Underwriting summary 2025

 

Here is a detailed overview of the underwriting summary for the year 2025.

Individuals:

The group size for individual underwriting consists of just one member. In this case, the underwriting process is categorized as individual medical underwriting, meaning that the assessment and decision-making are based solely on the health status and medical history of the individual applicant. The underwriting decision entails specific conditions: there are 12-month condition-specific waiting periods, a general waiting period of 3 months, and penalties for those who join late. The application form required for this process is the individual application for membership, and to move forward with the underwriting decision, it is essential that the application form is fully completed without any omissions.

Compulsory group:

This category accommodates groups consisting of between 2 to 9 principal members. The underwriting process here is classified as group medical underwriting, which means that the evaluation takes into account the collective health information of the group members. The underwriting decision is made collectively and is subject to certain qualification criteria that must be met. Similar to individual underwriting, the application form utilized is the individual application for membership; however, it is crucial that a fully completed application form is submitted for each member within the group to ensure a proper assessment and decision-making process.

Super group:

A super group is defined as having 10 or more principal members. The underwriting approach in this case is demographic underwriting, which focuses on the characteristics and health demographics of the group as a whole. Like the compulsory group, the underwriting decision is made based on collective criteria and is subject to qualification standards. For this category, the application form required is the super group application for membership, and the necessary information for the underwriting decision includes the demographic details of the group, which must be provided using the Health Import Template.

Waiting periods and prescribed minimum benefits for different types.

Type 1

This category applies to individuals who have either no previous medical cover or have experienced a break in coverage that exceeds three months from their previous medical scheme.

Type 2

Type 2 is designated for individuals who have had less than two years of continuous cover, with a break in coverage of less than three months from their prior medical scheme.

Type 3

Individuals in Type 3 have maintained more than two years of continuous cover, with a break in coverage that is also less than three months from their previous medical scheme.

Waiting periods for the types:

Type 1

For Type 1 applicants, there are specific waiting periods that must be observed, which include a 12-month condition-specific waiting period and an additional 3-month general waiting period.

Type 2

Applicants classified as Type 2 will face a 12-month condition-specific waiting period for any newly diagnosed conditions, in addition to any remaining waiting periods that are still active from their previous medical scheme.

Type 3

Those in Type 3 are subject to a more lenient 3-month general waiting period.

Prescribed Minimum Benefits for the types:

Type 1

Individuals classified as Type 1 are not eligible for coverage of Prescribed Minimum Benefits.

Type 2

Type 2 individuals are eligible for coverage of Prescribed Minimum Benefits.

Type 3

Type 3 individuals are also eligible for coverage of Prescribed Minimum Benefits.

Transferring from a closed or restricted scheme:

In the event that an applicant is transferring from a closed or restricted medical scheme due to a change in employment, and there has been less than a three-month break in coverage, Momentum Medical Scheme will not impose any waiting periods on the applicant.

Late Joiner Penalties: A late joiner is defined as an applicant or dependent who, at the time of application with Momentum Medical Scheme, meets any of the following criteria: they are 35 years of age or older, they were not a member of any registered medical scheme on or before April 1, 2001, or they have allowed for more than a three-month break in membership since April 1, 2001.

Years not covered on a previous medical scheme from age 35 onwards - Late joiner penalty (LJP): The penalties for late joiners are as follows: for 1 to 4 years of non-coverage, a 5% penalty applies; for 5 to 14 years, the penalty increases to 25%; for 15 to 24 years, the penalty is 50%; and for those with 25 or more years of non-coverage, the penalty is 75%.

Type 1 examples:

For instance, a 28-year-old single principal member with no previous medical scheme coverage and currently undergoing treatment for irritable bowel syndrome would face a decision that includes a 12-month waiting period specifically for irritable bowel syndrome, but would not incur a late joiner penalty.

In another case, a 39-year-old principal member with a 41-year-old spouse, who was previously covered by Fedhealth from April 2002 to January 2008, and who had gallbladder surgery eight years ago due to gallstones but is now fully recovered, would not face any waiting periods or late joiner penalties.

Conversely, a 58-year-old principal member with no prior medical scheme coverage, currently being treated for hypertension and diabetes, and who underwent coronary artery bypass surgery two years ago following a heart attack, would be subject to a 12-month waiting period for hypertension, diabetes, and coronary artery disease, along with a 3-month general waiting period, and a late joiner penalty of 50%.

Type 2 examples:

For Type 2, consider a 23-year-old principal member with a 31-year-old spouse who joined a previous scheme in July 2014 and is still a member. If the spouse was diagnosed with raised cholesterol in September 2015 and is currently on treatment, the decision would include a 12-month waiting period for hypercholesterolemia for the spouse, but no late joiner penalty would apply.

Another example involves a 48-year-old principal member who joined a previous scheme on September 1, 2015, and is still a member. If that scheme imposed a 12-month waiting period for arthritis, the decision for joining Momentum Medical Scheme on January 1, 2016, would require the balance of that 12-month waiting period, meaning 8 months would still apply, along with a 25% late joiner penalty.

Additionally, a 38-year-old principal member who joined a previous scheme in October 2014 and is still a member, where the previous scheme placed a 12-month waiting period for epilepsy, would not incur any waiting periods or late joiner penalties.

Type 3 examples:

In the case of Type 3, a 49-year-old principal member with a 37-year-old spouse who joined a previous scheme in January 2008 and is still a member, with the principal member currently being treated for a hiatus hernia, would not face any waiting periods, but would incur a 25% late joiner penalty for the principal member, while the spouse would not face any penalties.

Lastly, a 51-year-old principal member who joined a previous scheme in June 1999 and is still a member, having undergone a mastectomy for breast cancer two years ago and currently receiving treatment for depression, would be subject to a 3-month general waiting period, but would not incur a late joiner penalty.