Medical aid waiting periods: what the law allows

A medical scheme may make a new member wait up to three months before claiming anything (a general waiting period), and up to 12 months before claiming for a condition they already had (a condition-specific one). Section 29A of the Medical Schemes Act sets those limits and says who must be spared them. A scheme's rules cannot go beyond them.

Olvian is a lead-referral service, not a medical scheme, broker or adviser. A registered broker or medical scheme that pays Olvian a fee may call you back; this guide only explains what the Act says so you can ask them informed questions.

How long can a medical scheme make me wait?

It depends on your history of cover. Section 29A sets three situations, and the "up to" figures are ceilings, not promises.

• No scheme cover in the 90 days before you apply. Section 29A(1) lets the scheme impose a general waiting period of up to three months and a condition-specific waiting period of up to 12 months.
• Previous cover of up to 24 months, ending less than 90 days before you apply. Section 29A(2) allows a condition-specific waiting period of up to 12 months. It also allows the scheme to apply whatever was left of a waiting period your previous scheme had imposed.
• Previous cover of more than 24 months, ending less than 90 days before you apply. Section 29A(3) allows a general waiting period of up to three months and nothing more.

So an unbroken history of cover works in your favour, and a gap of 90 days or more puts you back in the first group.

What is the difference between a general and a condition-specific waiting period?

The Act defines both terms in section 1.

A general waiting period is "a period in which a beneficiary is not entitled to claim any benefits". For that time you can pay contributions but claim for nothing.

A condition-specific waiting period is a period during which you cannot claim for "a condition for which medical advice, diagnosis, care or treatment was recommended or received within the twelve-month period ending on the date on which an application for membership was made". It looks back 12 months from your application date. A new problem that starts after you apply is not held back by it.

The second definition is why honest answers on the application form matter. Section 29(2)(e) allows a scheme to cancel membership for non-disclosure of material information.

Do waiting periods apply if I am moving from another scheme?

Often they apply in part, and sometimes not at all.

• Moving because of a job change. Section 29A(6) says a scheme may not impose a general or condition-specific waiting period if you apply within 90 days of leaving a previous scheme and the move is required because you changed employment. The same goes where your employer changed or ended its scheme, as long as the transfer happens at the start of the financial year or the new scheme was given reasonable notice.
• Carrying over unexpired periods. In the cases above, section 29A(8) lets the new scheme impose only what remained of a waiting period set by the former scheme.
• Switching options inside one scheme. Section 29A(4) bars new waiting periods when you move to another option on the same scheme, apart from any period still running on your current option.

If you are changing schemes, keep a letter from the old scheme showing when your cover started, when it ended and whether you had a waiting period running. It is the evidence the new scheme will want.

Can my children and dependants be made to wait?

A child born while you are a member cannot. Section 29A(5) says a scheme may not impose a general or a condition-specific waiting period on a child dependant born during the period of membership.

Other dependants you add are treated as applicants under section 29A(1) to (3), so their own history of cover decides what applies to them.

Do waiting periods apply to prescribed minimum benefits?

The text is specific, and it is worth reading closely.

Section 29A(2)(a), which deals with a condition-specific waiting period after previous cover of up to 24 months, excludes "any treatment or diagnostic procedures covered within the prescribed minimum benefits". Section 29A(3), the general waiting period after more than 24 months of cover, carries the same exclusion.

Section 29A(1), which covers someone with no scheme in the previous 90 days, does not repeat those words. How a particular scheme treats prescribed minimum benefit conditions during a waiting period under that subsection is something to ask the scheme, and to ask for the answer in writing. Our guide on prescribed minimum benefits explains what those benefits are.

What can a scheme ask about my health when I apply?

Section 29A(7) limits it. A scheme may require a medical report on a proposed beneficiary "only in respect of a condition 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 for membership was made".

Regulation 12 adds that if the scheme requires a medical report under section 29A(7), it must pay the applicant or the health care provider for the cost of any medical tests or examinations it requires to compile the report.

Contributions are a separate question. Section 29(1)(n) says a scheme's admission terms provide for contributions on the basis of income or the number of dependants, "and shall not provide for any other grounds, including age, sex, past or present state of health", other than as prescribed. The "as prescribed" part is the late-joiner penalty, covered in our guide on the late-joiner penalty.

What if a scheme applies a waiting period I think is wrong?

Start with the scheme. Ask it in writing which paragraph of section 29A it relies on, and ask for the answer in writing too.

If that does not settle it, the Act gives you a route. Section 47 provides for a written complaint to the Council for Medical Schemes, which gives the other party a chance to comment and then resolves the matter or takes it to the Council. Section 48 lets a person aggrieved by a decision on a complaint appeal to the Council by affidavit, not later than three months after the decision, unless the Council allows more time for good cause.

The Council also says to use the scheme's own dispute process before you complain to it. Its complaints procedure page sets out what to send.

What should I ask the scheme or broker who calls me?

Olvian does not advise on which scheme or option suits anyone. These are factual questions the registered broker or medical scheme that calls you can answer.

1. Which waiting periods, if any, will apply to me and to each dependant, and for how long?
2. What did you base that on: my cover history, my application answers, or both?
3. Will you accept my previous scheme's letter as proof of continuous cover?
4. Are there prescribed minimum benefit conditions I could claim for during the waiting period?
5. Is the waiting period written into the scheme rules, and where?
6. What happens to a waiting period if I change option later?

Sources

• Medical Schemes Act 131 of 1998, as consolidated and published by the Council for Medical Schemes: section 1 (definitions), section 29(1)(n), 29(2) and 29(3)(c), section 29A, sections 47 and 48. https://www.medicalschemes.com/files/Acts%20and%20Regulations/MSACT19DEC2003.pdf
• Regulations made under the Medical Schemes Act, regulation 12 (medical reports), as consolidated by the Council for Medical Schemes. https://www.medicalschemes.com/files/Acts%20and%20Regulations/MSREGS19July2004.pdf
• Council for Medical Schemes, the complaints procedure. https://www.medicalschemes.co.za/consumer-assistance/complaintsprocedure/

The Act and Regulations are amended from time to time, and the consolidations linked above are the ones the Council published. Check the current text on the Council's website before relying on a section number.