Medical Aids Fear Medical Claims!

July 11, 2013

Are South Africans abusing the private health system by submitting false medical claims?

Why Medical Schemes Hate Medical ClaimsJust recently there was a case where Discovery Health Medical Scheme had to pay more than three and a half million rand in medical claims for the costs of keeping a sixty year old man on a ventilator for a hundred and fifty six days.

There is another example of a seventy year old patient that used assisted-breathing equipment for a hundred and eighteen days at a cost of more than three point two million rand. Medical schemes are certainly struggling with many exorbitant claims.


Discovery Shares Medical Claims Statistics

Here are some examples and statistics:

  • Discovery Health claims that about a half of its annual pay-outs go to approximately ten percent of its members.
  • One of the highest costs to medical schemes is ventilation. Heart problems, cancer and intensive care for young children also rate very high. Caesareans sections are particularly prevalent and cost a lot of money.
  • The number of people that claim more than half a million rand each year have increased dramatically.
  • According to Jonathan Broomberg, the CEO of Discovery Health, they received claims from thirteen out of every ten thousand claimants of more than fifty thousand rand a year in 2002. By 2012 this number has increased to twenty eight out of every ten thousand claimants. This constitutes an increase of an astounding hundred and fifteen percent!
  • The huge increase in high-cost patients makes it very difficult for medical schemes to keep contribution increases low.
  • Mark Arnold from Resolution Health says that they have had six claimants that demanded care of more than half a million rand this year.
  • Younger and healthy members of medical schemes increasingly feel that they are subsidizing older and fraudulent members.
  • More people land in hospital than ever before. This incurs huge costs for medical schemes. Naturally, these costs are transferred to the members of the scheme, leading to increased member contributions.
  • South Africa suffers under a massive burden of various diseases such as tuberculosis, HIV and AIDS. The cost of managing these diseases is mind boggling.

What are the biggest medical claims on medical schemes?

  • The biggest medical claims, by far, are for cancer medication. Chemotherapy is extremely costly and Mark Arnold from Resolution Health says that out of the four and a half million rand his scheme pays per month at least one million goes toward cancer treatments.
  • Caesarean sections account for the most admissions to hospitals, according to statistics released by Discovery Health. The necessity of many of these admissions is questionable.
  • The most common chronic disease is hypertension, or high blood pressure. This is one of the findings of Resolution Health.
  • Medical schemes spend far more on hospitalizations than on day-to-day medical needs.

What were the top medical claims costs last year? (According to Discovery Health)

  • More than an average of one point seven million was paid to heart patients.
  • One point seven million was the average payment for members claiming for heart and lung transplants.
  • More than six hundred thousand rand were paid for every patient needing long term ventilation.
  • Kidney and pancreas transplants cost more than half a million rand each.
  • Major operations on babies resulted in claims of more than fifty thousand rand each.
  • Hospital care for premature babies saw claims of more than three hundred thousand rand per case!

All info was correct at time of publishing