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Pre-⁠existing conditions

Pre-existing - image

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 the condition existed during the six months prior to you first joining hospital cover or upgrading to a higher level of hospital cover.

A health condition can still be considered pre-existing even if the illness had not been formally diagnosed prior to you purchasing or upgrading your hospital cover.

Can I still be covered if I have a pre-existing condition?

Yes, providing the procedure is included in your health cover. However, you'll need to finish serving a longer waiting period before you can claim on treatment.

How does my pre-existing condition affect my waiting periods?

If your condition meets the pre-existing condition definition, in most instances a 12 month waiting period applies from the date of joining or upgrading your hospital cover. nib will not pay hospital benefits for treatment for the condition during this waiting period.

You may be able to postpone your treatment until your waiting period is served, providing your specialist agrees. Australian residents can choose to be treated as a public patient in a public hospital, however you may have to go on to the public hospital waiting list for your procedure.

Why is there a pre-existing condition rule?

Similar to waiting periods, the pre-existing condition rule exists to keep health cover fair for all members, and it applies to all health funds. Otherwise it could be possible for people who are knowingly unwell to join a health fund and claim for a planned procedure and leave.

How is a pre-existing condition assessed?

With your doctor’s help, we’ll determine if your condition is pre-existing. Your doctor will have to complete some paperwork to identify if there were any signs or symptoms of the condition, or if signs would have been evident to a GP (had a GP been consulted) in the six months prior to joining or upgrading your hospital cover.

We make every effort to make the process as quick as possible. nib will normally require up to 5 working days from the date we receive the completed forms from your GP and specialist to finalise the pre-existing condition assessment, if no further information is required.

What do I do next?

If you think you have a pre-existing condition or you know you do, call us to discuss your options. If you don’t, your treatment could cost you thousands of dollars or result in a long wait to be seen in the public system.

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