Medical scheme waiting periods explained
When joining a medical scheme for the first time, new members may not understand why they have a waiting period before they are able to claim.
Considering that a medical scheme operates a pool of funds to cover claims of all members, and given the fact that a single claim can run into tens if not hundreds of thousands of rand, waiting periods are a reasonable measure.
Waiting periods essentially exist to ensure that people do not simply join a medical scheme when they require expensive medical treatment and then resign their membership, which would significantly erode the pool of funds available for all members’ needs.
A waiting period is, therefore, a defined period of time where members may not be eligible to claim, even though they are paying monthly contributions. This affords protection to the entire membership of the scheme, and is therefore in the best interests of all members, and supports the sustainability of the scheme.
When a child dependent is born to a member of a medical scheme in good standing, the baby is exempted from waiting periods even though the child is technically a new dependant who has not belonged to a scheme before.
Waiting periods generally exclude life-threatening emergencies and prescribed minimum benefits (PMBs), unless the individual has never contributed to a medical scheme before or has had a break in membership longer than 90 days.
In some cases, a new member joining the scheme with a particular pre-existing health condition may not be eligible to claim for treatment relating to that condition for a period of up to 12 months.
Where a member belonged to a different medical scheme for less than or up to 24 months, on joining a new scheme they may face a condition-specific waiting period, including for pregnancy. If the previous membership exceeded 24 months and there was not a 90-day break in membership, a three-month general waiting period may be applicable. As pregnancy is a PMB, the same rules apply with regards to waiting periods.
It is important to check from the outset what you are covered for and which waiting periods are applicable to you. Remember, depending on the option you have chosen, your scheme may place limitations on hospitalisation. For this reason, it is imperative that you check that the benefits offered will meet your specific requirements as well as those of your dependants.