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Medical aid benefit restrictions: Keeping brokers on their toes

01 October 2010 Adrian Hofman, Health & Accident

Medical aid schemes have all introduced numerous restrictions on selected procedures in order to control costs. Since these vary between schemes and even between options within the schemes, “best advice” with regard to the right medical aid option requires more time and effort than ever before.

To control soaring medical costs, all medical aid schemes have introduced restrictions and limits on certain procedures, treatments and benefits. While this is understandable in light of the sustainability issues faced by medical schemes, the problem arises when these restrictions are not highlighted at the time when a client selects a medical scheme option. This means that most members only understand the implications of the restrictions and limits when it is too late.

Extensive restrictions

Just a few examples of some of the restrictions that are applied include:

• a co-payment/excess for every hospital visit
• a co-payment/excess for a list of defined hospital procedures
• restricted benefits for prosthesis
• restricted benefits for organ transplant
• restricted benefits for chronic treatment
• restricted benefits for cancer treatment
• limited optical benefits
• limited child birth benefits
• limited overall hospital benefits.

The restriction and limits applied differ from scheme to scheme and from scheme option to scheme option. This means that healthcare brokers providing best advice to their clients need to be on their toes to ensure they can provide a thorough “apples-for-apples” comparison of the various options.

Extensive knowledge

Since a broker cannot possibly know which restrictions may affect a client or a client’s family, it is crucial that the client understands the restrictions and limits that apply to each of the scheme and option choices considered.

But best advice extends beyond simply reciting a list of restrictions and limits. How many clients know a prosthetic leg or an organ transplant costs? How can a client make an informed decision regarding whether the option will provide adequate cover if they do not know whether the cost of the procedures, treatments and benefits falls within, or well over, these restrictions?

It’s about choice

If a client does not fully understand the differences between the various medical scheme options, how can they make an informed decision? Without complete information and a thorough comparison highlighting the most suitable option, it is inevitable that a client would simply opt for the cheapest option.

The ideal is, of course, for the client to select the best and most comprehensive option, but this, by definition, would also be the most expensive. As with all our other insurance needs, consumers need to be prudent when selecting medical scheme options.

Going the extra mile

A professional broker should also be able to suggest alternative solutions to the best, most comprehensive and most expensive option. Perhaps an extension of an existing life policy will cover some of the restrictions and limits imposed by a medical aid scheme option? Of course, a life policy extension will not cover the insured’s dependents. Maybe a dread disease policy will address the medical scheme option limits on an organ transplant? Perhaps a disability policy will provide cover for a limb prosthesis? Or perhaps a health insurance policy can address some of the excess/co-payment requirements?

There is more to comprehensive healthcare cover than simply choosing a medical scheme and option, and “best advice” requires healthcare brokers to take a holistic view of their clients’ existing cover and crafting solutions that will provide real financial protection.

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