The Council for Medical Schemes has said that in the past financial year, it found in favour of more than 50% of members who complained about issues like denied claims – many of them relating to prescribed minimum benefit problems.
News24 reports that members paid R40bn for medical expenses not covered by their medical schemes last year, with around 2 000 of them complaining about not just denied claims but other issues as well.
The regulator found in favour of more than 50% of them, resulting in many members’ claims being paid, or paid more fully.
But many other complaints were dismissed because the council found their schemes applied scheme rules correctly. In these cases, members often did not know or understand the benefits provided by their schemes.
The CMS annual report for 2023/24 shows that schemes collected R232bn in contributions and paid out R218bn in benefits for more than 9m members and their dependants.
While many claims were paid, substantial sums are being paid from members’ pockets.
Some members choose to pay for treatment not covered by their scheme, but often out-of-pocket payments are a financial shock arising from failure to understand how scheme benefits and the law allow schemes to control their costs and ultimately their contributions.
The CMS noted “a gap in beneficiaries’ understanding of commonly used concepts in the medical scheme industry”, such as pre-authorisation, treatment protocols, formulary, and scheme tariffs, particularly in open schemes that were responsible for close to three quarters of all the complaints.
Minimum benefits denied
The council dealt with more than 500 complaints about (PMBs), the causes including:
• Disputes over the interpretation of PMB levels of care;
• Real or perceived unfairness in the application of treatment protocols and formularies; and
• Short payments when members do not use designated service providers.
The CMS said despite issuing numerous rulings against offending medical schemes, many continued to incorrectly apply monetary caps and benefit limits to PMB funding for post-amputation prosthetic limbs.
The largest category of complaints was those CMS classified as administrative.
The council dealt with more than 1 000 complaints relating to the payment of benefits, pre-authorisation, customer service, medical savings accounts, contributions and benefit option changes.
It also noted noted an increase in complaints where medical schemes failed to address member queries timeously, resulting in these matters being escalated to the Council as complaints. It said schemes fail to inform members of their internal dispute resolution committees and clinical appeal processes.
See more from MedicalBrief archives:
Know your medical benefits, avoid costly co-payments — Ophthalmological Society of SA
Family wins decade-long legal battle against Profmed