What is a pre-existing condition?
From a health insurance point of view, a pre-existing condition is any ailment, illness or condition with signs or symptoms that existed within the six months before you became a member or upgraded your existing policy to include any new services. Under the Private Health Insurance Act 2007, a health insurer may impose a 12-month waiting period on benefits for hospital treatment for pre-existing conditions.
Health funds appoint a medical practitioner to determine whether you have a pre-existing condition, based on information provided by the practitioners treating you. It’s important to note that a health condition can still be considered pre-existing even if the symptoms or illness weren’t formally diagnosed prior to you purchasing or upgrading your cover; only that signs or symptoms were reasonably evident to you or your treating doctor, were you to have been examined.
Examples of common pre-existing conditions
Pre-existing conditions can be either physical or mental health conditions. However, conditions from your family history won’t be considered a pre-existing condition unless you’ve shown signs or symptoms of it in the past six months prior to joining or upgrading your cover.1
Examples of health conditions and physical ailments that can be pre-existing conditions:
- Diabetes
- Cancer
- High blood pressure
- Heart disease
- Arthritis
- Sleep apnoea
- Depression or anxiety
- ACL injury
If you’re a Medibank member, you can go through our pre-existing condition (PEC) assessment process to determine whether your condition is a ‘Pre-existing condition’.
Does health insurance pay benefits towards pre-existing conditions?
Yes, once you’ve served the pre-existing condition waiting period, you’ll be entitled to receive benefits under your policy. And at Medibank, waiting periods for pre-existing conditions only apply to Hospital cover, not to Extras cover.
What are the waiting periods for pre-existing conditions?
Waiting periods on pre-existing conditions are 12 months. Once a member has been on their policy for a continuous period of 12 months, the pre-existing condition waiting period no longer applies and the member is entitled to receive benefits.1
Switching to Medibank from an insurer where you’ve already served pre-existing condition waiting periods? Good news is, you won’t need to re-serve those waiting periods again at Medibank, or any other fund.
However, if you’re upgrading your health insurance policy, you will most likely have to serve a 12-month waiting period to receive benefits towards treatment for that pre-existing condition.
As always, you can access treatment in the public system under Medicare while you’re serving waiting periods, but you’ll generally have to go through the public system process for wait lists and support with medical expenses.2
Learn more about waiting periods in health insurance
Frequently asked questions
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Things you need to know
1 Commonwealth Ombudsman; What is the Waiting Period for Pre-existing conditions?; retrieved April 2025.
2 Services Australia; Medical costs; retrieved April 2025.
3 Private Healthcare Australia; Private Health Insurance Community Rating System; retrieved April 2025.
4 Health Direct; Mental illness; retrieved April 2025.
% To be eligible for the waiver, you need to have held hospital cover without a break of more than 2 months. You can only use the Mental Health Waiver once in your lifetime. The waiver only applies to the 2-month waiting period for the higher Included benefits for in-hospital psychiatric services and all other applicable waiting periods will continue to apply.
< Some referred services may involve out of pocket costs and waiting periods may apply.
§ For members with mental health support included in their extras cover. Annual limits apply. Counsellors must be registered with Australian Counselling Association, Psychotherapy and Counselling Federation of Australia, Australian Traditional Medicine Society. Mental Health Social Workers must hold a mental health accreditation by the Australian Association of Social Workers.
While we hope you find this information helpful, please note that it is general in nature. It is not health advice and is not tailored to meet your individual health needs. You should always consult a trusted health professional before making decisions about your health care. While we have prepared the information carefully, we can’t guarantee that it is accurate, complete or up-to-date. And while we may mention goods or services provided by others, we aren’t specifically endorsing them and can’t accept responsibility for them. For these reasons we are unable to accept responsibility for any loss that may be sustained from acting on this information (subject to applicable consumer guarantees).