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Sat May 26 06:22:25 SAST 2012

Medical aid schemes 'breaking the law'

CHANDRÉ PRINCE | 05 August, 2011 00:239 Comments
A doctor holding a stethoscope.

Some of the country's biggest medical aid schemes have been accused of violating consumer laws - but that is about to change.

Frustrated scheme members have for years complained about rules and regulations being imposed on them without consultation. Some of the regulations have been labelled unconstitutional and discriminatory by the National Consumer Commission.

A recent investigation by the commission, the newly established national consumer watchdog, has alleged that the top five medical schemes are among many violating consumer-protection laws.

The investigation has spurred the Council for Medical Schemes to establish a committee that might try to amend legislation.

Consumer Commissioner Mamodupi Mohlala yesterday said that a preliminary analysis of medical scheme rules had found that schemes were contravening at least eight provisions of the Consumer Protection Act, which came into effect in April.

Highlighting some of the initial findings during a presentation at a conference of brokers in the Drakensberg, Mohlala said the commission's investigation was triggered by complaints, most of them from pensioners.

Most centred on the elderly not being able to understand the terms and conditions of the medical aid schemes.

"Pensioners are classed as vulnerable consumers and some of them don't have the ability to understand the complex terms. The law states that all contracts must be provided in plain and simple language," said Mohlala.

Her investigation, led by senior legal and medical experts over a two-month period, unearthed several regulations that would probably have to be amended.

The commission's preliminary analysis of the medical schemes' rules agreements revealed that:

  • In certain instances, rules are provided to consumers only after the agreement is entered into;
  • Schemes require applicants to consult a doctor nominated by them - which is contrary to consumers' right to select suppliers;
  • The boards of the schemes may, in their sole discretion, impose a waiting period in respect of members or dependants, which might exclude members from accessing services, which, according to the Consumer Act, is discriminatory;
  • Some schemes prevent women who fall pregnant within nine months of joining the scheme from claiming for the pregnancy even though they pay full premiums;
  • Some schemes require that members give three months' notice when terminating their membership, whereas the act deems 20 business days to be reasonable;
  • Members over 36 are penalised for being late joiners and pay higher contributions.

According to the act, it is unfair when a consumer is discriminated against on the grounds of age.

The consumer commission has jurisdiction over every transaction involving the promotion of goods or services, including those offered to medical aid members.

Mohlala said her aim was not to "tread on people's toes" but to ensure that consumers were not exploited.

Before her investigation, Mohlala's office had discussions with the Council for Medical Schemes. Shortly after their meeting, in May, the council sent out a circular to the medical schemes inviting comment on how the Medical Aids Schemes Act should be brought into line with the Consumer Act.

The Council for Medical Schemes' legal head, Craig Burton-Durham, said the council would have to discuss the effect of the consumer act and come up with ways of working with the Consumer Commission because there are overlapping regulations.

Mohlala's office will write to the top five medical schemes on Monday, encouraging them to engage in a corrective process.

Jonathan Broomberg, chief executive of Discovery Health, said that though it had received requests for information from Mohlala's office, it had not been notified that the scheme was not in compliance with the act.

"Discovery Health has received a request for information from the office of the Consumer Commissioner that will contribute towards an industry assessment the commissioner is conducting," said Broomberg.

He added: "A few consumer complaints have been directed to us and in all instances we have provided comprehensive evidence of our adherence to the Consumer Protection Act."

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Medical aid schemes 'breaking the law'

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COMMENTS [9]

$$$$$$$

Posted 294 days ago
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That is very true.....
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MlunguMnyama70

Posted 294 days ago
yip, screwed we will always be in SA!!Where are those with the teeth?

ColinMurray

Posted 294 days ago
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As a pensioners we are charged the same subscription fees as persons with well paid jobs, when you consider a pensioner earning R3900.00 per month has to pay R1284.00pm medical aid it is a bit harsh. however in this day and age one cannot be without a medical aid we just eat a lot less.

LULU76

Posted 294 days ago
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and why do medical aids force their clients to collect chronic medication from certain pharmacies only? with my medical aid they insist on sending my son's asthma medication by post from their own supplier otherwise there huge co-payments. Sometimes the medication arrives late. Its ridiculous. Hope they get stopped from doing this as well.
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kp57

Posted 292 days ago
I also have a problem with this practice. I have had a pharmacist that I have dealt with for over 20 years, one who has always provided great service and sound advice. A trust relaionship has been established. Now the medical aid is forcing me to use discount store pharmacies otherwise pay huge co-payments are required and secondly it is usually a different pharmacist on duty each time, some of which can't even find our details on their database - there goes the trust relationship. I truly hope that this investigation puts a stop to this practice!

MisterWendal

Posted 294 days ago
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It is generally accepted that we are being screwed by Medical Aids, who consistently post large profits while annually (collusively?) increase their subscriptions by supposedly inflation-related percentages.
However, it would be irresponsible to expect a private medical aid to accept an eight-month pregnant female, or a seriously ill person needing expensive surgery as a member without a punitive sanction, or at the same rate as a healthy young person.
We've got to get the balance right, or else the government medical aid scheme will be thrust upon us all!

JJRetief

Posted 294 days ago
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Uhm...I might be wrong, but I do not think medical aids post profits. We are all essentially contributing to a great big pool of money and paying each others' medical costs. If someone contributes less, or the market falls, we all suffer. It is like the old defined benefit pension funds where you contribute, but what you get out depended on length of service, final salary, etc. You essentially got what the rules said and not what you contributed (long service you got more, short service you got less). Money is only made by Discovery for the asset management and the administration of the scheme, but not money on the scheme itself (and I am not saying that this is not a lot of money...it is). Also, I understand some pensioners did not plan properly for retirement, but since they use medical aids a lot more than 30 somethings I see no reason why they should pay less. It is a bit cold hearted, but if they pay less now, I will have to pay a lot more when I am a pensioner to have the same benefits (ignoring inflation).

Kay2west

Posted 291 days ago
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This couldn’t have came at a better time. They must start with Discovery. When I was on father’s medical aid I was diagnosed with Migraine and last year when I joined Discovery I was told I had to divulge it which I did since I didn’t think it was going to be a problem. As I was pregnant I thought it would be beneficial for me and the baby. To my shock I was informed that I won’t be able to go to a doctor for any headache related illness or consult a doctor/gynae or anything else related to the pregnancy until after 12months. After my child was born I couldn’t take him to any doctor as he didn’t have a nominated doctor, now tell me should I take my child out of his province and he gets sick should I go back to his province and get him checked or take him to the doctor and pay from my own pocket?

PhumzileMbele

Posted 286 days ago
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Medical aids want to make profits at the patients' expense. Forcing the patients to receive the chronic medication via post is unfair to the patient who might need to discuss the side effects with the pharmacist , or maybe the patient could be taking medication incorectly and no one will notice this if SA continues to allow them do this. The SA pharmcacy council which is supposed to see to pharmaceutical needs of the people is turning a blind eye while medication that is to refrigerated is sent via post , what about the cold chain , the temperature under which these medications are sent ! Sent by a disgusted pharmacist.