It’s a crying shame how medical aid treated new dad
The Council for Medical Schemes appears to have a big job – it regulates 76 medical schemes, 19 administrators, 41 managed care organisations, 1,078 broker organisations and 6,053 individual brokers.
According to its 2019/20 annual report – released two months ago – in that financial reporting year, 8.9 million scheme beneficiaries “looked to and received protection from the CMS through its various regulatory activities”.
That’s the total number of members of all medical schemes in SA and all their beneficiaries, so clearly the report was referring in sweeping terms to the watchdog role it serves rather than the extent of individual protection it offered.
Last year was a particularly torrid one for the CMS: its chairperson, Dr Clarence Mini, died after contracting the coronavirus in March, and his replacement, Prof Lungile Pepeta, died in early August, also after contracting the virus, just two months after his appointment.
As if that weren’t bad enough, seven CMS executives and managers were suspended with full pay while being investigated for “improper and corrupt” conduct.
That led to a resignation, a termination and two hearings, the outcomes of which are still pending.
The council made it clear in its report it didn’t believe it got enough funding from government, on top of the bulk of its income, which it receives from beneficiaries, via the schemes.
“We were allocated a budget of R174m in 2019/20, and yet we regulated entities that collected in excess of R192bn in member contributions that year,” the report states.
Yet government funding of the CMS has increased year on year.
All of which brings me to Capetonian Jens Herf’s experience.
The Medical Schemes Act clearly states no medical scheme may apply exclusions and waiting periods on the cover of a baby born to a parent who is already a member of the scheme.
But when a daughter was born prematurely at 27 weeks to Herf and his partner last March, his medical scheme, Genesis, sought to do just that, even going as far as to question the paternity of the child.
Herf lodged a complaint with the CMS, and in May that body’s registrar ruled in his favour, directing the scheme to admit the child and cover her medical bills.
The ruling was fairly damning of the scheme:
For example: “With regard to the [scheme’s] unfounded allegations regarding the child’s paternity, we find it concerning that the scheme elected to descend to such levels as to question the paternity of the baby without any shred of evidence.
“Even more appalling is that the scheme considers its discontent with the child’s paternity as a legitimate reason to discriminate against the baby and refer to her as illegitimate.”
But the baby still can’t be registered with the scheme because it has appealed the decision.
Asked to comment, Genesis said at the time: “The matter is currently subject to an appeal and therefore sub judice. As a result of the appeal, the registrar’s ruling is suspended and of no force and effect. Any discussion at this stage may therefore be premature.”
Herf was assured by the council that the appeal would be held “in the next round of appeals” in August due to the urgency of the matter, but his case was not among August’s CMS appeal hearings.
So, seven months on, that appeal has yet to take place, and the service providers Herf initially managed to keep at bay regarding payment, given the pending appeal, have now run out of patience and are demanding payment.
The CMS has told him: “We will only be able to resume with appeal hearings from April 2021.
“The matter is beyond our hands as we await our budget to be approved by government.”
Herf, understandably, is incensed.
“Medical schemes are able to completely exploit the CMS process, as they know full well they will get away with it.”
I emailed the CMS, querying the funding issue, asking how much money was lost to those corrupt senior employees, and to what extent that – and them being suspended on full pay – affected the council’s ability to hold hearings in sufficient numbers.
I also asked how many Herfs there were on hold for appeals against CMS rulings in their favour.
On Friday, February 12 – two weeks later CMS responded with a timeline of events in the Herf matter, followed by: “Hearings were suspended due to national lockdown and Covid19. The hearings resumed in August 2020 [no explanation for why Herf’s was not heard in that round, as promised].
“The CMS endeavours to deal with all appeals as swiftly as possible and assures all members with pending appeals hearings that their matters will be dealt with from April 2021.”
Justice delayed is justice denied.
That open-ended “from” is concerning. As is the council’s failure to respond to any of my questions.
Asked again to comment this week, Genesis marketing manager Elmarie Jensen said: “We are unfortunately unable to comment, as the matter is still subject to an appeal and therefor sub judice.
“All of our rights in law are reserved.”
To be continued ...