What Are the Responsibilities of Medical Aid Members?

The South African public is fortunate to be able to access some of the very best medical facilities in the world and to be treated by medical practitioners that are world standard by anyone’s measure. Private hospitals are equipped with the latest equipment and cutting edge technology is offered when treatment becomes necessary.

In order to access high quality medical care it is necessary to belong to a medical aid scheme. People that do not belong to any medical aid have no option other than to use the public health system. South Africans can choose between many excellent schemes and there are literally hundreds of different medical care plans available to choose from.

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It is an unfortunate fact that there are many people that abuse their medical schemes and there are even service providers that fail to follow the rules of a specific scheme. In order to provide the best possible medical care to their members, the schemes have to take steps to avoid fraud and abuse. This is the only way in which to keep costs down and to increase the benefits enjoyed by the members of each scheme.

What are the most important difficulties experienced by medical schemes?

1.      All medical schemes have to deal with fraudulent claims every year. In some cases it is the member that claims for treatment or medication that never happened but there are even medical practitioners and other service providers that submit false claims. This type of fraud cost the medical schemes a fortune, forcing them to raise the cost of their care plans. Unfortunately, honest members have to pay for the dishonesty of others.
2.      All medical schemes struggle with members that do not obtain prior authorization for hospitalization or treatment when they are required to do so. This often leads to conflict and unhappiness because the scheme will refuse to pay the claim.
3.      Many members do not use the service providers that are approved by their schemes. Many plans require members to use only those facilities and practitioners that are under contract with the scheme. Failure to adhere to this condition may result in claims being refused or in members having to pay the difference in cost.
4.     Incorrect claims are perhaps the most common headache for medical schemes. Members submit claims for treatment or medication that is not covered in their specific plans and many members claim even when they have reached their limit.

What are the responsibilities of members?

1.      Members must accept personal responsibility for the management of their medical aid plans. It is vital to study the terms and conditions of the plan and to adhere to them. This will avoid conflict and unnecessary cost.
2.      Medical treatment should be sought judiciously. Some members visit doctors or use medication that is not necessary. Medical cover should be seen as a precious resource and it should be used only when it is necessary.
3.      Members need to take a close look at their needs regularly. When circumstances change it may be necessary to opt for a different plan or to upgrade the cover currently enjoyed.
4.      Members of medical schemes must understand that abuse of the system is a criminal offence. It may lead to prosecution and huge fine or even prison sentences.

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NOTES:

Your medical aid quote will include options to suit your pocket. Please ensure that the cover you select is exactly what you need and that you understand exactly what insurance you are buying. Do not hesitate to ask questions about the medical aid or hospital cover you choose.