Match­ing needs and ben­e­fits

How to choose the right scheme for you

Finweek English Edition - - Creating Wealth - SHAUN HAR­RIS

ASK SOME­ONE about his med­i­cal scheme and in­vari­ably there will be com­plaints. Health­care cover is es­sen­tial – but can also be ex­pen­sive and seem­ingly low on ben­e­fits. Po­ten­tial new mem­bers choos­ing a scheme have many as­pects to con­sider. There are va­ri­eties of rea­sons why schemes at times don’t seem to ben­e­fit their mem­bers, says Dr James Arens, clin­i­cal op­er­a­tions ex­ec­u­tive at Pro Sano med­i­cal scheme.

Says Arens: “Both mem­bers and ser­vice providers usu­ally have one stan­dard ex­pla­na­tion which is: ‘The scheme doesn’t want to pay.’ Mem­bers who feel they’re be­ing un­fairly de­nied ben­e­fits can re­port such schemes to the Coun­cil for Med­i­cal Schemes, which will nor­mally make a rul­ing on the mat­ter fol­low­ing a thor­ough re­view with in­put from both par­ties.”

But if pos­si­ble it’s prefer­able to avoid that has­sle and make sure you’re in the med­i­cal scheme that’s right for you and your fam­ily. Arens says mem­bers of­ten don’t un­der­stand the prod­uct they’ve bought, leav­ing the im­pres­sion they’re be­ing de­nied ben­e­fits. “Schemes and bro­kers are to blame for not clearly and con­stantly com­mu­ni­cat­ing the fea­tures of the prod­uct. Sim­i­larly, mem­bers are to blame for not ac­tively at­tempt­ing to un­der­stand the prod­ucts,” Arens says.

But if the scheme doesn’t serve the mem­ber’s in­ter­ests they can opt out and look for an­other scheme. How­ever, Arens cau­tions there may be penal­ties and/or un­der­writ­ing ex­clu­sions if the mem­ber has been with the pre­vi­ous scheme for less than two years.

Choos­ing a med­i­cal scheme can be com­plex. Arens of­fers a guide: should in­clude your ben­e­fi­cia­ries. Your doc­tor can as­sist and will in­vari­ably take a detailed fam­ily his­tory to de­ter­mine if there are any in­her­i­ta­ble dis­eases you may par­tic­u­larly be at risk for. It’s im­por­tant those con­di­tions be hon­estly rep­re­sented on the ap­pli­ca­tion form. If a scheme es­tab­lishes there was de­lib­er­ately no dis­clo­sure it may refuse to pay for that claim, sus­pend or ter­mi­nate mem­ber­ship. The scheme may also list such a mem­ber on the in­dus­try’s data­base. scheme. Sat­isfy your­self that all se­ri­ous and ex­pen­sive med­i­cal con­di­tions are funded by the scheme. “It’s es­sen­tial to en­sure hos­pi­tal­i­sa­tion costs are funded com­pre­hen­sively and that there are no sig­nif­i­cant co-pay­ments,” Arens says. Po­ten­tial mem­bers should look for value in the de­sign of a med­i­cal scheme op­tion. “The ben­e­fits in a tra­di­tional med­i­cal scheme op­tion are paid from ei­ther the risk pool or the sav­ings ac­count. Be­cause mem­bers are of­ten not well equipped to man­age their sav­ings it’s there­fore not sur­pris­ing those sav­ings don’t see them through all their needs. Arens says that’s fre­quently a source of con­flict be­tween the scheme and the mem­ber. You may want to use a bro­ker fa­mil­iar with a range of med­i­cal scheme ben­e­fits to match your needs. scheme. A scheme’s fi­nan­cial sta­bil­ity can be as­cer­tained by en­sur­ing its sol­vency lev­els are above the re­quired 25%. scheme, which is the scheme’s claims’ pay­ing abil­ity. The claims ra­tio also gives a good mea­sure of the scheme’s op­er­a­tional ef­fi­ciency.” Arens says a scheme un­der fi­nan­cial stress may un­ex­pect­edly al­ter its ben­e­fit struc­ture in a way that may com­pro­mise you and your de­pen­dants. “Ser­vice providers may get ner­vous with a scheme un­der fi­nan­cial dif­fi­culty and de­mand pay­ment up­front from mem­bers.” de­ter­mine the prod­uct you buy. “Draw a re­al­is­tic fam­ily ex­pen­di­ture bud­get be­fore ap­proach­ing a bro­ker. The health in­sur­ance por­tion of the bud­get will as­sist you and the bro­ker in terms of what level of cover you can af­ford. Schemes may sus­pend mem­bers in ar­rears,” Arens says. down to a short­list of about three med­i­cal schemes you think are right and you can then con­tact them di­rectly for fur­ther in­for­ma­tion. “It’s al­ways worth your while check­ing with your lo­cal ser­vice providers and get­ting their im­pres­sion of the med­i­cal scheme and what their work­ing re­la­tion­ship with the scheme is like.” Arens says des­ig­nated ser­vice providers (DSPs) may be as­signed to ren­der cer­tain ser­vices. Check those DSPs and which ser­vices the med­i­cal scheme engages them in. “Mem­bers have a re­spon­si­bil­ity to choose the scheme care­fully and to keep them­selves up to date with the ben­e­fits of the scheme.”

Fol­low­ing the five points above should help any­one looking for a new med­i­cal scheme. It may take time and ef­fort but the end re­sult will en­sure you and your fam­ily have cover you can af­ford and the ben­e­fits you need.

Re­port schemes.

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