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20 medical scheme myths you should not believe

By Faeza
25 July 2017


The world of medical schemes is a complicated one – and there are many myths and misconceptions doing the rounds. Below is the truth about some of these.

Myth: Medical schemes make a profit.

Fact: Medical schemes as such are not profit-making organisations. They might be part of bigger insurance companies, which do make a profit, but there are different laws governing insurance products and medical schemes. If a scheme registers a profit, it goes into the reserves of the scheme, and this belongs to the members. Medical schemes have trustees, not shareholders. Of the registered open medical schemes in SA, only 8 of the 23 achieved an operating surplus in 2015.

Myth: A scheme can refuse my application.

Fact. No it cannot. A scheme can make you pay a late-joiner penalty, and impose a general waiting period of three months or a condition-specific waiting period of no more than 12 months on a new member. But it cannot refuse your application if you can pay the membership contribution.

Myth: Medical inflation is higher in SA than elsewhere.

Fact: Medical inflation is a worldwide phenomenon. In SA, medical inflation, on average, has been 2% above CPI inflation over the last 16 years. High equipment and medication costs, the spiralling costs of private healthcare, overtreatment in the private sector, and the increase in lifestyle-related diseases all contribute to high medical inflation worldwide.

Myth: Medical insurance is the same as a medical scheme.

Fact: Medical insurance is not covered by the Medical Schemes Act, and functions more like an income-replacement product than medical cover. A medical insurance product pays you out for certain diagnoses, or a hospital stay – it does not pay your medical bills.

Myth: If my scheme gives 100% cover means I don’t have to pay in anything.

Fact: Not true. Schemes can cover you for 100% of the medical fund tariff, which may be considerably lower than the cost of the private hospital or private doctor. You could end up with a big co-payment.