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Medical Aid Benefits: Who knows whats covered?

01 April 2007 Adrian Hoffman, Health & Accident

Most people are not experts either in the medical aid industry, the provisions of the Medical Schemes Act or medical terminology. But knowledge is power and can make a difference to the bottom line as far as the correct payment of benefits are concerned.

Generally, whether people select their own medical aid cover or join the medical scheme contracted by their employer, they are very seldom specialists in medical aids, the Medical Schemes Act, or the thousands of medical procedures, which may or may not be included in the medical aid limits or day-to-day benefits.

Constant changes

In addition, during the past couple of years, legislation regarding the maximum taxable subsidies, as well as the list of Prescribed Minimum Benefits (PMB), has changed from year to year. These various legislative changes, together with the changes made every year by each medical aid scheme, make life extremely difficult for the consumer. Although a medical aid broker may be extremely knowledgeable, they do not have an answer for every eventuality, nor can brokers vouch for both medical service providers and medical aid staff.

Ignorance is not bliss

There is an increase of instances in which members of medical aid schemes submit valid claims, only to have the claim rejected, restricted or paid from their daily benefit limit. For example, if a scheme has not set up or registered a specific Designated Service Provider (DSP), for either a specific treatment process, or in an geographic area, and the member is treated for a listed PMB, the scheme is obliged to cover the cost of the treatment by the private service provider.

In most cases, the member whose claim is rejected or restricted is unhappy, but accepting! This is often due to ignorance.

However, medical service providers are starting to get up to speed on the procedures (or conditions) listed under the PMB's and with the rules governing schemes. They are either directly approaching the member's scheme (on behalf of the member) or assisting the member in understanding the list of PMB's or rules in order that the member may take up the issue with their scheme.

It is reasonably easy for the medical service provider to obtain this knowledge, as it forms part of their daily tasks, whereas such issues are foreign to the member.

Not intentional

I do not believe the restriction or rejection of various claims by some schemes are intentional, but rather due to either knowledge or staffing issues. It appears that when the informed member or medical service provider queries the decisions by the various schemes, these are either rectified or, where necessary, authorisation granted.

The end result is that all the parties involved in healthcare are becoming more knowledgeable about the rules and regulations governing the industry. Brokers should advise their clients that when they require a procedure or treatment, they should check with the service provider as well as the list of PMB's, before querying the cover offered by the scheme, to ensure they receive the full cover offered by their elected medical aid scheme.

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