Medical aid exclusion period

[getafix33]

Hi

I am changing from Discovery to Bonitas and my wife who is diabetic has been excluded for 3 months for her condition.

Is this normal?

TIA.

 

[Slootvreter]

I do think it is.

 

[Blu82]

Yes

 

[Aharon]

Yes it is. 3 month condition specific waiting period

 

[xrapidx]

Isn't it covered by PMBs?

EDIT:

Need to know: what are PMBs? Prescribed Minimum Benefits -

Prescribed minimum benefits (PMBs) are certain benefits that all medical aid members get if they have a chronic condition like diabetes.

sweetlife.org.za

Sometimes, members will not have cover for PMBs from their medical aid. This can happen if you join a medical aid for the first time (without switching from another medical aid) or if you join a new medical aid more than 90 days after leaving the previous one. If this is the case, there is a waiting period, during which you won’t have access to the PMBs for any pre-existing condition for 12 months.

 

[Blu82]

Where a member had a break in coverage of more than 90 days or where a member has never belonged to a medical scheme in the past the scheme may impose waiting periods which includes PMBs (this means that benefits are excluded for the duration of the waiting period).

Source

 

[Kosmik]

The person can still get their PMB treatment/medication from clinics/governemnt etc.

I wasn't aware that medical aid could deny PMB or waiting, my impression was that regardless of scheme, they MUST cover the basic PMBs without charge ( within guidelines ).

 

[Kosmik]

Actually I think the article is worded wrong. Acute PMB's can't be denied however ongoing chronic management can be put on the waiting period.

 

[Mr Smooth]

If you have that specific cover on your existing medical aid, surely you should be exempt from the waiting period on the new scheme?

 

[Polly101]

Check with Council for Medical Schemes, but afaik, if there's not been a break in cover, PMBs may not be exclusions

 

[Polly101]

Q32. When do waiting periods not apply?
Waiting periods do not apply in respect of:
a.Prescribed minimum benefits, unless the member has never belonged to a medical scheme before or had a break in coverage of more than 90 days (see Q28)
b.A child dependant born during the period of membership
c.A member moving between benefit options unless he/she has to complete the remaining period of previously imposed waiting periods.
d.An individual member who has to involuntarily transfer to another scheme due to a change of employment that causes that member to no longer meet the eligibility criteria of a restricted scheme; an employer changing the medical scheme of his/her employees from the beginning of the financial year.

Council for Medical Schemes (CMS) | Home

The Council for Medical Schemes is an autonomous statutory body created by parliament to regulate Medical Schemes in South Africa.

www.medicalschemes.com

 

[AlmightyBender]

Based on the OPs info there is no 90 day gap in cover and thus there should not be a waiting period. It is worth it to give Bonitas a call and remind them of this fact and ask them to justify the waiting period and the reasoning behind it.

This situation happened to me before when switching jobs and that was from Discovery to Discovery haha. Epic fail on their part. I phoned them and they dropped the waiting periods.

 

[hellfire]

Hi

I am changing from Discovery to Bonitas and my wife who is diabetic has been excluded for 3 months for her condition.

Is this normal?

TIA.

Unfortunately. Because she's had uninterrupted cover, they aren't allowed to exclude the condition, so they apply a blanket 3 month exclusion

 

[cr@zydude]

If there's no break in cover I wouldn't expect a waiting period. I didn't have one when I switched from my parents plan to my own when I started working.

 

[hellfire]

If there's no break in cover I wouldn't expect a waiting period. I didn't have one when I switched from my parents plan to my own when I started working.

Depends on your history - if you've got a condition or claimed for something large, they impose a waiting period.

 

[Kosmik]

Unfortunately. Because she's had uninterrupted cover, they aren't allowed to exclude the condition, so they apply a blanket 3 month exclusion

If its uninterrupted, they can't.

 

[hellfire]

If its uninterrupted, they can't.

They can.

See this document from FPI -section 4

 

[Kosmik]

They can.

See this document from FPI -section 4

Read it again: "Does have access to PMBs". They cannot impose a waiting period on PMB cover if unbroken. Normally for pre-existing conditions, a new scheme may apply loading against the premuim to offset the risk of a new member.

 

[Terence1983]

Hi

I am changing from Discovery to Bonitas and my wife who is diabetic has been excluded for 3 months for her condition.

Is this normal?

TIA.

She has a 3 month general waiting period for all non PMB claims, not a 3 month waiting period for her Diabetes. Her diabetes should be covered so long as you go to their DSP as this is a PMB condition, just call their chronic meds dept to make sure of who to use. I used to work for Bonitas as one of their underwriters so I can say this with certainty. Really good affordable medical aid but they are strict on their application of waiting periods.

 

[hellfire]

Read it again: "Does have access to PMBs". They cannot impose a waiting period on PMB cover if unbroken. Normally for pre-existing conditions, a new scheme may apply loading against the premuim to offset the risk of a new member.

Agreed re PMBs