Out-of-pocket health costs

Jana Bartels, from Medical Bills Sorted, advises on three options when your medical scheme declines funding for treatment and you and you incur out-of-pocket health costs.

You can listen to this article below, or by using your favourite podcast player at pod.link/buddiesforlife

Being diagnosed with cancer is a life-altering experience. The initial reaction is often one of fear – fear of the unknown, fear of your survival, and fear of the impact on your family.

Amidst this whirlwind of emotions, the last thing you consider is the cost of treatment. Having paid monthly medical aid premiums, you may assume that your coverage will fully support you in your hour of need. Unfortunately, the reality often reveals a different story as sadly many start paying out of pocket for healthcare services from the start.

Understanding the complexities of medical cover and finding avenues to secure full funding for treatment can be daunting, especially when your condition doesn’t qualify as a prescribed minimum benefit (PMB).

If your condition isn’t a PMB, there are still options available to secure support from your scheme for unexpected healthcare costs.

Below are a few options when faced with declines from your medical scheme or insurer.

Appeal process

Understand the reason for denial: The first step is to find out why the funding request was denied. This information is usually provided in the rejection letter from the medical scheme.
Gather supporting documentation: Collect all relevant medical records, test results, and any documentation that supports the need for treatment. This will be crucial for the appeal process.
Submit an appeal: You or your representative must submit a formal appeal to the medical scheme. This can usually be done online through their website or by sending a written letter. The appeal should include a detailed explanation of why the treatment is necessary and all supporting documentation.
Follow-up: After submitting the appeal, it’s important to follow up to ensure that the appeal is being processed. This can be done by contacting their customer service department.
Independent review: The appeal will be reviewed by an independent panel or a third-party reviewer who wasn’t involved in the initial decision. This ensures an unbiased evaluation of the case.
Receive the decision: You’ll be notified of the outcome of the appeal. If the appeal is successful, the medical scheme will approve the funding for treatment. If the appeal is denied, you can consider further steps, such as seeking assistance from The Council for Medical Schemes (CMS) or exploring other funding options.
Seek legal advice: If the appeal is denied and you believe the decision was unfair, you can seek legal advice to explore further options, including taking the case to court.

Exploring ex gratia funding

What is ex gratia funding?

A medical scheme may consider an ex gratia payment as a discretionary benefit if you’re experiencing exceptional clinical circumstances or extreme financial hardship.

Most medical schemes offer ex gratia funding, a process that provides financial assistance beyond the standard benefits. However, this process is complex and the last thing you will want to manage when you’re ill.

When to approach the CMS

If funding decisions made by your medical scheme are unsatisfactory, the final recourse is to approach the CMS. The CMS is dedicated to protecting the rights of members of all medical schemes in SA. You shouldn’t fear ridicule for lodging complaints, as most cases are ruled in favour of the members.

While the process can be lengthy, with turnaround times ranging from 30 days to 12 months, it’s a vital step for those who are financially and emotionally exhausted from battling their health issues.

When submitting a complaint to CMS, it’s important to have all the documents supporting the clinical treatment as well as proof that you tried to resolve the issue with your respective medical scheme.

NEED ASSISTANCE? Contact Medical Bills Sorted via medicalbillsorted.co.za, or email [email protected], or phone +27 64 534 6384, or WhatsApp 071 850 0199.

MEET THE EXPERT – Jana Bartels

Jana Bartels is a registered nurse (ICU and Trauma). With 25 years of experience in the medical industry, she has extensive knowledge of clinical practice, medical insurance, and the pharmaceutical sector. She specialises in creating access pathways for patients.