Does your medical scheme benefit you? How do you choose the right scheme?

There are many reasons why schemes at times do not seem to benefit their members. Both members and service providers usually have one standard explanation and that is "the scheme doesn't want to pay". Members who feel that they are being unfairly denied benefits can report such schemes to the CMS, which will normally make a ruling on the matter following a thorough review with input from both parties.

However, members often do not understand the product that they have purchased - from the benefits to the clinical governance of these benefits - and this may also leave the impression that members are being denied benefits. Schemes and brokers are also to blame for not clearly and constantly communicating the features of the product. Similarly, members are to blame for not actively attempting to understand the product.

If you feel a scheme does not serve your purposes, you can opt out and look for another one but if you do so, bear in mind there may be penalties and/or underwriting exclusions if you been with the previous scheme for less than two years.

The process of choosing a medical scheme is rather complex and requires a determined approach. Below is a guide that if followed, should largely minimize the unhappiness associated with not understanding your benefits, and help you select the right scheme for your needs.

1. Get your health risk profile:

Obtain a comprehensive health profile of all beneficiaries. Your doctor may assist in this and will invariably take a detailed family history to determine if there are any inheritable diseases for which anyone may particularly be at risk. It is important that these conditions be honestly represented on the application form. Should a scheme establish that you deliberately failed to disclose conditions on your application, it may refuse to pay for your current claim, or it may suspend your membership or even terminate it.

The scheme may also list you on the industry database.

2. Scrutinize the benefit structure of the scheme:

Once you have a good idea of the seriousness and cost implications of your conditions, you may want to engage a broker who is familiar with a range of medical scheme benefits to appropriately match your needs. Satisfy yourself that all serious and expensive medical conditions are funded by the scheme. It is essential to ensure that hospitalization costs are funded comprehensively and that there are no significant co-payments.

Potential members should always look for value in the design of a medical scheme option. The benefits in a traditional medical scheme option are paid from either the risk pool or the savings account. Because members are often not well equipped to manage their savings, it is therefore not surprising that it does not see them through all their needs.

This is frequently a source of conflict between the scheme and members when the latter have to pay out of pocket for the very essential healthcare needs that they thought the medical cover would cover.

ProSano has just launched their fifth and flagship option, ProElite, which they believe is the first of its kind to confer such comprehensive cover across all essential benefits. Dentistry, GP consultations, acute medicines, optometry, radiology and pathology are comprehensively covered from the risk pool. There is also no limit on the benefit for chronic medications. With the hospitalization benefit being unlimited, this option is designed to afford the member real peace of mind.

3. Check out the financial soundness of the scheme:

You need to check out the scheme's financial stability, and you can do that by ascertaining that the solvency levels are above the required 25%. All you do is simply obtain a Global Credits Ratings on the scheme - its claims-paying ability. The claims ratio also gives a good measure of the scheme's operational efficiency.

Schemes under financial stress may unexpectedly alter their benefit structure in a manner that may compromise you and your dependants. Moreover, service providers may get nervous with a scheme under financial difficulty and may demand upfront payment from members.

4. Ensure affordability:

Affordability will ultimately determine what product one buys so you should draw up a realistic family expenditure budget before approaching a broker. The health insurance portion of the budget will assist you and the broker in terms of what level of cover you can afford. Bear in mind that schemes may suspend members who are in arrears and may review your payment pattern before approving an option change.

5. Selecting the scheme of your choice:

Once you have short listed about three medical schemes you may contact the medical scheme directly for further information. However, it is always worth your while checking with your local service providers - your doctor, local pharmacy and so on - and obtain their impressions of your short listed medical schemes and what working relationships they have with each.

Designated service providers (DSPs) may be assigned to render certain services. It is advisable to know about these DSPs and in which services the schemes engage them.

Always remember that you, as a member of a scheme, have a responsibility to choose the scheme carefully and to keep yourself up to date with the benefits of the scheme.