FYI: med­i­cal aid wait­ing pe­ri­ods

Think­ing of chang­ing your med­i­cal aid? Here’s what you need to know about switch­ing and the con­di­tions that come with new mem­ber­ships

YOU (South Africa) - - CONTENTS - BY LETI­TIA WAT­SON Send sug­ges­tions for top­ics and re­quests for info to your­ We may an­swer your ques­tions in this col­umn but won’t reply per­son­ally.

THERE are wait­ing pe­ri­ods when switch­ing from one med­i­cal aid to an­other be­fore you’re fully cov­ered. The du­ra­tion de­pends on how long you’ve been a mem­ber of a med­i­cal aid.

Ba­si­cally, there are two cat­e­gories: hav­ing been a mem­ber of a med­i­cal aid for an un­in­ter­rupted two years; and hav­ing been


If you’ve been a mem­ber of a med­i­cal aid for two un­in­ter­rupted years and switch to a new med­i­cal aid within 90 days of leav­ing your old one, the wait­ing pe­riod is usu­ally just three months.

Dur­ing these three months you’ll have to pay your full monthly pre­mi­ums but you’ll be al­lowed to claim only for pre­scribed med­i­cal ben­e­fits (PMBs) – ben­e­fits that med­i­cal aids are re­quired by law to cover. PMBs in­clude hos­pi­tal cover for a range of con­di­tions and life-threat­en­ing emer­gen­cies, and treat­ment for a list of chronic con­di­tions.

The full list of PMBs is pub­lished on med­i­ Pro­ce­dures and med­i­ca­tion re­lated to PMBs are fully cov­ered pro­vided you use the fund’s pre­ferred ser­vice providers and med­i­ca­tion.

When the three months are over, the full ben­e­fits of your cho­sen plan op­tion come into ef­fect.

The penalty for join­ing late is called a late join­ing fee and is ap­pli­ca­ble only if the mem­ber is older than 35, as older mem­bers usu­ally have more med­i­cal ex­penses. It’s cal­cu­lated ac­cord­ing to your to­tal a mem­ber of a med­i­cal aid for less than two years.

If you want to switch, it’s im­por­tant to do it within three months (90 days) of leav­ing your old med­i­cal aid or a late join­ing fee and full un­der­writ­ing might be im­ple­mented.

Full un­der­writ­ing means the same cri­te­ria could ap­ply as when you join a med­i­cal aid for the first time. num­ber of mem­ber­ship years and your cur­rent age. The longer you were a mem­ber of a med­i­cal aid, the less the penalty. This fee forms part of your monthly pre­mium.

Go to med­i­ for an ex­pla­na­tion of how the late join­ing fee is cal­cu­lated. The new med­i­cal aid will tell you what the fee will be, or you can con­sult a med­i­cal bro­ker (see Get Help Here).

Even if the new pre­mium is for in­stance R50 higher as a re­sult of the penalty, you shouldn’t be put off. Rather com­pare the new fund’s ben­e­fits to those of­fered by your pre­vi­ous med­i­cal aid. EX­AM­PLES OF CLAIMS DUR­ING THE WAIT­ING PE­RIOD

Sarah has been a mem­ber of a med­i­cal aid for five years but switched to a new one as its ben­e­fits bet­ter suit her bud­get and needs. She’s now within the three­month wait­ing pe­riod.

Sarah has high choles­terol. Be­cause this chronic con­di­tion is a PMB, the new med­i­cal aid will cover her doc­tor’s vis­its and med­i­ca­tion, pro­vided the doc­tor and the meds are on its list of pre­ferred ser­vice providers and med­i­ca­tion. If Sarah was in a se­ri­ous ac­ci­dent and her con­di­tion was crit­i­cal, she’d be cov­ered be­cause this con- sti­tutes a life-threat­en­ing emer­gency un­der PMB cover.

Sarah has a si­nus in­fec­tion and vis­its her GP. The med­i­cal aid doesn’t cover the doc­tor’s visit nor the pre­scribed med­i­ca­tion as she’s still in the three-month wait­ing pe­riod and the con­di­tion isn’t a PMB.


If you were a mem­ber of a med­i­cal aid for less than two years and join a new fund (within 90 days of leav­ing the old fund), the new med­i­cal aid might re­quire a 12-month con­di­tion­spe­cific wait­ing pe­riod on any ex­ist­ing con­di­tions (such as hy­per­ten­sion) and planned pro­ce­dures (such as a back op­er­a­tion). Dur­ing this pe­riod you pay the full monthly con­tri­bu­tion but med­i­cal ex­penses re­lat­ing to the ex­ist­ing con­di­tion are paid out of pocket.

The 12-month ex­clu­sions are unique to your spe­cific health con­di­tions.

The three-month wait­ing pe­riod doesn’t ap­ply to other med­i­cal ex­penses and you’ll be al­lowed to claim ac­cord­ing to the plan you’re on. You’re also cov­ered for PMBs.

A late join­ing fee can be im­ple­mented if you’re older than 35. EX­AM­PLES OF CLAIMS DUR­ING A WAIT­ING PE­RIOD

Josh was a mem­ber of a med­i­cal aid for 18 months and has now switched to a dif­fer­ent fund.

He has a si­nus in­fec­tion and vis­its his GP within the first three months of his mem­ber­ship with the new med­i­cal aid. The new fund pays his doc­tor’s visit be­cause his cho­sen plan cov­ers doc­tors’ vis­its and pre­scrip­tion medicine.

Josh had a back op­er­a­tion be­fore ap­ply­ing for mem­ber­ship to the new med­i­cal aid, so the new scheme ex­cludes any claims for 12 months that re­late to his back con­di­tion. For 12 months he has to pay for medicine for his back out of his own pocket. Make sure your new mem­ber­ship starts on the day af­ter your old mem­ber­ship ends – it’s il­le­gal to be­long to more than one med­i­cal aid at a time. Be­fore switch­ing, call your ex­ist­ing med­i­cal aid and ask what the no­tice pe­riod is. When giv­ing no­tice, con­firm ex­actly on which day the mem­ber­ship ends.

Your old med­i­cal aid should give you a mem­ber­ship cer­tifi­cate, which you have to hand over to the new med­i­cal aid to con­firm you were a mem­ber. If you don’t have this, you can sign an af­fi­davit to con­firm your mem­ber­ship.

The new fund will re­quire your de­tailed health sta­tus and that of your de­pen­dants. This in­cludes chronic con­di­tions, med­i­cal his­tory and any surg­eries you’ve had.

If you stay with the same med­i­cal aid but change plans, there’s no wait­ing pe­riod. So be­fore you switch to a new med­i­cal aid, es­tab­lish whether your cur­rent med­i­cal aid has a dif­fer­ent plan that might suit you bet­ter.

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