How you should select a scheme that offers appropriate benefits

January 26, 2015

When you select a scheme, first ensure that the medical scheme is registered in terms of the Medical Schemes Act. The addresses, telephone numbers and names of the registered medical scheme appear on the medical scheme council website.

For general information, the list of all registered medical schemes is published in a government Gazette annually. You should request information about exclusions, benefits, limitations and contributions. If you are using an agent, you should ensure that the Council for Medical Schemes has registered the broker. Ask for proof of accreditation from the broker or the Council.

Select a SchemeTo avail yourself in a financial position, you should request for the latest annual report and financial statements of the medical scheme. Select your benefit option according to your finances and according to your healthcare needs. To make an informed choice, obtain the rules of the scheme thus you will be able to verify all the relevant information. In case of any change of your medical scheme contribution or benefits, you will be notified through a written notice.

Select a Scheme – Types of waiting periods

“Waiting period” is the period tjat a new member of the medical scheme contributes without receiving any benefits. Generally, there are two types of waiting periods, waiting period of up to one year and waiting period of three months. Waiting periods do not apply when a member switches between options. That is, unless:

  • the member has agreed to complete the remaining period imposed
  • a child is born during the membership period
  • where a member changes the scheme due to change of employment and
  • when the employer changes the scheme of his employees.

 

If you are more than 35 years of age and you have never joined another scheme,  a late joiner penalty will apply. If your employer is the one who pays your scheme contributions, supply a written notice to that effect. This is so that if he fails to pay the contributions by the due date, your membership will still stand.

Select a Scheme – Prescribed minimum benefits

Under the medical act, prescribed minimum benefit refers to the benefits in respect to designated service provider, health services or state hospitals. There are no restrictions to prescribed minimum benefits. In respect to prescribed minimum benefits, exclusions, copayments and waiting periods might be applied.

Complaint against your scheme

If you are not satisfied with a decision made by your scheme, you should submit a written complaint since any complaint is usually lodged by the scheme concerned. Many medical schemes have telephones to handle enquiries and complaints. Many medical schemes have independent disputes committee who settles the members’ disputes. Legal representatives and members of the scheme attend the disputes committee meetings in order to present their arguments and settle the matter. If your medical scheme has failed to resolve the issue, you can submit it to the Council for Medical Schemes.

All info was correct at time of publishing