Underwriting a new application

1. What is a Condition specific waiting period?

A period during which a beneficiary is not entitled to claim benefits in respect of a condition for which medical advice, diagnosis, care or treatment was recommended or received within the twelve-month period ending on the date on which an application for membership was made.

2. When can a Conditions specific waiting period be imposed on a member?

A medical scheme may impose upon any person in respect of whom an application is made for membership or admission as a dependant, and who was previously a beneficiary of a medical scheme for a continuous period of up to 24 months, terminating less than 90 days immediately prior to the date of application-

(a)        a condition-specific waiting period of up to 12 months, except in respect of any treatment or diagnostic procedures covered within the prescribed minimum benefits;

(b)        in respect of any person contemplated in this subsection, where the previous medical scheme had imposed a general or condition-specific waiting period, and such waiting period had not expired at the time of termination, a general or condition-specific waiting period for the unexpired duration of such waiting period imposed by the former medical scheme.

3. What is a General waiting period?

A period in which a beneficiary is not entitled to claim any benefits

4. When can a general waiting period be imposed on a member?

A medical scheme may impose upon a person in respect of whom an application is made for membership or admission as a dependant, and who was not a beneficiary of a medical scheme for a period of at least 90 days preceding the date of application-

a general waiting period of up to three months A medical scheme may impose upon any person in respect of whom an application is made for membership or admission as a dependant, and who was previously a beneficiary of a medical scheme for a continuous period of more than 24 months, terminating less than 90 days immediately prior to the date of application, a general waiting period of up to three months, except in respect of any treatment or diagnostic procedures covered within the prescribed minimum benefits.

5. What is covered during the three month General Waiting period?

*It is important to note that the following will only be covered if the member has inter-changeability (i.e. was on a previous scheme for more than two years)

 

The three month general waiting period applies to Major Medical claims only, i.e. Major Medical Benefits, extended medication benefits and Out-of-hospital expense benefits.

Fedhealth Medical Scheme will cover claims from a member’s savings benefit during the three month general waiting period. These claims however will not accumulate to the Safety Net Level.

Chronic conditions (excluding the 26 PMB chronic disease list) will be covered from the member’s savings benefit, during the waiting period.

The 26 listed Prescribed Minimum Benefits (PMB) will be covered from the Member’s Major Medical Benefit, (subject to the Rules of the Scheme and benefits of the selected option).

Claims, resulting from an emergency trauma event within the three month general waiting period will be covered subject to the Rules of the Scheme and benefits of the selected option.

6. What is the definition of an emergency trauma?

  •       Trauma is defined as “an event caused by accidental, violent, external and visible means, where failure to provide the medical attention would place the member’s health in serious jeopardy”

7. What is a late joiner penalty?

“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, as they case may be, is 35 years of age or older, but excludes any beneficiary who enjoyed coverage with one or more medical schemes as from a date preceding 1 April 2001, without a break in coverage exceeding three consecutive months since 1 April 2001.”

8. When can a Late Joiner penalty be imposed on a member?

A medical scheme may apply premium penalties to an applicant or dependant of a late joiner and such penalties must be applied only to the portion of the contribution related to the member or any adult dependant who qualifies for late joiner penalties.

The premium penalties referred to in sub-regulation (1) shall not exceed the following bands:

Penalty Bands Maximum penalty
1-4 years 1.05 x contribution
5-14 years 1.25 x contribution
15-24 years 1.50 x contribution
25+ years 1.75 x contribution

To determine the applicable penalty band to be applied to a late joiner in terms of the first column of the table in sub-regulation

(2) the following formula shall be applied:

A = B minus (35 + C)

Where:

“A” means the number of years referred to in the first column of the table in subregulation (2), for purposes of determining the appropriate penalty band;

“B” means the age of the late joiner at the time of his or her application for membership or admission as a dependant; and

“C” means the number of years of creditable coverage which can be demonstrated by the late joiner.