Welcome back to Cover to Cover: Medical Schemes Explained, a column in partnership with Medihelp, helping financial advisers to 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). The third edition examines waiting periods and how they affect medical scheme benefits.
In this edition, we look at dependants – who qualifies, what documentation is needed, and how advisers can guide clients through eligibility rules under the Medical Schemes Act (MSA),.
Who counts as a dependant?
Under section 1 of the MSA, a dependant is defined as:
- The spouse or partner of a member;
- A child of the member or of the member’s spouse or partner; or
- Any other dependant of a member who is eligible as a dependant under the rules of the medical scheme.
Medical schemes apply this definition through their registered scheme rules. When registering a dependant, schemes consider:
- The relationship between the member and the dependant; and
- The nature of financial dependency.
Supporting documents can be required if a member wants a child dependant 21 years and older to remain on their membership and may be applicable on any other dependant who is eligible to be registered as a dependant.
Schemes may require annual proof of continued dependency for other relatives who remain on the member’s membership, the scheme will usually request:
- An affidavit confirming dependency;
- Bank statements not older than three months or evidence of regular financial support;
- Payslips (or confirmation of unemployment); and
- Proof of residence if the dependant lives with the main member.
It is important that members provide proof of full-time student status from a recognised institution to schemes annually to ensure the further recognition of their adult dependant, to prevent the dependant from being removed unintentionally or paying adult dependant rates.
Partnerships and life partners
Medical schemes recognise life partnerships – including same-sex and common-law relationships – as eligible for dependant registration if the couple shares a marriage-like relationship.
Supporting documentation may include:
- A joint affidavit declaring the partnership and shared household;
- Proof of cohabitation (such as a joint lease, utility bill, or bank statement not older than three months); and
- A declaration of partnership form, if required by the scheme.
It’s important to note that a fiancé(e) is generally not eligible unless they can demonstrate an established, financially interdependent relationship.
Foster, adopted, and guardian children
Schemes treat foster, adopted, and guardian children equally to biological children if the legal documents required by the scheme are supplied. Required proof usually includes:
- A court order confirming guardianship, foster care, or temporary safe care; or
- A legal adoption order.
Parents and in-laws as adult dependants
Some medical schemes allow parents or parents-in-law to be added as adult dependants, subject to proof of financial dependency and the scheme’s rules.
Key points include:
- Each adult dependant attracts an additional contribution.
- The parent cannot be a member of another medical scheme simultaneously.
- Financial dependency must be proved through affidavits, pension statements, investments documents or bank statements (all statements must not be older than three months).
This option can be valuable for retirees or elderly parents who rely on the registered member for medical expenses.
Waiting periods and underwriting for dependants
New dependants are subject to the same underwriting rules as main members.
Schemes may impose:
- A three-months general waiting period, and
- A 12-months condition-specific waiting period for pre-existing conditions.
- The waiting periods shall also apply to the PMBs.
- Late-joiner penalties for dependants 35 years and older.
Exceptions:
- Newborns or newly adopted children are covered immediately if registered within 90 days of birth or adoption.
- Dependants transferring from another scheme with uninterrupted cover may have waiting periods waived or reduced under the Council for Medical Schemes’ portability rules.
Advisers should always confirm the maximum underwriting implications that apply before submitting applications.
When a dependant no longer qualifies
Dependants must be removed if they no longer meet the eligibility rules. For example:
- Adult children who become financially independent or reach the scheme’s age limit;
- An adult child becomes financially independent or turns 21 (if that’s the scheme’s age cap); or
- A relationship ends.
Most schemes allow the dependant to apply for membership as a main member within a specified grace period, ensuring continuous membership and avoiding underwriting conditions in terms of the scheme’s rules. Advisers should help to facilitate this transition.
Membership continuation after a member’s death
If a main member passes away:
- Registered dependants qualify for continued membership under the same scheme if the dependants accept membership in the prescribed period per the scheme’s rules to ensure no break in cover.
- The oldest adult dependant or the youngest dependant will typically become the new main member. Different schemes have different rules regarding this point.
Advisers play a key role in supporting the family through this transition, ensuring continuous membership to avoid waiting periods.
Advising clients when dependants don’t qualify
When dependants are no longer eligible, advisers can explore alternatives:
- Primary healthcare plans or medical insurance (regulated under the Insurance Act);
- Gap cover to protect against hospital shortfalls; or
- Health cash plans and day-to-day benefit products.
Always ensure clients understand that medical insurance is not the same as a medical scheme.
Tips for advisers:
- Always reference the scheme’s registered rules – these are legally binding.
- Encourage clients to provide full and accurate documentation upfront.
- Maintain records of all supporting evidence to facilitate smooth annual renewals.
- Be proactive – identify potential dependency changes (for example, a child nearing 21) before they trigger a disruption in cover.
Bottom line: Understanding who qualifies as a dependant and the supporting documentation required is key to keeping members and their families covered. Advisers play an essential role in guiding clients and preventing disruptions in cover.
