Discrimination or good business practice?

The practice by medical aid schemes of excluding treatments on the basis of the past medical history or pre-existing conditions, is not a new one. 

Medical aid schemes justify this practice as being good business. They argue that the exclusions, or inflated premiums, exist to protect the scheme and thereby other members of the scheme.

Medical aid schemes may no longer refuse people from their schemes on the basis that they have or have had cancer. However, what they can do, is refuse to pay for any cancer treatments (known as exclusions), or they inflate the premiums.

It is important to note through failure to disclose a pre-existing condition – such as cancer – will give the medical aid scheme the right to cancel membership.

In some cases, medical aids are entitled to impose a three month general waiting period, during which no claims will be paid, or a 12 month exclusion for any pre-existing medical conditions.

The question is whether these inflated premiums or exclusions are legal. The short answer is that they are. There is a list of 270 treatments for which all medical aid schemes in South Africa have to provide cover, in terms of the Medical Schemes Act. It also includes the following 26 chronic diseases:

Addison’s Disease, Asthma, Bipolar Mood Disorder, Bronchiectasis, Cardiac Failure, Cardiomyopathy, Chronic Renal Disease, Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Crohn’s Disease, Diabetes Insipidus, Diabetes Mellitus Type 1 & 2, Cardiac Dysrythmias, Epilepsy, Glaucoma, Haemophilia, HIV / AIDS, Hyperlipidaemia, Hypertension, Hypothyroidism, Multiple Sclerosis, Parkinson’s Disease, Rheumatoid Arthritis, Schizophrenia, Systemic Lupus Erythematosus and Ulcerative Colitis.

If you feel that you have been unfairly treated by your medical aid scheme, you can either switch schemes which is not as easy as it sounds, or you can refer a dispute to the Council for Medical Schemes. Their website is user friendly and you can download the complaint forms at: www.medicalschemes.com

They do however, encourage complainants to first try and resolve the dispute with the medical scheme itself.

In conclusion, medical aid schemes are private businesses which are there to make a profit, that is unfortunately very often on the misery of their members. The onus is on you to make sure you know what you are covered for when you sign up.

This may not seem fair or just, but with more cases coming out – particularly with patients claiming more from their schemes – the tide is turning.

Questions and answers

How long after my treatment do I have to submit my claim?

You have four months from the treatment date to submit claims.

Is it possible to belong to more than one medical aid scheme at a time?

No, but what you are able to do is buy a form of gap cover and insurance which pays out during any stay in hospital. 

Is my employer legally obliged to contribute towards my medical aid?

There is no legal obligation on the employer to do so.

When can a medical aid scheme terminate my membership?

They can terminate your membership if your contributions are not paid. 

What does it mean to be on a “restricted medical aid scheme”?

A restricted scheme is one where only specific groups of people can join. These are commonly ones which are linked to employment. i.e. your company might have a compulsory scheme. 

Written by Charles Ballie

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