Pre-existing conditions

What is a Pre-existing Condition?

A pre-exisiting 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 prior to you first joining 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.

When do pre-existing condition waiting periods apply?

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.

What are the pre-existing condition waiting periods?

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:

  • You proceed with your hospital admission without having confirmed your hospital benefits with nib
  • You proceed with your hospital admission before receiving confirmation from nib of the appointed medical practitioners decision, and nib decides the condition is pre-existing.
  • Depending on your procedure, this could cost you many thousands of dollars. So, it is vital that you confirm your entitlements with nib BEFORE you are admitted to hospital. nib would recommend delaying your hospital procedure (if possible) until the outcome of your ruling is known.
  • Every effort will be made to process the pre-existing assessment as quickly as possible and to notify you of nib's decision. nib will normally require 5 working days from the date we receive the completed forms from your treating general practitioner and specialist to finalise the pre-existing condition assessment.

What is the typical sequence of events?

  1. You or your hospital contact nib well before the planned admission to confirm your eligibility for nib hospital cover benefits
  2. nib will indicate to you that you need Pre-existing Condition documents completed. An information letter and the forms will be sent to you
  3. The specialist/healthcare provider involved in your care will need to complete the forms. This might mean booking a time to see your health care provider
  4. The completed forms need to be returned to nib. Delays may occur if forms are incomplete, are illegible or if phone numbers are not supplied
  5. nib will asses the information and the appointed medical practitioner may need to discuss further details with your treating medical practitioners
  6. nib will then contact you with confirmation of the decision

Where do I go for help?

Going to hospital - things to check before going to hospital

nib Customer Care Centre enquiries: phone 13 16 42

Visit your nearest nib Retail Centre