When you join Defence Health or upgrade your existing cover, you may have a waiting period before you can claim benefits.
Waiting periods apply when:
- you are taking up health insurance for the first time or have had a break in cover of two or more months,
- you transfer from another fund before completing equivalent waiting periods,
- you upgrade to a higher level of cover at Defence Health, including by reducing or removing an excess.
The waiting periods you will need to serve when you join Defence Health are:
- 12 months for a pre-existing condition (excluding psychiatric, rehabilitation and palliative care)
- 12 months for obstetric (pregnancy) related treatment
- 12 months for laser refractive eye surgery
- 2 months for rehabilitation, psychiatric and palliative care
- 2 months for all other hospital services
- 12 months for major dental and orthodontic treatment
- 12 months for most devices, aids and appliances
- 2 months for all other services
Cover for an accident is immediate where it is not claimable from another source such as workers compensation or third party insurance.
Why have waiting periods?
Waiting periods protect members of the fund by ensuring that individuals aren’t able to make a large claim shortly after joining and then cancel their membership. This would make premiums more expensive for all members, so waiting periods prevent this from happening.
If you are switching from another fund
If you join Defence Health within two months of leaving another fund, we will recognise the waiting periods you have already served, so you can claim immediately. You will only need to serve waiting periods for any treatments not included in your previous cover.
To check the waiting periods that apply to you personally, please refer to your certificate of cover or Online Member Services.
All waiting periods are waived for ADF personnel who join within two months of discharging.
Waiting periods for pre-existing conditions
A pre-existing condition is an ailment, illness or condition where signs or symptoms have existed at any time in the six months prior to you joining or upgrading to a higher level of cover. It is not necessary that you or your doctor knew what your condition was or that the condition had been diagnosed.
A condition can still be classed as pre-existing even if you hadn’t seen your doctor about it before joining or upgrading. If you knew you weren’t well, or had signs of an ailment that a doctor would have detected during the six months prior to joining or upgrading, then the ailment would be classed as pre-existing. Risk factors, including family history of an ailment, are not signs or symptoms of a pre-existing ailment. They will not be considered when deciding whether an ailment is pre-existing.
How to determine if a condition is pre-existing
The only person authorised to decide whether you have a pre-existing condition is a medical or other health practitioner appointed by Defence Health. The independent practitioner will consider the opinion and evidence presented by your treating practitioners before making an informed judgement.
If you have had your current cover for less than 12 months and need treatment, please check with us whether the pre-existing condition waiting period will apply.
Defence Health may require you and your treating practitioners to complete a pre-existing condition form in order to obtain facts about your illness. The practitioner appointed by Defence Health to review your case will need a number of business days to investigate and make an assessment.