What is a “Waiting period” and how does it affect me?

With the exception of refractive surgery on all benefit options and optical benefits on the Blue Diamond and Litunga benefit options, there is no defined waiting period in respect of benefits from the date of submission of application for membership to admission as a member.

The Fund reserves the right, however, to defer admission until the Board of Trustees are satisfied that all conditions for membership have been met. The effective date of membership may be postponed until all supporting documentation in respect of marriage certificates, birth certificate(s) or medical declaration/certificate(s) have been submitted. The Fund applies waiting periods in certain conditions:

Individual members:

  • A general waiting period of 3 months will apply for all Day-to-Day and Major Medical Expense claims excluding emergencies on all new individual members joining NHP. This means that members, within their first 3 months as new members to the Fund, will only qualify for emergency in-hospital treatment and emergency procedures performed in emergency rooms/ casualty wards.
  • A general waiting period of 6 months will apply for the optical benefit on the Blue Diamond and Litunga benefit options.
  • A general waiting period of 3 months for all Day-to-Day and Major Medical Expense claims will apply in respect of aged parents joining the Fund as a dependant, in addition to a 12 month condition specific waiting period for pre-existing conditions.
  • A condition specific waiting period of 12 months will apply to Day-to-Day and Major Medical Expense claims relating to maternity.

Employer group members:

  • All new employer group members joining the Fund will normally be exempt from the waiting period unless the member/dependants joins the Fund 3 months after becoming eligible for membership.
  • The 3 month general waiting period applies to‑ all Day-to-Day and Major Medical Expense claims, excluding emergencies. In the event of an employer group member only joining after the 3 month window period then, a general waiting period of 3 months will apply for all Day-to-Day and Major Medical Expense claims excluding emergency in-hospital treatment and emergency procedures performed in emergency rooms/casualty wards.
  • The 12 month condition specific period for maternity related claims. All dependants of employer group members joining as from the 4th month after the principal member or 3 months after becoming eligible to qualify as a dependant will be subjected to a 3 month general waiting period on all Day-to-Day and Major Medical Expense claims, excluding emergencies, as well as a 12 month condition specific waiting period for maternity related claims.

Condition-specific:

  • If a principal member and/or dependant suffers from a specific illness, the Fund has the right to exclude benefits for this specific condition for a period of up to 12 months.
  • A condition-specific waiting period will apply if the previous medical aid fund had imposed such waiting period and it had not expired at the time of termination.

Non-disclosure consequences:

  • If found that false information has been submitted or that any relevant information has deliberately been omitted on an application, the Fund may correct this in terms of its rules, which
    may include re-underwriting or termination of membership. 

Refractive surgery:

  • A 12 month waiting period will apply on all members across all benefit options where the benefit is available, including members previously covered by other medical aid funds.

Maternity:

  • All new employer group members joining the Fund will normally be exempt from the following unless the member/dependants join the Fund 3 months after becoming eligible for membership.
  • A condition-specific waiting period of 12 months will apply to new individual members and to a member who joins NHP already pregnant, until and including delivery.  All maternity related treatment falls under the 12 month waiting period. This also applies to members previously covered by other medical aid funds.

Newborn:

  • The principal member is required to register a newborn as a child dependant within 30 days from the date of birth.
  • If a member applies to register a newborn or newly adopted child as a dependant after 3 months following the date of birth or adoption of the child, the Fund may subject the child dependant to a general waiting period.  A medical declaration completed by a doctor will be required for the child dependant.