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Understanding the Medical Aid Application Process


While most of those who need to work for a living will, at some stage, also need to complete a medical aid application form in order to offset the cost of private healthcare, not everyone may be familiar with the requirements of the process or why much of the information requested is actually necessary. In practice, the process is not overly complex, but it will require the applicant to provide all of the information that may be asked for by a given scheme as a mandatory condition of entry.

To begin with, it is important to know whether or not it is the first time you are making a medical aid application. Those who have previously been members of another scheme will not be subject to the mandatory three-month waiting period that applies to first-time members. However, this exemption will only apply if you were still a member of that scheme at some time during the three-month period prior to your current request. If this was the case, it is only natural that you will also be required to attach documentary proof of your previous membership.

As for that waiting period, it is necessary to protect a scheme from those who might otherwise complete a medical aid application and then promptly submit an expensive claim only to cancel their membership as soon as their claim has been settled and they are no longer in need of attention. It is a precaution that also serves to protect other members from possible premium hikes.

Perhaps the most basic requirement is to provide one’s personal details and, as the form to be completed is a legal document equivalent to a signed affidavit, it is necessary to authenticate those details by including a copy of your South African ID document with a medical aid application.

Unlike the nation’s insurance companies, South Africa’s medical schemes are forbidden by their statutory body to discriminate against any potential member who might pose an increased risk. Insurers are entitled to respond, in such cases, by charging higher premiums and may even refuse to provide cover altogether. By contrast, while every applicant is required to provide details of any pre-existing condition as part of his or her medical aid application, a scheme is not entitled to increase its premiums or to refuse entry to anyone who admits to a pre-existing illness. Instead, the scheme is permitted to withhold cover for the declared condition for a discretionary period of up to 12 months, whilst honouring all of the member’s other claims.

On the upside, all schemes are now compelled to provide full cover for a list of 25 chronic illnesses with all of their products. The illnesses covered include asthma, diabetes, epilepsy, and hypertension, in addition to more than two hundred other prescribed minimum benefits (PMBs). For submission of claims associated with these, only a three-month waiting period is applicable while for those who are able to prove they have had continuous cover for more than 24-months, certain of these PMBs may even be made available within the statutory three-month waiting period.

Ensuring that a medical aid application is completed correctly is obviously important, but it is just as essential to choose the right scheme. A growing number of applicants believe this is KeyHealth.