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Medical Aid – Can a Medical Aid Refuse you Membership?

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Can a Medical Aid Refuse you Membership?

Can a medical aid refuse an applicant membership of its scheme? This is a question that is raised quite frequently. More often than not, it is a concern that will be voiced by a potential member who has a long history of ill health or who may be suffering from a condition that he or she knows may require treatment that is particularly expensive and whose needs are therefore acute.

While this was not always the case, it is now a matter of law that no prospective member may be refused either on the grounds of his or her age or any pre-existing condition from which he or she may be suffering at the time of the application. This, however, does not amount to an open invitation for someone who, for instance, may already be pregnant to sign up in the hope that she can start claiming antenatal benefits immediately. In practice, although she cannot be precluded from joining, her condition may be precluded for 12 months, as the scheme is only required to meet the cost when a pregnancy occurs after joining the scheme.

In practice, although no South African medical aid fund can legally refuse membership, it does have the right to enforce a full twelve-month waiting period before accepting any claims from a new member that relates to any pre-existing condition, such as hypertension, asthma or epilepsy.

Even for members who have no pre-existing condition, the nation’s schemes are entitled to stipulate a mandatory three-month waiting period before they are required to accept any type of claim from the main member or a dependent. Without such rules in place, schemes would find it very difficult to maintain the required solvency ratios which could expose other members to the risk of delayed payments or even non-payment.

South Africa’s fund managers are bound by the regulatory body to comply with stringent standards of practice and at KeyHealth, we aspire not just to meet these standards, but to exceed them. You can be certain our medical aid will never refuse you membership.

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