Knowledge is power in the fight for consumer rights in health industry

The introduction of the National Consumer Commission (NCC) has been hailed as a coup for consumers in the fight against abuse by medical aid providers – but its success will depend on consumer vigilance, experts have warned.

The consumer watchdog was established in 2011, following controversial reports of unlawful behaviour by several of the country’s top health insurance providers.

Sparked by consumer complaints, an NCC investigation branded the terms of these schemes “unlawful and unconstitutional”, revealing that the country’s five biggest medical aid providers were in violation of at least eight provisions of the Consumer Protection Act, introduced in April 2011.

But the fight isn’t over, healthcare experts warn. Now, consumers have more rights than ever before, but these rights come with responsibilities.

Too often, consumers feel victimised when they suddenly find themselves under-covered for specific illnesses, treatments and procedures, says David Eedes, Clinical Advisor for the Independent Clinical Oncology Network (ICON) an organisation that is seeking to empower patients and broaden access to quality cancer care in South Africa. Eedes notes that many complaints have centred around consumers’ inability to understand fully the terms and conditions of their medical coverage.

“There is no excuse for having the wrong kind of cover. Medical schemes offer their clients, annually, the chance to review their contracts and to make changes if need be,” he says. “Unfortunately, when we receive these letters or brochures in the post, we more often than not tend to ignore them and then we are surprised when we are not covered for this or that when it arises.”

These letters, carrying news of tariff changes and new cover options, amendments to existing options and basically all the aspects of the contract with the client, can be complex and confusing to digest.

“Because they are difficult to understand, people focus only on how their monthly payments will change. But there are so many things one needs to look out for and consider,” Eedes says.

By law, all contracts must be in plain and simple language, but the responsibility falls on consumers to take the time to read these contracts and properly understand them, even if this means going through other channels, he believes.

This is a view echoed by representatives of the insurance industry. In a statement issued by Insurance ZA, consumers were reminded that engagement by consumers was the key to cementing better service by medical aids. “Regardless of whether … exemptions to the Consumer Protection Act are granted to medical schemes, the principle of engaging members on real pain areas should be regarded as a positive step,” the statement read.

Industry experts have offered the following top tips for ensuring consumers get the most out of their medical aid schemes:

- Read the fine print. Pay attention to the limits for specialised drugs and whether the scheme has a designated service provider.

- If you can’t understand the contract, then talk to a broker who can better explain it to you. Most schemes have a toll-free number you can call (and the Act stipulates that assistance should be given within a reasonable time frame).

- Know your risk of certain critical illnesses and know what is important to cover for at your stage of life.

- If you’ve been diagnosed with a critical illness like cancer, consider changing to a higher option that will give you more financial cover. The temptation is to drop to a lower option as it costs less, but this will only leave you under-covered.

- If diagnosed, rather than switching service providers, take a higher option. Switching service providers after being diagnosed is complicated and there is a period where you may not be covered at all.

- Always keep your affairs in order. File away all important documents so that they can easily be retrieved. Life insurance policies, for example, often go forgotten and one might be able to claim for dreaded disease cover which goes a long way in affording costly treatments and procedures.

- Be critically aware of all things relating to your cover. Be careful to keep abreast of what is being billed to medical aid and always check whether some procedures are necessary, look for alternative treatments or second opinions.

- Keep an eye out for unnecessary billing and make sure that your scheme is paying what was agreed upon.

“The important thing is to realise that as individuals we are all responsible independently for our own wellbeing,” says Eedes. “When it comes to medical aid, one can’t assume things are just going to work out. Unfortunately it doesn’t work like that.”

Over the next decade or so, National Health Insurance is set to be phased in, providing all citizens with basic coverage, with optional “top-up” policies via private schemes for specialised treatment. Either way, medical schemes will still play a major role in medical cover and, if consumers are to guard against unscrupulous treatment by health insurance providers, they need to take responsibility for knowing their own rights – and when and how to fight for them.

The rhetoric around the new consumer act is one of revolution, where consumers have had to make their voices heard above fine print and direct marketing. And now there is the National Consumer Commission, the consumer revolution vanguard, trusted to protect and serve consumers. That is great for consumers, says Eedes, but doesn’t detract from the fact that one must stay vigilant and responsible for one’s own actions and decisions.

“The problem is that we live in a society where many people feel they are owed something. This entitlement mentality is what leads people to trust too easily and to ignore information they need to properly defend their rights,” he says. “People owe it to themselves to stay well informed so as to make the best decision for their family’s health and finances.”