Medical Scheme Waiting Periods

When joining a medical aid in South Africa, one important factor to understand is medical scheme waiting periods. Waiting periods are timeframes during which certain benefits are restricted or not covered. They exist to protect the scheme from members who might join only when they need expensive treatment, ensuring fairness for all members.

What Are Medical Scheme Waiting Periods?

A waiting period is a set period after joining a medical scheme during which your access to specific benefits is limited. These periods are legally regulated and can apply to general, chronic, or pre-existing conditions. They typically do not exceed 12 months for most benefits, depending on the type of waiting period.

Waiting periods ensure that medical schemes remain financially sustainable. They prevent members from joining only when they need costly medical treatment, which could increase premiums for all other members.

Types of Waiting Periods

1. General Waiting Period

This is usually the first three months after joining a scheme. During this time, benefits for all conditions may be limited or excluded. Most schemes apply a general waiting period to all new members to reduce risk and ensure fairness.

2. Condition-Specific Waiting Period

Also called a pre-existing condition waiting period, this applies to illnesses or medical conditions that existed before you joined the scheme. It typically lasts up to 12 months, depending on the scheme. For example, if you have diabetes before joining, treatment related to this condition may be restricted until the waiting period ends.

3. Emergency and Prescribed Minimum Benefit (PMB) Exceptions

Certain conditions, such as PMBs and emergencies, are usually exempt from waiting periods. This means if you have a life-threatening illness or emergency, your medical scheme must cover treatment even if you are still in a waiting period.

Why Waiting Periods Exist

Medical schemes implement waiting periods for several reasons:

• Risk management: To prevent members from joining only when treatment is needed.
• Financial sustainability: To ensure contributions from all members cover costs fairly.
• Encouraging early membership: Younger and healthier individuals are incentivized to join early, keeping premiums stable.

How Waiting Periods Affect You

During a waiting period, you may have limited or no access to certain benefits. Understanding how long you are affected and which conditions are included is crucial to avoid unexpected expenses. Always check your scheme’s rules carefully, especially if you have chronic illnesses or plan to switch schemes.

Tips to Minimize Waiting Periods

• Join a medical scheme early: Avoid waiting periods by enrolling before health issues arise.
• Transfer from another accredited scheme: Many schemes waive waiting periods if you provide proof of continuous membership.
• Check scheme policies: Some schemes may reduce or waive waiting periods for certain conditions or age groups.
• Plan for chronic conditions: Ensure your chronic treatment is covered after any required waiting period ends.

Frequently Asked Questions

What is a medical scheme waiting period?

A waiting period is a timeframe after joining a medical scheme during which certain benefits may be limited or excluded, especially for pre-existing conditions.

How long do waiting periods last?

General waiting periods usually last up to three months, while condition-specific or pre-existing condition waiting periods can last up to 12 months, depending on the scheme.

Are emergencies covered during waiting periods?

Yes. Emergencies and Prescribed Minimum Benefits (PMBs) are typically exempt from waiting periods and must be covered in full.

Can waiting periods be waived?

Yes. Many schemes waive waiting periods if you transfer from another accredited medical scheme and provide proof of continuous membership.

Do waiting periods apply to chronic conditions?

Yes. Chronic conditions may be subject to condition-specific waiting periods, unless the scheme waives them due to previous continuous coverage.