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Elmarie Jensen
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'Medical schemes may impose certain waiting periods'

16 March 2016, 14:37  - Elmarie Jensen

Dear Monique,

Medical schemes in SA may impose certain waiting periods on new members when joining a medical scheme.  Generally speaking, waiting periods depend on the amount of time an applicant has been a member of a SA medical scheme at the time of joining a new scheme.

According to the Medical Schemes Act, medical aid schemes are entitled to impose a 3 months general waiting period and/or a 12 months condition specific waiting period(s) for any pre-existing medical condition(s).  There are two kinds of waiting periods, i.e.:

1.    General waiting period of up to three months

During this period, members have to pay their normal monthly contributions, but are not entitled to claim any benefits whatsoever, except in certain instances with claims relating to PMBs.

2.    Condition-specific waiting period of up to 12 months

During this period, members have to pay their normal monthly contributions, but any pre-existing health condition(s) will be excluded and all medical costs associated during the first 12 months will be for the member’s own pocket, except in certain instances with claims relating to PMBs.  This waiting period can be applied for any condition for which a member sought medical advice, obtained a diagnosis or for which care or treatment was recommended or received within the 12 months before the date on which application is made to join a scheme.

To answer your question as to whether your family member’s medical scheme had legitimate grounds not to cover any costs related to the treatment of his/her hypertension (and related condition(s)), one would need to look at his/her previous medical scheme membership.  If he/she was not a member of a registered SA medical scheme for at least 90 days preceding the date of his application for membership to his/her current scheme, then he/she would not be entitled to any benefits whatsoever for hypertension and related conditions (including PMBs). 

If, however, he/she was a member of a registered SA medical scheme for less than two years, but applied for membership to his/her current scheme within 90 days of cancelling his/her previous membership, then his/her medical scheme had the right to exclude treatment relating to hypertension and related conditions, but would nonetheless be obliged to cover it as PMB benefit according the provision of the Rules of that scheme.

Elmarie Jensen

Marketing Manager at Genesis

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