A waiting period is the time between joining GMHBA and when you are covered for a treatment or service. If you receive a service or treatment during a waiting period, you are not eligible to receive a benefit payable from us, regardless of when you submit the claim. Waiting periods exist to protect members from claims made by those who join the fund or increase their level of cover because they have a condition or illness that may require treatment.
Waiting periods will apply to:
- New members to health insurance (members who have never held hospital or extras cover with a health fund)
- Existing GMHBA members who upgrade to a higher level of cover or reduce their excess payable
- Members who transfer from another health fund who have not fully served the required waiting and/or for equivalent benefits
- Additions to a membership (unless the addition/s has already served all waiting periods with GMHBA or another fund) except newborns, adopted and permanent foster children where the family membership has been in existence for at least two months, and where the addition/s has already served all waiting periods with GMHBA or another fund
Limited benefits may apply on hospital covers for cosmetic surgery, depending on the medical justification for the surgery.
For treatment that was covered under the old policy, at the same or higher level than the new policy, waiting periods are no longer than the balance of any unexpired waiting periods for the benefit that applied to the person under the policy.
For treatment that was covered under the old policy but at a lower level, the member is entitled to the lower benefits on their old cover during the waiting period.
Existing members with at least 12 months membership in total across their old and new cover are entitled to the lower benefits on their old cover during the waiting period.
The mental health waiver allows members who have served their 2 month waiting for restricted psychiatric benefits to upgrade their cover to a product which includes in-hospital psychiatric treatment without serving an additional 2 month wait. Members can use the waiver at the time of upgrading, or before the 2 month period for psychiatric treatment ends.
Members can use the Mental Health Waiver once in their lifetime. The waiver applies only to the 2 month waiting for in-hospital psychiatric treatment. Any other applicable waiting periods will still need to be served.
Hospital waiting periods
| Hospital services (when included on cover) | Waiting period |
|---|---|
| Accidents - bodily injuries resulting from accidents which occur after the date of joining GMHBA or upgrading to a higher cover. | 0 days (accidents must occur after joining) |
| Obstetrics and maternity. | 12 months |
| Pre-existing ailment, illness or condition (other than psychiatric, rehabilitation and palliative care). Important information regarding PEC. | 12 months |
| Any other benefit for hospital (or hospital substitution) treatment. | 2 months |
Extras waiting periods
| Extras services (when included on cover) | Waiting period |
|---|---|
| All extras benefits except as specified below. | 2 months |
| Optical, home and domestic aids and medical aids. | 6 months |
| Major dental services (including full & partial dentures, orthodontics, crown & bridgework, endodontic services such as root canal, gold fillings, indirect restorations, surgical extractions of a tooth/teeth including wisdom teeth). | 12 months |
| Health appliances including nebuliser pump, blood glucose monitor, pressure garments, sleep apnoea monitor, extremity pump, hearing aids, orthopaedic appliances (GMHBA approved), prostheses (GMHBA approved non-surgical), tens monitor, podiatry surgical procedures and orthotic appliances (foot). | 12 months |
Planning a child
If you are preparing to start a family and your hospital cover does not include pregnancy you will need to ensure you upgrade your hospital cover to include pregnancy at least 12 months before you have a child to ensure all waiting periods have been served.
If all goes well, a newborn baby is not admitted as a patient in hospital, but if you have complications and your baby requires any accommodation or medical attention, your newborn baby will be covered for accommodation or medical services provided they are added to the policy within 6 months of their date of birth.
A single policy will become a single parent policy, and a couples policy will become a family policy when the newborn is added to the policy.
Pre-existing conditions (PEC)
A pre-existing condition is one where signs or symptoms of your ailment, illness or condition, in the opinion of a medical practitioner appointed by GMHBA (not your own doctor), existed at any time during the six months preceding the day on which you purchased your hospital insurance or upgraded to a higher level of hospital cover and/or benefit entitlement.
A special waiting period applies to obtain benefits for hospital treatment for new members who have pre-existing conditions. The waiting period also applies to existing members who have recently upgraded their level of hospital cover. If the ailment, illness or condition is considered pre-existing:
-
New members must wait 12 months for any hospital benefits (other than psychiatric, rehabilitation and palliative care).
-
Members transferring/upgrading to a higher hospital cover must wait 12 months to get the higher hospital benefits (other than psychiatric, rehabilitation and palliative care).
Existing members with at least 12 months membership in total across their old and new cover are entitled to the lower benefits on their old cover.
If you haven’t held your current level of cover for at least 12 months, you are required to go through the PEC check for any hospitalisation. This involves asking your GP and specialist their written opinion on whether your condition is pre-existing. The process can take some time and it’s best to get this done as soon as possible to confirm whether GMHBA can cover your procedure. The documentation will then be assessed by a medical practitioner appointed by GMHBA, who will decide whether your condition is deemed pre-existing or not.
More information
For more information about waiting periods and pre-existing conditions please refer to the Important Information section of the GMHBA Member Guide.