Medical Aid Scheme Exclusions for New Applicants

Most medical aids in South Africa will accept any applicant wishing to join their scheme without requesting blood tests to verify diseases or medical disorders. However, applicants are requested to divulge all their pre-existing conditions or significant past medical history to the medical aid upon application. Failure to do so could have serious implications in the future should you or your health care provider attempt to claim from your medical aid.

Unlike life insurance or other insurance policies, medical aids will not refuse membership or increase medical aid premiums should you have any medical disorder.when joining  the scheme. Even HIV-positive applicants are accepted onto a medical aid without experiencing an increase in monthly medical aid premiums. However the medical aid will protect themselves by notifying the patient that they will not be covered for the pre-existing condition for up to 1 year after joining the medical scheme.

The onus is on you, the member of the medical aid, to finance these health services relating to your pre-existing condition in your first year of medical cover. The need for this exclusion conditions is to protect the pool of contributing medical aid members from latecomers to the medical aid who may drain financial resources.

A medical aid functions by ensuring that it has a bigger pool of young, healthy contributing members than older or ill members. Unfortunately financial constraints and ignorance means that some new members only join a medical aid when they need prolonged assistance for paying for medical services. In terms of age, many medical aids in South Africa will add a ‘late joiner’ fee on top of your monthly contribution. This is usually applicable to any person who did not belong to a medical aid before the age of 35 years although this may vary among medical aids.

To ensure the maximum benefit from your medical aid without any exclusions, it is best to join a medical aid at the earliest age possible. If you cannot afford comprehensive medical aid cover, speak to a medical scheme consultant to find you a cheaper option or even an affordable hospital plan. Upgrading your medical aid plan at a later stage will mean that waiting periods or exclusion criteria are not applicable even if you change over to another medical aid company.