With the South African public healthcare system in disarray and most South Africans struggling to save, medical aid schemes ensure patients get the necessary treatment on time. MARISKA MORRIS reports
The South African public healthcare system is synonymous with poor service, long queues and a lack of both resources and staff. The 2018/19 Annual Inspection Report by the Office of Health Standards Compliance (OHSC) cited 308 healthcare facilities in South Africa as non-compliant, and 224 facilities as critically non-compliant.
According to Dorothy-Anne Howitson, vice-chairperson of the National Centre for Persons with Disabilities (NCPD), the waiting period for a wheelchair in 2016 was three years, with 957 people on the list. On average, 70 new applications for a wheelchair were received each month.
Between May 2015 and June 2016, approximately 301 patients’ names were removed from the list – in most cases because they had passed away. Howitson believes that their immobility was the main reason for these deaths.
Although private healthcare offers a great alternative to the questionable conditions of some public hospitals, it is often much more expensive. South Africa doesn’t have much of a saving culture. Most people can’t afford to pay medical expenses out of pocket or from their savings.
Medical aid schemes assist people to access crucial healthcare facilities, including assistive devices, at a more affordable price. Sandra Gessner, healthcare consultant
at SELA Brokers, offers some insights into choosing a medical aid.
Read the fine print
“Look at the plan that will provide for your needs,” Gessner advises. “Consider the benefits and not the cost. Selecting a suitable medical aid scheme and plan requires careful research and an understanding of all available benefits. Generally, you can make changes to your plan only once a year.
“You need to decide what you require. Do you want a hospital plan, which covers only in-hospital expenses, or a hospital plan with medical aid savings to pay for your day-to-day medical expenses? Do you require chronic medication or oncology benefits?”
Not every plan covers all specialists, services, assistive devices and medication. As a rule, the more expensive the plan, the more is covered. A basic medical aid scheme, for example, might only offer a small contribution towards a wheelchair. This might not be sufficient if the wheelchair user requires a specialised wheelchair and cushion.
If cost is a big concern, Gessner recommends ensuring that your hospital costs are covered as a priority. A disability could result in related injuries that require hospital visits. A wheelchair user, for example, might suffer a pressure ulcer or a serious urinary tract infection, or need shoulder surgery.
Medical aid schemes calculate costs for doctors and specialists according to a medical aid rate. However, some medical practitioners charge more than this rate – even up to 400 percent more, which can easily run into the thousands. The patient will be liable for the shortfall. However, some medical aid plans cover up to 300 percent of the medical aid rate.
Gap cover is available to assist with any in-hospital costs that are not covered by the medical aid. This is particularly useful if a doctor or specialist charges more than the medical aid rate.
Medical aid savings cover most out-of-hospital and day-to-day expenses like doctor’s visits, dentistry, medication, blood tests and optometry.
The scheme will determine the total amount of savings that may be claimed. When the savings are depleted, expenses need to be covered out of pocket.
“Some plans, however, have a threshold benefit that will cover bills that are within the medical aid rates after you’ve gone through your self-payment gap,” Gessner says.
In addition to the amount of savings and the hospital cover, consider what conditions are covered by the plan. Most medical aid schemes will provide cover for cancer and multiple sclerosis, for example. Depression, a condition that affects many wheelchair users, and rehabilitation for drug and alcohol abuse are often not covered by basic plans, but might be included in executive medical aid schemes.
How to stretch your savings
“Use network providers that charge medical aid rates. Request that the medical aid scheme pay all your claims at medical aid rates and not at cost. If possible, pay for all over-the-counter medication and medication up to schedule three from your own pocket and not from the medical aid savings.
“Apply for a chronic illness benefit if you have a chronic condition. With this benefit, all chronic medication will be paid from the chronic illness benefit and not from your medical aid savings,” Gessner explains.
Cheaper generic substitutes may be available for certain medication. Discuss potential alternatives with your doctor or the pharmacists at your local dispensary. Be sure not to substitute chronic medication, though, as this might affect your reaction to the treatment. Also, ensure that the generic medication is covered by your medical aid scheme if you plan to pay through your savings.
After picking the ideal plan, it is important to get formal quotes from each medical aid scheme to compare and make the best choice. Application forms need to be completed and submitted along with supporting documents, which might include:
• Membership certificate or sworn affidavit that states you belonged to another medical aid scheme, with start and end dates;
• Copy of the main member’s identity document;
• Tax number;
• A bank statement or letter from the bank, not older than three months, confirming the bank account from which the monthly fees will be withdrawn;
• Copy of marriage certificate or court order of a divorce settlement to prove a spousal or adult dependant relationship where required;
• Birth certificate or adoption papers of minor dependants;
• Proof of registration at a recognised tertiary institution in the case of full-time students eligible for child rates.
Not all medical aid schemes offer child rates beyond the age of 21, but some do, particularly if the person is still studying.
Medical aid schemes are required to accept all membership applications as long as the applicant can afford the monthly payments. It is not allowed to charge a member more than the set premium because of an injury, illness or disability. Wheelchair users, therefore, should pay the same premium as other individuals on the same plan if they are the main member. However, medical aid schemes can implement a late joiner’s penalty fee.
“Medical aid schemes can charge up to 75 percent extra on a monthly premium if you didn’t belong to a registered South African medical aid scheme from the age of 35 years. This additional payment will be relevant for life,” Gessner explains.
“Aside from the late joiner’s penalty, medical aid schemes can enforce a three-month general waiting period, during which you cannot claim for certain benefits, and impose a 12-month exclusion on pre-existing conditions, for example asthma or diabetes,” she adds. During these 12 months, the patient may not claim for specific conditions from the medical aid.
It goes to show that joining a medical aid scheme is crucial if you wish to avoid potential life-long penalties. Medical aid schemes also may not refuse any dependents, which include a member’s spouse or life partner, children under the age of 21 and those with a mental or physical disability, and immediate family members who are financially dependent.
Medical aid scheme membership can be cancelled if payments are not settled regularly and on time, if the member is found guilty of trying to defraud the scheme, or if prior medical conditions were not disclosed when they applied for membership. Membership costs generally increase in January each year.
A claim is usually paid within 30 days of receipt, with the exception of any disputed items on a claim. “Remember to submit a claim to the medical aid scheme within four months of the event,” Gessner notes. “If you submit thereafter, the medical aid scheme sees it as a stale claim and will not pay it.”
“Understand your medical aid plan before you make your choice,” she concludes.
SELA Brokers is able to assist members of the public – including wheelchair users – and organisations with a wide range of insurance products and services including healthcare plans. It provides complete consultancy for medical schemes. The SELA Brokers head office is located in Houghton, Johannesburg, South Africa, and can be contacted on 011 483 4800 or via email at firstname.lastname@example.org.