Every time that a medical aid claim is rejected or not paid in full it just has to be the scheme’s fault.
Well, who else should we blame?
Medical aid, like any other insurance product, is a grudge purchase mainly because we have it as a result of some kind of fear of loss. Compounding the issue is the fact that we very often have nothing to show for the monthly outlay.
When we go to the shops we pay our money as we come away with a few bags of groceries. Pay your medical aid contributions and there is typically nothing to show for the “purchase”. Peace of mind is not a tangible asset. Invaluable perhaps, but not tangible.
Naturally, when a claim is submitted we expect it to be paid in full and we get angry when it isn’t.
Why are claims rejected?
The relationship between members and the medical scheme is one of a legally binding contract. And, that may just be the point at which the problem starts.
The “contract” goes on and on and on. The many pages of terms and conditions are difficult to comprehend at the best of times. Very few people can reasonably remember all of the terms of the contract without reference to them. The “contract” is of course the rules of the medical scheme that are binding on all members. These rules, however, contain the exact details of benefits payable by the medical scheme and include the specific benefits pertaining to each benefit option, the rate of reimbursement, sub-limits or co-payments that may apply, exclusions, etc. Any claim(s) that is paid (or rejected), is therefore assessed according to the benefits (or limitation) set out in the rules. It is not based on the subjective assessment of a claims assessor.
The role of the doctor
In times of need we consult a doctor who may advise that an operation is necessary. Sudden anxiety often accompanies such news and our minds go blank.
You ask how much the procedure will cost. The doctor answers by asking if you have medical aid. You say yes and he says not to worry “this is a PMB – I will fight with them and sort it out”. You are reassured and some semblance of peace of mind returns.
This of course is not the time to start negotiating with the very person that is going to dissect your body while you are fast asleep. You naturally want your doctor to be happy because he is going to make the pain go away. Moreover, you have got medial aid!
Who to believe
The question that arises is just who should you believe? Your medical scheme tells you that you have a hospital plan so costs should be covered when in hospital.
On the other hand, your doctor is telling you that your condition is a PMB and so the medical scheme must “by law” pay in full.
The answer to the question is that you should of course believe both parties – but, for different reasons.
Your doctor is the person that will treat you. He is your healthcare provider and he will advise and treat you to the best of his ability. Whenever you consult with your doctor, your medical scheme is never present. The scheme is not a party to the contract and the relationship that you have with your doctor.
Your medical scheme, on the other hand, does not provide any kind of healthcare treatment. The scheme does not offer advice or clinical care. The risk of the scheme is limited to the administration of money.
In the same way that your medical scheme is not a party to the contract between you and your doctor, so your doctor is not a party to your contract with your scheme.. The relationship between the member and his medical scheme is a legal one in the sense that it does not involve clinical or medical treatment, but the defraying of expenditure that relates to clinical treatment.
Problems can of course arise when doctors enter into the realm of legal issues or when accountants or lawyers enter into the medical or clinical world.
It may be best practice to let doctors “doctor” and the lawyers “lawyer”.
If your doctor says “Don’t worry, I will fight with the medical scheme”, it may just be worth a call to your scheme to get confirmation of what your benefits “in law” actually are.