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Changing from one medical scheme to another - effortlessly

By Danielle van Wyk

It is coming up to the end of the year and you might be looking to change medical schemes, or options within a scheme in preparation for the new year. While you don’t necessarily have to wait for year-end to do so, providers often recommend it.

If you want to move schemes however, there are quite a few things to note.

Here is what you need to know:

Will there be a change-over waiting period?

While the cancellation process is simple, depending on the scheme and option there may be a general waiting period.

Typically, this period is up to three months while a condition-specific waiting period can be up to 12 months. This means that within this period you are not allowed to claim. Should you see the process through after this waiting period you will be a fully-fledged member, according to Discovery Health.

However, it is important to note that this is not extended to the prescribed minimum benefits.  

Which other exclusions are important to note?

New schemes have the right to exclude you from claiming for a specific condition for up to 12 months. For this reason, many people are discouraged from disclosing prior medical conditions at the inception of the policy.

But following on the recent Momentum non-disclosure saga where a hefty claim was initially denied due to non-disclosure of a medical condition, it has been reiterated just how important full disclosure is.

The claim was later paid out because the member did not die due to a medical condition. However, afterwards Momentum issued a press release on the importance of full and honest disclosure at application stage.

According to this release all medical and health information need to be shared during application. Non-disclosure is seen as fraudulent behaviour.

What will you need to produce at the inception of your new policy?

One of the most important things to remember when cancelling your policy is to ensure that you receive your membership certificate at the latest within a month of the termination date from the scheme you are leaving. If you’re unable to access this certificate an affidavit must be issued.

This is to confirm your length of membership.

If you belonged to another scheme before, you may have to get a certificate from that scheme too if you don’t already have one.

If you are older than 35 and you are unable to prove continuous membership of a scheme, you may be charged a late-joiner penalty.

According to HIS Independent Medical Aid Specialist a late-joiner penalty will be added to the member’s monthly contribution. It is worked out as a percentage of the contribution and is based on the total number of years a member has not been on a medical aid since the age of 35 years.

In addition, other typical documents you may have to provide, include:

  • Identification document (ID)
  • Payslip of the main member
  • Marriage certificate, if applicable
  • Access to medical history, including any relevant documentation

Serving your notice after termination

Most scheme options have a stipulated termination notice period. This outlines both the timeframe that needs to be adhered to as well as whether you’re expected to continue paying.

According to the Council for Medical Schemes (CMS) contributions must still be paid until the last effective date of membership. A member remains liable for full contributions for the whole notice period regardless of whether they serve the termination notice or not.

According to CMS a medical scheme may institute legal proceedings to recover outstanding contributions or backdate the termination to the last date of contributions received. This may result in a reversal of claims already paid by the scheme during the notice period.

If the member had a savings account, the debt may be offset before the balance is transferred to the new medical scheme or paid out to the member if the member does not join a new benefit option with a savings account.

What to look for when changing schemes or options?

There are many reasons people may opt to change their cover. When doing so, consider the following:

Is the change in the best interest of yourself and your pocket? In other words, am I making a good decision that will in fact benefit me in the long term? Often people are motivated by wanting to pay less and they compromise their cover only to realise their mistake when it comes to the claim stage.

Is this enough cover? Make sure that you are not underinsured. For example, this could mean that you do not have enough cover for the expected expenses of needing to be hospitalised. Which is undoubtedly an expensive mistake to make.

Is this what your health needs? Ensure that you understand how the benefit options operate and select according to your healthcare needs and what you can afford. The Prescribed Minimum Benefits (PMBs) must be included in every benefit option, according to CMS.

The registered rules of medical schemes fully disclose detailed information regarding the relevant benefits and contributions. It is essential that you obtain the rules of the scheme or a summary thereof to verify all information relevant to enable you to make an informed choice.

Always consider the risks associated with cancelling a medical aid membership or switching to another option. Where possible discuss alternatives with your scheme before deciding to cancel. Your health is your most valuable commodity.

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