The Impact of Pre-Existing Conditions on Health Insurance Plans in Australia
Published March 26, 2026
There are a lot of Australians who are concerned about whether or not their medical history will impact. Whether or not they can obtain private healthcare, or whether the premiums for that healthcare will suddenly become very high. Thanks to Australia’s community rating system, which says you will essentially be on the same level as everyone else, and you will pay the same premium for the same level of coverage, no matter what your age or health status is. However, there are a few significant things to consider around pre-existing conditions including waiting periods and limitations on your policy, which could impact both when you can claim and how much you are going to shell out from the pocket.
Will having a pre-existing condition increase my health insurance premium?
Unlike in some countries where you are forced to pay higher health insurance premium if you have a pre-existing condition, Australian health insurance funds are legally not allowed to increase your premium based on your health. This is due to the Australian government enforcing the Community Rating system to ensure that you pay the same price for the same level of cover despite your age, gender, pre-existing conditions, and other factors.
How do insurance companies determine if I have a pre-existing condition?
The best news is that insurance companies don’t make their own decisions regarding whether you have a pre-existing condition. What they do is to appoint an independent medical advisor to make the decision. Your medical advisor will examine your medical records and consult your treating doctors to determine if you had any signs and symptoms of your condition in the six months prior to taking out or upgrading your current policy.
3 Tips for Managing Your Health Insurance Costs with Pre-Existing Conditions
1. Get the Right Level of Cover
You can get different levels of health insurance. Bronze and basic level insurance only offer basic cover. You don’t get any benefits for treatment of chronic conditions and surgeries. This means that you could be left with huge bills to pay. On the other hand, silver and gold level insurance offer wider benefits that include treatment for conditions like cancer, joint replacements, and heart surgery. However, they come with higher premiums.
2. Determine Whether You Need Extras Cover
Extras cover provides benefits for allied health services like physiotherapy, chiropractic treatment, dental treatment, optical treatment, and mental health services. Pre-existing conditions do not affect your premiums. However, there are waiting periods that apply:
- 2 months – General dental treatment, optical treatment, physiotherapy, etc.
- 12 months – Major dental treatment, hearing aids, orthodontics, etc.
You can consider investing in a policy that offers high extras benefits to reduce your costs for therapy sessions for your pre-existing conditions.
3. Choose a higher excess
By choosing to pay a higher excess, you can reduce your monthly premiums. However, remember that if you think you will be going to the hospital a lot in the coming months, then it might be more economical to choose a lower excess.
Myths about pre-existing conditions and health insurance
Myth #1: Pre-existing conditions make private health insurance more expensive.
Is this true?: False.
Myth #2: Extras cover has waiting periods for pre-existing conditions.
Is this true?: False.
Myth #3: You are able to claim hospital benefits for pre-existing conditions
False. At least a 1 year waiting period is needed for hospital cover in regard to pre-existing conditions.
To summarise:
If you have a pre-existing condition, private health insurance can be an incredibly valuable tool that provides you with better treatment options and a broader range of medical practitioners and hospitals. Just make sure that you get the right level of cover and take advantage of government rebates to help you get the best out of your private health insurance at the best price.
Before entering into a private health insurance policy, it’s well worth comparing your options and seeking advice from a private health insurance expert to ensure that the policy you want to choose provides the best level of cover for your needs.
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