You’ve been dutifully paying your insurance premiums month after month. You figured that if the worst happened, you’d be covered. You’d be looked after and treated fairly when you make a claim.
Then, the insurer asks the question you didn’t see coming: “Do you have any pre-existing medical conditions?”
For many Australians who’ve been through this situation, it can be a major shock. A pre-existing condition could be an ongoing illness, injury, or medical problem you’ve had for years. But it could also be something you suffered and recovered from, or even vague symptoms you had without knowing.
Insurers often rely on pre-existing condition clauses to refuse cover, reduce benefits, or enforce waiting periods. But the details of how they define and apply these clauses vary — and those details make all the difference to whether your claim is accepted.
This article will help you understand:
- What insurers mean by a “pre-existing condition.”
- How insurers investigate your history.
- How pre-existing conditions affect TPD, TTD, income protection, trauma, and life cover.
- Real-world examples of accepted and denied claims.
- Common traps and misconceptions.
- How AFCA and courts treat disputes.
- Steps to protect yourself and your family.
What Is a Pre-Existing Medical Condition?
In simple terms, a pre-existing condition is any illness, injury, or medical problem you had before your insurance cover began.
Insurers often use very broad definitions to catch as many situations as possible. Typical wording includes:
- “Any condition for which you sought medical advice, treatment, or medication in the last 5 years.”
- “Any illness, injury, or symptom that existed before the policy commenced, whether or not you saw a doctor.”
This means a pre-existing condition could be:
- Common issues like asthma, diabetes, high blood pressure, or depression.
- An old injury (e.g. a knee ligament tear, back pain).
- A condition you fully recovered from (e.g. pneumonia, broken bones).
- Undiagnosed symptoms you didn’t think were serious (e.g. fatigue, chest pains, migraines).
How Do Insurers Investigate Pre-Existing Conditions?
When you make a claim, insurers often take a forensic approach to your medical history. They will:
- Request GP and specialist records, sometimes going back a decade.
- Examine pharmacy scripts to identify ongoing or past prescriptions.
- Review hospital admissions, radiology reports, physio or mental health notes.
- Look for patterns of treatment — such as repeat referrals or medications.
- Consider whether you had symptoms you failed to disclose.
Some insurers even conduct:
- Interviews about your medical history and lifestyle.
- Surveillance in disputed claims to see if your disability appears inconsistent.
Even vague symptoms — like occasional headaches or fatigue — can be presented as “evidence” of an underlying pre-existing problem. This is one of the main reasons so many claims are initially denied.
How Pre-Existing Conditions Affect Different Types of Cover
TPD (Total and Permanent Disability) Insurance
- Super-linked TPD policies are most likely to exclude pre-existing conditions.
- Many provide only “new events cover” — only conditions arising after you joined the fund are covered.
- If your disability is connected to an older condition, the insurer may refuse to pay.
TTD (Total Temporary Disability)
- Common exclusions for illnesses or injuries existing before cover commenced.
- Even temporary flare-ups of old conditions may lead to denial.
Income Protection Insurance
- One of the strictest policies for pre-existing conditions.
- Two common approaches:
- Blanket exclusion for all pre-existing conditions.
- A 12–24 month exclusion period before those conditions become eligible.
- Group (employer) policies often impose blanket exclusions.
Trauma (Critical Illness) Cover
- Covers specific conditions (heart attack, stroke, cancer).
- If early signs or diagnosis existed before cover, claims are usually rejected.
Life Insurance
- Broader coverage: most pre-existing conditions don’t block death payouts.
- Exceptions:
- Fraudulent non-disclosure when applying.
- Death during the initial exclusion period (12–24 months after cover begins).
Real-Life Claim Examples
Case 1: The Back Injury
David, a warehouse worker, joined a super fund in 2020. He had back strain since 2017. In 2022, he suffered a disc injury and lodged a TPD claim. His insurer refused, citing the back injury as pre-existing.
Case 2: The Mental Health Condition
Sarah, a nurse, was treated for depression in 2018. She relapsed in 2021 and claimed income protection. Her insurer denied the claim, as her policy excluded pre-existing mental health conditions.
Case 3: The Undiagnosed Illness
Alan experienced chest pains in 2019 but didn’t seek treatment. In 2021, he had a heart attack and claimed TTD. The insurer denied cover, arguing the chest pains were “early symptoms.”
Case 4: The Successful Claim
Monique disclosed migraines when applying for income protection. The insurer excluded migraines but approved cover for everything else. Later, she developed rheumatoid arthritis and was paid because it was unrelated.
Case 5: The “Grey Area” Claim
Peter had knee pain years earlier but never needed surgery. After a new workplace injury, he tore the ACL in the same knee. His insurer tried to argue it was pre-existing, but AFCA ruled the new injury was distinct, and benefits were paid.
Common Misconceptions
- “If I didn’t see a doctor, it’s not pre-existing.”
False — insurers often exclude based on symptoms, not just diagnoses. - “Super insurance is comprehensive.”
Wrong — default cover often excludes pre-existing conditions, especially under the Protecting Your Super reforms. - “If I recovered, it’s no longer pre-existing.”
Incorrect — even fully resolved conditions can be excluded if they flare up again. - “Switching funds gives me fresh cover.”
Not always — new funds typically maintain exclusions unless you apply for underwriting. - “Courts will automatically overturn unfair exclusions.”
Courts usually uphold clear policy wording. However, where terms are ambiguous, decisions may favour the claimant.
How Courts and AFCA Handle Disputes
When disputes escalate:
- AFCA (Australian Financial Complaints Authority) assesses whether insurers applied pre-existing definitions fairly.
- Courts consider:
- The exact policy wording.
- Whether symptoms reasonably indicated the condition.
- Whether non-disclosure was innocent or deliberate.
Example
In AFCA cases, insurers have denied claims by linking vague past symptoms to major illnesses. Where the link was weak, AFCA ordered payouts. In contrast, courts have upheld exclusions when the medical evidence showed symptoms were clearly present before cover.
The Consequences for Families
Pre-existing exclusions can have devastating impacts:
- Financial strain: Without insurance payouts, families face mortgage arrears, credit card debt, and rising medical bills.
- Centrelink reliance: Benefits are often far less than prior income and may exclude middle-income families.
- Relationship stress: Lost income and disputes with insurers add enormous pressure.
- Health impact: Prolonged financial hardship can worsen the very medical conditions at issue.
Steps to Protect Yourself and Your Family
- Disclose Everything
Always disclose medical history honestly. Non-disclosure can void the policy entirely. - Understand Your Cover
Read your PDS carefully. Look for exclusions, waiting periods, and “new events only” clauses. - Get Underwritten Cover
Tailored policies may exclude specific conditions but provide certainty for others. - Consider Layered Cover
Don’t rely only on default super insurance. Consider additional retail cover. - Build an Emergency Fund
Savings can protect you if exclusions block a claim. - Seek Expert Help
If denied, get legal advice. Many pre-existing condition rejections are successfully challenged with evidence and advocacy.
FAQs
Does every policy exclude pre-existing conditions?
Not all. Individually underwritten policies may allow cover with loadings or exclusions.
Are mental health conditions always excluded?
Not always, but many group super policies restrict them heavily.
Can insurers access my full medical records?
Yes, with your consent. They commonly request years of GP and hospital notes.
What if I didn’t know about my condition?
Even undiagnosed conditions can be excluded if symptoms existed. Disputes often turn on whether a “reasonable person” would have known.
Does changing super or insurer reset exclusions?
No. Exclusions generally carry over unless you apply for fully underwritten cover.
Can I still claim if my disability is unrelated to the pre-existing condition?
Yes. Exclusions only apply if the disability is directly linked.
Can pre-existing exclusions be challenged?
Yes. Many cases succeed before AFCA or courts, especially if insurers overreach.
Are pregnancy-related conditions pre-existing?
Often yes, unless specifically included in the policy. Always check the PDS.
Pre-existing medical conditions are one of the most common stumbling blocks in insurance claims. Whether through superannuation or private cover, insurers often use them to deny benefits.
But exclusions don’t always apply the way insurers claim. The definitions are broad, but ambiguous wording, medical evidence, and fair review can lead to successful challenges.
The key is to know your cover upfront: read your PDS, ask questions, and understand whether exclusions apply. That way, you and your family can plan financially and avoid nasty surprises.
At TPD Claims Lawyers, we fight unfair pre-existing condition exclusions every day. If you’re unsure whether you’re covered — or you’ve already had a claim denied — get in touch for no-obligation advice tailored to your circumstances.
Last updated: 29 August 2025