Navigating medical aid waiting periods is essential for making informed healthcare decisions. In this guide, we explore:
- Why waiting periods exist – Protecting medical schemes from financial risk while ensuring fairness for all members.
- How reserves are maintained – Understanding how member contributions sustain the risk pool and prevent rapid depletion.
- Types of waiting periods – From general waiting periods to condition-specific exclusions and how they impact cover.
- Waiting periods when switching medical aids – What happens when you move between schemes and whether previous waiting periods carry over.
- Dependants and waiting periods – When family members may face their own waiting periods, even if the main member has completed theirs.
- Disputing or waiving a waiting period – Situations where waiting periods may not apply and when they can be challenged.
- Why planning ahead matters – Ensuring continuous cover and avoiding unexpected gaps in healthcare benefits.
Why do medical aids impose waiting periods?
Protecting medical scheme reserves
Medical aid schemes in South Africa are classified as a non-profit entity, so the biggest contributor to their funding model and financial sustainability is in the members’ monthly contributions. These contributions go into a “risk pool” and the overall annual limits allocated to scheme plans come from that risk pool, so when a scheme says that your benefits (such as in-hospital cover) are paid from “risk”, this is what they mean.
It is an unfortunate reality that many individuals only take out medical aid when they need extensive medical cover. This is understandable, but many of these members make use of benefits which require the scheme to pay out an exorbitant amount of money while the member pays a contribution that is a fraction in comparison to those medical expenses. When this happens, the medical aid takes on a high level of risk because their risk pool (and reserves) is being depleted faster than it is being built.
To prevent the depletion of these funds (because it affects every single member of that scheme), waiting periods are imposed to ensure that members contribute toward that risk pool before claiming from it. Not only does this sustain the level of reserves, but it also protects every other member of the medical scheme who need to claim from the scheme.
Medical aid waiting periods exist to protect the financial stability of medical schemes and ensure fairness among all members. These periods prevent individuals from joining a scheme only when they require costly medical treatments, contributing very little and then leaving once their needs are met. Without waiting periods, this behaviour—known as anti-selection—could quickly drain the scheme’s financial reserves, which are funded solely by member contributions.
The role of the council for medical schemes in regulating medical aid compliance
The CMS is a statutory body that regulates medical aids in South Africa. One of the duties of the CMS is to enforce legislation which includes waiting periods to ensure that medical schemes comply with the Medical Schemes Act to protect beneficiaries. The medical aid waiting period rules prevent exploitation of benefits while ensuring medical aids remain viable for all members.
In order for schemes to ensure that their risk pool remains large enough to pay out member claims, medical schemes have a reserve of funds (also built from member contributions), and the Council for Medical Schemes require those reserves to be at a certain level in order to ensure that the scheme is financially sustainable. One of the ways that those reserves are sustained is with the implementation of waiting periods.
What are the different types of medical aid waiting periods?
General medical aid waiting period in South Africa without PMB cover
- No cover for any medical expenses during this period.
- Members must use state healthcare for any medical treatment.
General medical aid waiting period in South Africa with PMB cover
Covers Prescribed Minimum Benefits (PMBs), including:
- Life-threatening emergencies
- Accidents requiring immediate medical intervention
- Certain serious illnesses that qualify under PMBs:
- PMBs have a list of 26 chronic conditions and 270 additional conditions
Will medical aids cover accidents or emergencies during a waiting period?
General waiting period (made up of 3 months in total) without PMB cover
- No cover for any medical expenses, including emergencies.
- Patients must rely on state healthcare.
- The remaining 7 months continue on the new plan
General waiting period with PMB cover
- Covers life-threatening emergencies and PMB-related conditions.
Will you have to serve a new waiting period if you switch medical aids within the same scheme?
No new waiting periods, but existing ones carryover
- If a member switches plans within the same scheme, they do not receive new waiting periods.
- Any uncompleted waiting periods continue on the new plan.
Example of waiting period carry-over
- A member has a 12-month waiting period on Plan A.
- They switch to Plan B after 5 months.
When no medical aid waiting periods apply
- If a member has completed all waiting periods (the full 12 months), no new waiting periods apply when switching plans within the same scheme.
Are waiting periods waived if you switch from one open scheme to another?
Scenario 1: Switching before 12 months of membership
If a member moves to a new scheme within their first 12 months, the new scheme can apply:
- 3-month waiting period without PMB cover
- Any remaining condition-specific waiting period from the previous scheme
Scenario 2: Switching after 2+ years of continuous cover
If a member moves directly from one scheme to another without a break:
- 3-month waiting period with PMB cover
- No 12-month condition-specific waiting period
Scenario 3: A gap of more than 90 days between medical aids
If a member cancels medical aid and waits more than 90 days before joining a new scheme:
- 3-month general waiting period without PMB cover
- 12-month condition-specific waiting period applies
Scenario 4: Switching to a new medical aid after only 12 months of membership
- You may not necessarily get a general waiting period but will receive a condition specific waiting period (if applicable)
Why you should always expect a 3-month waiting period
- It is rare for schemes to waive waiting periods when switching between open medical schemes.
Do dependants have to serve a waiting period if the main member has already completed one?
Waiting periods are applied to each individual
- Even if the main member has completed their medical aid waiting period in South Africa, dependants will still receive them.
Example of dependant waiting periods
- 2020: Main member joins with no chronic conditions ➔ 3-month waiting period without PMB cover.
- 2022: Spouse joins with a chronic condition ➔ 3-month waiting period without PMB cover + 12-month condition-specific waiting period.
- 2024: Baby is born and added to the scheme ➔ No waiting period applies as they were born into the scheme.
When no medical aid waiting periods apply
- If a member has completed all waiting periods (the full 12 months), no new waiting periods apply when switching plans within the same scheme.
How do you dispute an imposed waiting period?
Situations where you can dispute a waiting period
- Closed scheme or employer subsidised medical aid termination
- If a member was on a company medical aid and was retrenched, or in other words, you were involuntarily removed from your company’s medical aid, they should not receive waiting periods when moving to private medical aid. This is referred to as a forced moved. Proof of termination is required when applying to another medical aid, and you should do this within 90 days of termination This rule will not apply if you make the voluntary decision to leave your company or your company’s medical aid.
- Continuous cover for 24+ months with a gap of fewer than 90 days
- If a member had cover for over 2 years and joined a new scheme within 90 days, they should not receive waiting periods. Proof of previous membership is required.
When medical aid waiting periods cannot be disputed
- Outside of the above situations, waiting periods cannot be removed or disputed, as they are legally enforced under the Medical Schemes Act.
Is there an option to waive or reduce waiting periods?
- Rarely
- A scheme may waive waiting periods on a discretionary basis, but this is uncommon.
- Certain low-risk individuals (healthy with no chronic conditions) might receive reduced waiting periods, but this is at the scheme’s discretion.
Final thoughts
Comprehending the waiting periods for medical aid is of paramount importance in making smart choices when it comes to health cover. Waiting periods may seem binding, restrictive, but these waiting periods are legislated and are all about ensuring that medical schemes remain sustainable, fairly accessible in terms of benefits, and in a position to pay for your claims. Should you consider switching medical aid or adding a dependant, always keep in mind to confirm potential waiting periods to avoid any unplanned periods without cover. Reach out to MedXpert if you have questions, if you’re considering switching your medical aid, adding a dependant, or if you want to make sense of your health cover benefits.
Alternatively, you can call us on 0860 860 860 or email ask@MedXpert.co.za
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