A pre-existing condition is a 12-month waiting period for hospital treatment relating to a pre-existing condition – it’s a rule that applies whether the ailment, illness or condition was known to the member or not.
A pre-existing condition is defined as, ‘Any ailment, illness, or condition where, in the opinion of a medical adviser appointed by the health insurer, the signs or symptoms of that illness, ailment or condition existed at any time in the period of six months ending on the day on which the person became insured under the policy.’ The pre-existing condition waiting period applies to new members and existing members upgrading their cover. The test applied under the law relies on the presence of signs or symptoms of the illness, ailment or condition, not on a diagnosis (i.e. it’s not necessary for the member or their doctor to know what their condition is or for it to be diagnosed). In forming an opinion about whether or not an illness is a pre-existing condition, an HIF-appointed medical practitioner will take into account information provided by the member’s treating doctor.
It's important to understand that the PEC rule applies across all health funds and it exists to keep health insurance fair for all members. Essentially, these rules were put in place to protect our loyal members by ensuring they don't subsidise that type of claiming behaviour; and while we understand that not everyone who purchases health cover is knowingly unwell (or intentionally plans to make a claim and then leave), there's simply no way for us to know. That's why the PEC rule is applied to private hospital insurance policies for the first 12 months of cover, and it applies to all members equally. The pre-existing condition waiting period does not apply to psychiatric care, rehabilitation and palliative care (a two-month waiting period applies to these services).
Why does HIF use an independent medical specialist for PEC assessments?
In many cases, members can be confused by a PEC ruling if they can't see the link between the signs and symptoms that they're aware of themselves, and the reason for which they require treatment. Our independent medical advisor has the expertise and judgment to identify the signs and symptoms which are linked to the condition in question, and they will provide the final conclusion to HIF on whether a condition is considered pre-existing or not, therefore determining if benefits are payable on their claim.
What can I do if I disagree with a PEC ruling?
If we've rejected a claim on PEC grounds and you wish to appeal the decision, please follow the steps in our Dispute Resolution Process.
Related Links: