Health Insurance Waiting Periods Not Being Honoured

Sarinella on 25/02/2025 - 14:17
Last edited 03/03/2025 - 09:27 by 2 other users

UPDATE:
Finally, after lots of phone calls, They told me that my waiting periods served with my other insurances are honoured and I'm covered. One thing I didn't know is that the watining periods are accumulative. so basically I can stay with one insurance for 5 months and the other for 7 months and still have the waiting periods served. I learnt this from [The right to change] (https://www.ombudsman.gov.au/__data/assets/pdf_file/0020/294…) that YesPleaseThankYou shared.

Original Post:

Hi, I have a question regarding health insurance which might be off interest of a lot of OzBargain community who change their health insurance within a year.

I have been with a health insurance provider for more than 12 months in 2020. After that I have been changing insurance based on the offers of the providers but always kept silver level.

I now have an upcoming surgery, and I have been with my current insurer for 2 months. The item numbers I will be claiming require 12 months waiting periods (Cancer related). My provider is keep sending me in loops of providing more documents and each time I provide the document to them there is an up to 7 business days of getting back to me. I have been calling them every day to resolve this. I need to confirm my hospitalisation date with the involved surgeons (more than 1) in the private hospital which is tentatively booked for next week and everything is dependent on the confirmation of my current bloody insurer.

I would like to know whether they can deny my claim? What are my options and rights? Honestly, considering the stress that they are giving me I am more inclined now to go public and later sue this provider for not having an urgent channel for upcoming hospitalisations.

Also, any comments on what OzBargainers did when moving in between funds to make sure the waiting period is honoured other than providing the last clearance certificate?

Please only provide constructive comments whether positive or negative but no time waster.

Thank you.

Health & Beauty Health Insurance Insurance

Comments

  • Amazingly on 25/02/2025 - 14:27
    +1

    I don’t get it… “ I have been with my curent insurer for 2 months. The item numbers I will be claiming require 12 months waiting perios”

    Why would they pay for your surgery?

    • scrambledeggs on 25/02/2025 - 14:29
      +3

      Waiting periods are supposed to not apply if you were previously insured with another insurer. New insurer is requiring documentation confirming previous insurance. Makes sense to me.

      • Amazingly on 25/02/2025 - 14:34
        +2

        Ok so that part has no relevance to the situation. Thanks.

  • Dumax on 25/02/2025 - 14:50
    +3

    If you haven't already, lodge a complaint with the insurer - tell them that you'll need a reference number because you are going to the Commonwealth Ombudsman.

    • YesPleaseThankYou on 25/02/2025 - 18:50
      +1

      Unsure why the above is being downvoted, the advice provided is certainly an option the OP can exercise.

  • alvian on 25/02/2025 - 14:59

    every time I provide the document to them there is an upto 7 bussiness days of getting back to me.

    The insurer should get contact you within 5 working days, not 7.

    The following advices are for a person who may be subject to a waiting period for a pre-existing condition, but they are also applicable for a person who is questioning if a waiting period applies to the insurance policy.

    You may wish to complain to the PHIO about your insurer using delay tactics to avoid covering you. But given the tone of the advices I don't know if the PHIO would be helpful to you.

    What happens if I need to go to hospital during the pre-existing conditions waiting period?

    If you need to be admitted to hospital during your waiting period, you should contact your health insurer straight away to check if you will be entitled to hospital benefits. Your health insurer should:

    • Give you some general advice about the pre-existing condition rule. However, at this stage, they cannot tell you whether or not your condition is pre-existing.
    • Send you documentation for your doctor/s to complete and return to the insurer.
    • Contact you within five working days of sending them the information. If not, you should contact the insurer and ask if they have made a decision.

    If you need to go to hospital urgently, your health insurer might not have enough time before you are admitted to decide whether your condition is pre-existing. This means you may be admitted before you know whether you will receive any health insurer benefits. If you proceed with your admission before the health insurer has advised you whether you are entitled to benefits, you may become responsible for all costs associated with the admission.

    If you are concerned that you may be liable for your own private hospital treatment and want to look at other options, it is a good idea to check with your doctor for advice. Your doctor is in the best position to advise you if delaying treatment is medically advisable or whether you can opt to use the public system instead.

  • Drakesy on 25/02/2025 - 15:50
    +1

    I now have an upcoming surgery, and I have been with my current insurer for 2 months. The item numbers I will be claiming require 12 months waiting periods (Cancer related).

    is there an exemption in the T's & C's that allows for this? i know some waive the waiting periods however they would no doubt keep the high cost items off this.

    • YesPleaseThankYou on 25/02/2025 - 20:37

      is there an exemption in the T's & C's that allows for this?

      If the issue is just waiting periods, then there is no exemption. The new insurer is required by law to honour waiting periods already served.

  • Ocker on 25/02/2025 - 15:54
    +4

    May OP should have checked with the fund before changing just to chase the buck.

    • YesPleaseThankYou on 25/02/2025 - 20:35

      Rubbish. There is no need to re-serve hospital waiting periods already served.

      There is likely a miscommunication or other error that will be corrected.

  • gomertose on 25/02/2025 - 15:56
    +1

    They are trying to find out if it was a pre-existing condition that you did not tell them about when you joined.

    • YesPleaseThankYou on 25/02/2025 - 20:40
      -2

      Irrelevant in Australia when it comes to health insurance.^

      You cannot be denied health insurance cover if you have served relevant waiting periods, even if the condition was pre-existing.

      ^ Life insurance, disability insurance etc can deny based on pre-existing conditions.

  • star-ggg on 25/02/2025 - 16:55

    I'm guessing the point of contention is if you've had cover for cancer related treatments for 12 months? As in you didn't switch from a lower level of cover. What does your transfer certificate say? With the current standardisation of hospital cover, silver has the same coverage regardless of provider.

  • omguleh on 25/02/2025 - 17:20
    +1

    Your old insurer would have issued a clearance/transfer certificate when you left. Normally the new provider will honour the time already waited from the old provider.

    • YesPleaseThankYou on 25/02/2025 - 18:52

      Normally the new provider will honour the time already waited from the old provider.

      For hospital, by law, the new insurer is required to honour waiting periods already served.

      For extras, for competitive reasons, they all recognise waits already served.

  • vegemite2008 on 25/02/2025 - 18:18
    +2

    Contact your old insurer and ask them to send you a clearance/transfer certificate.

    Once received, contact the new insurer and send it to them.

    I had a similar issue in a few years ago.

    The fund I transferred to did not receive the certificate. Some communication breakdown.

  • YesPleaseThankYou on 25/02/2025 - 18:54

    I have a question regarding health insurance which might be off interest of a lot of OzBargain community who change their health insurance within a year

    I have had 28 policies / funds (some funds repeated) since 2019. You need to keep track of your transfer certificates and give them to your new fund.

    • star-ggg on 26/02/2025 - 11:20

      Do you get sent transfer certificates directly on cancellation or need to request on day of cancellation?

      • YesPleaseThankYou on 26/02/2025 - 12:37

        Each fund has a different process.

        The point is—it is important to retain your own copy of the transfer certificates and related Private Health Information Statements ('PHIS'). (I have done this.)

        I note the OP, despite being last seen here 5 hours 50 min ago, has not updated the thread. I hope their surgery goes well.

  • Meho2026 on 25/02/2025 - 20:31

    Its not as simple as going forward with your treatment and then fighting your claim. The private hospital wont actually admit you for the treatment unless they receive confirmation from your insurer that you are covered, unless you agree to pay the hospital upfront.

  • YesPleaseThankYou on 25/02/2025 - 20:41
    +1

    OP and others in this thread should read The right to change.

  • YesPleaseThankYou on 25/02/2025 - 21:00

    OP, what funds have you been with over the last 12 months and what were the policy names? eg.

    Start Date End Date Fund Name Policy Name
    DD/MM/YYYY DD/MM/YYYY Fund name 1 Policy name 1
    DD/MM/YYYY DD/MM/YYYY Fund name 2 Policy name 2
    DD/MM/YYYY DD/MM/YYYY Fund name 3 Policy name 3
    DD/MM/YYYY DD/MM/YYYY Fund name 4 Policy name 4
    • Pagu on 27/02/2025 - 00:37

      So can we churn any number of times ( possible) and still not need to serve waiting periods for hospital, if we are joining for the first time
      say if I am joining Fund A : churn after 2 months, join B churn after 3 months, Fund C churn after 5 months , Fund D for 2 months and still have served 12 months waiting period ?Thanks in advance.

    • Sarinella on 03/03/2025 - 09:32
      +1

      Yes I had that table, what I didn't know was that we can actually be with each insurer less than 12 months and still accumulate the waiting periods during switching. I sent them the clearance certificate I had from 2020 and the last transfer certificate that was showing them I have 0 loading meaning I haven't been without hospital and they kept asking me to send certificates in between. In the end, I sent them all transfer certificates I had from 2020 and they honoured it. It was enough to send them the transfer certificates in the last 12 months showing I had always been on the same hospital level during switching.Thanks for the link you provided on the right to change.

      • YesPleaseThankYou on 03/03/2025 - 20:37

        Unfortunately, many insurers seem to have incompetent staff who fail to understand basic industry concepts.

        I'm really glad you got it sorted, and I sincerely hope that your surgery went well.

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