Waiting Periods & Benefit Limitation Periods
A waiting period is the time between joining GMHBA and when you can start claiming. Waiting periods exist to protect members’ funds from those who wait until they are sick to join a health fund claiming large sums immediately.
Waiting periods apply to:
New members to health insurance (members who have never held hospital or extras cover with a health fund).
Existing GMHBA members who upgrade to a higher level of cover or reduce their excess payable.
Members who transfer from another health fund who have not fully served the required waiting and/or benefit limitation period for equivalent benefits.
Treatment for a pre-existing condition.
Additions to a membership (unless the addition/s has already served all waiting periods with GMHBA or another fund) except newborns, adopted and permanent foster children where the family membership has been in existence for at least two months, and where the addition/s has already served all waiting periods with GMHBA or another fund.
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)|
|Obstetrics and maternity.||12 months|
|Pre-existing ailment, illness or condition (other than psychiatric, rehabilitation and palliative care).||12 months|
|Any other benefit for hospital (or hospital substitution) treatment.||2 months|
Extras waiting periods
|Extras services (when included on cover)||Waiting period|
|All extras benefits except as specified below.||2 months|
|Optical, home and domestic aids and medical aids.||6 months|
|Major dental services (including full & partial dentures, orthodontics, crown & bridgework, endodontic services such as root canal, gold fillings, indirect restorations, surgical extractions of a tooth/teeth including wisdom teeth).||12 months|
|Health appliances 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, podiatry surgical procedures and orthotic appliances (foot).||12 months|
Planning a child
If you are preparing to start a family and your hospital cover does not include obstetrics, you will need to ensure you upgrade your hospital cover to include obstetrics at least 12 months before you have a child to ensure all waiting periods have been served.
When a baby is born in most cases they won’t usually require a hospital admission. In some instances where there may be complications and your baby requires special care, you will not be covered for accommodation or medical services unless your baby has served the waiting periods. Therefore, if you are currently on a single or couple membership, you will need to change to a family membership.
Pre-existing conditions (PEC)
A pre-existing condition is one where signs or symptoms of your ailment, illness or condition, in the opinion of a medical practitioner 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.
A special waiting period applies to obtain benefits for hospital treatment for new members who have pre-existing conditions. The waiting period also applies to existing members who have recently upgraded their level of hospital cover. If the ailment, illness or condition is considered pre-existing:
New members must wait 12 months for any hospital benefits (other than psychiatric, rehabilitation and palliative care).
Members transferring/upgrading to a higher hospital cover must wait 12 months to get the higher hospital benefits (other than psychiatric, rehabilitation and palliative care).
Existing members with at least 12 months membership in total across their old and new cover are entitled to the lower benefits on their old cover.
Benefit limitation periods
During your first 24 months of cover – after the standard hospital waiting periods have been served – Gold Hospital covers are subject to benefit limitations on selected services.
This means that the benefits payable on these services are limited to the minimum shared room rate under the Private Health Insurance Act for private hospital admissions, during the 24 month benefit limitation period.
Once the waiting period and benefit limitation period has been served, you will have access to the benefits applicable on your level of cover.
No benefit limitation periods apply on Gold Hospital cover with Gap Saver.
For more information about waiting periods and pre-existing conditions please refer to the Important Information section of the GMHBA Member Guide.