Understanding medical aid waiting periods
Susan Weedman, Senior Consulting Manager at Alexander Forbes Health
New members applying to medical aid schemes need to understand that there is a waiting period before they may claim. They pay full contributions to the medical scheme during this waiting period, but cannot yet claim for full benefits from the scheme.
Why does the medical scheme apply a waiting period?
A waiting period protects the medical scheme and its members so that it is sustainable. It prevents members from joining a medical aid scheme just to claim large medical expenses before cancelling their membership.
In terms of the Medical Schemes Act, medical schemes may apply a general waiting period of 3 or 12 months. During the waiting period the applicant and their registered dependants may not claim any benefits, except for prescribed minimum benefits in certain circumstances.
When does the scheme apply a waiting period?
The scheme considers how long an applicant has been a medical aid member, how many days have passed since they ended their membership and applied for new membership and whether they are joining as part of an employer group or as an individual member
The scheme may then apply the following:
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Waiting period situations |
Type of waiting period |
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You have not been a member of a medical scheme or You have been a member of a medical scheme and have had a break of more than 90 days since ending your membership with your previous scheme |
General waiting period: 3 months AND Condition-specific waiting period: 12 months
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You have been a member of a medical scheme for less than 24 months and have applied for new membership within 90 days of ending your membership with your previous scheme |
Condition-specific waiting period: 12 months |
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You have been a member of a medical scheme for 24 months or more and have applied for new membership within 90 days of ending your membership with their previous scheme |
General waiting period: 3 months
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The medical scheme may not apply a waiting period when a member is moving benefit options within the same medical scheme, when a baby born into the scheme is added on as a dependant (most schemes set a time period of 30 days within which the child must be registered), ,or when an employer changes medical schemes for their employees.
It is important to check before applying to a medical scheme if any waiting periods will apply, as this will affect your benefits and when they will be made available. The medical scheme or a medical scheme adviser will assist you in clarifying any applicable waiting periods.
