What is a pre-existing ailment?
A pre-existing ailment (PEA) is one where signs or symptoms of your ailment, illness or condition, in the opinion of a medical practitioner appointed by TUH (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. The only person authorised to decide that an ailment is pre-existing is the medical practitioner appointed by us. The fund medical practitioner must, however, consider any information regarding signs and symptoms provided by your treating medical practitioner(s).
The pre-existing ailment rule still applies even if your ailment, illness or condition was not diagnosed prior to joining the hospital table. The only test is whether or not, in the six months prior to joining your current hospital table signs and symptoms:
- were evident to you; or
- would have been evident to a reasonable general practitioner if a general practitioner had been consulted.
PEA waiting period
We apply a waiting period to new members of hospital covers who have pre-existing ailments. This 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;
- members transferring/upgrading to a higher hospital table must wait 12 months to get the higher hospital benefits.
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.
When to contact TUH
If you have less than 12 months membership on your current hospital cover, make sure you contact us before you are admitted to hospital and find out whether the pre-existing ailment waiting period applies to you. We need about five working days to make the pre-existing ailment assessment, subject to the timely receipt of information from your treating medical practitioner(s). Make sure you allow for this timeframe when you agree to a hospital admission date.
If you proceed with the admission without confirming benefit entitlements and we subsequently determine your condition to be pre-existing, you will be required to pay all outstanding hospital charges and medical charges not covered by Medicare.
In an emergency, we may not have time to determine if you are affected by the pre-existing ailment rule before your admission. Consequently if you have less than 12 months membership on your current hospital cover you might have to pay for some or all of the hospital and medical charges if:
- you are admitted to hospital and you choose to be treated as a private patient; and
- we later determine that your condition was pre-existing