Avoiding Medical Mayhem:

Medical cover is much like any other form of insurance in that it is unappreciated (if not resented) when unneeded but greatly appreciated when something is amiss. Just like anything else in life, you get what you pay for. Unfortunately this poses an age old problem because when unneeded most people pay very little attention to what cover they have bought and then discover too late that they do not have what they need.
Regrettably there isn’t an exact science for establishing exactly what you need for some-thing as unforeseen as your future health. However, there are several things that may help you make the right decision in the first place.
You may not be worried about your medical costs because you pay your scheme contribution every month. Case closed right? Unfortunately not. While medical schemes honour their commitments when you need them most, many medical scheme members can get a grim surprise when they least need it due to the scheme they themselves have chosen.
This is why is it absolutely essential to read the terms on the benefits for the particular option you have chosen. There are huge differences in benefits offered from scheme to scheme and from option to option within those schemes. You could find yourself having to make a co-payment of thousands when you least expected it.
You get what you pay for: never is that more true than when it comes to medical schemes. It’s a bit like any other insurance – you don’t want to find out you’re not covered for an event when it has already happened. If you haven’t done so yet, make it a priority today to go and read the terms describing your benefits.
While some of these limits may seem unfair, it must be remembered that if a scheme were to pay all costs for all of its members, it would go under very quickly. It has to limit its health-care expenditure for the benefit of all its members. It’s just not very pleasant when you are the one having to fork out unexpectedly. Here are a few things that medical scheme members should consider and evaluate about their current cover:
Cancer treatment
Many schemes have a rand limit on approved oncology treatment within a 12-month period. It could be anything, but the ceiling is usually between R250 000 and R400 000. After this, you could be required to make a 20% co-payment, or pay for it yourself, which could amount to a substantial amount of money. You can be required to go to a net-work specialist specified by the scheme. Find out if you need to be hospitalised before your scheme will pay for this treatment.
In-house agreed tariff
Every scheme has tariffs, according to which they pay doctors and specialists. In other words, if you choose to go to a doctor that charges three times what the scheme’s tariffs are, you will be footing two-thirds of the bill. Don’t be fooled by the words ‘100%’ in the benefit tables – it is followed by the very important phrase ‘of the agreed tariffs’. The same goes for in-hospital specialists and hospitals not part of a specific network.
Medical savings account
The medical savings account (MSA) is usually 15% to 20% of your total contributions. It is put into a savings account, from which items such as GP visits and acute medication will be paid. Check to see what benefits are paid from the savings account. It is all added together to reach the total. So a visit to the dentist and a bout of bronchitis could actually wipe out your MSA for the year. Then you go into a self-payment gap (which is self-explanatory), after which above thresh-old benefits can kick in. Check what, if any, limits there are on these. This is only for people on full medical schemes with day-to-day cover. Hospital plans do not have MSAs. Remember, this money is yours. What you don’t use gets carried over to the next year, and if you leave the scheme, unused funds from the MSA will be paid out to you.
Dentistry
In many countries medical schemes do not cover dentistry at all. People have to take out a separate plan to cover dental work. If your dentistry benefits are paid from your MSA, they don’t go very far. Also remember that schemes will not pay for anything they see as purely cosmetic – and they are conservative in this regard. If you need several teeth crowned, best you start saving.
MRI and CT scans
MRI’s and CT scans can cost thousands. Check to see whether your plan will only pay if you are hospitalised, or whether they will only pay for a certain number of scans per calendar year. Some options cap this benefit on a rand value, such as R2 750. This might not cover the cost.
Chronic medicines
Schemes and hospital plans have to pay for the medication for 27 chronic conditions. Some schemes have medicine formularies, ac-cording to which they either cap a rand value on what they will pay for a certain condition, or prescribe which drugs (often generics) they will fund. If you want to take specific brand medicines not listed, you will have to pay the difference yourself.
Network hospitals and specialists
Generally, if you use hospitals and specialists on the network of your scheme, you should have no co-payments. But not every scheme has a network. Contact your scheme before you go for treatment or before you are hospitalised, to make sure that you are not landed with a huge unexpected bill. Use the network hospitals and specialists wherever you can.
Home nursing and frail care
Few options on medical schemes have benefits for this. If they do, it is usually limited for a specified time, or a specified amount. Don’t assume these services will be paid for. Most schemes would go under if they had to fund unlimited frail care, so it is understandable.
Elected Caesareans
More and more women are choosing to have Caesarean sections rather than natural births. But it costs more, and schemes are within their rights not to pay for elective Caesareans. It’s a different matter if it is a medical emergency, or there is no choice in the matter, but don’t assume your scheme will foot the bill if it is your personal choice.

Generally, if you use hospitals and specialists on the network of your scheme, you should have no co-payments.