What is a pre-existing condition?

A Pre-existing Condition (PEC), or Pre-Existing Ailment as it's sometimes referred to (PEA), is defined as a condition or ailment for which the signs or symptoms were evident or known at any time during the 6 months prior to when the member (a) joins HIF; or (b) upgrades to a higher level of cover or the same cover with a reduced or nil excess.

It's important to understand that the PEC rule applies across all health funds and it exists to keep health insurance fair for all members. Waiting periods exist for the same reason; otherwise people could join a health fund, claim immediately for a service or procedure and then leave again - subsequently making health cover more expensive for everyone else. 

Essentially, these rules were put in place to protect our loyal members by ensuring they don't subsidise that type of claiming behaviour; and while we understand that not everyone who purchases health cover is knowingly unwell (or intentionally plans to make a claim and then leave), there's simply no way for us to know. That's why the PEC rule is applied to private hospital insurance policies for the first 12 months of cover, and it applies to all members equally.

Why does HIF use an independent medical specialist for PEC assessments?
In many cases, members can be confused by a PEC ruling if they can't see the link between the signs and symptoms that they're aware of themselves, and the reason for which they require treatment. Our independent medical advisor has the expertise and judgment to identify the signs and symptoms which are linked to the condition in question, and they will provide the final conclusion to HIF on whether a condition is considered pre-existing or not, therefore determining if benefits are payable on their claim.

What can I do if I disagree with a PEC ruling?
If we've rejected a claim on PEC grounds and you wish to appeal the decision, please follow the steps in our Dispute Resolution Process.

Category: Hospital Cover
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