20 quick facts on medical schemes in SA

Many medical scheme members are baffled by scheme rules and regulations. And by constant changes to benefits and contributions.

Here are 20 quick facts on medical schemes in South Africa which might answer some of your questions:

A person may not legally belong to more than one medical scheme.

You do not need to apply for medical scheme membership through a broker: you can apply directly to the scheme.

A minor may become a medical scheme member with the assistance of a parent or guardian, and provided the contributions are paid.

If you have terminated your membership of a medical scheme, you will be covered until midnight of the last day of the month in which you paid your final membership contribution.

Employers do not have to subsidise an employee’s contributions to a medical scheme.

Medical schemes are not allowed to pay out no-claim bonuses or rebates.

If a medical scheme principal member dies, his/her dependants may continue to be members provided the contributions are paid.

An employer may insist that a permanent employee belongs to a medical scheme as a condition of employment.

Medical schemes may not refuse membership to an applicant, but they may charge late-joiner penalties or waiting periods before claims can be made for specific conditions.

Claims must be submitted within four months of the treatment date, otherwise they will not be paid out.If you have money in your savings account, you may not withdraw it in cash. It can only be paid out when you terminate your membership.

Claims should be paid out within 30 days of receipt of the claim.

Medical schemes are non-profit organisations.

Medical schemes have to hold surplus or accumulated funds equal to 25% of the total annual contributions by members.

Medical insurance products are not governed by the rules of the Medical Schemes Act.

A scheme may terminate someone’s membership if contributions are not paid, or if the member has withheld crucial medical information on their application forms, or if they have submitted fraudulent claims.

Schemes may expect members to use Designated Service Providers (DSPs). These could include doctors, specialists and hospitals.

At least half of the Board of Trustees of a medical scheme must be elected or appointed from the ranks of members.

(Source: the Council for Medical Schemes)

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