If you are planning a hospital admission and are currently serving waiting periods, this guide explains how a Pre-Existing Condition (PEC) assessment works.
What is a pre-existing condition?
A pre-existing condition is any illness, ailment, or condition where, in the opinion of a Medical Practitioner appointed by ahm, the signs or symptoms of that ailment, illness or condition existed at any time in the period of six months ending on the day on which you became insured under the policy or changed your cover.
Only a Medical Practitioner appointed by ahm can decide whether a condition is pre-existing.
It’s good to know that you do not need to have been diagnosed for your condition to be pre-existing. The assessment is based on signs and symptoms, not the timing of a diagnosis.
For more information on how pre-existing conditions affect health insurance, visit our What’s a pre-existing condition for health insurance? help page.
Waiting periods on your hospital cover
When you take out or upgrade hospital cover, the following waiting periods apply:
2 months → for conditions that are not pre-existing
12 months → for pre-existing conditions
If you need a hospital admission between the 2 and 12-month waiting periods, a clinical assessment is required to determine which waiting period applies:
Not pre-existing → 2-month waiting period applies – benefits payable for admission at current level of cover.
Pre-existing → the 12-month waiting period applies – benefits payable per previous cover / no benefits, as applicable.
Exceptions apply. Obstetrics and pregnancy always have a 12-month waiting period, and rehabilitation, hospital psychiatric, and palliative care have a maximum 2 month waiting period.
Who assesses your application?
Our Clinical Team, made up of qualified health practitioners, review your case using the medical information provided by you and your treating practitioners.
How the assessment works
Step 1: Complete and sign your sections of the PEC Certificate
For children under 16, a parent or guardian must sign. If you are the policy holder or authorised partner, you may sign for your dependents or partner aged 16 or over where you have Personal Information and Claims Consent.
If you are not on the policy, you can only sign if you are an Authorised Person with Claims Consent. For help with authorisations, please contact us.
Step 2: Your health practitioners complete their sections
Referring practitioner (for example GP, dentist, optometrist) completes section 3. Treating specialist completes section 4.
Tip: Booking appointments early can help avoid delays.
Step 3: Submit your certificates
Email them to our Clinical Team or upload via your ahm membership.
Step 4: Clinical review
We review all submitted information.
Step 5: If needed, we may request further information, such as:
- Referral letters
- Consultation notes, especially from the 6 months before joining or upgrading
- Correspondence between providers, test results or hospital records
You may consider requesting these from your health care practitioners now, so they are on hand if requested. You may also submit additional evidence together with your certificates.
Step 6: Outcome
We will contact you to confirm the result and whether benefits can be paid.
Timeframes
Most assessments are completed within 10 business days of receiving all required information.
If your admission is sooner, we will make all reasonable efforts to prioritise your case, however we are unable to guarantee an outcome before your admission date.
Other important info
You can choose to self-fund your admission while the assessment is underway and submit a claim later if approved.
If the assessment is only to determine your excess, standard processing timeframes apply.
What you need to do
✔ Complete your sections of the form | ✔ Arrange for your doctors to complete theirs | ✔ Submit everything as early as possible | ✔ Optional: Gather supporting documents in advance
Frequently Asked Questions
Do I have to complete a PEC assessment?
No, it is optional. However, if one is not completed, the 12-month waiting period will apply.
I have been a member for years, why do waiting periods apply?
Waiting periods apply when you upgrade your cover to include new services.
Can I start my assessment within my 2-month waiting period?
Yes, provided your admission is scheduled after the 2-month period has finished.
What if some sections are missing?
Submitting complete forms helps avoid delays. If your admission is urgent, send what you have along with any supporting documents and let us know what is missing.
Can I appeal the outcome?
Yes, if you have new or additional medical information.
Can I sign digitally?
Yes, you can sign everything required digitally.
I have already had treatment; can I still apply?
Yes, you can still complete an assessment.
Got questions? We’ve got answers
Message us at ahm.com.au or call us on 134 246