What do we need to determine whether your
condition is pre-existing or not?
Documentation we may require includes:
• Bupa medical certificates signed by your general
practitioner (GP) and any specialists you consulted.
• Referral letters from your GP to specialist/s.
• Emergency department notes if you were treated
through a hospital emergency department.
• Doctors’ notes from your medical appointments.
• For injuries resulting from accidents, we will also
need a medical certificate or report from the
licensed practitioner you saw in the 72 hours
following the accident.
What do we do with this documentation?
We’ll appoint a doctor to determine whether, in their
opinion, there would have been signs or symptoms
of the condition evident in the 6 months immediately
prior to you joining us or changing your level of
hospital cover.
If our appointed doctor finds that signs or symptoms
were evident, then this is considered a pre-existing
condition under the Act.
Once there is sucient information and a decision
can be made, we’ll notify you.
What are signs and symptoms?
A symptom is what you experience because of your
condition, while signs are evidence of the condition that
your doctor could have found through examination.
A doctor may find signs of a condition even if you
have no symptoms and you haven’t noticed anything
wrong. If this is the case, you may have a pre-existing
condition without realising it. A diagnosis doesn’t need
to have been made for a condition to be pre-existing.
Frequently
asked
questions
about the
pre-existing
condition
assessment
process
When you take out health insurance,
change funds, or change the level of
cover you have, you’re advised you may
have to serve certain waiting periods.
This includes a 12-month waiting period
for pre-existing conditions.
The definition of a pre-existing condition
and the 12-month waiting period are
outlined in the Private Health Insurance
Act (2007).
If it’s been less than 12 months since
you joined us or upgraded your
cover, we’ll usually ask you to provide
documentation, so we can confirm if
you’re being treated for a new condition
or if it’s pre-existing.
I’m not a new customer, why do I have to do this?
If you’ve been asked to provide documentation,
it’s because you’ve upgraded your cover, or moved
from a dierent health fund, or made some other
change to your cover. Your previous product may have
had coverage for this service, but your new product
may have a higher level of cover or a lower hospital
excess. So, if it’s less than 12 months since the change
was made, we’ll need to find out if this service can be
paid under your new level of cover, and we’ll need the
same sort of documentation to allow for the appointed
doctor to make their assessment.
I haven’t been diagnosed with anything,
so do I still have a pre-existing condition?
Your doctor or specialist may say they hadn’t yet
diagnosed your condition and therefore you didn’t have
a pre-existing condition. However, our appointed doctor
may determine – based on the documentation you
provide as well as their own medical knowledge – that
signs or symptoms of your condition had been present.
Even with the best of intentions, your doctors may
not have had all the information they needed and may
not be used to making this assessment for insurance
purposes. It’s still our appointed doctor who needs to
take all these things into account, even where there
has been no prior diagnosis made.
My doctor doesn’t think I have a pre-existing
condition. Why do they have a dierent
opinion to you?
Your doctor may not be aware of the information
provided to us by any other doctors that may have
seen you. They also may not be aware of the definition
of a pre-existing condition under the legislation.
Some doctors may believe you should’ve been
experiencing signs and symptoms continuously to
have a pre-existing condition, but this isn’t the case.
It’s common with some chronic or even acute conditions
(for example, ear infections or tonsillitis) for you to have
experienced gaps between episodes of illness. However,
the underlying cause and certain signs of your condition
have been there, even if you haven’t noticed it.
What other information
may I be asked to provide?
It may not be clear from the documentation you
provide if your condition was pre-existing and we
may ask you to provide further information.
This may include:
• Records from a previous general practitioner.
• Correspondence between health professionals,
or between hospitals and health professionals.
• Hospital discharge summary statements.
• Hospital inpatient records.
• Results of clinical investigations like blood tests
and medical imaging.
My claim has been assessed as being due to
a pre-existing condition. What do I need to
tell the doctor and/or hospital?
If you have been assessed as having a pre-existing
condition, we won’t pay benefits for any treatment
for this condition during the 12-month waiting period.
It’s important you discuss this with your treating
professionals, so they can advise you of the
treatment options available.
Treatment facilities have an obligation to provide
“Informed Financial Consent”. This will provide you
with a list of all the costs you may be liable for if you
choose to go ahead with the treatment.
I still have questions. Who can help me further?
If you have further questions, visit bupa.com.au
or call us on 134 135.
Have further questions?
Talk to our friendly sta.
134 135
bupa.com.au
Visit a Bupa store
Version 1.0 July 2019