Restrictions on Medical Aids in South Africa

The medical aid industry in South Africa is strictly regulated and includes restrictions, thanks to the Medical Schemes Act. This protects members and also helps to ensure the various schemes are financially sustainable.

South Africa is very progressive in this regard and many other countries do not enjoy the same protection that we have had for the past 25 years.

Under the Medical Schemes Act, medical aid members are protected regardless of whether they are on a cost-effective hospital plan or if they have full comprehensive medical cover.

Rules and Restrictions Covering Medical Aids in South Africa

There are many rules and restrictions governing how South African medical aids must behave. By law, they cannot:

• Refuse your application: medical aids must accept all applications if the scheme is an open one. The scheme can, however, impose a late joiner penalty and certain waiting periods before late joiners can claim benefits. The scheme can also impose an exclusion period on certain pre-existing conditions.

 

• Medical schemes may not turn down your true dependents. These include:
  • Spouse or life partner
  • Children under 21
  • Child of any age with mental or physical disability
  • Immediate family members who are financially dependent on you (including parents, although they will have to pay full adult rates)

 

• Cancel your membership, except for in the following circumstances:
  • If you don’t pay contributions
  • Or if you don’t pay debts to the scheme
  • If you are guilty of defrauding or trying to defraud the scheme
  • If you failed to disclose information on pre-existing conditions prior to joining the scheme

More Restrictions

• Force you to use specific service providers. However, you may have to pay a portion of the bill if you choose to use hospitals or doctors outside of the scheme’s network.

 

• Change benefits or contributions during the year: benefits must stay in place for a year and the medical aids usually process increases in January. The Council for Medical Schemes would have to approve any other changes, and this would only be in exceptional circumstances.

 

• Give discounts to pensioners: most open schemes don’t differentiate based on income and usually have all-embracing contribution scales.

 

• Increase premiums based on claims: your contribution is not dependent on your claims history (unlike in the insurance industry).

 

• Refuse to pay for Prescribed Minimum Benefits: payment for a specified 270 conditionsis required by law and no restrictions, exclusions or waiting periods may apply.

 

• Pay medical savings in cash (unless you have resigned from the scheme).

 

• Pay more than 30 days after a claim: unless there is a disputed item on the claim, medical aids may not delay payment. This is monitored by the Medical Schemes Council.

 

All info was correct at time of publishing