When you take out health insurance, you do it because you love your family and you want to help protect them against certain healthcare costs when they need care. That is a meaningful step towards planning for your family’s healthcare needs. To make an informed decision, you need to understand, which benefits are available, when cover begins, and what exclusions, waiting periods and benefits limits apply. Many people only read their policy for the first time when they sit in a hospital waiting room, worried and afraid.  Understanding your policy before you need to claim can help you make informed decisions about your cover and ask any questions you may need to raise with your insurer.

Three parts of every policy deserve your close attention. These are waiting periods, exclusions and benefit limits. Once you understand them, you can plan better, avoid surprises and feel confident that your cover will work for you.

Health insurance and medical aid work differently

Before you look at the details, it helps to know what kind of cover you have. In South Africa, medical aids and health insurers operate under different regulatory frameworks. Medical schemes fall under the Medical Schemes Act of 1998, while insurance companies fall under the Insurance Act of 2017. The regulatory framework distinguishes medical scheme benefits from health insurance products, which differ in their structure, benefits and applicable terms. If you want to know more about the differences between medical aids and health insurances, read this.

This matters because health insurance pays benefits according to the amounts and rules in your policy document. Benefits are subject to the applicable policy terms and conditions including, waiting periods, exclusions, benefits limits and any applicable sub-limits or pre-authorisation requirements. Reviewing these provisions can help you understand the extent of your cover.

What a waiting period is

A waiting period is the time between the commencement of cover and the date on which a specified benefit becomes available as set out in the policy terms. Waiting periods may apply to particular benefits or circumstances.

Different benefits often carry different waiting periods, so read each one carefully. On the Affinity Health Standard Hospital Plan,  the applicable waiting periods differ according to the benefit and circumstance. The current benefit brochure indicates no waiting period for accident hospitalisation, a three-month waiting period for illness-related hospitalisation and a twelve-month waiting period for pre-existing conditions. These periods remain subject to the applicable policy terms and conditions.

On the everyday side, the Affinity Health Day to Day Plan gives you unlimited 24/7 telephonic consultations with a nurse, doctor or mental health professional with no waiting period for the consultation benefit, while most other benefits carry a waiting period of one to three months.  Members should check the policy wording and benefit brochure for any conditions or limits applicable to each service.

Take a moment to write down the date your cover started and the date each benefit becomes available. Keep this note somewhere safe. If your child falls ill or your partner needs a procedure, you will know immediately what you can claim for.

Understanding pre-existing conditions

A pre-existing condition is a health concern you already had, or showed signs of, before your policy began. Chronic conditions such as diabetes, high blood pressure and asthma are common examples, but these can also include sign and symptoms that lead to acute conditions such as appendicitis and kidney stones. Even a current pregnancy is considered a pre-existing condition. Pre-existing conditions are generally excluded for a specified period, up to 12 months, but depend on your policy terms, exclusions and disclosure requirements. Members should review the relevant policy provisions to understand how these conditions may affect their benefits.

 When you apply for cover, answer all questions about your health and medical history fully and accurately. If you are unsure whether information is relevant, ask the insurer for clarification.  Affinity Health’s policy terms should be consulted for the consequences of inaccurate, incomplete or non-disclosed information. Providing accurate information helps the insurer assess the application and determine whether the cover is the right one for you.

What an exclusion is

Exclusions are the treatments, conditions or situations for which benefits are not payable.  Exclusions vary between products and can be found in the applicable product’s policy wording. Many health insurance policies, for example, do not pay for cosmetic procedures or treatment that a doctor does not consider medically necessary.

Find the section in your policy document called exclusions and read it carefully. If something on the list worries you, call your insurer and ask them to explain it. A short phone call today can spare you frustration and unexpected bills later.

What limits mean

A limit is the maximum amount or specific circumstance your insurer will pay for a benefit. Limits can be applied per event, for a specific timeframe, such as annually, or for the lifetime of the policy. Understanding them helps you plan for the costs you may need to cover yourself.

The Affinity Health Hospital Plan policy wording shows how different limits work in practice. Accident hospitalisation pays up to R275 000 per single member per event, or R325 000 per family per event. Serious illness hospitalisation pays up to R300 000 for the lifetime of the policy, depending on the treatment plan. Daily illness hospitalisation pays R22 000 per day for the first three days, then smaller daily amounts, for up to 21 days per illness event and two admissions per member each year.

Some benefits also carry sub-limits, meaning that certain procedures or events will be covered for their own specified amounts. Others require a member to make a co-payment.   Most benefits may require pre-authorisation from the insurer before treatment. Members should confirm where pre-authorisation is required, what the process is and whether any restrictions or conditions may affect payment of the benefit.

Simple steps to read your policy with confidence

Start by reading your benefit brochure and your policy document carefully. Highlight every waiting period, exclusion and limit that affects you and your family. Write down any questions you have and call your insurer to ask them. Where the benefit brochure and policy wording appear inconsistent, ask the insurer to clarify which terms apply.

Keep your insurer’s contact details saved on your phone and on paper at home. Affinity Health members can call 0861 11 00 33 or send a WhatsApp to 0861 11 3000 for help with benefits and cover. If you are considering taking out cover, contact Affinity Health to obtain the relevant product information, applicable terms and conditions, and details of the premiums and benefits before deciding. Review your policy each year, especially when updates are sent, when your family grows, when your health changes or when your budget shifts.