As a medical scheme member, you rely on your scheme to play by the rules. Here are some things which they cannot do.
10 Things your medical aid cannot do:
- Turn down your application – no medical scheme my refuse a member. They may not refuse you on race, culture or conditions. They may impose penalties and waiting periods.
- Refuse to accept a dependant of yours – as long as you want to add a valid dependant, no medical aid may refuse to add a dependant. This would include a spouse or a life partner, children under the age of 21, a child of any age with a mental or physical disability, or any immediate family members who are financially dependent on you provided you have legal guardianship. This includes any parents who are dependent on you, but they can be required to pay full adult membership contributions.
- Cancel your medical aid – They may cancel if you fail to pay contributions, fraud or non declaration.
- Force you to use network doctors or hospitals unless you have selected a network option– using certain doctors or hospitals may avoid co payments and member portions but no medical aid can force you to use a certain medical provider.
- Change benefit options or contributions in the middle of the year – this may be done at the end of the year or in a life changing event. However certain schemes may allow an upgrade or downgrade with the correct motivation.
- Give pensioners a contribution discount – no pensioner may qualify for discount because of their pensioner status.
- Load your contributions if you are a high risk or high claimer – this may be done by short term insurance companies but not by a medical aid scheme.
- Not pay for prescribed minimum benefits – every medical aid scheme according to law and the medical schemes act must pay for prescribed minimum benefits. There are 270 conditions. You however have to use the scheme’s designated service provider. If you move between schemes or have a break of longer than 90 days between schemes then you will not qualify for PMB cover in your 3 month waiting period or exclusions on pre-existing conditions
- Pay out medical savings as cash – The only time a medical scheme can pay out the money is when you have resigned as a member from the scheme. You can still submit claims for four months after you have resigned your membership. You will have to wait until that time is over before the money is paid out to you.
- Wait more than 30 days to pay out a claim – if a medical aid claim is submitted with all the required information, the scheme only has 30 days to process and pay.