Medical Aid Membership, Pre-Existing Conditions, Waiting Periods

Medical aids are an essential form of financial assistance for any person who wishes to utilise private medical services in South Africa. With the spiralling costs of private healthcare in the country, most of us need a medical aid to ensure that we can meet with the financial obligations should we fall ill or be injured. These costs are not affordable for most of us and the only other option is the public healthcare system. A South African citizen or any person legally residing in South Africa may join a medical aid in the country, irrespective of the health status of the person.

Members and Dependents

The person who applies for the medical aid and is responsible for payment of monthly contributions is known as the main member. Spouses, partners, children and even parents who are financially dependent on the main member can then join the medical aid under the main member and are known as dependents, either adult or child dependents. The main member and the adult dependents tend to pay the highest premiums while child dependents usually pay lower rates as part of the single medical aid membership. Many medical aids in South Africa, now provide a discount, for more than 2 to 3 child dependents. However, this is dependent on individual schemes and medical aids are not obliged to do so.

Pre-Existing Conditions

A pre-existing condition is any illness or disability that a person has prior to joining the medical scheme. This includes serious ailments such as cancer and HIV. No medical aid is allowed to refuse membership due to pre-existing conditions. However, a medical aid may enforce an exclusion period after joining the scheme where a member or dependent will not be covered for any medical services, procedures or medication relating to this pre-existing conditions. This is typically a period of one year from the date of membership.

Medical aid exclusion criteria for new applicants is not a form of discrimination. Instead it is intended to protect the interests of all members of the medical scheme so that new members do not drain pooled resources without having contributed to the fund for a period of time. It further discourages new members to join a medical aid for a short period, only to leave the scheme shortly after essential medical services have been completed and paid for by the scheme.

Public and Restricted Medical Aids

Some medical aids restrict membership to people, employees and members of a particular profession, sector of industry or union. This means that any person working or affiliated with these entities will be allowed to join the medical aid in question and their family will also be covered. These schemes are known as restricted medical aids or ‘closed’ medical aids. It is also commonly referred to as the company medical aid or industry medical aid. However, not all company medical aids are restricted schemes. Other medical aids are willing to admit any person, irrespective of the profession, affiliation with specific sectors of industry or membership with a union. These schemes are known as public medical aids or ‘open’ medical aids.

There are also some schemes that only allow membership to a person with a university degree or equivalent and these specific medical aid for professionals are rare in South Africa. Although restricted medical aids and medical aids for professionals may offer slightly better rates and greater cover, the difference is usually minor and most well-established public schemes are just as competitive. The risk in being a member of a restricted medical aid is that should a member be retrenched or made redundant, they may then have to end their membership with the scheme a short while thereafter. Refer to the list of medical aids for more details.

Waiting Periods on Medical Aids

Waiting periods are time spans where a person is not covered by the medical despite being a member. The general waiting period is a 3 month period where the member or dependents cannot utilise their medical aid for any related services, procedures or medication. This is applicable only to members who have not previously belonged to a scheme. If you are transferring membership from one medical aid to another, or from one plan to another, there is usually no waiting period.

Condition-specific waiting periods, also known as the pre-existing condition waiting period, is the time span where one will not be covered for any services, procedures or medication relating to a condition that existed prior to joining the medical aid. Waiting periods do not apply to newborn babies either even if they are born with any medial condition (congenital disease). Babies are covered from the time of birth as a separate dependent even though one has not paid any additional contribution for the baby. However, if a parent does not inform the medical aid of the child’s birth within the first month of life, this immediate cover may fall away.

Membership Application and Termination

Becoming a member of a medical aid is simple. An application form needs to be completed and submitted to the medical aid. Employees wishing to join the company medical aid can do this directly with the employer, HR department of the company, union or medical aid broker. Medical aids usually advise new applicants on the plans that will best suit them and that which is affordable for their level of income. The final decision, however, is in the hands of the applicant and no medical aid can refuse membership based on a person’s health status.

A medical aid member can terminate their membership or that of their dependents at any time that they choose. The benefits will end on the last day of cover. Medical aids may terminate membership if a person has not paid their monthly contributions. Initially medical aids suspend the cover but do not terminate it unless there is non-payment for several months. Similarly a medical aid can terminate a membership if the main member or dependents belong to more than one medical aid at the same time.