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Benefits becoming a sticky issue

01 November 2013 Adrian Hofman, Health & Accident

There are numerous healthcare costs, conditions and procedures which are not covered by Medical Aid Schemes. Some of these are deemed subject to abuse while some are deemed to be bordering on cosmetic (elective) procedure, some of these procedures or conditions, appear to have no reason for either being restricted or excluded fully.

If one assumes the basis of insurance as regards the cover offered by a Medical Aid Scheme, one would imagine that the insurer (the Medical Aid Scheme) would firstly cover any unforeseen healthcare event and the costs related to such healthcare event. This may be questioned as we do have evidence that certain health conditions would manifest themselves in all of us at any given time.

Historical overview

However, if we look at history, most schemes have included restrictions on benefits as regards dental and optical benefits. These two areas of healthcare costs, and treatment, have always been subject to debate as to whether treatment is for the repair of a deteriorating condition, or whether the treatment results in an improvement of either teeth or vision, both from a functional perspective and from a lifestyle perspective. These aspects may be debated on a case by case basis.

Let us, however, look at other aspects of healthcare treatment that generally follow unforeseen healthcare conditions, yet they are restricted, or excluded, from cover with many schemes.

Trauma counseling generally only results from an event which triggers such treatment. This may be anything form a motor vehicle accident, a home invasion or an armed robbery. Yet most schemes will restrict the cover for trauma counseling by either specifically limiting the number of sessions, or by utilizing the cover to the savings available in the member’s scheme option. This type of treatment is clearly not an abusive aspect of healthcare cover, yet is generally limited.

Internal or external prosthesis is often a restricted benefit and a much debated issue. An internal prosthesis should not be viewed as elective as few, if any, members would want to choose which prosthesis fits them the best. An external prosthesis (prosthetic limb) capable of allowing the member to continue to live a similar life to what they enjoyed prior to the incident leading to the fitment of a prosthetic, may be costly. However, if the scheme does not fully cover the costs, how does the member insure against such possible costs?

Prosthetic limbs may well be expensive, but a member cannot be expected to end up with a rigid prosthetic which does not offer mobility. One cannot expect the scheme to fund various prosthetic limbs for different activities such as blades for running, as well as different prosthetics for general walking.

Splitting hairs

Many schemes refer to disease management, yet split benefits into hospitalisation benefits and those benefits covered from a day-to-day basis. Should cover not be rated per disease or incident and be covered from start to finish? For example, if you break your leg and require pins to be inserted, the costs for in hospital treatment are generally covered, but the follow up costs generally come from savings, or are restricted. The member will require crutches, yet generally the cost of crutches will come out of savings. If your leg has been immobilized for some weeks, it is expected that the member will require physiotherapy. Physiotherapy sessions may be ongoing, yet the benefit may be restricted by many schemes. The member will also require the removal of the stiches, removal of the cast and the re-application of the cast, all of which must be funded by the member.

Another benefit that often is restricted is that of a wheelchair and related costs. If, for instance, the member, aged 70, required a wheelchair due to a medical condition, it is unlikely that a 70 year old member is able to power the wheelchair themselves.

The above medical conditions are not always covered by a medical scheme, yet seldom is the member able to buy additional cover to cover some of these shortfalls. The reality is that top-up cover or gap cover remains essential over and above your client’s medical scheme.

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