Understanding 'pre-existing ailments'
A pre-existing condition is an ailment, illness or condition, the signs or symptoms of which, in the opinion of a medical practitioner appointed by MBF (not your own doctor), were in existence at any time during the 6 months period ending on the day you took hospital insurance or upgraded to a higher level of hospital cover.
If your health condition or illness is determined to meet the definition of a pre-existing condition, a 12-month waiting period applies from the date of joining or upgrading your level of hospital cover and MBF may not pay hospital benefits for treatment received for the condition during this waiting period.
The test used by the medical practitioner appointed by MBF to determine if a condition is a pre-existing ailment is whether or not, in the 6 months prior to joining or upgrading your current level of hospital cover signs or symptoms:
- were evident to you, or
- would have been evident to a reasonable general practitioner if a general practitioner had been consulted.
This means that a health condition could still be a pre-existing ailment although the illness had not been formally diagnosed prior to you purchasing or upgrading your hospital cover.
Your treating doctor will be asked for an opinion about your signs and symptoms. MBF's appointed medical practitioner must consider any information provided by your medical practitioner in deciding whether your condition or illness is a pre-existing ailment.
The rules and guidelines regarding the definition of pre-existing ailments have been developed by the Federal Government and adopted by all private health funds in Australia. The pre-existing ailment rule relates to your MBF hospital cover only. It does not impact your MBF extras cover.
When do pre-existing ailment waiting periods apply to you?
If you have held your existing level of hospital cover for greater than twelve (12) months, pre-existing waiting periods do not apply to you.
If you are going to hospital and have less than 12 months membership on your current level of hospital cover, the pre-existing ailment waiting period might apply to you.
Key points to understand:
- It is the medical practitioner appointed by MBF who decides if an ailment, illness or condition is pre-existing. They must also consider any information regarding signs and symptoms provided by your treating doctor.
- Whether or not you have a pre-existing ailment must always be assessed based on your individual circumstance.
- If the medical practitioner appointed by MBF is satisfied that there is a direct link between the ailment, illness or condition that requires hospital treatment and the signs and symptoms that existed in the 6-month period ending on the day you joined or upgraded your hospital cover, it is a pre-existing ailment.
- It is not necessary for the ailment, illness or condition, to have been diagnosed in the 6-month period prior to purchasing or upgrading your hospital cover- only that signs or symptoms were, or would have been, evident.
- These signs and symptoms should have been reasonably apparent to either you or a medical practitioner had you been examined in this 6 month period.
- The waiting period for pre-existing ailments cannot exceed 12 months from date of joining or upgrading hospital tables.
How do pre-existing ailment waiting periods work?
If the condition for which you are going to hospital is determined to be pre-existing:
- As a new member to hospital cover you must wait twelve months from the date of joining for benefits to be paid for treatment for that condition. That is, benefits will not be paid for treatment of that condition that are provided during the first twelve (12) months of the membership; and
- As a member who has transferred or upgraded hospital cover, you must wait twelve months from the date of transfer or upgrade for the higher benefits to be paid for that condition. If you have at least 12 months membership in total across both your old and new hospital cover, you are entitled to the benefits that are payable on your old hospital cover. If your old hospital cover excludes benefits for the condition, you must wait 12 months from the date of transfer or upgrade for benefits to be paid for that condition.
If you proceed with your hospital admission without confirming benefit entitlements, and MBF subsequently determines your condition is pre-existing, you will be required to pay all hospital charges and in the case of medical charges any amount charged above the Medicare benefits you receive.
What do I need to do?
If you are going to hospital and are concerned about pre-existing ailments, please contact MBF with questions regarding pre-existing ailments prior to going to hospital.
- MBF member enquiries 131 137
- MBF corporate member enquiries 1300 653 525
- Visit your nearest MBF Centre
In order to determine a pre-existing ailment, the following process will be completed after speaking with an MBF representative:
- MBF will commence the pre-existing ailment assessment process immediately.
- MBF will send you a pre-existing ailment medical certificate that you need to sign and take to your treating medical practitioner for completion.
- Once MBF receives a completed medical certificate from your doctor, MBF will need a minimum of five (5) working days to complete the assessment.
Important Note: If MBF is notified less than 5 days before a planned admission, MBF may not have enough time to confirm if your condition is pre-existing prior to the admission. Every reasonable effort will be made to carry out the pre-existing ailment assessment as quickly as possible.
You should discuss alternative options with your doctor(s) in case the pre-existing ailment determination is not completed prior to your admission. If you wish to proceed with the admission knowing that MBF may not pay benefits for the hospital and medical treatment, we suggest you obtain a written estimate of costs from the treating hospital and your medical practitioner(s). This is called informed financial consent.
Want additional information?
Additional Pre-existing Ailment Information from the Private Health Insurance Ombudsman.
Additional 'Going to hospital' information
Feel better prepared and make informed decisions when preparing for your hospital -stay by using MBF's health assistance 5-step checklist.
Learn more about Gap and Informed Financial Consent.
