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
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
What are the most important
difficulties experienced by medical schemes?
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.
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
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.
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
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.
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.
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
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
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