Pre-existing conditions

A pre-existing condition is an ailment, illness or condition where the signs or symptoms existed and would have been evident to you or a medical practitioner during the six months prior to joining private health insurance.

The decision of whether or not your condition is pre-existing is made by an independent medical referee appointed by, once they have reviewed all the information provided by your GP and Specialist.

A new policy holder with a pre-existing condition will have to wait 12 months before they can be covered for the services in question. This also applies to any new services you add when upgrading an existing cover.

To go through the pre-existing process, you must complete the following steps:

  • Have both your GP and Specialist fill out the form below that provides us with the necessary information our medical referee needs to assess your condition.
  • Once both forms are completed, drop us a line with the attachments and with your member number included.
  • From here, we’ll forward them on to an independent medical referee for assessing.
  • Once assessed, the medical referee will send us a response with the outcome included, and we will contact you to let you know the result. Please Note: This process can take up to 5 business days to complete as per PHIO guidelines.
  • If the outcome results in your condition being deemed not pre-existing, you will be able to book in your admission prior to the 12 month waiting period being fully served, provided your initial 2 month waiting period has been served.
  • If your condition is deemed pre-existing, you’ll need to serve the 12 month waiting period before you can be covered.

If this is your first time using private health insurance to go to hospital, our handy going to hospital guide has all the relevant info needed for you to understand how everything works.

Please note that psychiatric and rehabilitation services aren’t considered to be pre-existing conditions, and are only subject to a two month waiting period.  


Have you been in an accident?

An accident is defined by as an incident that occurs unexpectedly and unintentionally, resulting in injury. This definition excludes unforeseen conditions that develop as a result of as medical condition. Cover for accidents with attracts a one (1) day waiting period.

Coverage for accidents whilst serving waiting periods:

A member who has sustained an accident whilst within the 12 month pre-existing condition waiting period will need to follow the accident process in order to have their admission and any subsequent treatments/surgeries as a result of the incident covered.  

To complete the process, the member will need to complete the following criteria:

  • Present to a GP or an emergency room within 24 hours of the incident. This is important, as will not consider your ailment an accident if you present to a GP or an emergency room outside of the specified time period.
  • Have one accident form and one medical practitioner certificate filled out by the attending doctor and drop us a line with the attachment and your membership number included. The accident form is designed to describe the incident and the injuries sustained as a result, and the medical practitioner form allows us to ensure the injuries/ailments present are not a pre-existing condition.
  • will assess the information presented, and provide a decision on whether or not the admission can be deemed an accident and covered in a private hospital. If approved, you’ll be able to have your stay and any relevant treatments/surgeries covered, provided they’re not directly related to an exclusion on your cover.



Have you heard the word?

On 1 July 2021, will join forces with Frank Health Insurance.

Learn more about how this may affect your Extras cover here.