Welcome back to Cover to Cover: Medical Schemes Explained, a column in partnership with Medihelp, helping financial advisers break down the complexities of medical schemes so clients can make informed decisions.
Read the first edition of Cover to Cover on decoding medical scheme plans, and the second edition, which explains the Prescribed Minimum Benefits (PMBs).
In this edition, we explore waiting periods – a common feature of medical scheme membership that can affect when benefits become available.
Why waiting periods exist
When someone joins a medical scheme, a waiting period may apply before full benefits are available. This is designed to protect all members and ensure people do not only join a scheme when they are sick.
Who is affected?
Waiting periods can apply to:
- New applicants who have never been on a medical scheme.
- Members rejoining after a break in cover.
- Members switching between medical schemes.
- Dependants added during registration, including spouses and children.
Types of waiting periods
- General waiting period (up to three months): You pay contributions but cannot claim any benefits. Emergency treatment and the PMBs apply for members who belonged to a medical scheme for more than two years, and where the break in membership between the previous scheme and the new scheme is less than 90 days.
- Condition-specific waiting period (up to 12 months): For any pre-existing condition before joining, the scheme may apply a waiting period for that condition during the first year of membership. The member is entitled to benefits depending on the benefit plan for any other condition not related to the condition that was underwritten.
How waiting periods are determined
Schemes have some flexibility in setting waiting periods, within the framework of the law. Factors include:
- Membership history and whether the applicant has been on another medical scheme.
- The applicant’s health risk profile.
- Compliance with the Medical Schemes Act, which permits waiting periods to be applied.
Do waiting periods apply to everyone?
Not always. Members transferring from another scheme without a break – or with a break shorter than 90 days – may see reduced waiting periods. Babies added within 90 days of birth are typically covered immediately.
Can schemes be flexible?
Yes. Some schemes have arrangements with corporate groups that may reduce or waive waiting periods for employees who join through these agreements.
What can clients do?
- Join sooner rather than later, before cover is needed.
- Ask about bridging cover – short-term insurance can help while you wait.
- Avoid letting cover lapse, because gaps can trigger waiting periods.
- Keep the bigger picture in mind – waiting periods are temporary, but the long-term protection offered by medical scheme membership is invaluable.
Bottom line: Waiting periods are short term, but medical scheme cover is a lifelong safeguard. Advisers can help clients understand the rules and plan ahead to avoid surprises, ensuring access to essential healthcare when it matters most.
