HIV, cancer and medical schemes

Being a member of a medical scheme is a necessity in today's world. Medical expenses today are higher than ever. If a member of the family has to see a doctor or be hospitalised, and you are not adequately covered, your out-of-pocket costs are likely to be a lot higher than you might ever have planned for.

Having some form of medical cover provides security in the event of a medical emergency and will cover your day-to-day medical expenses.

"The type of medical aid cover you choose depends on your budget as well as your family's healthcare needs,” says Dr James Arens, Clinical Operations Executive of Pro Sano Medical Scheme.

Broadly speaking, most schemes offer various choices between comprehensive medical scheme cover on the one end of the spectrum – which will pay for a wide range of services such as doctors' consultations, tests and medical treatment – and hospital plan cover on the other end, which is a lower-cost medical aid option that only covers hospital expenses.

Choose the best cover for you

When choosing what type of medical cover will suit you best, says Dr Arens, you need to ask yourself some simple, straightforward questions. These include:

  • How often do members of the family visit the doctor, dentist and other healthcare practitioners?
  • What annual check-ups and tests will members of the family require in the coming year (such as mammograms, cholesterol tests, cancer screening, bone density tests, etc)?
  • Are you planning any major medical procedures, such as pregnancy and operations?

"However, not all of our healthcare needs are predictable or within our control," says Dr Arens. So, what should you do if someone in your family is diagnosed with a serious disease such as HIV or cancer?

Know you benefits

"Until we or a loved one is actually in the situation ourselves," he says, "most of us don’t know what type of benefits we have for these types of serious diseases."

"Don't wait until someone in the family has been diagnosed with a chronic disease before you familiarise yourself with the benefits offered by your scheme and option," he advises. Make sure you know the answers to questions such as the following:

  1. What are my benefits for chronic and serious diseases (such as HIV and cancer)? For example, will my scheme pay for antiretroviral treatment, chemotherapy or radiation, and under what conditions?
  2. Do co-payments apply? (A co-payment is when the medical scheme pays only a portion of the medical bill and the member is liable for the balance.)
  3. Are the benefits relating to specific conditions limited?
  4. Is all additional medicine covered?
  5. Are there limitations relating to which healthcare providers will be paid for?

"Forewarned is forearmed," says Dr Arens. "Long-term medical treatment not covered by a medical scheme can impose heavy financial burdens on patients and their families. For this reason, it is imperative to find out exactly what medical treatment and procedures are included in your plan, what your medical aid will pay for, and discuss the situation as early as possible after your diagnosis and into your treatment, with both your scheme and your healthcare team, to avoid any nasty financial surprises down the line."

"Every medical scheme member should make sure they know exactly what benefits they are entitled to, before they need them, so that their only concern during treatment is their recovery!"

(Issued by Global Interface on behalf of the Pro Sano Medical Scheme, May 2010)

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