If you are HIV Positive then the short answer to the question is yes, but the joining and moving to a medical aid scheme are done according to the rules set out by the Medical Schemes Act of 1998.
The “new” Medical Schemes Act was legislated and introduced significant changes regarding benefits, risk management methodologies and regulatory control.
The Medical Schemes may however apply certain risk management techniques to mitigate the risk of providing these comprehensive benefits to members, including:
The above methodologies are to improve the efficiency and effectiveness of health care so as to limit the financial impact of PMB on the financial performance of the scheme.
The practical implications of point two of the act are that no membership can be denied based on, age, health status and medical history. This means, that in line with the principles of open enrolment, cross-subsidisation and community rating in the medical scheme business, schemes cannot risk rate and underwrite the risk associated with a prospective member’s age or health status. Contributions paid towards membership cannot be increased because of older age or a sicker member.
However to give protection to medical schemes against prospective members who wait until they are older or develop an ailment before joining, the Act makes provision that medical schemes, at the time of evaluating an application for membership, can apply:
Late joiner means an applicant or the adult dependent of an applicant who, at the date of application for membership or admission as a dependent, as the 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 (3) consecutive months since 1 April 2001.
A waiting period refers to a period during which the member pays a contribution towards the medical scheme joined but during which time the member and/or dependants are not entitled to benefits.
There are two kinds of waiting periods, i.e.:
Condition-specific waiting periods can accordingly be imposed in respect of conditions that an applicant suffered from or/sought medical treatment for during the twelve (12) month period before an application for membership of the scheme was made.
Waiting periods do not apply in respect of the following:
|Category 1||Category 2||Category 3|
|No scheme for 90 days or more||Lapse = less than 90 days and continuous period of less than 24 months at previous scheme||Lapse = less than 90 days and continuous period of longer than 24 months at previous scheme|
|Penalty Intervals||% late joiner penalty|
|1 – 4 years||5%|
|5 – 14 years||25%|
|15 – 24 years||50%|
|25 years and more||75%|
Let’s look at two examples:
I am HIV+ and have never been on a medical aid before and am 45 years of age.
First let’s look if late joiner penalty is applicable
Secondly what waiting periods will be applicable and will my HIV be covered?
I will be a category 1 client
Here is the solution for the HIV condition of 12 months
One will only be excluded for the first 3 months as HIV is a PMB and remember waiting periods are not applicable to PMB conditions, but it is subject to other waiting periods like the 3 months general waiting period where no PMB’s are covered for a Category 1 client.
I am HIV+ and are a active member of a medical aid for the last 11 years and am 45 years of age
First let’s look if late joiner penalty is applicable:
What waiting periods will be applicable and will my HIV be covered?
I will be a category 3 client
Here is the solution for the HIV condition of 3 months
No waiting period for HIV for the 3 months general waiting period will not be applicable as you enjoy PMB cover.
TRIARC is an authorised financial services provider FSP45009. TRIARC insurance products underwritten by Guardrisk Life FSP76. Council of Medical Scheme
Number ORG 4040.