It is important to understand how waiting periods work, particularly for maternity and chronic diseases. All medical schemes apply waiting periods for new members. This means that the medical aid member cannot claim for a specified period of time. However, there are different types of waiting periods which applies to different situations. Even though you cannot claim during this time, you are still required to continue paying your monthly contributions.

What are waiting periods?

Waiting periods are a specified periods of time during which a person cannot claim for healthcare expenses from their medical aid. It may seem unfair to be paying for cover but not being able to claim. However, waiting periods exist to protect the scheme and all of its members. It prevents South Africans from signing up for medical aid only when they need cover, claiming from the scheme and then terminating membership.

Fortunately medical schemes in South Africa cannot refuse to cover these pre-existing conditions forever. Once the waiting period lapses, the new member can enjoy full medical aid benefits as per the plan. Furthermore these waiting periods may not apply to new members who were already covered by another scheme.

Types of Waiting Periods

There is a general waiting period that applies to all new members and for any condition. This lasts for 3 months from the time a new membership commences. Then there is the pre-existing condition waiting period which extends for a period of 12 months. The latter applies to a a host of acute and chronic diseases but also extends to pregnancy and childbirth.

Acute and Chronic Diseases

It is important to note that this pre-existing condition applies to any medical condition that exists prior to starting cover. It can be acute meaning that it is short term. It also applies to chronic conditions which can last a lifetime. Depending on the plan, this inability to claim may extend to the day-to-day, chronic and in-hospital benefit.

Pregnancy and Childbirth

Pregnancy is not a disease but it is a condition and therefore falls within the ambit of a pre-existing condition. Women who are already pregnant when starting medical aid will therefore not be able to claim for the existing pregnancy. However, pregnancy that occurs after this waiting period will be covered.

Non-Disclosure Can Affect Membership

Medical schemes are constantly encountering some new members who do not disclose their entire medical history. This means that the new member does not mention any of their pre-existing acute or chronic diseases. Similarly pregnant women may attempt to not inform the new medical scheme about their pre-existing pregnancy. This non-disclosure is essentially fraud.

It is not difficult for a medical scheme to investigate claims and identify pre-existing diseases. Many new members claim ignorance when exposed. Attempting to say that you were not aware about you pre-existing condition does not mean that the medical aid will waive the waiting period. In fact a medical scheme can terminate the membership if a new member appears to be defrauding the scheme.

It is always better to sign up for medical aid when you are young and healthy and do not need the cover. Unfortunately this is not always possible. Nevertheless, medical aid members should rather be honest about their pre-existing conditions and let the waiting period lapse before making any claims.

 

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