Medical aid waiting periods and exclusions: what the law allows

The law names two kinds of wait, and a scheme may not invent any other (section 29(3)(c) of the Act bars waiting periods that section 29A does not allow).

• General waiting period: up to 3 months. For a set time after you join you pay contributions but the scheme may decline claims.
• Condition-specific waiting period: up to 12 months. The scheme may decline claims for a named condition you already had, or one for which you received advice, diagnosis or treatment before joining.

These are maximums. A scheme may impose a shorter wait or none at all, and you should ask which it will apply before you sign. A scheme may also ask for a medical report only about a condition you had advice, diagnosis, care or treatment for in the 12 months before you applied.

Your cover history in the 90 days before you apply decides it. The rules below are from section 29A of the Act.

So a short gap does not make waiting periods vanish. It reduces you to one kind of wait. A gap of 90 days or more puts you back in the first row, treated like a new joiner. If you are changing schemes, the how to change medical aid guide shows how to line up the dates.

Searches for "medical aid with no waiting period" usually mean one of four things.

1. You changed jobs, or your employer changed or ended its scheme. Section 29A(6) bars any waiting period if the gap is under 90 days. The employer change must happen at the start of the financial year or with reasonable notice.
2. You are moving between options in the same scheme. No new wait applies, although a wait still running on your old option may continue.
3. Your new scheme chooses not to impose one. Because 3 months and 12 months are maximums, a scheme can drop them. Ask for this in writing, and check whether "no waiting period" means no general wait only, or also no condition-specific wait.
4. Your baby is born while you are a member. The child gets cover without a wait.

If none of these fits, expect the scheme to use the limits in the table above. The same rules apply to hospital plans, so a cheaper plan type does not avoid them. Compare what different schemes actually apply using our questions to ask before joining a scheme checklist.

The Act does not create a special waiting period for pregnancy, and a registered scheme must not unfairly discriminate on grounds that include pregnancy and state of health. The general and condition-specific limits above are the legal ceiling for everyone, pregnant or not.

What the Act does not spell out is how a particular scheme treats a pregnancy that has already started when you apply. That is a matter of the scheme's rules and the plan's maternity benefit, so do not assume. Before you apply:

• Ask in writing whether maternity benefits are subject to a waiting period on the plan you want.
• Ask what proof of earlier cover the scheme needs to reduce the wait.
• Check whether the plan covers antenatal care, delivery and newborn care, or only the hospital stay.

Two things help. If you already have cover and switch with a gap of under 90 days, the scheme is limited to one kind of wait. And a child born while you are a member cannot be made to serve a wait. Our medical aid for pregnancy page compares plans, and the maternity benefits checklist lists what to ask.

Prescribed Minimum Benefits are the conditions every scheme must cover. The CMS describes them as 271 conditions in the Diagnosis Treatment Pairs plus the Chronic Disease List, which its PMB page puts at 26 chronic conditions (one CMS slide from August 2026 says 27). Any emergency medical condition is also a PMB.

What this means during a wait:

• In the two shorter-gap rows of the table, the Act excludes PMB treatment from the wait. A scheme cannot make you wait for PMB care in those cases.
• For someone with no scheme cover in the previous 90 days, the Act text we checked does not carve out PMBs from the 3-month and 12-month limits. Ask the scheme in writing what it will pay during the wait.
• In an emergency, a scheme may not stop a provider from starting appropriate treatment before authorisation, and the CMS says you may go to the nearest facility even if it is not a designated provider.

Exclusions do not apply to PMBs either. The full list and your rights are in our prescribed minimum benefits guide.

An exclusion is care your plan does not pay for at all, and it does not expire after 12 months the way a wait does. Common examples are cosmetic surgery, some elective procedures and treatment that is not clinically necessary. Your plan's rules list them, so read that section before you join.

Exclusions have one important limit. The CMS says exclusions do not apply to PMBs. Its example: if you develop septicaemia after cosmetic surgery, the scheme must still cover the septicaemia, because septicaemia is a PMB, even though the cosmetic surgery itself stays excluded.

Do not confuse exclusions with sub-limits and co-payments, which cap or share the cost of care that is covered. Those are explained in co-payments and sub-limits.

Gap cover, hospital cash plans and primary care insurance are insurance products, not medical schemes. Treasury's demarcation regulations place them outside the Medical Schemes Act, so section 29A does not govern them. The insurer sets waiting periods in the policy, and they can differ from any scheme's.

That matters for searches such as "gap cover with no waiting period" or "hospital cash plan with no waiting period". Read the policy schedule for the waiting period on illness, accidents and pre-existing conditions. These products do not replace a medical scheme, and complaints about them go to the National Financial Ombud, not the Council for Medical Schemes.

See gap cover explained and medical aid vs health insurance for how the two differ.

A waiting period is a delay in cover. A late joiner penalty is an extra amount added to the contribution of a person who first applies at 35 or older, and it can continue when you move schemes. You can face both at once. The penalty depends on your age and your years of earlier cover, and our late joiner penalty guide has the bands and a worked example.

If you think a scheme has applied a wait or penalty incorrectly, take it up with the scheme first. If it does not resolve it, you can complain to the CMS. The steps are in the CMS complaints guide, and the official rules are in the Medical Schemes Act on the CMS site.