Med scheme minimum benefits aren’t understood

A number of medical schemes in South Africa are flouting regulations regarding the provision of prescribed minimum benefits (PMBs) — medical conditions that must be covered by a medical scheme — leaving consumers to face hefty medical bills for conditions that should be covered.

According to Clayton Samsodien, managing director of Genesis Capital’s healthcare subsidiary — Genesis Healthcare Consultants — some medical schemes have chosen to flout this requirement as many consumers, and even some medical service providers, such as doctors and specialists do not understand what PMB legislation actually means.

“Under the current law, PMB’s must be paid in full by all medical schemes; yet despite this, some schemes have chosen to reject legitimate medical claims. These decisions are often not challenged by affected consumers, as they have little understanding of both their own rights and the responsibility of the scheme.”

Samsodien says, however, that the blame does not always lie with the medical schemes.

“In some cases we have seen medical service providers not use the correct ICD-10 coding to identify PMB’s at claim stage. Many consumers are also unaware that they must use designated service providers for planned PMB procedures. If this process is not followed, then the scheme has the right to pay only a portion of the claim, with the member being held liable for the balance.”


He says that among the illnesses often not being covered in full by schemes are chronic medications and emergencies, as well as maternity costs.

Conditions of legislation
Samsodien says all medical scheme members should consult their healthcare consultant, who will be able to explain exactly what conditions are covered under the PMB legislation and how they can ensure that any claim is paid.

“However, if the consumer is still battling to get their medical scheme to pay out on a legitimate claim then there are certain steps one can take to escalate the matter,” he adds.

“Firstly, the consumer must lodge a complaint with the medical scheme itself and follow his or her own complaints procedure, as is stipulated by the Financial Advisory and Intermediary Services Act. If the member has a healthcare consultant they should also report the matter to them, as they should already have an established relationship with the scheme and therefore be able to expedite the matter.”

If the scheme concerned does not respond positively to the complaint, then the next step is to report the matter to the Council for Medical Schemes, which has standard complaint forms that can be downloaded from their website, he notes.

“This process is quite simple and feedback is normally provided within 30 days.”

Consumers educating themselves
Samsodien says that while some medical schemes have raised concerns regarding the high cost of providing full medical care on all PMBs, he believes they are vital to the industry.

“PMB’s are a good complement to government’s proposed national health insurance initiative, as both seek to provide a basic right to a minimum set of benefits. However, with some schemes deliberately flouting legislation governing their provision, it is critical that consumers educate themselves as to their rights under their medical scheme.”

He explains that like any insurance, medical cover is risk-based — as not all members will claim at the same time.

“We believe there is already sufficient protection for medical schemes in the form of late joiner penalties, pre-authorisation and designated service providers,” Samsodien says. — I-Net Bridge

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