Who can be a member of the Scheme?
All permanent employees of Nedbank Group Limited and Old Mutual Insure must belong to the Nedgroup Medical Aid Scheme as a condition of employment, unless they are dependants on their spouse’s or partner’s medical scheme. (If you terminate your employment with Nedgroup or Old Mutual Insure, you may no longer belong to the Nedgroup Medical Aid Scheme.)
As an employee, you qualify to become a member of the Scheme if you fall into one of the following categories and are not a beneficiary of another medical scheme:
- Employees – Permanent staff.
- Married employees or partner – If you are married or in a committed relationship, you may either join the Nedgroup Medical Aid Scheme or your spouse’s or partner’s medical scheme as a dependant.
- Retirees/pensioners – A member of the Scheme who retires and continues to belong to the Scheme is called a continuation member. Retirees who were not members of the Nedgroup Medical Aid Scheme prior to retirement do not qualify for membership after retirement. Retirees who leave the Nedgroup Medical Aid Scheme after retirement do not qualify to join the Scheme again at a later stage.
- Widow/widower and dependants of a deceased member – Unless they join another medical scheme, this group of dependants is entitled to apply to become continuation members of the Scheme. Dependants of a deceased member who elect not to join the Nedgroup Medical Aid Scheme following the member’s death do not qualify to join the Scheme at a later stage.
Who is regarded as a dependant of the member?
The following people qualify as dependants:
- Spouse – Your spouse to whom you are legally married and who is not a member of another medical scheme. Documentation required: A copy of the marriage certificate or ID.
- Spouse(s) in polygamous and traditional marriages – Your spouse(s) to whom you are married in terms of any law or custom and who is not a member of another medical scheme. Documentation required: A marriage certificate, suitable other certificate or an affidavit (available from your respective HR Consultant).
- Same-sex or other partner – A person with whom you have a committed and serious relationship, similar to a marriage, based on objective criteria of mutual dependency and a shared and common household, irrespective of the gender of either party. Documentation required: An affidavit.
Children, adopted children, stepchildren and children placed in the care and custody of a member, spouse or partner by virtue of a court order – You or your spouse’s/ partner’s child who is dependent on you, until the child turns 23. After the child turns 23, you will need to provide proof of the child’s financial dependency on you. When your child marries, he /she will no longer qualify to continue as your dependant and you are obligated to advise the Scheme of this change of marital status. The child’s membership of the Scheme will terminate with effect from the end of the month in which he/she is married. There are two categories of dependency:
- A child who is financially dependent on you (you must submit financial proof of this dependence).
- A child who is incapable of earning an income owing to mental or physical disabilities, or any similar cause (you must submit medical proof). This dependant will be charged child dependant rates.
- Ex-spouse – Your ex-spouse for whose medical expenses you are responsible in terms of a divorce settlement. Documentation required: A copy of the relevant portion of the divorce agreement.
- Any other member of the member’s immediate family (parent, brother, sister or grandchild) in respect of whom you are liable for family care and support, and who is dependent on you and not a member or registered dependent of a member of another medical scheme. Siblings and grandchildren will be considered if you as member are the legal guardian, or if both parents are unemployed/earn less than the annual tax threshold. (Documentation required in the latter case: Proof of income for the parents.) Grandchildren also need to live with the main member to qualify as dependants.
- Nieces and nephews will only be considered if you have legal guardianship and the parents of the niece/nephew are deceased.
- In-laws and grandparents do NOT qualify as dependants.
When you, as a member, apply to add a dependant to the Scheme, you will need to provide proof of your relationship to the dependant, and of the dependant’s financial dependence on you.
You should register a new dependant (for example, spouse, new-born baby, adopted child or parent) within 30 days after they become eligible to join the Scheme as a dependant, otherwise a waiting period may apply. If you are a Nedbank employee, you can register your child telephonically with the Scheme’s Call Centre. If you are an Old Mutual Insure employee, please notify your HR department. Please send Medscheme a copy of the birth certificate as soon as it becomes available.
You can obtain application forms for membership from Medscheme.
It is your responsibility to ensure that the correct contributions are deducted from your salary or, if you are a retiree, that the correct amount is deducted via debit order or any other payment method. The Scheme has implemented a credit policy to ensure that arrear debt is managed appropriately.
Dependants of the member
How are waiting periods applied?
Waiting periods will be applied as follows:
|Your (or a beneficiary’s) circumstances||Will a three-month general waiting period apply?||12-month condition-specific waiting period||Prescribed Minimum Benefits (PMBs)|
|If your membership of the Nedgroup Medical Aid Scheme is compulsory.||No, there will not be waiting period, provided you apply within 30 days of your employment.||Will not apply.||Will be covered immediately.|
|If, for a period of more than 90 days before your application to the Nedgroup Medical Aid Scheme, you were not a member of a medical scheme.||Yes, a three-month waiting period will apply, including for Prescribed Minimum Benefits (PMBs).||Will apply if you have a preexisting medical condition.||Will not be covered for the first 12 months if you have a pre-existing medical condition.|
|If you have been a member of a medical scheme for less than 24 months and you apply to the Nedgroup Medical Aid Scheme within three months terminating your membership of the previous medical scheme.||It depends. In the case of preexisting medical conditions, any unexpired waiting period balance on your previous medical scheme will be applied.||Will apply if you have a preexisting medical condition.||Will be covered immediately.|
|If you (or a beneficiary) have been a beneficiary of a medical scheme for more than 24 months and you apply to the Nedgroup Medical Aid Scheme within three months of terminating your membership of the previous medical scheme.||Yes, a three-month waiting period will apply. You will be entitled to Prescribed Minimum Benefits (PMBs).||Will not apply.||Will be covered immediately.|
|If you have a child while you are a member of the Scheme and you register him/her within 30 days from the date of birth.||No, there will not be a waiting period for the child and he/ she will be covered from date of birth.||Will not apply.||Will be covered immediately.|
|If you have a child while you are a member of the Scheme and you register him/her after 30 days but before 24 months from the date of birth.||No, there will not be a waiting period for the child, and he/she will be covered from the 1st of the month following registration.||Will not apply.||Will be covered immediately.|
|If you have a child while you are a member of the Scheme and you register him/her after 24 months from the date of birth.||Yes, a three-month waiting period will apply, including for Prescribed Minimum Benefits (PMBs).||Will apply if he/she has a preexisting medical condition.||Will not be covered for the first 12 months if he/she has a pre-existing medical condition.|
If you experience one of the following lifechanging events:
||No, there will not be a waiting period, provided that you apply to join, and submit proof of the life-changing event, within 30 days of the event taking place.||Will not apply.||Will be covered immediately.|
What is a Late Joiner Penalty (LJP)?
Dependants’ LJPs are, for example, calculated as follows: A dependant is 65 years and has had 5 years’ previous medical scheme cover. Then we take 65 (age) – 35 = 30 (without medical scheme cover) – 5 (previous cover) = 25 years without medical scheme cover, therefore the LJP will be 75%.
|Years without medical cover||Late joiner penalty (LJP) payable|
|1 – 4 years||5% of contribution|
|5 – 14 years||25% of contribution|
|15 – 24 years||50% of contribution|
|25 years and more||75% of contribution|
On receipt of the member’s application form, the administrator will impose LJPs and waiting periods as per the approved Scheme Rules.
It is important to provide all supporting documents, such as membership certificates of previous medical schemes (indicating the membership end date) to the Scheme as soon as possible, to ensure that LJPs, if applicable, are not calculated incorrectly. An affidavit will also be accepted in respect of proof of previous medical scheme cover. Any LJP is only adjusted from the 1st of the next month after proof of previous membership is received and there will be no refunds or backdating.
Please take note that LJPs are implemented for life and do not expire.
What do I need to do if my dependants/membership details change?
You must notify Medscheme of the following(Old Mutual Insure employees must notify their HR Consultant):
- a change in your marital status
- the birth of an infant or adoption of a child
- the death of any of your dependants
- your child becoming independent/self-supporting, or if the child marries
- your child registering as a dependant or a member of another scheme
- change in banking details (refunds will only be done to the member’s bank account). (Supporting documents must also be sent.)
WHAT YOU NEED TO DO
- Obtain a Change in Membership Details form from Medscheme.
- Include the necessary documentation such as birth certificate, registration certificate issued by the hospital, or death certificate.
- Return the completed form and documentation to Medscheme.
Once these changes have been processed, your monthly contributions and benefits will be adjusted accordingly.
Although your membership details may change during the benefit year, you may not change Plans until the beginning of the following benefit year.
What will happen when my Scheme membership comes to an end?
You are entitled to benefits until the last day of the month in which you terminate your membership.
- Contributions are payable for the full month when a member terminates their employment on or after the 11th day of such month and benefits will continue until the end of such month. The termination date will be for the end of that month.
If your membership of the Scheme ends, for example if you resign, are retrenched, die or transfer to your spouse’s medical scheme, the following will happen:
- Any amounts that have been paid by the Scheme, but which exceed the benefits to which you are entitled, will be recovered from you (or your estate).
- The money in your personal medical savings account (if applicable) will be used by the Scheme to settle your share of any outstanding claims.
- If there is no money in your personal medical savings account, only the benefit amount will be paid to the service provider. You (or your estate) will be responsible for settling the balance with the service provider.
If you were on the Savings or Comprehensive Plans and you have used your upfront PMSA and then resigned before the end of the benefit year, the overspent amount will have to be paid back to the Scheme within 30 days of your membership termination date.
What will happen to my personal medical savings account balance?
If you leave the Scheme or transfer to a Plan that does not permit personal medical savings, then your personal medical savings account balance will be refunded to you. If you leave the Scheme and join another medical scheme that permits personal medical savings, then your personal medical savings balance must be transferred to the new medical scheme.
The refund or transfer of personal medical savings account balances will take place six months after you leave or transfer. This period allows any outstanding claims to be settled against your personal medical savings account balance. The Scheme will recover any outstanding amounts from you directly if your personal medical savings balance is insufficient or if the balance has already been paid out.
Can I belong to more than one medical scheme?
Section 28 of the Medical Schemes Act No 131 of 1998 prohibits any person from being a member or dependant of more than one medical scheme. It is unlawful for any person to claim or accept benefits from more than one medical scheme. The medical scheme industry monitors for duplicate membership and should the Nedgroup Medical Aid Scheme become aware of any duplicate membership for a dependant, your dependant’s membership will be automatically terminated to the date prior to the start of their membership on the other medical scheme. Any authorisation or claim paid after the date of their membership on the new medical scheme will be reversed by Nedgroup Medical Aid Scheme and must be submitted to the new medical scheme for processing.