Waiting period or condition-specific exclusion applies

Confirm the type and length of the waiting period in your membership certificate, and whether it was correctly disclosed when you joined. Waiting periods must be applied within the limits of the Medical Schemes Act, and cannot be imposed after the fact or extended beyond what was agreed at underwriting.

• Ask the scheme, in writing, for the exact rule or code it relied on. A reason code on a statement is not a reasoned decision.
• Check whether the treatment relates to a Prescribed Minimum Benefit. Option rules and annual limits cannot lawfully be used to refuse PMB care.
• Compare the ICD-10 and procedure codes on the account against your clinical notes. Coding mismatches cause a large share of rejections.
• Note the scheme’s internal dispute deadline, and the deadlines for escalating to the Council for Medical Schemes.