Matching needs and benefits
How to choose the right scheme for you
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.