Waiting periods are imposed by the medical aid scheme on new members, based on their medical history as well as on their medical aid membership history.
The Medical Act allows waiting periods to be imposed to prevent potential members from joining a scheme only as they become ill. The goal is to encourage members to join a scheme while they are generally healthy.
The application of waiting periods by a scheme is known as “underwriting”.
What are the waiting periods?
There are two types of waiting periods: 3 month general waiting period and 12-month conditional waiting period.
3 month general waiting period
This is a waiting period that can be applied to all health services for the first 3 months of membership, including in some cases PMBs ie life-threatening conditions.
12 month specific condition exclusion
According to the Act, schemes can restrict treatment for certain conditions for which “medical advice, diagnosis, care or treatment was recommended or received within the 12-month period ending on the date on which an application was made“. Even if some schemes ask for a medical history that extends beyond the past 12 months, they are not allowed to impose restrictions based on any medical history older than 12 months.
Top Tip: It is very much worth your while to time your scheme change so as to avoid this 12 month waiting period, if at all possible. For example, if you were diagnosed with a hernia 10 months ago and have not received any treatment or advice since then, it might be worth your while to wait two months before switching schemes so as avoid the 12 month waiting period for the hernia. Speak to us should you want to time your change carefully.
What waiting period applies to you?
Which of the two exclusion, if any, can apply to you depends on your specific circumstance.
You want to change plans within the same scheme.
Waiting periods: None can be applied, although any current waiting periods will continue until they expire.
You have not been a member of a scheme for more than 90 days
Waiting periods: Both the 3 month general exclusion (including PMBs, see below) and the 12 month condition-specific exclusion (including PMBs, see below) can be applied.
You are changing schemes voluntarily, and have been a member of a scheme(s) for less than 24 continuous months.
Waiting periods: The 12 month condition-specific exclusion (excluding PMBs, see below) can be applied. No general 3 month exclusion can be applied.
You are changing schemes voluntarily, and have been a member of a scheme for the past 24 continuous months or longer
Waiting periods: Only the 3 month general waiting period (excluding PMBs, see below) can be applied.
You are changing schemes involuntarily due to change in employment
Waiting periods: Generally, no exclusions can be applied.
Excluded and Included PMBs
Waiting periods that exclude PMBs mean that you must be treated for all PMBs during the waiting period (for example: injuries due to car accident).
Waiting periods that include PMBs mean that you will not receive treatment for PMBs, even life threatening ones (car accident). Some schemes might cover you for some PMBs, at their discretion.
Note that during the waiting period, the schemes are obliged to only offer coverage for PMBs according to the PMB level of care ie. through designated providers, which sometimes may include state hospitals only (depending on the plan).
It’s all at the discretion of the scheme
Schemes cannot impose more exclusions than allowed by law, but they can impose less. Speak to your potential new scheme to get clarification regarding waiting periods in your specific case.
The Medical Schemes Act
If you want to see the legislation that deals with waiting periods, we have included the relevant part of the ACT below: