Are the medical aids really fleecing you?

Medical aids may be increasingly willing to fork over the cash to cover your hospital visits, but there’s a good reason to propose new protections for consumers, a Competition Commission investigation finds.

The Medical Schemes Act introduced prescribed minimum benefits (PMBs) to protect patients from losing medical cover when they needed it most: when they fall sick. Today, schemes are supposed to cover specified treatments for each of the 270 conditions on this list, including emergency medical care and chronic illnesses. 

But if you get the sneaking suspicion that your medical cover hasn’t been perfect with PMBs, you’re not alone. The Competition Commission decided to put this theory to the test as part of its recent four-year investigation and analyse 2014 data. It turns out consumers may be wrong. In part. 

The statutory body found that for hospital care, medical aids were complying with the law. In 2014, almost 60% of medical aid claims for hospital care were for a PMB diagnosis, a 2017 commission report shows. Schemes paid for nearly all of these claims from their pockets with less than 4% being deducted from members’ savings account. Less than 1% went unpaid. 

Healthcare funders did not fare as well when the commission looked at PMBs that did not require hospital admission. Almost 86% of these sorts of claims were paid from the scheme’s funds. But nearly one in 10 of these cases were covered by members’ savings and 5% were not paid out at all. 

The good news? In a 2018 provisional report of its investigation, the commission found that, generally, the percentage of PMB claims paid by medical schemes have been on the rise, a phenomenon the body chalked up to either better behaved medical aids — or better informed and more demanding consumers. If the latter is true, it is no small feat. 

“The process of claiming for a PMB has multiple steps and involves a large number of players,” the commission writes. “Failure at any point of the claim chain will result in the liability being passed onto the member.” 

Your medical aid isn’t just checking to see if what you claim for is on the PMB list. There are no fewer than 11 tests PMB claims go through before they are paid out either in part or in full, if at all, the commission describes. Questions asked about the claim include: “Was the correct disease classification code used by a patient’s doctor?” “Can a special case be made for extraordinary treatment?” “Did a member get special authorisation?” 

This complexity, the body says, makes PMBs difficult to enforce. 

Although the commission’s final report is expected to be released in September, it has recommended that the PMB package be revised to include more out-of-hospital, day-to-day, and preventative care. Eventually, this new set of PMBs would be replaced with one standardised healthcare package that every medical aid should be expected to offer to help to cut down on consumer confusion. But the commission admits this won’t be enough to address concerns around cost. 

The Competition Commission wasn’t able to find evidence to support industry claims that PMBs were the reason behind escalating private healthcare costs. Its research did show that they are taking an increasing bite out of schemes’ pockets, but commissioners couldn’t rule out that these escalating costs weren’t the product of healthcare providers gaming an unruly system of PMBs that seems to challenge regulators, patients and schemes alike.

These are unprecedented times, and the role of media to tell and record the story of South Africa as it develops is more important than ever. But it comes at a cost. Advertisers are cancelling campaigns, and our live events have come to an abrupt halt. Our income has been slashed.

The Mail & Guardian is a proud news publisher with roots stretching back 35 years. We’ve survived thanks to the support of our readers, we will need you to help us get through this.

To help us ensure another 35 future years of fiercely independent journalism, please subscribe.

Laura Lopez Gonzalez
Laura Lopez Gonzalez
@Bhekisisa_MG deputy editor. Science lover & lurker.
Bhekisisa team
Bhekisisa Team
Health features and news from across Africa by Bhekisisa, the Mail & Guardian's health journalism centre.

Ndabeni-Abrahams lockdown debacle: What we know

The minister has to answer to the president after a picture was posted of her apparently breaking lockdown rules

Covid-19 grounds Nigeria’s medical tourists

The country’s elites, including the president, travelled abroad for treatment but now they must use the country’s neglected health system

Nehawu launches urgent court bid over protective gear for health...

The health workers’ union says the government has rebuffed its attempts to meet about mitigating risks to workers

Stay at home, Cyril said. But what about the homeless?

In Tshwane, forcing homeless people off the street resulted in chaos and the abuse of a vulnerable population. In Durban, a smooth, well-planned operation fared far better

Press Releases

Everyone’s talking about it. Even Kentucky

Earlier this year South African fried chicken fast-food chain, Chicken Licken®, launched a campaign for their wallet-friendly EasyBucks® meals, based on the idea of ‘Everyone’s talking about it.’

New energy mix on the cards

REI4P already has and will continue to yield thousands of employment opportunities

The online value of executive education in a Covid-19 world

Executive education courses further develop the skills of leaders in the workplace

Sisa Ntshona urges everyone to stay home, and consider travelling later

Sisa Ntshona has urged everyone to limit their movements in line with government’s request

SAB Zenzele’s special AGM postponed until further notice

An arrangement has been announced for shareholders and retailers to receive a 77.5% cash payout

20th Edition of the National Teaching Awards

Teachers are seldom recognised but they are indispensable to the country's education system

Awards affirm the vital work that teachers do

Government is committed to empowering South Africa’s teachers with skills, knowledge and techniques for a changing world