Updated 09 February 2016

Honesty and your medical history

When you want to join a new medical scheme, you have to fill in a detailed medical history. So how much do you tell? And can they suspend you medical aid membership?

Susan Erasmus is a freelance writer for Health24.

When you want to join a new medical scheme, you have to fill in a detailed medical history. Medical schemes can refuse to pay for treatment for a particular condition for 12 months. So the temptation is definitely there to not tell all.

Problem is, if you’re caught lying about your history, they can suspend your membership.

Full disclosure of any health issues is vital in forging and maintaining a good relationship with your medical aid provider, say the experts.

“It is better to be honest and rather be excluded for twelve months from treatment for a particular condition than to be caught lying, and having your membership suspended,” says Johan van Tonder, independent medical scheme researcher. “The temptation is of course there to try and buck the system, but this often backfires. Once you have been suspended from one medical scheme, it will be very difficult to join another one.”

Large, unpaid bills for your account
Too often consumers are faced with large medical bills when a medical aid refuses to pay due to undisclosed health issues - this can easily be avoided if consumers honestly answer the question: Are there any health conditions that might impact on your health?

“This question is a standard question on a medical aid application form, but consumers often regard it as rhetorical or unimportant,” says Joslinah Heyman, healthcare consultant to AON SA, a leading risk management and insurance consulting organisation in South Africa. “Disclosure will assist you in gaining access to medical care funding - but non-disclosure can lead to funding being refused.”

“Not entirely,” says Johan van Tonder. “You have to accept that if you have a heart problem, no medical scheme will cover you for twelve months. If however, you have disclosed your condition, they cannot refuse you treatment after the expiry of that date.”

Why these rules?
The rules regarding disclosure are in place to prevent someone only joining a medical scheme when he/she needs a bypass operation and one can understand the industry wanting to protect itself against this, says Van Tonder.

When you apply to become a member of the medical scheme, it is crucial to complete the application form comprehensively. This is especially true with regards to the section that deals with your medical history - it is important to disclose any condition (illness) that you have suffered from in the past that may be relevant in terms of insuring a health risk.

Read more: 10 tips on choosing a medical scheme

Case history
For example, several years ago, an applicant was diagnosed with high cholesterol, which was treated with a special diet and prescribed medication. After six months, the applicant felt better and stopped taking the pills. Three years ago, he applied to become a member of a medical scheme. He decided that it was not necessary to disclose his high cholesterol. He then suffered a massive heart attack a couple of weeks later. The medical scheme found out about his previous condition and declined to pay his medical bills.

“Remember, a medical scheme may not refuse an applicant cover, no matter what condition he suffers from,” says Heyman. “By disclosing your health status in detail, the scheme can ensure that the clinical and the financial risk of both the member and the Medical Scheme are well managed. In order to manage risk effectively, the scheme holistically manages each individual member’s unique healthcare funding needs.”

While a medical scheme may not refuse an applicant cover, they can refuse to cover that person for a specific, disclosed condition for twelve months.

Van Tonder also mentioned that new medical scheme members must remember that there is usually a waiting period of three months before they can claim anything. This does not apply to people who have changed from one medical scheme to another without any intervening period. It also does not apply tp claims for any PMBs.

In the case of non-disclosure, the member may face non-payment of the accounts incurred for the illness not disclosed to the scheme, or he may even be dismissed from the scheme. The Medical Schemes Act 29(2) prohibits a medical scheme from cancelling or suspending a member’s membership or that of his dependants, except on the grounds of the non-disclosure of material information.

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