What waiting periods can my medical scheme apply?

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

Open medical 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.

Some rules

• 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.