For many of us, medical aid contributions are a major monthly budget item, but are you fully aware of what your scheme covers? And what about those who cannot afford to be on a medical aid? CLAIRE RENCKEN investigates.
A common misconception about people with disabilities is that they are sickly or become ill more often than people without disabilities. This is generally untrue. However, it is true that people with disabilities often need disability aids that can be very costly and, in most instances, are not affordable out of their own pockets. In addition, people with disabilities may be prone to afflictions related to their disabilities, as well as conditions that relate to limited or no physical activity. As a result, higher-than-usual medical costs are a reality.
In an ideal world, everyone, no matter what their situation, would have access to a medical aid. Unfortunately, only a small percentage of the population, both able-bodied and disabled, can afford the high premiums charged by most medical aids. Those fortunate enough to be covered by a comprehensive medical aid are generally satisfied with what is covered.
For instance, Margot Bertelsmann has a five-year-old son, Richie, who has spina bifida. “We are with Discovery Classic Comprehensive, thanks to my husband’s work, which covers most of the medical aid contributions (Sean is a doctor). Richie wears orthotics, which means regular consultations with an orthotist and new splints annually (at this stage, while he is growing fast). Discovery has to date paid for this in full every year, in amounts of several thousand or even tens of thousands of rands.”
Richie also goes to weekly physiotherapy sessions and these are covered, up to a limit, from the Discovery benefits. “Once we have used up our savings for the year, we are in the ‘self-payment gap’ where, for a while, we have to make the payments. Soon the above-threshold benefit kicks in and Richie’s sessions are once again paid for. Every year we can apply for the allied and therapeutic extender benefit, which allows someone like Richie, who needs physiotherapy in the long term, to be covered above and beyond other Discovery limits,” says Margot.
Sadly, Richie is the exception. Most people with disabilities who belong to a medical aid have to make do with less expensive benefit options which, more often than not, do not adequately cover their needs. Rodney Outram, manager at wheelchair and seating specialists CE Mobility, has first-hand knowledge of medical aids across the spectrum. He provides the following insights from a manufacturer’s perspective: “Dealing with the medical aids is my least favourite part of the job. We have quite a good understanding with Discovery, but many of the other administrators have a ‘non-payment policy’, so it can be very infuriating trying to get payment out of them.”
He points out that there are so many different service providers in the medical aid field, and so many different schemes within these organisations, that every case is different in terms of what is and isn’t covered. There is no rule of thumb that can be applied when it comes to claims. The ideal situation would be for coverage to be standardised and for everyone to have access to it, but sadly at present that seems to be wishful thinking.
However, sometimes wishful thinking has a way of becoming a reality – in August the Southern African Spinal Cord Association (SASCA) published the “Assistive devices guidelines for persons with mobility impairment”. This guideline provides information per level of spinal-cord injury, on wheelchair specifications and other appliances required, in order to guide decision-makers and funders on the minimum requirements for people with mobility impairments.
In the meantime, when selecting a medical aid service provider, and scheme, it’s important that you research carefully what’s included (or not). Find out from the scheme management; check with your doctor or specialist; and make a realistic assessment of your current and likely needs, in order to ensure you’ll get the maximum benefit from it.