Polishing first impressions

01 November 2016 Elmarie Jensen, Genesis Medical Scheme

People join medical schemes for no reason other than that they want assistance in paying medical bills.

So let’s face it - private healthcare may be seen as a grudge purchase; a colossal one. Especially to those members who pay their monthly contributions but hardly ever experience the immeasurable benefit of financial cover in the event of big accident, illness or disease.

Meeting expectations

Generally speaking, members are happy when claims are settled in line with expectations. The only time they contact their scheme is to obtain a tax certificate or to update personal details.

However, from time to time, members find themselves in the dire situation where bills are not paid - either partially or in full; and then they complain – loudly and publicly. Complaints fly around on social media, some make their way to Hellopeter and some are formally lodged with the Council for Medical Schemes (CMS).

According to the recently published annual report from the CMS, only around 28% of the complaints received were found to be valid.

Does this mean that members whose complaints were found to be not valid, suddenly had a change of heart and became happy members because they were in the wrong? This is highly unlikely...

Profiling complaints

Medical scheme related complaints, generally speaking, can be channeled into two main categories, namely benefits related complaints and service related complaints.
Trying to resolve benefit related complaints is probably one of the most difficult areas in striving for member satisfaction in any medical scheme call centre environment. This is because the member, in all likelihood, was never familiar with his exact benefits and the scheme rules to start with.

The contract between the scheme and the member are the rules of the scheme which are binding on all members. Claims that are short paid or rejected are assessed according to the benefits – or limitations thereof – set out in the rules and are not based on the subjective assessment of a claims assessor.

Neither wild or slanderous accusations when claims are not paid, nor the most fantastic call centre staff, can change the outcome of these types of complaints. The responsibility of understanding membership terms and conditions will always remain that of the member. It cannot be shifted to the medical scheme or another third party.

Service related complaints

Service related complaints are driven by predominantly service expectation, perceived quality and perceived value. In this instance, the paramount importance of call centers can never be underestimated.

Competent staff should be taught that unsatisfactory service cannot be replaced or repaired. Irrespective of whether members’ complaints are valid or not, their biggest needs are to be heard and understood. They also need to be given timeous, accurate and consistent feedback.

Dealing with reality

All members are supposed to be familiar with their scheme rules, but the reality is that they are actually not familiar with it. Most members, however informed they may be, do not know – and do not care – about scheme rules, solvency ratios or the Act.

All they care about when they make a call to their scheme is:

• to find out why a claim was not paid;
• to obtain authorization;
• to enquire about benefits for a loved one; and
• to register chronic conditions.

Good service from call centers is about how they make their members feel during that call. Even though members’ claims or demands may not be valid, it is an unforgivable sin to ignore, mistreat or belittle members.

Call centers should continuously strive to maintain the human touch in all the elements of their member interaction. Members don’t want to talk to machines and they don’t want to be ignored. They want to be treated with dignity and respect.

Quick Polls


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