Frequently Asked Questions: Complaints Against Schemes

Where do I complain if claims are not paid timeously or when I am dissatisfied with a   decision taken by the Scheme?} Any complaint must first be lodged with the scheme concerned. All schemes should have dedicated telephone lines to handle everyday complaints and enquiries, however written complaints are preferable so you as the member have written proof. All schemes are also required to have independent disputes committees where members' disputes may be settled. Members and or their legal representatives may be present at disputes committee meetings to present their arguments. Should all efforts fail to resolve an issue with your scheme, you can submit your complaint to the Council for medical Schemes Complaints Unit by either posting, faxing, emailing or submit online by going to the following website address: http://www.medicalschemes.com/Consumer_Assistance/C

Gap Cover

DIFFERENT gap cover products are available. A short description is given below.  Should you need more indepth explanations contact 0861 633 336

percentageGap cover is a short term insurance stated benefit product that covers the difference between the medical aid rate and private rates charged by doctors or specialists for in-hospital treatment.

If your medical aid covers you at 100% in hospital, Gap Cover will cover up to 400 or even 500%  over-and-above which your medical aid pays.

Anaesthetist, gynaecologist, radiologist, pathologist and other specialist surgeons are covered while in hospital.

Gap cover can be used with any medical aid.

Children are covered up to age 25 if studying, proof would be needed from the institution every year.

Co-payment cover is a benefit equal to charges in the form of a co-payment or deductible that applies to:in hospital

in-hospital admissions and/or
the necessity for chemotherapy or radiotherapy for the treatment of cancer on an outpatient basis and/or
outpatient procedures as defined in the policy document.

Hospital excess cover, charges in excess of R200, 000 for overall scheme and/or hospital limitation for in-hospital admissions in aggregate (the sum of all hospital confinements per family) per annum but limited to conditions that are not listed as a prescribed minimum benefit.

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Cancer sub-limit gap, covers the sub-limitation imposed by the medical scheme for either the necessity for chemotherapy or radiotherapy for the treatment of cancer or biological cancer drugs, limited to Herceptin, Mylotarg, Nexaar, Gleevec, Sprycel, Fasodex, Velcade, Tarceva, Alimta, Zevalin, Avastin, Erbitux, Sutent, Fludara, Mabthera with specific oncological condition and/or specific sub-groups of cancers limited to the sub-groups of the following categories:

· HER 2+ breast cancer
· Acute myeloid leukaemia
· Advanced hepatocellular carcinoma
· Acute lymphoblastic leukaemia
· Chronic myeloid leukaemia
· Chronic lymphocytic leukaemia
· Hairy cell leukaemia
· Myelodysplasia
· HER –ve breast cancer
· Gastrointestinal stromal tumour
· Multiple myeloma
· Non-small cell lung cancer
· Non-Hodgkins lymphoma
· Metastatic colorectal cancer
· Advanced renal cell carcinoma
· Head and neck cancer

 

Such co-payment or deductible and/or sub-limitation amounts applied are as per the rules of the principal's registered medical scheme. No benefit shall be paid on any sub-limitation for conditions listed as a prescribed minimum benefit. Pre-existing cancer will be excluded when joining the policy.

In-hospital sub-limit cover provides you with an additional R20,000 per family per annum in the event that you exceed an in-hospital sub-limit as per your medical scheme option.

Contact us for more info 0861 633 336

Schemes Offered

The Mission of BESTmed is to operate a non–profit mutual medical scheme in terms of the Medical Schemes Act in a financially responsible manner for the defrayal of its members’ health–care expenses by means of –
- the optimal appropriation of members’ contributions and other income
- the operation and administration of several benefit options and / or schemes
- the striving for a balanced growth in membership; -the rendering of health care services; and negotiations with service providers for the supply of quality and cost effective services
 
 
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Bonitas Medical Fund is the second largest open medical scheme in South Africa, with an annual contribution income of over R4.5 billion. Size is an important factor when considering which medical scheme to join as large risk pools are less prone to statistical fluctuation in claims experience. This means that claims costs are more predictable and in turn so are members' contribution rates. Founded 26 years ago Bonitas' rich history has resulted in well established products and systems backed by medical, actuarial and technical expertise and strong IT systems. Medscheme has been the sole administrator of Bonitas since inception. Established in 1982 as a Fund specifically for black civil servants, the Fund has however been opened to all South Africans since 1994. Bonitas has grown from strength to strength by diversifying into all sectors of the market. Today government employees only make up 25% of the membership, whilst we have over 119 000 corporate members.
Discovery’s core purpose is to make people healthier and to enhance and protect their lives. Our health and life assurance products and our Vitality wellness programme deliver on this purpose to more than 2 million Discovery clients in South Africa. One of our greatest assets is the world-class standard of South Africa’s healthcare sector. South Africa is home to talented medical experts, outstanding academic institutions and excellent healthcare facilities. Even so, most South Africans are unable to afford anything more than the most basic care. The facilities they depend on are often over-burdened and under-staffed.

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At Fedhealth we focus only on core business, and that is to provide real benefits at affordable rates. To substantiate this, an independent brokerage house appraised Fedhealth for providing value for money through the range of options offered. Fedhealth members are our priority and we see to it that they receive the service they deserve. Fedhealth has a friendly and efficient member call centre that is measured regularly on performance, in order to maintain the high standards set.
Hosmed is an open medical scheme providing cover to public service employees as well as the private sector. The scheme was established in 1988, to provide cover for civil employees. With a membership base of over 36 000, Hosmed has shown consistent growth and is set to grow in private sector.
 
   Choosing a medical scheme is almost always a complicated task. Medical jargon, a wide variety of schemes, and an even wider range of benefit options that make it extremely difficult to find the right one for you. KeyHealth Medical Scheme is one exception – true to its philosophy of being smart and keeping it simple, we believe that you should only ever require ONE good reason to do something.

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LA Health Medical Scheme provides cover to more than 45 000 beneficiaries and has been operating in the Local Government industry for more than 40 years. Discovery Health (Pty) Ltd administers LA Health Medical Scheme. The Scheme offers five different benefit options to choose from, catering for every members’ different needs. This makes it an attractive option for potential members. The Scheme has grown its membership by more than 12% annually from 2005!
 
Medihelp , established in 1905, is without question one of the leading, largest open medical schemes in South Africa. With reserve levels at 27.09% it offers financial stability and proven exceptional client service. A recent survey of customer satisfaction done by Interface Management, published in the Financial Mail (02/02/01) rated Medihelp tops on member satisfaction with a score of 88%. Medihelp medical scheme offers innovative, tailor made benefit options to suite every stage of life. It offers a range of products, including Traditional Benefit options (Sentinel) as well as new generation benefit options(Dimension) and a product for the emerging market (Nucleus). Sound administration, efficient claims payment, effective risk management and exceptional client service resulted in awards such as the Silver Arrow by the PMR Magazine, and a A+ rating by Duff Phelps.
 
At Momentum Health, you can choose to save up to 35% on your medical aid contribution. You can also earn up to R5 400 in HealthReturns a year from Momentum, as well as free GP visits and increased in-hospital cover.
Why has Momentum Health grown faster than the industry over the past five years? Healthcare advisers believe the flexibility that allows you to really shape your cover according to your needs, and budget, is what has propelled the Scheme to one of the largest open schemes in SA.
Find the best option for you!
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At Medshield you are guaranteed to find a healthcare option that meets your specific personal requirements. We focus on providing quality, affordable healthcare products that are enhanced with more benefits to ensure that you receive more value for your money. In addition, our Wellness benefit offers a number of tests, curbing your healthcare expenditure through preventative healthcare. Over and above affordable rates, a product to suit your personal requirements and enhanced benefits, the Scheme has a rich history with an exceptionally experienced and friendly team to assist you. You can trust us to care for you and your family.

 

 
As the largest medical scheme in South Africa exclusively for graduate professionals, Profmed is focused on providing you with quality medical cover with extensive benefits to match your professional lifestyle. Prestige service and an approach of premium care are the hallmarks of Profmed - which have earned us the status and standing as the preferred choice for the discerning few who want to see their own levels of excellence reflected in their financial decisions.  Profmed's focus is on continuing to provide you with the truly exceptional benefits you've come to expect from Profmed , while at the same time remaining committed to keeping contributions competitive.
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Thebemed is a medical aid scheme tailored to people who need affordable health cover.Thebemed is administrated by Thebe Ya Bophelo Healthcare Administrators (TYB), a member of Thebe Investment Corporation. Founded in 1992 as a pioneering black-owned company, Thebe Investment Corporation (Thebe) was established by a community-based trust, Batho Batho trust, which included original trustees Nelson Mandela (Chairman), Walter Sisulu, Enos Mabuza and Reverend Beyers Naudé. Thebe creates value by establishing, acquiring, growing and actively managing businesses for the benefit of our communities.

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