What waiting periods can my medical scheme apply?

Key takeaways

  • Medical schemes are allowed to impose waiting periods during which time you cannot claim.
  • Waiting periods prevent members from anti-selecting or only joining a scheme when they are sick.
  • There are two kinds of waiting periods:
    • A three month general waiting period; and
    • A 12 month waiting period that applies only to claims related to a condition you had when you joined a scheme.
  • These waiting periods can only be applied in specific circumstances.
  • If you have been a member of a scheme for at least two years continuously and you join a new scheme with no more than a three month break in membership, the only waiting period that can be applied is the three month waiting period.  It will not apply to the prescribed minimum benefits.


Medical schemes are obliged by law to admit as members anyone who applies to the scheme.

Open schemes must, by law, admit anyone. Restricted schemes must admit anyone who is a member of the employer or group to whom the scheme restricts its membership.

As open schemes are obliged to admit anyone, they are at risk of members only joining a scheme when they know they need to claim, and leaving once they have received the treatment they need.

Schemes need contributions from healthy members to subsidise the claims of members who are sick.

When a member joins a scheme knowing they need to claim for a health condition, it is known as anti-selection.

To protect schemes and other members from anti-selection, schemes are allowed to apply waiting periods – periods after joining during which you do not enjoy benefits or certain benefits.

The waiting periods schemes can impose and the circumstances under which they can be imposed are specified in the Medical Schemes Act.

Two waiting periods

Currently, the Act provides for two waiting periods that a scheme can impose. These are:

A three month general waiting period

During the three month general waiting period, members and their dependents won’t be eligible for any benefits.

This waiting period can be applied to any member and dependent/s when moving from one scheme to another.

The exceptions are:

  • A member and his / her dependents move schemes after a change in employment; or
  • An employer changing the scheme to which its employees may belong.

In these cases, the new scheme can only continue any waiting period imposed by the previous scheme and which has not yet expired.

If a member changes schemes with less than a three month break in membership, and has been a member of a scheme for two years continuously before the change, the new scheme will have to pay claims for conditions listed as prescribed minimum benefits (PMBs) during the waiting period. Read: What is a prescribed minimum benefit?

This means you will be covered for hospitalisation in the case of an accident, as all emergencies are covered by the PMBs.

If a member has a break in membership of more than three months between being a member of one scheme and joining another, the new scheme can impose the three month waiting period, and cover for PMB benefits will also be excluded. This means medical emergencies are also not covered.

A 12 month condition-specific waiting period

A condition-specific waiting period is a period during which a member or his / her dependent is unable to claim benefits for a condition that was diagnosed, or for which they sought or received medical advice, care or treatment, within 12 months of applying for membership.

This waiting period can only be applied if you have a break in membership of more than three months.

If you have not been on a scheme for two years continuously and you change schemes without a three month break, the scheme can impose condition-specific waiting periods and also exclude PMBs for this period. It can also continue any general waiting that has not yet expired.

How the waiting periods work

You have been a beneficiary of a scheme within the past 90 days, and have been a beneficiary of one or more schemes for a continuous period of more than 24 months.

 

  • The three month general waiting period.
  • The waiting period will not apply to the PMBs.

You have not been a beneficiary of a scheme for more than 90 days.
  • A three month general waiting period.
  • A 12 month condition-specific waiting period (if you have a condition).
  • These waiting periods will apply to treatment falling under the PMBs.

You have been a beneficiary of a scheme within the past 90 days, but you have not been a beneficiary of a scheme for a continuous period of up to 24 months.

  • The 12 month condition-specific waiting period.
  • The waiting period is not applicable to the PMBs.
  • The balance of any unexpired general or condition-specific waiting period imposed by the previous scheme.


Some rules

Waiting periods are not the only term that a scheme may impose on your membership.

If you join a scheme after the age of 36 without having been a member before, a scheme may also impose a late-joiner penalty on your contributions, resulting in you paying higher contributions throughout your membership.

  • Waiting periods cannot be applied when:
    • You move from one option to another on the same scheme.
    • You register a child as a dependent on your scheme.
  • The waiting periods are applied to the member and their adult dependents individually.

  • If an employer moves employees from one scheme to another, it must also take any pensioner members – known as continuation members - to the new scheme.

  • You cannot buy out of any waiting period or remain a member of one scheme and join another at the same time in order to have cover while the waiting periods on the new scheme apply. The Medical Schemes Act prohibits membership of more than one scheme.

  • If you move from one medical scheme to another before a waiting period has expired, the new scheme may apply the unexpired duration of the waiting period imposed by the previous scheme as well as any new waiting period that applies.

  • A medical scheme can ask you to submit a medical report so that the scheme knows what conditions to apply waiting periods to, but the scheme must pay the costs of any medical tests or examinations required.

 

HEALTHCARE TIP

Remember you need to be honest when completing an application form to join a medical scheme.

The worst thing that can happen when you disclose your health conditions is that you have a waiting period of one year imposed for your condition.

However, if you lie on your application and then claim for your condition, the scheme may investigate your health records.

On finding out that you had the condition before you joined, the scheme may impose the waiting period or even terminate your membership on the grounds that you did not make an honest disclosure.

If your membership is terminated, the contract between you and the scheme can be regarded as null and void from the time you joined, and you can be asked to pay back all claims paid to you.  The scheme will in turn reimburse you your contributions.