Waiting Periods
August 1, 2016

Medical Aid Waiting Periods

I often deal with clients who, when joining a medical aid, do not understand why waiting periods or exclusions have been imposed on their membership.  Medical aid waiting periods can sometimes be a contentious issue so in this article I will shed more light on this topic.

Medical schemes in South Africa

Medical schemes in South Africa cannot refuse membership to any potential member, except in the case where you were previously a member of the scheme and did not pay your contributions, or if you apply to a restricted scheme (for example GEMS which only covers government employees) and do not qualify for membership of the scheme. Because of this, schemes are at risk when older and sickly members want to join, without having previously contributed to the risk pool.

To combat the increased risk, schemes are allowed to impose the following waiting periods and/or exclusions:

  • If you have not been a member of a South African medical scheme for the past 90 days or longer, you are seen as a new entrant to the market, and a scheme could impose a 3-month general waiting period, as well as 12-month exclusions on pre-existing conditions.  During the waiting period you will have no cover at all. Not even for emergencies.  Should a scheme cover emergency care during this time, it is a concession made by the scheme, and not a legal requirement.

 

  • If you have been a member of a South African medical scheme for the past 24 months or longer, and you do a voluntary change of medical schemes (for example, you change schemes for better rates or benefits), the new medical scheme may impose only a 3-month waiting period, and no  twelve month exclusions on pre-existing conditions.  However, during the 3-month waiting period, you are covered for life-threatening conditions and emergencies. This cover will only be at the scheme’s designated service provider and will be ICD 10 code-based. So you need to check the limitations with the new scheme you join, and not assume that you will be fully covered during the three month waiting period.

 

  • If you have been a member of a South African medical scheme for less than 24 months, and you do a voluntary change of medical schemes, the new medical scheme may impose only a twelve month exclusion on pre-existing conditions, and no three month waiting period.

 

  • When moving from a ‘restricted’ scheme (such as a medical scheme only available to employees of a certain company) to an ‘open’ scheme (which any member of the public may join), due to a change in employment, no waiting periods or exclusions may be imposed.  But you do need to join the new scheme within 90 days of leaving your old scheme – otherwise, you will be seen as a new entrant to the market, and full waiting periods and exclusions will apply.

The above underwriting criteria is what medical schemes could impose. Some schemes are more lenient and do not necessarily impose these waiting periods and exclusions, but this is always done at the scheme’s discretion.

Speak to a specialist

From the above, you can see that joining a new scheme and knowing your rights with regard to waiting periods and exclusions can become quite confusing. This is why a medical aid specialist is the best person to contact when considering changing medical schemes.  They can guide you through the process and ensure that you are not forced into accepting unfair terms when joining a new scheme.  It is always better to speak to a specialist in the field than to negotiate on your own behalf.

Should you wish to know more about changing schemes, or whether the waiting periods imposed by your scheme fall within the rules. Please contact one of our medical aid specialists for advice.