on.

Other people on your policy

The mental health waiting period exemption applies to everyone covered by your policy. Each person can access the exemption at any time once in their lifetime.

Find out more about mental health exemptions for higher benefits.

Last updated: 
24 December 2019

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