If you are a member of a Medical Aid Scheme, then you need to know your medical aid rights and responsibilities. Medical Aid in South Africa is seen as a luxury due to the fact that we unfortunately have to pay exorbitant rates for our monthly premiums and as a result we have a deteriation in our public health care as the medical practitioners want to work for the hospitals etc that are covered by the Medical Aids.
This means that they are generally working for private institutions which are too expensive for the general public to afford. As a result, in order to receive the best medical care, people are being forced to join medical aid schemes. What is unfortunate is that many people are unaware of their rights when they join medical aids and as a result get taken advantage of. So in order to give you a general understanding of what your rights are, carry on reading this article.
Your rights:
- You cannot be unfairly discriminated against because of your age, sex, race, gender, marital status, ethnic or social origin, sexual orientation, disability, or state of health.
- Your dependants have the right to be covered by your scheme. This means that your spouse, any children under 21 years old who are dependent on you, or children over 21 who are disabled, and basically any family member that you are liable for their car and support, can be covered by your medical aid scheme. In addition to this, dependants have the right to continue their membership of the scheme should they wish to. What is extremely important to note is that should the main dependant die for any reason; the medical aid must cover them until they leave the scheme as long as they can afford the monthly payments.
- If you claim against your scheme, they have to pay you out timeously – 30days from the claim being received to be exact. Should it take longer than 30 days for the medical aid scheme to pay you out, you have the right to make a formal complaint against them.
- You cannot be charged based on your health. The only variables that come in to play when calculating your monthly instalment is your income, and your number of dependants. Should any medical aid scheme try and charge you more because for example you have contracted HIV/AIDS or have discovered a chronic condition, you can report them. The only time they are allowed to charge you more is when you join for the first time in order to provide you with the basic set of benefits known as the Prescribed Minimum Benefits that will cover any chronic condition that you may have for the first year of your membership.
- You are entitled to receive statements from your medical scheme on a regular basis. These statements need to detail all the information surrounding any expenses that you are incurring.
- You have the right to question a declined claim or not paid you in full. Should this occur and they have not informed you within 30 days of why they are not paying, you can report this to the medical aid board.
- Your medical aid cannot share your medical history with any other party without your permission. If they do so, it is a breach of your right to privacy and therefore can be taken to court.
You have the following responsibilities:
- Be honest on your application as any false information supplied may result in you losing your membership and criminal charges can be laid against you.
- Never submit a fraudulent claim
- You have to declare any chronic conditions or pregnancy when applying for membership. Many people do not do so due to the fact that many schemes will make you endure a waiting period before they cover the specific condition that you have. Should they however find out that you are hiding a prediagnosed condition they have the right to report you.
- Pay your instalments timeously