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Category:
Insurance
News /
Medical
Aid /
January 2008
Medical Aid Schemes in South
Africa
Medical Aid in South Africa is
sometimes taken as a luxury considering the amount one needs to pay
for monthly premiums. Taking form the deterioration found in
our national public health care system, its becoming imperative for
members of the public to join medical aid schemes amid the high
costs. Unfortunately, few South Africans know about their
rights as medical aid members or even before they join a medical aid
scheme. As a member of a medical scheme, you have both rights
and duties. What are these and how does the Medical Scheme Act
131 (1998) affect you?
You have a
right not to be unfairly discriminated against on the basis of your:
Race
Age
Gender
Marital status
Ethnic or social origin
Sexual orientation
Disability
State of health
You may join a medical scheme of
your choice, as long as you can afford it and provided your employer
does not require you to join a specific scheme. But remember: The
scheme must be registered with the Council for Medical Schemes - or
you may not be able to enforce your rights.
Your dependants have the right
to be covered by your scheme. A “dependant” is defined in
the Medical Schemes Act as:
-
Spouse/partner
-
Children under 21 who are
dependent on you
-
Children over 21 who are
financially dependent because of a disability
-
Your mother, father, brother
or sister, if you as the member are liable for their care and
support
-
In certain other cases
individuals can be recognised as dependants in terms of the
scheme's own rules
Dependants have the right to
continue membership of the scheme.
If the principal member dies,
dependants must be covered until they choose to leave the scheme,
join the same scheme in their own right, or join another scheme, as
long as they can afford the contributions.
Your medical scheme may not
charge you more because you are older or sicker.
Variations in contribution rates may only be based on:
-
Income and
-
Number of dependants.
However, if you are joining a
medical scheme later in life, for the first time, you may have to
pay more. All Medical Schemes have to provide a basic set of
benefits known as Prescribed Minimum Benefits – PMBs. And these will
be extended to cover many chronic conditions in 2004. If your
condition is covered as a PMB (eg. many cancers) the treatment may
be given in a public hospital, but all the costs, diagnosis,
treatment and care must be paid for by your scheme. From 2004 when
the benefits were extended there are also restrictions on where
treatment can be offered. Your scheme is not allowed to force you to
go to a hospital which does not offer the necessary treatment.
Your scheme
must pay claims timeously.
Your medical scheme must repay
valid claims within 30 days of the claim being received.
You have the
right to receive regular statements.
In addition to paying an account,
a scheme must furnish you with statements detailing:
-
Name of supplier (doctor,
hospital, pharmacist etc.)
-
Date of service rendered
-
Total amount charged
-
Amount of benefit paid
You have the
right to resubmit a claim if the scheme has not paid a valid claim.
If a medical scheme believes that
an account or claim is incorrect or unacceptable, it must:
-
Inform you within 30 days,
giving the reason for declining the payment, and allow you to
resubmit the claim. You have a right to participate in the way
your scheme is run.
-
At least 50% of the members
of a scheme’s board of trustees must be elected from among
scheme members.
-
Annual general meetings must
be held, at which members may voice opinions, ask questions and
present motions.
You have the right to
information about your scheme.
A scheme must give you
information about:
-
Scheme’s rules and benefits
-
Latest annual financial
statements
-
Management accounts
accompanying annual financial statements.
You have the
right to advance notice of changes in:
-
Contributions
-
Benefits, or
-
Any other changes affecting
membership.
You have the
right to confidentiality of medical information.
Your scheme must keep information
strictly confidential about the diagnosis, treatment and health
status of you and your dependants.
You have the
right to obtain proof of membership.
A scheme must issue to each
member written proof of membership including:
-
Date of entitlement to
benefits
-
Details of any waiting
periods
You have the
right to complain if any of these rights are not respected or if the
service is deficient in some other way.
If you have exhausted all avenues
of complaint at your scheme and its disputes committee – you may
take it up with the complaints department of the Council for Medical
Schemes or appeal directly to council if unhappy with the findings.
You have a duty to do the
following things
-
Be honest and open with your
scheme. If you are found to have provided false information, you
may lose your membership. If you act illegally, criminal charges
may be laid against you.
-
Do not submit fraudulent
claims e.g. boosting the amount claimed for, or claiming for
sunglasses and toiletries or other items not strictly allowed by
your scheme.
-
You must disclose any
material information about your health asked on application to
the scheme as this helps in assessing your portfolio
requirements. Sometimes people try to join a medical aid without
disclosing things like chronic illness, pregnancy or some other
medical conditions hoping to be covered by the scheme but this
bears consequences when discovered.
-
Pay contributions (timeously).
-
Contributions must be paid
directly to your medical scheme.
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