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Medical Schemes
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24 June 2011
The best savings vehicle is a Unit Trust Based Education Fund (UTBEF), says Hubert Feris, a Financia...
19 June 2011
A proposed system of tax credits for medical scheme contributions could make scheme membership more ...
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 Home  Medical Schemes What you should know
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 What you should know
Late Joiner Penalties.
A medical scheme may apply premium penalties to a late joiner. It must be applied only to the portion of the contribution relating to the person who qualifies for the late joiner penalties.
“Late joiner” means an applicant or the adult dependant of an applicant who, at the date of application for membership or admission as a dependant, is 35 years or older. This excludes any beneficiary who enjoyed uninterrupted coverage with one or more medical schemes before 1 April 2001, and as long as they did not have a break in coverage exceeding three consecutive months since 1 April 2001.
Waiting Periods.
A waiting period refers to a period during which contributions (medical aid premiums) are payable without the member being entitled to benefits.
A general waiting period is a period were no benefits (except those covered by the Prescribed Minimum Benefits) are available to the member and his dependants. (A general waiting period is normally 3 months long)
A condition-specific waiting period is a period when a member or a dependant cannot receive a benefit relating to a specific pre-existing condition. (It could be up to 12 months long)
Waiting periods DO NOT APPLY in respect of:
 Prescribed Minimum Benefits
A child dependant born during the period of membership (when the newborn
is registered as a dependant within 30 days of birth.)
An applicant who has been a member (or a dependant of a member) of one or more
medical schemes for a continuous period of two years or more and applies for
membership to the new scheme within a period of three months of termination of
membership of the previous scheme.
A member or his dependants moving between benefit options (unless he has to
complete the remaining period of previously imposed waiting periods).
Exclusions.
Medical schemes are allowed to exclude certain services, for example:
Expenses incurred in connection with any of the following:
Injuries or conditions sustained during wilful participation in a riot, civil commotion,
war, invasion, terrorist activity or rebellion.
Illegal behaviour, negligence or a breach of law
Failure to carry out the instructions of a medical doctor or dentist.
Treatment of an experimental nature.
For cosmetic (e.g. otoplasty for bat-ears, hair removal, eyelid surgery) or personal
reasons.
Healthcare services relating to obesity.
Medication not registered by the Medicine Control Council.
Prescribed Minimum Benefits.
Medical schemes are required by law to pay in full, without co-payment or the use of deductibles, the diagnosis, treatment and care costs of any medical emergency plus the following:
The above are diagnoses only, for the codes and treatments, please refer to
www.medicalschemes.com
The 25 chronic conditions that are covered by the prescribed minimum benefits are:
Addison’s Disease
Asthma
Bipolar Mood Disorder
Bronchiectasis
Cardiac Failure
Cardiomyopathy
Chronic Renal Disease
Chronic Obstructive Pulmonary Disease
Coronary Artery Disease
Crohn’s Disease
Diabetes Insipidus
Diabetes Mellitus Type 1 and 2
Dysrythmias
Epilepsy
Glaucoma
Haemophilia
Hyperlipidaemia
Hypertension
Hypothyroidism
Multiple Sclerosis
Parkinson’s Disease
Rheumatoid Arthritis
Schizophrenia
Systemic Lupus Erythematosus
Ulcerative Colitis
Some medical schemes cover more than these 25 chronic conditions.
For example, on Discovery Health members have an option to purchase a “Chronic Extender Benefit”. This benefit is purchased additionally at a monthly premium and provides unlimited cover for 63 chronic conditions (including the 25 conditions in the prescribed minimum benefits) from any provider.
Medical schemes (e.g. Discovery, Pulz and Oxygen) cover chronic medication through a preferred service provider like Direct Medicines or Scriptnet Pharmacies. They also have a list of medicines (called a formulary) that is available to you.
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2002-2005
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