As a member of a medical scheme, you have both rights and duties. What are these and how does the Medical chemes Act 131 (1998) affect you?
You have a right not to be unfairly discriminated against on the basis of your:
Race
Age
Gender
Marital status
Ethnic or social origin
Sexual orientation
Disability
State of health
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You may join a medical scheme of your choice, as long as you can afford it and provided your employer does not require you to join a specific scheme.
But remember: The scheme must be registered with the Council for Medical Schemes - or you may not be able to enforce your rights.
Your dependants have the right to be covered by your scheme.
A “dependant” is defined in the Medical Schemes Act as:
Spouse/partner
Children under 21 who are dependent on you
Children over 21 who are financially dependent because of a disability
Your mother, father, brother or sister, if you as the member are liable for their care and support
In certain other cases individuals can be recognised as dependants in terms of the scheme's own rules
Dependants have the right to continue membership of the scheme.
If the principal member dies, dependants must be covered until they choose to leave the scheme, join the same scheme in their own right, or join another scheme, as long as they can afford the contributions.
Your medical scheme may not charge you more because you are older or sicker. Variations in contribution rates may only be based on:
Income and
Number of dependants.
However, if you are joining a medical scheme later in life, for the first time, you may have to pay more.
All Medical Schemes have to provide a basic set of benefits known as Prescribed Minimum Benefits – PMBs. And these will be extended to cover many chronic conditions in 2004.
If your condition is covered as a PMB (eg. many cancers) the treatment may be given in a public hospital, but all the costs, diagnosis, treatment and care must be paid for by your scheme.
From 2004 when the benefits are extended there will also be restrictions on where treatment can be offered. Your scheme will not be allowed to force you to go to a hospital which does not offer the necessary treatment.
Your scheme must pay claims timeously.
Your medical scheme must repay valid claims within 30 days of the claim being received.
You have the right to receive regular statements.
In addition to paying an account, a scheme must furnish you with statements detailing:
Name of supplier (doctor, hospital, pharmacist etc.)
Date of service rendered
Total amount charged
Amount of benefit paid
You have the right to resubmit a claim if the scheme has not paid a valid claim.
If a medical scheme believes that an account or claim is incorrect or unacceptable, it must:
Inform you within 30 days, giving the reason for declining the payment, and allow you to resubmit the claim. You have a right to participate in the way your scheme is run.
At least 50% of the members of a scheme’s board of trustees must be elected from among scheme members.
Annual general meetings must be held, at which members may voice opinions, ask questions and present motions.
You have the right to information about your scheme.
You have the right to advance notice of changes in:
Contributions
Benefits, or
Any other changes affecting membership.
You have the right to confidentiality of medical information.
Your scheme must keep information strictly confidential about the diagnosis, treatment and health status of you and your dependants.
You have the right to obtain proof of membership.
A scheme must issue to each member written proof of membership including:
Date of entitlement to benefits
Details of any waiting periods
You have the right to complain if any of these rights are not respected or if the service is deficient in some other way.
If you have exhausted all avenues of complaint at your scheme and its disputes committee – you may take it up with the complaints department of the Council for Medical Schemes or appeal directly to council if unhappy with the findings.
B. You have a duty to do the following things
Be honest and open with your scheme. If you are found to have provided false information, you may lose your membership. If you act illegally, criminal charges may be laid against you.
Do not submit fraudulent claims e.g. boosting the amount claimed for, or claiming for sunglasses and toiletries or other items not strictly allowed by your scheme.
You must disclose any material information about your health asked on application to the scheme.
Pay contributions (timeously).
Contributions must be paid directly to your medical scheme.
C. Limitations on member rights
Some rights can be limited in the rules of the scheme.
Scheme rules may restrict benefits covered and limit amounts payable on items not covered by the Medical Schemes Act, its regulations and the prescribed minimum benefits. Some schemes, for instance, limit dental or optometry benefits. Some options within schemes can cover 100% on all benefits, while other options within the same scheme may cover less.
Some schemes may require you to get their authorisation before undergoing certain procedures. This and other similar cost-saving interventions are known as “managed care” and may be applied – but must be contained in the rules of the scheme.
If your scheme has contracted with certain hospital groups, doctors or pharmacists for services, it may direct you to these – but this must be contained in the rules of the scheme.
A scheme may refuse to pay a claim that is submitted 4 months after:
The last date of service rendered, as stated on the account, or
The date on which the account was returned for correction.
Neither members nor their dependants may belong to more than one scheme at a time.
No person may:
be a dependant of more than one scheme e.g. a child cannot be registered on both parents' medical schemes
claim against more than one scheme. This can be regarded as fraud.
Schemes may restrict changes between options to the beginning of a year. Schemes may ask for adequate notice before changes are made.
Waiting periods and late joiner penalties may be imposed under certain strictly limited circumstances.
On admission to membership a scheme may impose a:
3-month general waiting period
12-month waiting period for a pre-existing condition, or
Waiting period on certain PMBs
Except:
A child born to a member
Change between benefit options
Termination of membership due to employment or employer changing schemes.
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