Waiting periods are imposed by the medical aid scheme on new members, based on their medical history. The waiting periods can also be applied to Prescribed Minimum Benefits (PMBs). To find out more about PMBs, see here.
The Medical Act allows waiting periods to be imposed so as to prevent potential members from joining a scheme as they become ill. The idea is that members should join a scheme while they are generally healthy. It is, however, freely admitted by the department of Health and the Council of Medical Schemes that the legislation governing waiting periods was poorly drafted, and can result in medical schemes exploiting members who are “not necessarily engaging in opportunistic behaviour“.
There are two types of waiting periods: 3 month general waiting period and 12-month conditional waiting period.
3 month general waiting period
This is a waiting period that can be applied to all health services for the first 3 months of membership, including in some cases PMBs ie life-threatening conditions. For example, if you are involved in a car accident during this waiting period, it is very possible that you will not receive any coverage from your scheme for any claims.
12 month specific condition exclusion
According to the Act, schemes can restrict treatment for certain conditions for which “medical advice, diagnosis, care or treatment was recommended or received within the 12-month period ending on the date on which an application was made“. Even if some schemes ask for a medical history that extends beyond the past 12 months, they are not allowed to impose restrictions based on any medical history older than 12 months.
Which of the two exclusion, if any, can apply to you depends on your specific circumstance.
You want to change plans within the same scheme.
Exclusions: None can be applied, although any current exclusions will continue.
You have not been a member of a scheme for more than 90 days
Exclusions: Both the 3 month general exclusion (including PMBs) and the 12 month condition-specific exclusion (including PMBs) can be applied.
You are changing schemes voluntarily, and have been a member of a scheme(s) for less than 24 continuous months.
Exclusions: The 12 month condition-specific exclusion (excluding PMBs) can be applied. No general 3 month exclusion can be applied.
You are changing schemes voluntarily, and have been a member of a scheme for the past 24 continuous months or longer
Exclusion: Only the 3 month general waiting period (excluding PMBs) can be applied.
You are changing schemes involuntarily due to change in employment
Exclusions: Generally, no exclusions can be applied.
Waiting periods and PMBs
Waiting periods that exclude PMBs mean that you must be treated for all PMBs during the waiting period (for example: injuries due to car accident).
Waiting periods that include PMBs mean that you will not receive treatment for PMBs, even life threatening ones (car accident). Some schemes might cover you for some PMBs, at their discretion.
Note that during the waiting period, the schemes are obliged to only offer coverage for PMBs according to the PMB level of care ie. through designated providers, including state hospitals only.
It’s all at the discretion of the scheme
Schemes cannot impose more exclusions than allowed by law, but they can impose less. Speak to your potential new scheme to get clarification regarding waiting periods in your specific case.
The part of the ACT that deals with waiting periods: