What Are the Responsibilities of Medical Aid Members?


South Africans are privileged to enjoy some of the most sophisticated medical care in the world. 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 are given the most advanced treatment options. Medical training in South Africa, too, is well regarded 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. 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.

Medical aid schemes do everything within their power to keep the cost of treatment as low as possible. Members that 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, thereby making it more difficult for honest members to maintain their level of medical cover.


What are the main problems experienced by the schemes?

  • Sadly, most medical aid schemes have to deal with a large number of fraudulent claims every year. 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. Fraud 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 being admitted to hospital or before commencing specific treatment. 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 are required 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 allowed by the particular plan.


What is expected from medical aid members?

  • Members have to take responsibility for the management of their medical plans. 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. There are many members that claim numerous unnecessary doctors’ visits and medication.
  • Members must assess their own circumstances on a regular basis. 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. 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.