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Updated 08 August 2013

Schemes: the good, the bad, and the ugly

Last week we asked our users to write to us about their experiences with their medical schemes. As can be expected, what we got was the good, the bad and the ugly.

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Last week we asked our users to write to us about their experiences with their medical schemes. As can be expected, what we got was the good, the bad and the ugly. Here is a selection of what we received.

The good

Why schemes are in trouble

I have been a member of various medical aids for 50 years . The major problems I see now are over claming by members, fraud and dodgy practices by medical aids . Over -charging by medical practitioners and private hospitals and with a national medical aid on cards . Private medical aids will lose members . To overcome all these problems will require some very skilfull balancing . My suggestion is that medical aids employ highly skilled staff and not rely so much on computer generated out put . Medical savings paying real interest should be re introduced and be transferable from fund to fund.

(P. Tapscott)


Discovery good to me

As a Discovery member, I must say that even though they do not cover medication well at all, they have been exceptionally good to me – to date – (I almost want to cross my thumbs when I say this in fear of things changing).

I was a member for approximately 5 months when it was discovered that I require brain surgery and boy, was I panicked! Yet to my intense relief, Discovery stepped up to the plate and authorised the treatment and surgery – the differences I had to pay was mostly to the anaesthetist whose fees were frightening and for blood tests and radiologists who charge way over the 100% limit. All said and done,  with all its warts, bad medicine coverage and other little irritations,  when it came to taking care of me when it mattered most, Discovery has not yet let me down.


My suggestion would be not to nail the medical aid schemes so much as to regulate the rates certain medical practitioners insist on asking. Really, does it have to be that high?

(B. N)

The bad


Pensioner: high contributions

My husband used to work for Sasol (earning bout R45000.00 pm) and we belong to Sasolmed medical scheme contribution R4051.00 p/m no problem to pay the medical aid contribution, and pay anything between R800.00 - R1500.00 when collect our cronic medicine each month to chemist not covered by Sasolmed.

After retirement pension of R11000.00 p/m medical R4600.00 p/m and still to pay chemist between R800.00 and R1500.00 for cronic medicine not covered by Sasolmed.

How is it possible when you earn  R45000.00 pm your contribution is R4051.00 pm and when you on pension earning R11000.00 pm your contribution is R4600.00 pm ?

(M. K)

Spectramed, Discovery and a pair of glasses

At last someone who will listen to reason.  I agree that we need to be mindful and honest with our claims to settle legitimate expenses.

I am a very old member of Spectramed Medical Scheme, and  was very happy with the way my claims were settled.  That was when my husband, my dependant, was alive.  He cost the scheme an awful lot of money, being a heart sufferer and having to undergo many operations.  I hardly ever claimed on my behalf, as like you, I am very healthy.  I take no medication at all, and apart from the odd dentist and spectacles life goes very smoothly for me.

However, this year, Spectramed moved me to Discovery, and my bad luck started.  I fell flat on my face on the pavement in front of my bank.  This is South Africa, and all our roads, including pavements in our small "Dorp" are in disrepair. My 2013 glasses were scratched, mangled and had to be replaced.  

Discovery, not knowing that Spectramed allowed claims once yearly for glasses, settled the claim for new glasses. And I, not knowing that I would be moved back to Spectramed, was very relieved the claim was met.


To my dismay, when I was moved back I received a call from Spetramed claims department to let me know that the repeat spectacle claim for this year would not be allowed.  I assumed that as Discovery had received at least one month's contributions and would not be out of pocket, fairness would have prevailed.  I fell on my face, this was an accident and if I had broken a limb that claim would have been paid!

To cut a long story short,  Discovery are now claiming back the money paid for my glasses.  I feel like visiting a GP every month just to get even with the injustice of the whole episode.  After all, in this case, honesty does not pay.  GP visits and pathology tests for whatever will gladly be settled, but just don't have an accident and break your once a year glasses.

(H. K)

The ugly

Bonitas and a baby with cerebral palsy

My 11 year old daughter was diagnosed with Cerebral palsy at 18months. She underwent a botox procedure in May this year when we applied to my medical aid (Bonitas) for the PMB benefit for physiotherapy for at least one a week for her.


The Paediatric neurologist and the physiotherapist forwarded supporting motivation letters to them. Bonitas took weeks to respond; I had to persistently request feedback and eventually, they only authorized 12 sessions for the entire year for her!


I was under the assumption that medical aid scheme’s are under legal obligation to approve a PMB benefit under the Medical Scheme’s Act 1998.

(Simundree Abel)

 

 
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