Updated 14 December 2015

12 ways to tell if your medical scheme is good

It is difficult to have a full grasp of all the ins and outs of any medical scheme. Rules change, benefits change, contributions change. So how do you tell if yours is a good one?


Most people don’t scrutinise their benefits extremely closely – that is until they need them. Don’t wait until then before you take a closer look. Do so today.

Read: What you need to know about PMBs in 2016

Here are a few ongoing things by which you can judge how efficient your medical scheme is, and whether it is the right one for you:

1. Regular information updates

Your scheme should communicate with you regularly and efficiently, and keep you up to date with benefit and contribution changes. Whether you receive this information by e-mail or post, it is important to read it.

2. It’s easy to contact them

If your scheme has a call centre, is it a major mission to get someone on the line, or do they answer the phone within a minute or two?

3. Does the consultant know the answers to your questions?

It’s a good sign if the consultants are knowledgeable and well-trained and can deal with your query. If it’s complicated, they might have to escalate it to a supervisor, which is still fine, but a sign of inefficiency is when you find yourself telling the same story over and over again to different people who don’t seem to know what to do.

4. The claims process is quick and easy

Whether you are scanning and e-mailing your claims, putting them in specified boxes (in some workplaces, for example), or sending them by fax or mail, the scheme acknowledges receipt of your claim and puts the process in motion.

5. Your claims are paid within 30 days of receipt

The Council for Medical Schemes queries claim payments which take longer than this. But that doesn’t mean that all schemes adhere to this.

Read: 20 claims medical schemes don’t have to pay for

6. Pre-authorisation is easy to obtain

Before you can go to a hospital (unless it is an emergency), you need pre-authorisation from your scheme. Is this easy to obtain, or does it require an endless and exhausting process?

7. Your scheme is financially sound

That means it has 25% of the contributions in reserve and there is no imminent danger that it would suddenly go under. Financial details are available on request from the scheme. It also means that the scheme is alert to members who might act fraudulently, thereby having a negative impact on all other scheme members.

8. You have a clear picture of what the scheme will pay for

No scheme has unlimited benefits – and many private consultations outside-of-network doctors or hospitals can result in a co-payment from your side. Co-payments as such are sometimes unavoidable if you use non DSPs, but the important thing is that you should have a clear picture of what your scheme will pay for. Well-written and clear benefit brochures will give you that.

9. Their online systems work

If you’re standing at the pharmacy waiting for prescription medication, you want your scheme’s online systems to work so that payment can be approved.

10. The scheme encourages members to get involved as trustees

If you have no idea who the trustees of your scheme are (OK, it’s your fault if the scheme sends info and you don’t read it), and have never been encouraged to nominate or vote for someone, it might be a problem. Take the time to attend scheme AGMs. Your contribution might be valuable.

11. Your scheme is there for you when you really need them.

If you’ve been in an accident, or you have a medical emergency, you need your scheme to be on your side. The last thing you want to worry about when you have a broken leg, is whether your bill will be paid for. Small co-payments one can still deal with, as long as the lion’s share of hospital bills are paid.

12. Huge contribution increases and slashing of benefits.

Medical inflation is higher than normal inflation, and in order to stay afloat, schemes often have to introduce a higher than usual contribution increase, and rein in benefits. That is not unusual. But if your scheme’s contribution increases are higher than the industry average for a few years in a row, it might be time to look around for something else.

Read more:

The best medical aid in SA

SA medical service providers are overcharging

Patients vote on SA’s best hospitals


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