Health Insurance

Health insurance will not provide cover for all treatments, medical procedures or medications. Check your policy for limitations and exclusions. When you apply for insurance, tell your insurer your whole health history to avoid issues later if you need to make a claim. Pre-existing conditions are not usually covered, unless the insurer says they are.

  1. Check your policy

    Get a copy of your policy and check what you are, and are not, covered for. Ask questions if you don’t understand.

  2. Look out for policy exclusions

    Declined health insurance claims due to exclusions are a common complaint to the IFSO Schemes. Examples of health insurance exclusions might include treatment or procedures for cosmetic, dental or pregnancy-related issues; alternative or experimental treatments; and anything relating to a symptom or health issue you had before you took out the insurance (pre-existing conditions).

  3. Pre-existing conditions will not be covered unless the insurer has agreed to cover them

    Pre-existing conditions are commonly defined as any condition, sign, symptom or circumstance that you know about or ought to have reasonably known about. This can be something as simple as having a sore knee or back that you may have discussed with your doctor, was not diagnosed as a medical condition. Health insurers won’t provide cover for pre-existing conditions unless they have specifically agreed to cover them.

  4. Tell your insurer the full details of your medical history, even if you don’t think they are important

    Declined health insurance claims due to non-disclosure are a common complaint. Even if you accidentally leave out details about your medical history, your claim could be declined, and your policy treated as though it didn’t exist. If in doubt, tell your insurer everything. It can be helpful to get a copy of your medical notes you can refer to when filling out the insurance application form, or provide a copy to the insurer.

  5. Before you incur medical costs, make a claim to your insurer to make sure it will be covered

    If you want to make a claim for the cost of a treatment, procedure or doctor’s visit, you will need to apply to your insurer to make sure it will pay the claim before you have the treatment, procedure or visit. This is called pre-approval.

Tooth extraction excluded from cover image
Check your policy for exclusions.
Fiona's claim, for the surgical removal of her son’s tooth, was declined. The policy only covered wisdom tooth extraction.
See the case summary
Weight loss surgery excluded image
Check your policy for exclusions.
Penny’s insurer declined to pay for weight loss surgery (a sleeve gastrectomy), recommended by her doctor.
See the case summary
Excluding tonsils, not adenoids image
Provide medical details for everyone under the policy.
Dougal's insurer declined to pay for his daughter Sally’s adenotonsillectomy, because she'd had enlarged tonsils.
See the case summary
Overseas treatment – no specialist letter, no cover image
If you’re making a claim for overseas treatment, contact your insurer well in advance.
The day before Ms B took her daughter to Australia for thyroid treatment, she phoned her health insurer to check the cover.
See the case summary
Skin surgery benefit changed image
Check your policy to see if your insurer can change your policy cover.
Kaia’s health insurer wrote to inform her it was changing the limits for skin surgery under her policy.
See the case summary
Bad knee, no cover image
Health insurance won’t pay claims for pre-existing conditions, unless the insurer has agreed.
Kate needed a knee replacement but her insurer wouldn’t pay, as she'd had knee pain 16 years earlier.
See the case summary
Leaving out medical details is a problem image
Tell your insurer your full medical history, even if you don’t think it's relevant.
Yasmin didn’t mention her two spinal injuries when she applied for insurance. Her claim for a spinal cyst was declined.
See the case summary

What is a pre-existing condition?

This will be defined in the policy. There are a number of different definitions. Some policies may define a pre-existing condition as any medical condition traceable to a condition you had before taking out the policy, even if you didn’t know you had it. Others will define them as conditions you knew you had before taking out your insurance. Remember if you have an injury or sickness, or develop a condition while you have insurance cover and you subsequently change to a new company, this is likely to be treated as a pre-existing condition and won’t be covered by the new insurer.

Do I have to tell my insurer everything about my medical history?

Yes. This information helps your insurer assess your application and can affect the terms of cover it will offer you. If you leave information out, your insurer can decline to consider your claim, or make changes to you policy or even treat your policy as though it didn’t exist. If you are unsure or can’t remember your full medical history, check with your doctor, or provide a full copy of your medical history with your application.

But what if I just forgot or didn't leave out the information on purpose?

The current law doesn’t differentiate between information that was left out deliberately or accidentally. There are still serious consequences for unintentional non-disclosure.

Why has my insurer only raised this issue about lack of information now, when I have made a claim?

When you make a claim, your insurer will ask you more questions or check up on your medical history. This can lead to your insurer finding out information which it should have received when you applied for insurance.

How much information can my insurer ask me to give when I make a claim?

You must give your insurer enough information to prove you have a valid claim. However, your insurer is entitled to obtain further information, which may include specialist medical reports. This can be an ongoing process, as your insurer may need information from a number of people, and they may ask you to see a doctor or specialist it appoints and you will usually have to pay for it.

How long can my insurer take to accept my claim?

It is difficult to put a time limit on how long it takes to assess a claim. Often your insurer will need more information from medical specialists, and this can take a number of months. Your insurer is entitled to fully assess the claim and can request this information, even if you do not think it is necessary.

Why won't my insurer cover the full costs of my surgery?

Your insurer only has to meet its obligations under the policy. Unless your policy says the company will meet all your costs, it does not have to do so. Often your insurer will cover a proportion of the costs or will pay standard costs for a procedure.

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