FAQ’s

In compiling these Frequently Asked Questions, we have drawn on our extensive experience in responding to typical questions posed by our clients. This list is by no means exhaustive! In the event that there are any additional issues that you seek clarity on, please do not hesitate to contact us. Similarly, if there are issues in the FAQs that require further explanation, contact us. Please note that the Q+A herein does not constitute “advice”, as defined. These FAQs are provided merely as an aid to help you understand some of the issues involved in your membership of a medical scheme. We urge you to make contact with us in the event that you are unsure about any of the concepts contained herein.

Memberships

Benefits

Contributions

Governance

Claims

 


 

Membership


How may a member ascertain what his obligations to the scheme are and what his rights, benefits, contributions and
limitations or benefits are from time to time?

A member is entitled to request copies of the scheme’s rules, financial statements, and annual reports upon payment of a
reasonable fee for such documents. On admission to membership medical schemes are obliged to furnish members with a summary of the registered rules that comprise rights and obligations of both the scheme and members and all benefit options and relevant contributions. This summary usually is the brochure that the scheme will issue when they send your membership card.


Can I belong to more than one medical scheme at the same time?
No, it is illegal. The Medical Scheme Act specifically prohibits this.


Will I receive a membership card?
Yes, all medical schemes will issue you with a membership card, as proof that you are a member of that Scheme. The Service
Providers will also ask for your membership card whenever you receive treatment. The card usually contains the following
information:

  1. Your membership number
  2. Your name and surname
  3. The names of your beneficiaries
  4. The date from which you and your beneficiaries are covered
  5. The details of your chosen benefit option

We recommend that you keep your membership card with you at all times. Remember that the card belongs to you and it must not be used by any person other than you and / or your registered beneficiaries. Should your membership card be stolen or lost, please report this to the scheme immediately. Contact us in the event that you wish to apply for a duplicate or replacement membership card.


May a medical scheme refuse to admit my dependant?
No! In terms of the Medical Schemes Act, a medical scheme may not refuse to admit persons who are dependent on the member. Generally speaking, dependants are regarded as anyone who relies on the member for “family care and support”, and will include:

  • his/her spouse or partner, including partners in same-sex relationships
  • children under the age of 21 (or older, under certain conditions, eg if that child is a fulltime student at a registered educational institution)
  • a child who is dependent upon the member due to a mental or physical disability
  • immediate family in respect of whom the member is legally liable for family care and support (eg parents), and
  • other persons who are recognized by the scheme as dependants.

In our experience, each scheme has its own unique Rules concerning dependants’ membership. We recommend that you contact us so as to discuss the specific conditions that your medical scheme will impose.


Must I give notice to the medical scheme in the event that I wish to resign my membership?
Yes! Each scheme has a specific provision with regard to resignation from membership. For example, some schemes will require that you give them three-month’s notice of your decision to resign, whilst other schemes will have a one-month notice period. Refer to your scheme’s Rules to establish what the minimum requirements are. If in doubt, please do not hesitate to call on us for guidance.


What does a “waiting period” mean?
This is regarded as a period during which you will be required to pay your normal monthly contributions, but you will not be
entitled to any benefits from the scheme.


What are the types of waiting periods?
There are two kinds of waiting periods i.e.:

  1. General waiting period of up to three months.
  2. Condition-specific waiting period (usually referred to as “an exclusion”) of up to 12 months


When is the medical scheme allowed to impose the three-month general waiting period?
According to the Medical Schemes Act, a medical scheme may impose a waiting period of up to three months in the following instances:

  1. where an applicant has not been a member of a medical aid scheme in the 24 months prior to joining a medical scheme, or
  2. where an applicant was a member of a prior medical scheme for more than 24 months, but did not apply to the new medical scheme within 90 days of resigning from the prior medical scheme, or
  3. even if an applicant was a member of a previous medical scheme for more than 24 months and he applies to join another medical scheme before the expiry of 90 days, but the change of medical scheme is requested on a voluntary basis.

Remember that the scheme is entitled to withhold benefits during this three-month waiting period.


What is meant by a condition specific waiting period?
The waiting period (or “exclusion”, as it is also referred to) is applied in instances where a member received “care,
diagnosis or treatment” in the 12 months immediately prior to joining a medical scheme. However, schemes are not allowed to impose this exclusion in instances where you move from one scheme to another and the break in membership is no longer than 90 days.


Are there any circumstances under which a waiting period will not apply?
Waiting periods will not apply in respect of:

  1. Prescribed minimum benefits,
  2. A child dependant born during the period of membership
  3. A member moving between benefit options unless he has to complete the remaining period of previously imposed waiting periods.
  4. When an individual has to involuntarily transfer to another scheme due to a change of employment.
  5. In instances where an employer changes the medical scheme of his employees with effect from the beginning of the financial year.


How can I prove to a new scheme that I was a member of another scheme?
A scheme must provide, a former member with a membership certificate stating the period of cover and other prescribed
information. This certificate is issued usually only on request of the member and / or the members dependant.
If you cannot obtain a membership certificate from your previous medical scheme (eg the scheme administrator has gone out of business) then you are also entitled to produce a sworn declaration in verification of your past periods of membership. Some schemes have formulated their own stationery that must be used. Contact us for further advice in this regard.


What happens in the case of the death of the member?
The surviving beneficiaries may continue as members of the medical scheme, provided that they were registered on the scheme at the time of the main member’s death. The surviving beneficiaries would have to continue with the payment of the contributions. However, should the widow/widower remarry, and he / she becomes a dependent on the new spouse’s scheme, the membership will terminate. (Just a reminder that it is illegal to belong to two medical schemes at the same time.)


Where do I complain if claims are not paid timeously or when I am dissatisfied with a decision taken by the Scheme?
Step 1 – Try to resolve the issue with the scheme directly

Any complaint must first be lodged with the scheme concerned.
Most schemes will provide you with a Call Centre number, and we suggest that you register your complaint here first. Remember to take the details of the person that you dealt with, and of possible, get a reference number, just so that you have a formal record of your complaint. If you get no joy from the Call Centre, we recommend that you put your complaint in writing, and remember to keep a copy of the letter. Be sure to describe your complaint in full. Detail in clear and unambiguous language how you wish that the complaint be resolved. Include in your letter the attempts that you have made to resolve the complaint, by detailing your previous contact with the scheme Call Centre.

If the scheme does not resolve your complaint to your satisfaction, then you will be entitled to declare a formal Dispute
against the scheme. All schemes are required to have a Disputes Committees where members’ disputes must be considered. We suggest that you obtain a copy of the Rules of the scheme, and that you familiarise yourself with this Disputes Procedure.
Members may be present at the meeting of the Disputes Committee to present their arguments. Should you choose (and should you be able to afford it), you will be allowed to involve your lawyer in the dispute resolution process.
Step 2 – Refer the issue to the Council for Medical Schemes.

Should all efforts fail to resolve the issue with your scheme, you can submit your complaint to the Council for Medical
Schemes Complaints Unit. There are a number of ways that you can refer your issue to the Council, namely by posting, faxing,
emailing or submit online by going to the following website address:

http://www.medicalschemes.com/Categories/Complaints Zone/complaints.htm.

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Benefits


How do I know which benefit option to select?
Ensure that you understand how the benefit options operate and select an option according to your healthcare needs. The relevant cost of the option will naturally also be an important fact when you consider which option suits you.
The registered Rules of medical schemes fully disclose detailed information regarding the relevant benefits and contributions. It is essential that you familiarise yourself with the Rules of the scheme or a summary thereof to verify all information relevant to enable you to make an informed choice. We recommend that you contact us providing a telephone number so that we can discuss your specific needs and match this against the proposed scheme option.


What can I do if I am not satisfied with my current benefit option?
Instead of changing schemes and be faced with waiting periods, we recommend that you consult with us with a view to changing to a different option on your existing medical scheme. Please contact us providing a telephone number so that we can discuss this with you. However, if there are no suitable alternative options on the scheme that you are currently a member of, you will be entitled to join another medical scheme. Just remember that the new medical scheme may impose waiting periods and / or exclusions.


Can I change benefit options during the year?
No. Medical schemes will usually only allow you to change options once per year, with effect 01 January of that year. Certain scheme however do allow you to amend your option during the year, but only under very strict conditions.


What are prescribed minimum benefits (PMBs)?
These are benefits in respect of relevant health services prescribed by the regulations under the Act, and rendered by State hospitals or designated service provider according to clinical protocols and criteria. Each and every medical scheme must offer these PMB benefits on an unlimited basis.


To what extent are the prescribed minimum benefits restricted?
No restrictions, co-payments, waiting periods or exclusions may be applied to any person in respect of the prescribed minimum benefits if the services are rendered by State hospitals or other DSP’s (designated service providers are providers of health care services (either individually or in a network) selected by the scheme as the preferred and exclusive provider of treatment and care in respect of one or more benefit conditions.) In instances where services are voluntarily obtained from a non-DSP, the scheme may require that you pay a portion of the account, or it may impose a waiting period only on those applicants who have never belonged to a medical scheme, or have not been beneficiaries for the preceding 90 days.


Am I entitled to benefits while serving notice of termination?
Yes, you will be covered by your existing medical scheme until the last day of membership, provided contributions are being paid.

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Contributions


Must my employer subsidize my contributions to the medical scheme?
No. There is no provision in the Medical Schemes Act that compels an employer to subsidise the medical scheme contribution. A subsidy is usually regulated in your conditions of employment and will have to be negotiated directly with your employer.


If I do not submit any claims, will the medical scheme refund me the contributions that I have paid every month?
No. The Medical Schemes Act prohibits the payment of bonuses, rebates or repayment of any portion of contributions, other than in respect of savings accounts in certain circumstances. Remember that you medical scheme exists as a type of “insurance” to pay your medical expenses as and when you submit a claim.


May the medical scheme call upon me for increased contributions with retrospective effect?
No, in terms of the Act a medical scheme must give members advance written notice of any change in contributions and benefits or any other condition affecting their membership. These changes in contributions and benefits must also be registered and approved with the Council for Medical Schemes.


What is a late joiner penalty (ljp)?
The ljp is an additional contribution over and above the normal monthly contribution that will be paid by members each and every month. This ljp is imposed on persons :

  1. who join a medical scheme “late in life” (ie an applicant who is 30 years of age or older), and
  2. who were not members of a registered medical aid scheme before 01 April 2001. (Many people took out membership of an insurance-based
    hospital plan (ie not a formally registered medical aid scheme. Regrettably, these insurance-based products do not count in this instance.)

Ljp’s were introduced into the legislation in order to protect medical schemes from people who wait until they are old and sickly before they join a medical scheme, and then make large claims against the scheme after only contributing for a short time. Ideally, people should start contributing to medical schemes at a time when they are young and healthy


How is this ljp calculated?
The ljp is calculated according to a fixed formula that has been determined in the Regulations to the Medical Schemes Act. The longer a person waits to join a medical scheme after the age of 30, the higher the late joiner penalty that will be applied by the scheme. If you have been a member of a registered medical aid scheme, then this will count in your favour. This is referred to as “creditable coverage” in the relevant legislation. Remember that the scheme will require that you provide proof of such prior medical scheme membership. To calculate the applicable ljp, we use the following formula :

A = B minus (35 + C).

“A” is the number of years referred to in Column 1 in the table below.
“B” is the current age of the member,
“C” is the number of years that the member was a member of a registered medical aid scheme (but not
including the number of years when the member was a member of a medical scheme as a dependant under the age of 21 years)


The number of years that the applicant was not a member of a registered medical aid scheme after the age of 30.

Maximum late joiner penalty
1 to 4 years Normal monthly contribution multiplied by 1.05
5 to 14 years Normal monthly contribution multiplied by 1.25
15 to 24 years Normal monthly contribution multiplied by 1.50
More than 25 years Normal monthly contribution multiplied by 1.75

 

Let’s demonstrate this with an example. Let’s assume that :

  • the member is currently aged 58,
  • the member has been an adult member of a previous medical aid scheme for a total of 11 years,
  • the normal contribution (before the imposition of the ljp) is R1 500 per month.

A = B minus (35 + C)
A = 58 minus (35 + 11)
A = 58 minus 46
A = 12

Now, refer to Column 1 in the table. In this case, the member will therefore have a late joiner penalty of 1.25 times the normal monthly contribution applied to his payment each and every month. The contribution will therefore increase from R1 500 to R1 875 per month. Does all this sound confusing? Please give us a call at your convenience, and we’ll explain it all to you!


Can I withdraw whatever money I have left over in the medical savings account (MSA) at the end of the year?
No. The Medical Schemes Act is quite clear about this. You will not be able to withdraw any monies from your MSA for as long as you are a member of the medical scheme. The MSA is available only to pay claims and benefits as provided for in the Rules of your medical scheme. On the other hand, if you resign from the medical scheme and you have money left over in your MSA, then this money will either :

  1. be refunded to you, only if you’re not going to join another medical aid scheme that also has its own MSA, or
  2. if you join another medical scheme and you select a MSA on that new scheme, then the balance of the funds will be transferred into
    your MSA on the new scheme.


May contributions be paid out of my savings account?
No, except on termination of membership. Funds in the MSA may be used by the scheme to offset any debt owed by the member that would include contributions


Can co – payments in respect of PMB benefits be paid out of my MSA?
No, the Act specifically prohibits it.


How do I know whether or not my scheme has paid and what amount has been paid in respect of a claim?
All medical schemes will send members a “claims statement”. Some members choose to receive their statements electronically, but most members receive their statements in the post. These statements will detail all the claims that were paid by the scheme, including the amounts that were paid and the date when the claim was paid.


What is an ex gratia payment and do I have a right to such benefits?
Members do not have a right to an ex gratia payment. This is a discretionary benefit that a medical scheme may (or may not!) pay. The medical scheme is under no obligation to pay such ex gratia benefits. The Rules of certain medical schemes allow the Trustees to consider the payment of an ex gratia benefit in instances where the member is suffering financial hardship.


What is National Health Reference Price List (NHRPL)?
This is a price list for health services published by Council for Medical Schemes and is used to reimburse service providers. If you are a member of a medical scheme that pays BHF rates to service providers and you visit a medical practitioner that charges at private rates you will need to pay the difference.


What are SAMA rates?
Sama rates are the private rates charged by medical practitioners who do not charge medical aid rates, ie the NHRPL tariff.


Is a provider of health care service entitled to charge more than the fees determined by medical schemes / the tariff specified in the NHRPL?
Yes. Health care providers are free to determine their own fees. Consequently, if an account is in excess of the fee determined by the rules of a medical scheme / NHRPL for a particular service, the difference will have to be paid by the member.

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Governance


When did the Medical Schemes Act come into operation?
The Medical Schemes Act 1998 (Act 131 of 1998) came into operation on 1 February 1999. Regulations were introduced by Government Gazette No 20556 dated 20 October 1999, with effect from 1 November 1999 and 1 January 2000.


Who manages the affairs of a medical scheme?
Medical schemes are managed by a Board of Trustees (BoT). At least half of the members of the BoT must be elected or appointed by the members at the Annual General Meeting. These persons must be “fit and proper” to perform their duties and ensure that the interests of members are protected and that the scheme is properly administered.


May I participate in the operation of my scheme?
Yes, in terms of the Medical Schemes Act, a medical scheme must convene an Annual General Meeting (AGM) where members may voice their views and propose resolutions. Medical schemes may also hold meetings at different venues for the benefit of members or provide for regional meetings to maximize member participation


Can a medical scheme change its rules and thereby reduce the level of cover that I have?
Yes. There is provision in the Act and in the rules of every medical scheme on how the Board of Trustees may amend rules. All changes to contributions and benefits must however be approved and registered by the Council for Medical Schemes before they can be implemented by the scheme.


Who does the medical scheme belong to?
A medical scheme is owned by all its members. It is a “not for profit” mutual fund.


What is a solvency ratio?
The Act requires medical schemes to have reserves of at least 25% of the total contributions paid by members in a year. As a guide, the higher the solvency ratio, the greater the ability of the scheme to pay your claims.


Who provides financial backing for medical schemes?
The Medical Schemes Act prohibits a medical scheme from borrowing money. It is for this reason that a medical scheme does not have a financial backer. The success of a scheme is dependant on various factors including the structure of its benefits, pricing of its premiums, management of its day-to-day activities and of course the risk of its members.

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Claims


How do I submit an account for a claim?
Simply mail your account (or hand deliver it, if convenient) as soon as possible to your medical scheme. Remember that you have four months to submit to your claim to the scheme – that is, four months from the date of treatment. Claims received by the scheme after this month deadline will be regarded as stale, and will not be paid by the scheme.
If you have already paid the account, and you want the scheme to refund the benefit amount to you, simply attach the receipt to the account. We recommend that you write on the account “Paid – please refund member” in bold red ink!
Medical schemes require that the account contain the following information. Please ensure that all of it is included on the account.

  1. Your name and surname,
  2. Your medical scheme number – very important,
  3. The date of treatment,
  4. The name of the patient that was treated (as reflected on your membership card),
  5. The tariff code relating to the treatment that was rendered,
  6. The practice number of the doctor,
  7. The amount charged,
  8. The nature and cost of each relevant health service rendered, including the supply of medicine to the member concerned or to a registered
    dependant of that member, and the name, quantity and dosage of and net amount payable by the member in respect of the medicine


Who should submit the claim, the member or the Service Provider?
In most cases, this depends on your provider of service. Many doctors submit their accounts to the medical scheme directly, in which event you will not need to submit the account as well. However, in instances where the doctor does not submit the account directly, it will be your responsibility to ensure that the scheme reaches the medical scheme before the cut-off date. We recommend that you talk to your doctor and reach agreement with him about who will be required the account to the medical scheme.


What is Pre-authorisation?
If you or a member of your family is to be admitted to hospital, you must telephone your medical aid scheme at least 48 hours before you are admitted in order to obtain authorisation from the scheme. In the case of an un-planned, un-scheduled or emergency admission, you must contact your scheme within 24 hours after admission. In order to pre-authorise your hospitalisation, you will be asked for the following information:

  • your membership number
  • the name of the member or dependant who is going to hospital
  • the reason for the admission (ie the diagnosis)
  • the date of admission and the expected date of discharge
  • the name and telephone number of the hospital and the doctor who is admitting you.

Please make sure that you record your pre-authorisation number and be sure to hand it to the admissions desk when you are admitted to hospital. Remember that certain schemes may require that you pay a substantial portion of the account if you do not pre-authorise the hospital admission.

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