How a Medical Scheme Works

Here’s how a medical scheme works. All contributions go into a pool for the benefit of the members of the scheme. Medical scheme belong to the members and they are not for profit organizations. The surplus that is made always remains in the scheme for the benefit of the members. In terms of the Medical Schemes Act, the scheme will provide annual meetings where the members will discuss their motions and their views.

More About How a Medical Scheme Works

To maximize the members’ participation, the medical scheme can choose to hold their meetings at different areas. In terms of the Medical Schemes Act, the scheme must have assets to cover various liabilities. To ensure financial stability, the scheme must have accumulated funds that must be equal to the annual contributions.

How a medical scheme worksYour scheme membership can be suspended or terminated when you fail to pay your fees on time or when you submit fraudulent claims. You should keep in mind that it is illegal to belong to more than one scheme at one time. With assistance from a guardian or parent, a minor can easily become a member of the scheme. That is, provided he pays the required contribution.

According to the Medical Schemes Act, there is no scheme that will fail to admit the specific persons who are dependent on a member of the scheme. The dependents can be:

  • his children who are under the age of 21 years
  • his spouse
  • or his partner
  • a child with mental illness
  • a child with physical disabilities or
  • an immediate family member who is legally liable for support and care.

How a medical scheme works for families

The immediate family member can be a mother, a father, a brother or a sister.  The scheme will ask for additional contributions in regard to extended cover and they will also ask for proof of dependency.

If you are an employee, your employer may decide to determine whether you belong to a medical scheme. Your employer will also determine whether the levels that applies to different categories. Your employer will play a very important role in collecting contributions of the scheme.

When your employer fails to pay the membership fees, the scheme has the right to cancel your membership. The scheme will first submit a written notice to your employer that states that if the fee is not settled within a stipulated date, the scheme will cancel the membership.

Your contribution is normally based on your income and if in case you fail to claim for you scheme, you will not receive bonus since the medical act prohibits the bonus payment.

Different medical cover have different options according to the level you can afford. In terms of medical act, a medical scheme must provide a written notice to all members in case the contributions are increased. A medical scheme has the right to request for a pre- authorization in respect to certain benefits. Later joiner and waiting periods are the major restrictions that a medical scheme imposes on new applicants.

All info was correct at time of publishing