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Medical Scheme Rules

Understand your Medical Scheme Rules

One of our members recently found themselves in the very unfortunate position where his / her spouse was involved in an accident relating to a certain extreme sport.  The medical bills related to this accident were not covered in a private hospital by Genesis Medical Scheme, as the specific sporting event relates to an exclusion in terms of the registered Rules of the Scheme.

It is of paramount importance that all new applicants of a medical scheme (and existing members who have not done so yet) familiarise themselves with the Rules of their medical aid benefit option (Terms, Conditions and Exclusions).

According to the Medical Schemes Act, the Rules of a medical scheme shall be binding on both the scheme and its members.  The Act continues to state that a medical scheme shall provide to its members a detailed summary of its Rules, specifying such member’s rights and obligations.  Generally, the Rules of a medical scheme are available to members on the schemes’ websites or alternatively, upon request from the scheme.

When signing the scheme’s member application form, which is a legally binding contract, the applicant confirms that he / she is familiar with the Rules of the scheme and that, notwithstanding representation by any other party, they understand that their benefits and contributions are those contained in the Rules.  The general rule of law is that a party is bound by all the terms set out in a contract if they have signed it, whether or not they have read the terms or understood them.

From time to time, members find themselves in the dire situation where medical bills in respect of a scheme exclusion or benefit option are not covered, and they then blame the medical aid.  Any claim(s) that is paid (or rejected), is assessed according to the benefits (or limitations) set out in the Rules.  And, that may just be the point at which the problem starts, as members often fail to familiarise themselves with these Rules that are binding on all members.

The Rules 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.  Angry members that have been denied a benefit to which they thought they were entitled to, do not realise that their membership is governed by the Rules of the medical scheme that regulate the relationship with all members equally.

Whilst this may sound harsh and unfair to the affected members, no medical scheme will allow benefits outside of its Rules.  The public is best advised to shop around to find a medical aid that best caters for their specific medical / lifestyle needs in relation to what they can afford. It is essential that you obtain the Rules of the scheme, or a summary thereof, to verify all information relevant to enable you to make an informed choice.

The responsibility of understanding medical aid membership terms and conditions has and will always remain that of the applicant / member; it cannot be shifted to the medical scheme or another third party.  Wild and slanderous accusations and allegations when claims are not paid, will not change matters afterwards; such behaviour really does little more than embarrass the person making such remarks.

Genesis members who have any questions about the Scheme Rules, are welcome to email us at (please quote your membership / ID number), or contact us on 0860 10 20 10.

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