All medical aids in South Africa have a rule – no person can be refused membership based on their age or health status but pre-existing conditions can be excluded from cover for the first 12 months. It is one way in which medical aids can ensure that new members do not join the scheme and drain the pool of funds contributed by the existing members over time. It is not discriminatory as some people may feel. It does not matter whether you are pregnant, have diabetes or are HIV-positive. It is just an across the board rule to ensure that only people who are contributing to a scheme as a loyal member have access to the full range of benefits. Any person can become a member of the medical aid and therefore any person can enjoy these benefits.
Which pre-existing conditions are excluded?
All pre-existing conditions are subject to the 12 month exclusion period. This does not only mean acute or chronic diseases. It also refers to physiological states like pregnancy and menopause which are not diseases. For example there is no medical aid for pregnant women who are already pregnant at the time of joining a medical aid as a new member. However, future pregnancies will be covered. The same applies for any disease be it asthma, hypertension, diabetes or HIV and AIDS. You have to wait for a 12 month period before you can claim for the costs of these bills from your medical aid.
Cover for Medical Conditions that Start After Joining
If you develop some disease after joining then it is not considered as a pre-existing condition. It is therefore not subject to the 1 year exclusion period but it will not be covered in the first 3 months of a new membership. The first 3 months of joining a new medical aid is a general waiting period where you cannot claim for any medical expenses. After the 3 months you will start being covered for any medical condition that develops at that point onwards. This is provided that the medical aid does not find any evidence that the medical condition was pre-existing and simply not disclosed by the member at the time of joining the scheme.
Immediate Cover for Pre-existing Conditions
The waiting periods for pre-existing conditions do not apply if you were a member of one medical aid and simply changed to another scheme. Similarly it does not apply if you switch from one plan to another within the same medical scheme. Beware though. If you were not a member for at least one year with your previous medical aid then the exclusion and waiting periods may still continue with your new medical aid as it is still viewed as a pre-existing condition subject to 12 month exclusion from cover. Medical schemes do communicate with each other on all aspects of cover, especially when it comes to new members. Therefore it is important to join a medical as soon as you can afford to, preferably while you are young and healthy.
Penalty for Pre-Existing Conditions
Medical aids do not charge any penalty for a pre-existing condition. In other words, a person who is HIV positive at the time of joining a scheme will pay the same as person who is not HIV infected. Only a waiting period applies but no difference in the medical aid monthly premium. The only time that a medical aid adds a penalty fee to the monthly contributions is when a person first joins a medical aid after 35 years of age. This is known as a late joiner penalty. It affects the rate you pay for medical aid cover for life and this is why young people are encouraged to join a scheme as soon as they can afford to. Late joiner penalties are not applicable if you are older provided that you joined the scheme before 35.