An elderly man is urgently waiting in the emergency room complaining of chest pain, who knows maybe it’s a heart attack. After an hour of waiting without any help and in agony his name gets called. The lady behind the counter opens his file and looks at him with disgust. She explained to him that the hospital would not be able to treat him due to medical aid issues. “The medical aid needs a treatment plan or motivational letter from the doctor (who hasn’t seen this patient yet) in order to give authorisation for treatment” she explains.
This is what is happening everyday in our health facilities to the lower class families with lower medical plan coverage. Some of these patients are stabilised and sent to the government hospitals after asked for an upfront deposit that they can’t even afford to pay.
The whole idea behind having medical aid coverage was to help people afford medical treatment in case of emergency and checkups without having to worry about cash. Situation like this has a horrendous impact on negativity attitudes towards medical aids by patients and doctors.
Some of these disadvantages include:
* Co-payments – this is the portion of amount you are required to pay by your medical aid before receiving healthcare. Some medical aids you can claim this monies back from them.
* Exclusions – this are procedures and diseases that medical aid do not pay (scheme rules).
* Denial of healthcare – this can happen in case pre-existing conditions was not disclosed on registration.
* Waiting periods – if you just join the medical aid you have to wait three to six months before getting sick.
* Hospital limits – e.g. Back pain is treated for three days in hospital unless operated.
If the above requirements are not met clients are requested to pay cash or leave the premises to a government healthcare facility. Government healthcare is one place you don’t’ want your family member admitted. It’s overcrowded and short staffed. Most of our people just stay home with their sickness while paying their monthly medical aid premiums.
Why do we have medical insurance if we are not allowed to use it?
These are the most important things that our people do not do when they commit themselves to these contracts:
* Read everything about the option you are choosing – e.g. to avoid the risk of co-payment you should use the doctor who is participating in your medical aid direct payment arrangement.
* Familiarise your self with different procedures and diseases.
* Do not ask your doctor because they know nothing about your option. They are only there to treat what they diagnose it will be impossible for them to remember all the exclusions on all the medical aids.
* On admission ask the consultant at the medical aid about your illness benefits or limits when requesting authorisation number.
* Ask your doctor to do small procedures at his rooms rather than in the hospital, this way you stand to gain as most of these procedures are paid full by medical aids if done at the doctor’s rooms. Where as if done at the hospital you find yourself paying co-payments. E.g. investigations such as Gastroscopies and colonoscopies.
* Inquire with the medical aid if they cover blood tests and other tests such as x-rays and MRI. Because most of the tests are only 50% covered and the rest you will have to pay from your pocket.
* You must understand that even if it says you are covered 100% hospitalisation doesn’t mean they are no exclusions and co-payments. This is where most patients go wrong by assuming that everything is 100% covered.
* Disclose your pre-existing medical conditions (e.g. High Blood Pressure, Diabetes, Heart diseases) – most medical aids have chronic packages for their clients but if they only find out about it after admission they might refuse to pay the account.
* Follow the scheme rules – e.g. medical aid doesn’t cover private room, certain procedures and medicines.
Remember medical aid is just like any other company; their aim is to make as much profit as they can. If they can get away with rejecting claim from as many clients as possible the better for them. So my advice is, be aware of everything about your medical aid.