What Are the Responsibilities of Medical Aid Members?

What are the responsibilities of medical aid members?

South Africans enjoy some of the most sophisticated medical care in the world. In addition, South African hospitals and other medical facilities enjoy an excellent reputation everywhere in the world.

Most private hospitals boast the very latest technology and patients receive the most advanced treatment options. Medical training in South Africa, too, is excellent. And South African specialists have made their mark internationally time and time again.

Medical schemes

In order to enjoy the very best facilities and the latest treatment, it is necessary to belong to a medical scheme. Importantly, there are many reputable medical aid schemes and between them they offer a dazzling array of medical health care plans.

Unfortunately, some members abuse the medical system, making it very difficult for the various schemes Responsibilities of Medical Aid Membersto provide a quality service to all their members. Remember, there are distinct responsibilities of medical aid members.

Medical aid schemes do everything within their power to keep the cost of treatment as low as possible. But some members do not adhere to the terms and conditions of their various plans and individuals that use the system to their own unfair advantage are the cause of increases. Therefore they make it more difficult for honest members to maintain their level of medical cover.


What are the schemes’ main problems?

  • Sadly, most medical aid schemes have to deal with a large number of fraudulent claims every year. And it is not only members that submit false claims; there have been several cases of medical practitioners that submit non-existent claims on behalf of patients that did not receive any treatment. Significantly, traud makes it difficult for the various schemes to keep their annual increases as low as possible.
  • Failure to obtain prior approval. Most medical aid schemes require their members to obtain approval before admission to hospital or before commencing specific treatment. And this can lead to a refusal of the claim and conflict between the member and the scheme.
  • Failure to make use of specified facilities or approved service providers. Many schemes have agreements with certain medical specialists and hospitals. Their members have to make use of these facilities and specialists only.
  • Incorrect claims are common. Many medical aid members submit claims for procedures and treatment that is not covered by their plans. It is also common for members to claim amounts that are above the limit for the particular plan.


What are the responsibilities of medical aid members?

  • Members have to take responsibility for the management of their medical plans. And they must make sure that they adhere to the terms and conditions of the specific plan. If this is not done, claims or even treatment may be refused.
  • Medical cover should only be used when it is really necessary. Unfortunately, there are many members that claim numerous unnecessary doctors’ visits and medication.
  • Members must assess their own circumstances on a regular basis. In addition, it is vital to communicate with the scheme and to ask advice when changes become necessary.
  • Abuse of a medical plan is a serious offence and may even lead to prosecution. So members must understand that abusive behaviour will lead to increases in the cost of medical cover. Everybody loses when a small percentage of members are dishonest.


All info was correct at time of publishing