A waiting period is the time between when you first take out health insurance or upgrade your cover and when you are covered for a treatment or service.
Waiting periods exist to deter people from joining the fund or increasing their level of cover only when they have a condition or illness that may require immediate treatment. This practice can place pressure on premiums for all members of the fund.
Waiting periods will apply to:
- New members who have never held private health insurance before. If you receive a service or treatment during a waiting period, you are not eligible to receive a benefit under your health insurance cover, regardless of when you submit the claim.
- Members who transfer from another health fund and have had a gap in and/or upgraded their cover (see Switching to GMHBA below).
- Existing GMHBA members who upgrade to a higher level of cover or reduce their excess payable. If treatment or service was included on the previous cover at a lower level, and waiting periods have previously been served, members are entitled to the lower benefits on their previous cover while serving the new waiting period for higher benefits or reduced excess.
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Additional members added onto a policy (unless they've already served their relevant waiting periods). Exceptions apply for newborns, adopted and permanent foster children where the family membership has been in existence for at least two months.
Switching to GMHBA
If you have already served your waiting periods on an equivalent or higher level of cover with another fund, and joined GMHBA within 30 days of leaving that fund, you won't have to re-serve your waiting periods. Otherwise, waiting periods will apply from the date you take out your new cover with GMHBA. If you’ve upgraded your cover, your waiting periods for higher cover will start on the date you upgraded, but you can still claim the equivalent benefit to your previous level of cover during that period.
Mental health waiver
The mental health waiver allows members who have served their 2 month waiting period for restricted psychiatric benefits to upgrade their hospital cover to include inpatient psychiatric treatment without serving an additional 2 month waiting period. The waiver applies only to the 2 month waiting period for in-hospital psychiatric treatment. Waiting periods for any other newly included services will still need to be served. Members can use the Mental Health Waiver once in their lifetime.
Hospital waiting periods
| Hospital services (when included on cover) | Waiting period |
|---|---|
| Accidents – bodily injuries resulting from accidents which occur after the date of joining GMHBA or upgrading to a higher cover. | 0 days (accidents must occur after joining) |
| Ambulance benefits | 0 days |
| Pregnancy and birth-related services | 12 months |
| Pre-existing ailment, illness or condition (other than psychiatric, rehabilitation and palliative care). See important information regarding pre-existing conditions. | 12 months |
| Psychiatric, rehabilitation or palliative care | 2 months |
| Any other benefit for hospital (or hospital substitution) treatment | 2 months |
Extras waiting periods
| Extras services (when included on cover) | Waiting period |
|---|---|
| Ambulance subscriptions and transport | 0 days |
| Any eligible extras services that are not specified below | 2 months |
| Optical | 6 months |
| Major dental services (including full and partial dentures, crown and bridgework, endodontic services such as root canal, gold fillings, indirect restorations, surgical extractions of a tooth/teeth including wisdom teeth) and orthodontics. | 12 months |
| Medical devices and aids including nebuliser pump, blood glucose monitor, pressure garments, sleep apnoea monitor, extremity pump, hearing aids, orthopaedic appliances (GMHBA approved), prostheses (GMHBA approved non-surgical), tens monitor, orthotic appliances (foot), and podiatry surgical procedures. | 12 months |
Planning for a child
If you are preparing to start or expand your family and want the option of choosing your obstetrician and giving birth as a private patient in a private hospital, you’ll need to have pregnancy and birth included as a clinical category on your hospital cover. Note that any outpatient appointments (regular obstetrician appointments, blood tests etc.) are not covered by private health insurance.
If you upgrade your hospital cover to include pregnancy and birth, you’ll need to do this at least 12 months before you plan to give birth. This is to make sure that all waiting periods have been served before you claim for pregnancy and birth-related hospital admissions. If a baby is born early, waiting periods are assessed from the baby's estimated due date.
In a standard delivery, your newborn baby will not be admitted as a patient in hospital. Any medical expenses for a newborn not admitted to hospital will be deemed outpatient services and are claimable through Medicare only. If you have complications and your newborn baby is admitted to hospital and requires any separate accommodation or medical attention, they will be covered for accommodation or medical services, provided:
- waiting periods have been served by the parent, and
- the baby is added to the policy within 6 months of their date of birth, and
- change to family status (from couple to family, for example) is backdated to their date of birth.
When a newborn is added to a policy, a single policy automatically becomes a single parent policy, and a couples policy becomes a family policy.
Note: cover changes, including a change to family status, may result in a change to your premiums.
Pre-existing conditions (PEC)
A pre-existing condition is one where signs or symptoms of your ailment, illness or condition, in the opinion of an external medical adviser appointed by GMHBA (not your own doctor), existed at any time during the six months preceding the day on which you purchased your hospital insurance or upgraded to a higher level of hospital cover and/or benefit entitlement.
GMHBA will ask that you provide information from both your GP and treating specialist in order for an external medical adviser to determine whether your condition is deemed pre-existing or not. The process can take some time and it’s best to get this done as soon as possible to confirm whether GMHBA can cover your procedure.
Be aware, the pre-existing condition rule still applies even if your ailment, illness or condition was not diagnosed prior to joining the hospital cover.
If your condition is found to have been pre-existing, you will not be covered for the admission, and must wait until after the waiting periods have been served for benefits to be payable.
The only test is whether or not, in the six months prior to joining your current hospital cover signs and symptoms:
- Were evident to you;
- Would have been evident to a reasonable medical practitioner, if a medical practitioner had been consulted.
In an emergency, we may not have time to determine if you are affected by the pre-existing condition rule before your admission. Consequently, if you have less than 12 months membership on your current hospital cover you might have to pay for some or all of the hospital and medical charges if:
- You are admitted to hospital and you choose to be treated as a private patient; and
- We later determine that your condition was pre-existing.
More information
For more information about waiting periods and pre-existing conditions please refer to our Important Information Guide.