Your medical aid could be terminated – this is how

If you’re completely honest with your medical aid provider, you may be excluded from certain benefits, or prevented from receiving full cover immediately.

We find out what happens if you’re dishonest in order to avoid these restrictions, and how to remedy the situation if this applies to you.

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What happens if you lie?

According to Craig Comrie, chief executive officer at Profmed, insurers regularly have to deal with clients who don’t disclose their pre-existing medical conditions.

“If you disclose pre-existing medical conditions to your medical aid provider, the scheme would apply conditions to your contract, such as a one-year exclusion of benefits related to these conditions or a three-month general waiting period,” says Comrie.

He explains that this mechanism protects existing members of the scheme who have contributed to its reserves for years.

“The dishonest new member then claims these savings out of the old members' reserves, which they have not yet contributed towards,” says Comrie.

Comrie notes that dishonesty is most prevalent in maternity cases, where a prospective client will fail to disclose their pregnancy at the time of applying for a policy. In this way, the new member would attempt to illegitimately gain access to services, such as antenatal consultations, a private ward for delivery, and pathology.  

“All claims related to the treatment of undisclosed conditions are investigated by a specialised team. This group is tasked with gathering evidence that the condition occurred before the member joined the scheme,” says Comrie.

When it comes to pregnancy non-disclosure, a medical aid scheme may initially pay out. However, once they realise the timeline does not add up, they will require reimbursement from the new member. 

“Where sufficient evidence exists of this dishonesty, the contract with the member is technically breached and the scheme will terminate membership back to the starting date of the member,” says Comrie.

He explains that this is done to protect other members in the scheme who have contributed to the scheme for many years.

How can you redress the situation?

Comrie says that if you have failed to mention something to your medical aid scheme, whether intentionally or unintentionally, you should immediately go to them and talk to the underwriting department.

“You need to amend your declaration before you encounter the above scenario where your membership is cancelled, which could leave you without cover,” says Comrie.

He adds that a scheme may be more lenient should you voluntarily approach them, but they will still apply the relevant scheme rules which usually include underwriting conditions.

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