private-healthcare

Member Rights and Obligations under the Medical Schemes Act, 131(1998)

 

–>  The right not to be unfairly discriminated against on the basis of:

  • Race
  • Age
  • Gender
  • Marital status
  • Ethnic or social origin
  • Sexual orientation
  • Pregnancy
  • Disability
  • State of health

 

–>  The right to join a medical scheme of their choice

Anyone can join an open medical scheme as long as they can afford the contribution and provided your employer does not require you to join a specific scheme.  Employer-based schemes must accept every applicant in the relevant employee grouping as defined in the schemes rules.

–>  The right to acquire cover for dependants:

  • Who is a dependant Spouse/partner Children< 21 financially dependent on member
  • Children > 21, financially dependent on member due to mental or physical disability.
  • Mother, father, brother, sister of member, in respect of whom member is legally liable for care and support; other persons recognised as dependants in terms of the scheme’s rules.

 

–>  The right to as a dependant, to continue membership

After the death principal of member, dependants must be covered until they choose to leave the scheme or to join another scheme, as long as they can afford the contributions.

–>  The right not to be charged more because of OLD AGE or ILL HEALTH.

Contributions can only be based on:

  • INCOME, and
  • NUMBER of DEPENDANTS

 

–>  The right to at least a Basic Set of Benefits

(Prescribe Minimum Benefits PMB) – As a minimum, schemes must offer the benefits listed in a Schedule to the Act at  full cost, for diagnosis, treatment and care, at least in a public hospital

–>  The right to have claims paid timeously

A medical scheme must, subject to the rules of the scheme, pay to a member or health care provider any benefit owing within 30 days of the claim being received

–>  The right to receive regular statements

In addition to paying an account, a scheme must furnish the member with statements detailing:

  • Name of supplier
  • Date of service rendered
  • Total amount charged
  • Amount of benefit paid

 

–>  The right to rectify erroneous claims

If a medical scheme believes that an account or claim is incorrect or unacceptable, it must –

  • Inform the member with reason, within 30 days of receipt, and
  • Allow the member opportunity to correct and resubmit the account or claim

 

–>  The right to participate in schemes governance

  • At least 50% of the members of a scheme’s board of trustees must be elected from amongst members
  • Annual general meetings must be held, at which members may voice opinions and present motions

 

–>  The right to access to scheme information

A scheme must furnish a member with information, on demand

  • Schemes rules
  • Latest annual financial statements
  • Management accounts accompanying annual financial statements

 

–>  The right to advance notice of change in:

  • Contributions
  • Benefits or
  • Any other condition affecting membership.

 

–>  The right to confidentiality of medical information

Pertaining to the diagnosis, treatment or health status of any member or dependent.

–>  The right to obtain proof of membership

A scheme must issue to each member written proof of membership including:

  • Date of entitlement to benefits
  • Details of any condition-specific waiting period or general waiting period
  • If applicable, details of limitations on health care providers.

 

–>  The right to complain

When a member is dissatisfied with a service from a medical scheme, it is his/her duty to express this dissatisfaction to the medical scheme so that the latter can rectify or resolve the issue satisfactory.   Always follow the proper complains procedures.

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CureMED