Khadija Magardie
Sara Rasool*, a freelance journalist, thought the perfect birthday gift for her 59-year-old mother, Mariam*, would be signing her up as a member of one of the country’s premier medical schemes.
Though her mother was in perfect health, Rasool felt she could cover all her bases in case of illness by putting her mother on her medi-cal aid as a dependent.
Excited by talk of the new legislation, which opened the doors for medical aid membership to anyone, regardless of age or health status, she approached a broker in mid-1999 to make an application.
Because she would be paying the premiums, Rasool handed in all the necessary paperwork, confident that by her mother’s birthday in November, she would be a registered member.
But the application was put on ice; the medi-cal scheme said her mother needed a physical. This was the first of several delays and requests for “further tests” from the medical scheme. By the end of the year, after submitting the battery of test results, Rasool still had not received confirmation from the medical scheme.
Rasool turned to the Department of Health for assistance, which contacted the scheme and threatened it with court action unless it furnished reasons for delaying the application. The scheme continued to procrastinate until early last year, when it requested further tests.
After intervention by the Council for Medical Schemes, Rasool’s mother was finally registered late last year, after a compulsory three-month exclusionary period, during which premiums have to be paid but a member can’t make a claim.
This is one of several situations anticipated by enforcers of the new legislation surrounding medical scheme regulations. Though the law broadens the ambit of who may join a medical aid, in reality dozens of people face numerous obstacles in accessing medical aid.
There have been extensive changes to the laws governing medical schemes in the past two years, particularly the controversial Medical Schemes Act of 1998 the full effect of which began being felt only in January last year.
The Act aimed to broaden access to health care, particularly private medical schemes, in order to ease the burden on the public health system. Previously, medical schemes designed benefit structures to attract the young and healthy, and in some cases even discouraged membership by “high-risk” individuals and groups through high premiums. This resulted in these “high-risk” individuals, such as the elderly and people with chronic medical conditions, being “dumped” on public hospitals.
The new Act outlawed discrimination on the basis of age, medical history and health status. Previously the elderly and people with chronic illness were considered “a bad financial risk” and were excluded from medical aid cover or severely restricted in terms of benefits.
The new legislation means that medical aids have to accept any new applications for membership, regardless of health status. In addition, contributions can be determined only on the basis of income level and/or number of dependents. In this way low earners can have access to medical aid. Proponents of the Act said this will promote “cross-subsidisation”, whereby the elderly and ailing are supported by the young and healthy, and the low-income earners by the high-income earners.
High-risk joiners have until March 31 to join medical schemes and still be treated on an equal basis with low-risk members; after that date a penalty will likely be paid by those in high-risk categories.
* Not their real names