Why medical scheme members are complaining

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Speaking at the 17^th Board of Healthcare Funders Conference, Phaswane said the majority of complaints were a result of gaps in communication from medical schemes and members failure to understand the benefit structure. She outlined the most common grievances.

Inadequate information on benefits changes

From the side of the scheme, she said, some communication on benefit offerings and exclusions are not clear. General communication focused on a few additions, with less attention drawn to critical changes and reduction in benefits. In terms of Section 57(4)(d) of the Medical Schemes Act, the board of trustees (BoT) of the scheme is responsible for providing adequate and appropriate information is communicated to members regarding benefits.

On the other hand, members only learn about these changes when trying to access benefits of the reduction of benefits.

“There is also a poor understanding of benefit structure and extent of benefit entitlement and that the nature and extent of benefits differ from one medical scheme to another,” she said.

So there is a perception of unfairness when different schemes provide different benefits. In addition, when there is a change of administrator, it may not be properly coordinated resulting in loss or corruption of data, which results in complaints relating to non-payment or delayed payment of claims due to inaccurate data transferred.

“Section 57(4)(c) says the BoT has to ensure proper control systems are employed by or on behalf of the medical scheme, while Section 57(4)(h) places the duty of the BoT to ensure operation and administration of medical scheme comply with the provisions of the Medical Schemes Act.

Understanding what emergency means

Phaswane said a lot of complaints arise from the fact that members do not always understand the definition of an emergency compared to a planned surgical intervention, and why they are liable for a co-payment if they deviate from using a designated service provider (DSP). She added that an emergency is clearly defined in the Act.

Misconduct by medical practitioners

According to Phaswane, another source of complaint comes when doctors don’t adequately advise their patients about the liability of medical schemes on funding treatment for prescribed minimum benefits (PMB) conditions, or their failure to disclose their non-DSP status to the patients.

“The Act imposes a legal duty to disclose fees, and a practitioner has a duty to provide information about the costs associated with each treatment option or alternative available to the patient to enable the patient to make an informed decision. The CMS refers complaints to Health Professions Council of South Africa after making rulings in favour of medical schemes.”

Non-disclosure of material information

In these instances, members often don’t disclose or aren’t aware that they have to declare pre-existing conditions to their medical aids, which are material to their membership to a scheme, and then lodge a complaint when their membership is cancelled.

“There’s no definition of what material means in legislation, and we have to use insurance and case law in these cases.”

The way forward

“Medical schemes must not only respond to complaints, but take corrective measures to curb recurrence of similar complaints. They must improve communication with members and engage in ongoing training of staff – in particular, call centre agents.“

“Furthermore they need to strengthen internal resolution of member queries and complaints and have a properly drafted complaints procedure in place to allow escalation,” she explained.

The 17^th Board of Healthcare Funders Conference took place at the CTICC from 17-20 July.