Medical schemes group main members and dependants according to certain criteria. You may not have to be blood relatives but the main member cannot add just any person to a scheme. You may feel responsible for a person. You may even be supporting them financially. But this does not mean that you can take any adult onto your medical aid as a dependant unless they meet certain criteria.
So before you consider signing up that nephew, grandfather, brother or adult child, make sure that they do indeed fall under the criteria of a dependant as your medical aid sees it. The fact that you are paying the monthly contribution does not mean you can sign up just any adult. By attempting to put dependants on your medical aid who do not qualify to be there, you are committing fraud or at the very least failing to disclose crucial information. Both fraud and non-disclosure can lead to termination of membership.
Who is a dependant?
Understanding the context of a dependant in the way medical schemes see it is important when you are looking at joining a scheme or changing a plan. A dependant is any person who depends on you financially and cannot take care of himself/herself due to certain factors, like age or disability, that makes them unable to work.
The dependant can be a child or an adult. The only exception is for spouses of the main members – as long as there marriage is legal, a spouse can be an adult dependant irrespective of his/her ability to work. Divorce obviously changes. Most schemes will allow children, beyond your own biological children, to be dependants if they are your legal guardians or you are financially responsible for them.
However, adult dependants and in particularly your own children who are adults is where the issue becomes contentious. Some schemes will now consider adult children up to the age of 27, but many will refuse them membership as a dependant after 21 years of age. If a parent can prove the child is still a dependant despite being an adult then the medical aid may be lenient. For example, if your child can provide proof of studying at a university or college then that may suffice.
Ex-Spouse As A Dependant
Divorce immediately revokes the right of your spouse, now ex-spouse, to be on your medical aid as an adult dependant. However, if there is a court settlement that stipulates that the main member is financially responsible for the upkeep and care of the ex then continuing medical aid membership as a dependant may be allowed. Failing to disclose a divorce and keeping an ex-spouse as an adult dependant on your scheme can have consequences.
It is usually considered as material non-disclosure and lead to immediate termination of your ex-spouse. Payment of medical bills by the scheme can be reversed leaving your ex-spouse with a mountain of debt. It can have even more far reaching consequences for the main member if he/she knowingly registered an ex-spouse on the scheme. The way the matter will be dealt with largely depends on the scheme.
Unemployed Children As Dependants
Youth unemployment is extremely high in South Africa. Many children cannot find a job after school, and not even after getting a tertiary qualification. They may be dependent on their parents for a long period of time after school or university. Medical schemes understand this issue and will give leeway to some degree for adult dependants on a medical aid who are still under the financial care of the main member.
If the child is no longer a full time student, the main member must verify that he/she does not have full time employment either and can therefore not afford to pay for medical aid cover on their own. However, attempting to keep your child on your medical aid despite him/her being financially independent is fraudulent. Here as well it can lead to termination of membership and reversal of payments to providers.
Siblings, Parents and Grandparents
Medical schemes do allow elderly parents of the main member to be on the same plan as adult dependants provided that it can be proven that the parents are not working. However, the issue becomes a bit more complicated with parents-in-law and siblings. Here the main member has to prove that they are financially responsible for these individuals. These dependants are known as special dependants.
The issue of grandparent nephews and nieces on the medical aid face different criteria. Grandparents are not considered as special dependants and cannot be on the medical aid as an adult dependant.The main member can only add nephews, nieces or any other child who is not their biological child, onto the medical aid as a child dependant if there is proof of legal guardianship.
It is advisable to speak to your scheme directly about adult dependants and special dependants. The situation may be considered in a different light depending on individual factors.