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 Underwriting

 
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New employees are required to join the company’s preferred scheme within 90 days of permanent employment in order to be accepted onto the scheme free of any underwriting restrictions.

It is vital that any break in membership does not exceed a 90-day period. This applies to the principal member and dependants. If this happens, a scheme may impose both a general and condition-specific waiting period. If a scheme imposes both waiting periods, they run concurrently.

Eligible employees who elect to remain on their spouse or partner’s medical scheme arrangements will be required to provide proof of this coverage on an annual basis. Should these employees elect to withdraw voluntarily as a dependant in order to join the company’s scheme after 90 days of permanent employment will be subject to underwriting and the following restrictions may be imposed on your membership:

  • 3 month general waiting period
  • 12 month exclusion on any pre-existing conditions
  • Late joiner penalty if the employee is over the age of 35

What are waiting periods and late joiner penalties?

Medical schemes may impose waiting periods on new members or dependants who are individually underwritten. This depends on the employee’s health risk status and their previous medical scheme membership history.

The scheme may impose the following waiting periods in terms of the Medical Schemes Act 131 of 1998:

  • Three month general waiting period. A member cannot claim any benefits during the general waiting period, including those related to prescribed minimum benefits except in specific circumstances
  • 12-month pre-existing condition specific waiting period. Condition-specific has a wide meaning and refers to a medical condition whereby medical advice, diagnosis, care or treatment was recommended or given to a prospective member for the twelve month period immediately prior to application to a scheme.

It is vital that any break in membership does not exceed a 90-day period. If this happens, a scheme may impose both a general and condition-specific waiting period. If a scheme imposes both waiting periods, they run concurrently.

Employees or dependants who did not previously belong to a medical scheme and are over the age of 35, in terms of the Medical Schemes Act, may be subjected to a Late Joiner Penalty (LJP). A LJP is a percentage penalty of the medical scheme risk contribution. LJP’s are calculated according to the number of years the employee has not belonged to a registered South African medical scheme.

The following percentage penalties may be imposed:

Number of years the employee was not a member of a registered South African medical scheme after the age of 35.

Late Joiner Penalty:

1-4 Years

5%

5-14 Years

25%

15-24 Years

50%

25+ Years

75%