Patients often too quick to moan

17 October 2016 - 09:47 By KATHARINE CHILD

People love to complain about their medical aid scheme's premiums but most of them have got it wrong, the schemes' regulator says. The Council for Medical Schemes released its annual report on Friday. It showed that of 3527 complaints regarding open medical plans, 1172 were resolved in favour of the plan, in 260 instances both parties were said to be in the right and only 971 complaints were ruled to be valid.Council complaints manager Thembekile Phaswane said a common problem was that scheme members did not understand the terms and conditions of the scheme and so faced unexpected medical bills when they needed treatment.Schemes are obliged to pay in full for the treatment of 270 diseases and 26 common chronic conditions, "prescribed minimum benefits".But a medical aid scheme can tell a member which doctors or hospital to use if he wants full financial cover.When medical aid schemes can prove that a member did not use the specified doctor or hospital, the member must pay extra.Phaswane said doctors did not always disclose that they were not among a medical aid scheme's designated service providers.The schemes with the highest rate of complaints per member were Spectra Med, Resolution Health, Genesis, Suremed and Keyhealth."It's not the first time we have seen these same schemes in the top 10 with respect to complaints," said Phaswane.In restricted schemes, Netcare received the most complaints.Most medical aids schemes ran at a loss this year, including Bonitas and the Government Employee Medical Scheme - they paid out more than they earned in premiums.This is partly explained by an ailing population and the average age of medical aid scheme members increasing every year.The government scheme hit the headlines recently because of its financial losses, but it is now said to be stable and will pay claims for the next year ...

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