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.

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