New members often ask if there is a waiting period for medical aid. The short answer is yes. However, two different types could apply. Medical aid membership operates on lines similar to an insurance policy, but there are also some significant differences. Both depend on the statistical principle of shared risk to balance their books. However, insurers can cherry-pick, hiking the premiums of those they believe might be a high risk or even refusing cover.
By contrast, South Africa’s medical schemes must accept all applicants and charge the same price to everyone who receives the same services, regardless of their risk status. While that seems fair, it also exposes them to potential fraud. Without a waiting period for medical aid, new members could join just long enough to receive treatment worth far more than the premiums paid and then cancel their membership.
Accordingly, medical schemes apply a mandatory three-month exclusion period for new applicants who have not been members of another scheme during the three months prior to their application. This restraint means they may only claim for services received after the waiting period has expired. Let’s examine the other reason a member may need to wait before submitting a claim.
- Pre-existing medical conditions:
In insurance terms, a pre-existing illness equates to increased risk. However, a medical scheme can’t refuse membership or charge more to compensate for the perceived risk. Instead, the member will not be permitted to submit claims arising from such conditions for the first 12 months of membership. A three-month wait may apply to certain prescribed minimum benefits. These constraints apply only to the pre-existing condition, and all other valid claims will be accepted, subject to the standard three-month exclusion clause if this waiting period for medical aid should still apply.
Other Factors That Might Affect Your Cover
In addition to the waiting periods described, medical aid providers are permitted to impose one additional penalty under certain circumstances. It is a statistical fact that as we grow older, we become more prone to illnesses and injuries. Medical aid companies must strive to balance the number of young and older members to avoid increasing their liability disproportionately. The following is one way they can do this:
People are often content to manage without cover while young and only consider membership when older and more prone to sickness. In addition to the initial waiting period for medical aid, premiums for first-time members over 35 could carry a penalty charge based on their years without cover.
We urge you to protect your health. Contact KeyHealth Medical today for exceptional protection that meets your needs and budget.
