What Are Medical Aid Restrictions?

As a member of a medical aid, you have to follow the rules and deal with medical aid restrictions. Fortunately, you have a lot more protection from the South African government than you might think.

For instance, before ObamaCare came into being, medical aids in America could drop clients that made too many claims. In South Africa, that is illegal. In this post, we will go through other things that your medical aid may not do.

Medical Aid Restrictions – Decline Your Application

When the scheme is open, all applications must be accepted. The scheme may impose harsh penalties for joining late. Also they may require that you wait a certain period before receiving full cover.

Generally speaking, this will be three months or, if you have a pre-existing condition, twelve months before claims in Medical Aid Restrictionsrespect of that are paid out.

Medical Aid Restrictions – Decline Your Dependent

If you have a dependent who is solely financially dependent on you, they must accept them as members of your policy. You would, however, have to pay the full adult rate for them where applicable.

Medical Aid Restrictions – Drop You as a Client

They may not to do this unless you have not been paying you account on time, or if you do not pay your portion of the debt that the medical aid subsequently paid. If they find you guilty of defrauding them, they can legally cancel your membership.

Medical Aid Restrictions – Force You to Only Use Certain Doctors

On the whole you will have to use network doctors but if none are available, you can use the doctor that you choose. Just keep in mind that you will then be liable for a copayment of whatever amount exceeds the medical standard tariff.

Medical Aid Restrictions – Altering Benefits Mid-Year

The Medical Schemes Council can grant a medical aid permission to do this if the complainant makes a good case. However, the medical aid cannot do so on its own. You premiums cannot increase in the middle of the year either.

Medical Aid Restrictions – Increase the Contributions of Frequent Claimants

A registered medical scheme may not do this. Every member should pay the same contribution irrespective of claims they have made.

Medical Aid Restrictions – Refuse to Pay for Prescribed Minimum Benefits

Medical aids must, by law, cover the Prescribed Minimum Benefits. However, the medical aid may enforce regulations when it comes to the doctors you visit and the medication that you have access to.

Medical Aid Restrictions – Drag their Heels When Paying a Claim

Medical aids have a month in which to pay a claim presented. If there are disputed items on the claim, this may allow them some time to delay but otherwise they have 30 days.

Medical Aid Restrictions – Let You Draw Your Medical Savings Account

As long as you are a member of the scheme, they may not pay out any money in your medical savings account directly to you at all.

So, as you can see, there is a lot more to the stolid old medical aids than we thought. Our government has found good ways to keep them in line and protect the rights of the members.


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All info was correct at time of publishing