A pre-existing condition (PEC) is an ailment, illness or condition where, in the opinion of a medical practitioner appointed by nib (not your own doctor), the signs or symptoms of a condition existed during the six months before you first joined hospital cover or upgraded to a higher level of hospital cover.
nib's medical practitioner will assess whether in the six months prior to joining or upgrading your current level of hospital cover, the signs or symptoms of the condition were evident to you or would have been evident to a reasonable general practitioner (had a general practitioner been consulted).
A health condition can still be considered pre-existing even though the illness had not been formally diagnosed prior to you purchasing or upgrading your level of hospital cover.
If your condition or illness is determined to have met the pre-existing condition definition, a 12 month waiting period applies from the date of joining or upgrading your level of hospital cover. nib may not pay hospital benefits for treatment for the condition during this waiting periods (or, if you have upgraded, may pay benefits in line with your previous level of cover).
The pre-existing condition rule applies the same way across all health funds. Similar to waiting periods, the pre-existing condition rule exists to keep health cover fair. Otherwise it could be possible for people who are knowingly unwell to join a health fund and claim for a planned procedure and leave. It is this type of claiming behaviour that makes health insurance more expensive for everyone.
Not everyone who joins a health fund is knowingly unwell (or intends to have a procedure, make a claim and and leave) but there is no way for health funds to know this. This is why the pre-existing condition rule exists during the first 12 months and applies equally to all people.
Your treating doctor and specialist will be asked to complete a form which will provide information about your signs and symptoms. This information will be used by nib's appointed medical practitioner to decide if your ailment, illness or condition is a pre-existing condition. nib's medical practitioner may need to phone your general practitioner, specialist or dentist to clarify the specific circumstances of your condition.
If you're going to hospital and have less than 12 months membership on your current level of hospital cover, or if you have recently resumed your cover after a period of suspension, the pre-existing condition waiting period apply to you. It may also apply if you have decreased your level of hospital excess in the last 12 months.
Keep in mind:
nib's appointed medical practitioner will decide if your ailment, illness or condition is a pre-existing condition (having considered the information your doctor provides to nib) It is not necessary for the ailment, illness or condition, to have been diagnosed in the 6 month period prior to purchasing or upgrading your hospital cover.
If the condition for which you are going to hospital is determined to be pre-existing:
For new nib customers:
You must wait 12 months from the date of joining nib for benefits to be paid for treatment for that condition. Benefits will not be payable on procedures undertaken before 12 months of active membership
For existing nib customers who have transferred or upgraded hospital cover:
You must wait 12 months from the effective date of your policy change or upgrade for the higher benefits to be paid for that condition. If you have at least 12 months membership in total across both your old and new hospital cover, you are entitled to the benefits that are payable on your previous hospital cover. If your previous hospital cover excludes benefits for that condition, you must wait 12 months from the date of change or upgrade for benefits to be paid for that condition
Important: You will be required to pay all hospital charges and medical charges above the Medicare benefits received if: