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Understanding How Waiting Periods Could Affect Your Medical Aid Membership

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Many people only join a medical aid scheme when their health fails. However, they are often unaware that their claims could be subject to a waiting period. Healthcare services are expensive, whether provided by a government-funded institution or a private clinic. Consequently, more than 71 per cent of South Africans must continue to rely on overburdened and underfunded public facilities for their medical attention. Of the remainder, just over 16 per cent are members of a medical scheme, while the rest have health insurance or settle their own healthcare expenses.

Medical schemes in South Africa are required to operate as non-profit companies. As a result, they must apply various constraints to remain solvent and continue meeting their members’ claims. However, unlike an insurance company, a medical aid scheme is not permitted to deny support to applicants that insurers would classify as high-risk. Neither are they allowed to load the premium prices for such applicants. However, they do have the right to impose waiting periods where these may be necessary for operational purposes. These are two types, and it is essential for new members to be aware of them and to understand their implications. Next, we will examine these in more detail.

 

  1. Waiting period for new medical aid member

This rule applies to applicants who have never previously been a member of a South African medical scheme and to anyone who was not covered by another scheme during the three months before their application. Anyone who is simply switching providers and has enjoyed continuous coverage will not be subject to this rule.

The rule states that those who fail to meet the required criteria must manage their own healthcare expenses for the first three months of their membership. Only new claims for expenses incurred after this mandatory waiting period will be processed.

Applicants often wonder about the reason for this rule. The explanation is quite simple. It is designed to discourage opportunists who need immediate costly treatment from signing up and cancelling their membership once their claim has been paid, a practice that could potentially jeopardise other members’ benefits.

 

  1. Waiting period for medical aid members with a pre-existing condition

Medical schemes find it necessary to impose a waiting period on members with certain pre-existing illnesses for much the same reason as the new members’ ruling. If too many new members should make sizeable claims in the first month or two of their membership, this could severely erode the cash reserves from which a scheme must support the claims made by its established members.

In this case, a member may only submit claims related to that specific illness for treatment received after the first 12 months of their membership. The membership year commences on the first of January and ends on the thirty-first of December. Consequently, anyone joining later in the year will not complete the waiting period until the following year.

On the plus side, cover for all other contingencies will start immediately or after three months, depending on one’s membership history. The other good news is that in compliance with the Medical Schemes Act 131 of 1998, all schemes are obliged to include cover for medical emergencies and certain other prescribed minimum benefits (PMBs) in all their products. Those mandatory benefits are not subject to a waiting period and include cover for the diagnosis, treatment and care of 25 listed chronic illnesses. These include asthma, bronchiectasis, COPD, diabetes, epilepsy, hypertension and multiple sclerosis, to name just seven. You can view the complete list here.

 

Quality medical aid with or without the wait

No matter which scheme you choose to join, you might be subject to these stipulated waiting periods. There are no exceptions. However, the service you receive afterwards can vary significantly. Will co-payments tend to be the rule rather than an exception? Will your claims be settled promptly and in full? Is your chosen scheme financially sound? Will it still be operating next year? Given that you are entrusting your family’s health to a third party, these concerns are valid.

KeyHealth has been providing medical aid for South Africans since 1968, long enough to earn widespread trust and gain the experience necessary to develop products to suit all needs and budgets. Core benefits and affordable premiums are our cornerstones, from our entry-level hospital plan to our comprehensive top-of-the-range products. Why not view our 2023 benefits and start protecting your loved ones today?

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