Medical Aid - What is the Waiting Period for Medical Aid?

What is the Waiting Period for Medical Aid?

The financial support provided by a company towards the cost of private healthcare is a form of insurance policy, and although it differs in many ways from that offered by commercial long- and short-term insurers, it is also subject to various conditions. One of these conditions sets a limit on how soon after signing up the insured is entitled to lodge a claim. In the case of a life insurance policy, that interval is normally, at least, 12 months. So, what is the usual waiting period for medical aid? In practice, the answer is not quite as straightforward as is the case when purchasing a life policy.

Firstly, both long- and short-term insurers retain the right to refuse cover to any individual who is believed to be too much of a risk. In the case of motor insurance, this could be because the driver has made several previous claims due to personal carelessness or has a driving conviction, while someone who is known to have a terminal illness may also be refused life cover. By contrast, South Africa’s medical schemes are not permitted to refuse cover on any such ground, but may, instead, only agree to start processing a member’s claims after an agreed interval, which may vary according to circumstances.

What is clear, however, is that the waiting period for medical aid, as it is applied by most of South Africa’s schemes when taking on a new member, is generally three months. While some members may wonder why this wait is necessary, the explanation is quite simple. Unlike insurance companies, medical schemes are not-for-profit companies, and so, their premium income requires especially strict management. Sadly, there are too many opportunists who might otherwise sign up for just long enough to benefit from some costly private treatment, only to resign their membership as soon as they no longer require the scheme’s financial support. Clearly, permitting this practice could jeopardise the claims lodged by other members.

In the case of a pre-existing medical condition, what is likely to be the waiting period for medical aid does tend to differ. Firstly, it may differ purely as a result of the internal policies that are set by the board of trustees of a given scheme. The other factor that will affect the statutory delay in accepting claims is the nature of the pre-existing condition. For example, though not actually an illness, a main or dependent member who happens to be pregnant at the time of joining a scheme can be precluded from claiming for the cost of any service relating to the birth or for subsequent paediatric care, for up to 12 months. By contrast, members may claim full maternity benefits when their pregnancy occurs within the membership period.

One of the more specific questions that is sometimes asked is: what is the waiting period for Medical Aid before one is free to claim the prescribed minimum benefits (PMBs)? The simple answer is that new members of a scheme must even wait three months before claiming PMBs unless they were previously enrolled in another scheme for at least 90 days before applying.

For exceptional value and clarity regarding what will be your waiting periods for medical aid, KeyHealth is the sensible choice.

Medical Aid - Why is it Important to Have Medical Aid?

Why is it Important to Have Medical Aid?

In seeking to understand why it is so important to have medical aid, it may pay to first ask yourself a few questions.  For example, how confident are you that you will have immediate access to whatever treatment you might need if you were to depend solely on the services currently provided by the state-funded healthcare system. If the year was now 1950 rather than 2019, your answer might well have been; “I am extremely confident”. At that time, however, South Africa’s relatively new National Health Service was still the envy of many other nations. Unfortunately, it was not too long before the demands on the system began to exceed its capacity to meet them, and the result was that those who could afford it began to seek help from the private healthcare sector.

If this alone fails to explain why it is important to have medical aid, perhaps you should consider the cost of treatment when it is not subsidised by the State. According to figures compiled in 2014, you could have been charged R8 800 for an MRI scan, R17 000 for a normal birth, almost R5 500 per day for hospital accommodation, and a massive R 300 000 or more for a heart bypass. Since then, costs have increased. What kind of impact might a serious injury, as the result of a motor accident or any of the requirements mentioned above, have on your family budget? There is every possibility that an average family could be forced to spend its entire life savings and still end up deep in debt.

While not all treatments might appear as dramatic as an emergency appendectomy, they can be just as vital and equally costly when compounded over a longer period. This is yet another reason why it is important to have medical aid. Some illnesses are for life and the cost of lifelong monitoring, treatment, and care can account for a sizeable chunk of a family’s disposable income. Since 1998, all medical schemes have been compelled to cover the costs of all healthcare requirements arising from 25 chronic illnesses. These include diabetes types 1 and 2, chronic obstructive pulmonary disorder (COPD), Crohn’s disease, epilepsy, haemophilia, multiple sclerosis, and systemic lupus erythematosus, to name just a few. Knowing that the cost of diagnosis, treatment, and care are fully covered offers peace of mind for the patient, as well as for his or her family.

While the benefits described should be more than sufficient to explain exactly why it is important to have medical aid in South Africa, it is just as important to ensure that the scheme, in which you plan to enrol, is the one best able to meet your likely healthcare needs and those of any of your dependents who might also be included under the scheme. However, it is not always easy to see exactly what you will be getting for your money. A high premium price tends to indicate that the benefits are more comprehensive, but it is also important to know that they are your personal needs.

Affordable prices, clearly defined benefits, plus some valuable core extras are just three reasons why many South Africans believe it is even more important to have medical aid from KeyHealth.

Medical Scheme - What Are the Benefits of a Medical Scheme?

What Are the Benefits of a Medical Scheme?

The shortest and perhaps the most significant response to this question is that most people with this kind of health insurance would say that peace of mind should be ranked high on the list of benefits of enrolling in a medical scheme. As a member, this means that, should you or one of your family members, be involved in an accident or develop a serious illness, the services of the appropriate healthcare professionals are instantly available and at a fraction of the price that would be required of a non-member and, in many cases, at no cost at all. While treatment at a state hospital may be free or offered for a nominal sum, the facilities at their disposal are extremely limited by comparison, as is the availability of trained staff. As a result, even attention to urgent cases is frequently delayed.

More specifically, however, the benefits of a medical scheme are those listed in its product prospectus. These, in turn, will be subject to any specific terms and conditions that may have been set by the particular cover provider. Typically, each of a scheme’s options will indicate the maximum sum that can be claimed by a member for each of the contingencies listed. These limits may apply to a single event and to the total period of cover. Cover is limited to a 12-month period, after which membership must be renewed, and on renewal, both the prevailing terms and premium price could be subject to change.

To some extent, the range of benefits of a given medical scheme will be determined by the amount the member is willing and able to contribute to the monthly premiums. Some, however, are not negotiable, and are independent of the premium price. Since the formation of the Council for Medical Schemes (CMS), in 1998, all medical aid products are required to include what are known as Prescribed Minimum Benefits (PMB). This, for example, provides for those who may be suffering from one of 25 named chronic diseases, as well as for all emergency medical conditions and a set of 270 medical conditions defined under the Act of 1998 and defined as treatment pairs. Examining physicians must base their diagnoses on symptoms alone, irrespective of the particular circumstances that might have led to the illness or injury.

For many members, the PMBs alone can be invaluable. As basic benefits of all medical scheme products apart from the hospital plan, which normally only applies to members while they are hospitalised, cover includes all costs relating to the diagnosis, treatment, and care of the listed conditions, throughout the membership period.

The types of schemes are: open and closed or restricted. The former is open to all and aimed at the self-employed, professionals, and those without access to a closed scheme. Closed types provide cover to defined groups, such as the employees of a large company or a specific industry, or the members of a professional body. They all benefit from group rates, so their premiums are lower than those offered to individuals, while employers normally contribute a portion of the premium as well.

That the benefits of being a member of a medical scheme are invaluable goes without saying. That KeyHealth offers the best value for money is equally true.

Medical Aid - Affordable Medical Aid Scheme in South Africa

Finding an Affordable Medical Aid Scheme in South Africa

It is a regrettable fact that private healthcare services would be out of the reach of almost everyone in South Africa without access to an affordable medical aid scheme. Many of the state-run hospitals are now limited to providing primary care, while others continue to be plagued by spiralling demands and chronic underfunding. This has led to long queues in the emergency and outpatient departments and equally lengthy waiting lists for this in need of surgery. Not surprisingly, the private sector has become the more viable option, at least, for those who have sufficient income to meet the premiums.

For many people, deciding on the right scheme can be something of a balancing act in which it is important for them to weigh the cost of the monthly payments against the value and the relevance of the cover they will be receiving. Considering the cost, however, is as much about security as the economy. Unless the monthly medical aid premiums are affordable, missing one could mean being denied cover. Although, in South Africa, these schemes are not permitted to load premium prices because a member has an existing problem or has made a lot of claims, as is the case with motor insurance. However, in common with the short-term insurers, they are entitled to suspend cover if a member should fail to keep up with the premiums.

As a general rule, the more comprehensive the cover a scheme provides, the higher the monthly premiums are likely to be. One way to avoid blowing the monthly budget is to select a product with a more limited range of benefits, such as a hospital plan. This is the ideal choice for young people with good general health, but a limited income, or for families who can afford to pay for their day-to-day private healthcare, but who would struggle if faced with a bill of more than R300 000 for a heart bypass.

For truly affordable medical aid in South Africa, whether fully comprehensive or providing more basic cover, KeyHealth is hard to beat.

Medical Aid - Be Sure to Get the Right Medical Aid for You

Be Sure to Get the Right Medical Aid for You

There are few people in South Africa who would be able to enjoy access to private healthcare without the financial support provided by medical aid schemes. However, with so many to pick from, it is important to get the right one for you. That is easily said, but just how does one go about choosing the best option? Well, firstly, remember that it is your health that is at stake, and quite possibly that of your spouse and kids. So, you will have to pick a product for which you know you will be able to keep paying the monthly premiums, or you could risk losing your cover. At the same time, you need to be quite certain that the chosen product offers the kind of cover that you and your family are most likely to need.

Not everyone is married with kids, however, and if you happen to be young, single, and in good general health, it should be easy to get the right medical aid for you. A hospital plan should be just perfect. It will, of course, mean that you will still have to pay for the odd GP visit and for any medication he or she may prescribe, but it will definitely relieve you of what is likely to be your biggest health-related concern: the potentially crippling costs that could result if you were hospitalised for treatment of severe injuries suffered in a car crash or perhaps to undergo an emergency appendectomy. These are certainly not expenses that the average South African could meet from his or her own pocket.

Whether old or young, married or single, the one thing that need not affect your ability to get the right medical aid for you is a chronic illness. Since the Medical Schemes Act 131 of 1998, all products offered by all schemes are required, by law, to provide cover for 25 defined chronic illnesses and a total of 270 medical conditions defined in a list of diagnosis/treatment pairs. Known collectively as prescribed minimum benefits or simply PMBs, members are not restricted by any mandatory exclusion period, but are entitled to submit claims for PMBs from the date of joining a scheme. Those with a pre-existing illness not included in these lists can, however, be precluded from submitting claims relating to that condition for a period set by the terms and condition of a given scheme.

If you are self-employed or not covered by a group scheme, it is especially important to get the medical aid that is right for you. Look at all of those you can afford, and be sure to pick one that offers the benefits you most need. If you are planning a family, for example, check out the maternity benefits applicable prior to, during, and following the birth. Similarly, if you already have young kids, it might be a good idea to make sure that any scheme you may choose will provide sufficient help with the cost of both basic dental work and orthodontics.

A better way to get the right medical aid for you is to deal with a scheme that keeps things simple and affordable while providing benefits that are relevant to its member’s needs, and let KeyHealth look after your healthcare expenses.