At first glance, the rules as to who qualifies as a dependant on a medical aid scheme might appear a little confusing. It is actually pretty straight forward and while pricing and certain conditions might differ from one provider to another, the basic rules are quite clear and apply to all South African medical aid schemes. The rules are dictated by the Medical Schemes Act and in short, state that no person dependant on a member may be refused admission to the plan.
Specifically, dependents are defined as follows:
- A spouse
- A life partner or spouse from a traditional marriage
- A former spouse if such condition forms part of a legal divorce agreement
- Children under 21 years of age
- Children over 21 years of age that are dependant on the member as a result of a physical or mental disability
- Children over the age of 21 that are financially dependant on the member
- Non biological children for which the member is legally responsible. The same criteria as above apply
- Immediate family (parents) of the member for which the member is legally responsible for supporting
- Parents, parents in-law and siblings that have no source of income and for which you are legally responsible for financially. The will qualify as “special dependants”
- Any other people the scheme recognises as dependants
The medical aid is free to request proof of financial or other dependency and is also free to charge higher rates for adult dependents. Some will even charge as much as the principal member in certain instances.
Certain medical aids are more flexible and lenient with child dependents over the age of 21. Some will require proof that the child is studying to consider them as financially dependent whereas others will take unemployment into consideration. This does, however, come at a cost as your premiums will be that of an adult which is significantly higher than child dependents.
So the main exclusion is any child or family member over 21 years of age that is not financially dependant on the member. Grandparents are also excluded unless the scheme makes a specific exception for them.
If your circumstances require that you have additional adult members on your scheme it is wise to compare costs and benefits as these will differ from one medical aid to the next.