How Medical Aids Pay Claims

The Medical Scheme Act makes provision for several channels through which members of medical aids are able to lodge complaints. The vast majority of complaints focus upon pay-outs.

Members become unhappy because they are expected to pay a portion of a specific medical bill and sometimes they are even held responsible for the entire amount. Most of these complaints can be attributed to one of four reasons:

• Members fail to study the terms and conditions of their specific plans and they therefore do not claim according to the rules.
• In many cases the member received treatment or medication for a condition that is simply not covered by the specific plan of which he is a member.
• The member has reached his limit as specified in his plan.
• The member failed to make use of a prescribed and obligatory network of medical service providers.

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Important Considerations Relating To Claims

 

A comprehensive medical aid plan does not mean that it offers unlimited treatment. Every single plan has strict terms and conditions that detail the exact nature of the cover offered by that specific plan. In fact, there are substantial differences in the benefits offered by the various schemes and the plans that they offer. Here are some considerations that may help members of medical aid plans to claim more successfully:

 

•         All comprehensive medical aid plans offer full in-hospital cover. However, in some cases members are obliged to use very specific hospitals and in many cases it is necessary to obtain approval from the scheme prior to hospitalization. In addition, in many cases it is also necessary to obtain approval for specific treatments and procedures.
•         Full in-hospital cover unfortunately does not necessarily mean that all the expenses will be paid by the scheme. In some cases the cover provided will only pay approved medical aid rate. In reality, the costs are often substantially higher that this approved rate. In such cases the member is expected to pay for the difference himself. The reality is that the actual costs are routinely as high as four times the approved medical aid rate. Members must make sure that they know exactly what the final cost will be and what portion of it they will be liable for.
•        Members of comprehensive plans that suffer from chronic conditions should be very careful to make sure that they are covered. Many schemes will pay only for medication that appears on an approved list and most schemes require their members to obtain approval for the treatment of a chronic condition. In addition, it may be necessary to make use of approved service providers. If any of these conditions are not met the member can be held liable for the cost.
•         Almost all chronic plans also cover the costs of day-to-day medical treatments and it is precisely this cover that causes the most complaints from members. In almost all instances this type of cover is categorized and the amount of cover for each category is limited. In may therefore happen that the cover for one category, dental cover for example, is exhausted while no claims have been made in another category. Members then fail to understand why a claim in terms of dental treatment is rejected.

Members of medical aid schemes should make very sure that they understand the terms and conditions of their specific plans and how medical aids pay claims. Most medical aid schemes place a high priority on customer satisfaction and they will happily answer any questions.

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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.