If not by experience; we all have at least heard one recollection of an event from a friend, colleague or family member, where a medical aid scheme has rejected cover for a specified medicine or medical procedure.

The Covid-19 virus and its associated heightened risk of infection and potential life-threatening implications; forces closer consideration of what our medical aid and medical insurance schemes will cover in respect of treatment.

Medical Aid vs Medical Insurance

Most medical aid users are familiar with the processes of visiting a physician or pharmacy and having a ‘claim’ processed in respect of their particular medical aid scheme. Whether a claim is covered or rejected, is then dependent on the internal processes and policies of the particular scheme as agreed by the policy-holder upon signature of the relevant policy document.

Medical aid schemes usually have set policies and guidelines in respect of the practitioners and medication that will be covered in respect of each policy package offered. It is this specific characteristic which sets medical aid-schemes apart from medical insurance or rather health insurance policies.

Medical aid schemes are regulated by the Medical Schemes Act and has the Council for Medical Schemes as an overseeing body. On the other hand, medical or health insurance policies are governed by the Long Term Insurance Act or the Short Term Insurance Act and has the Financial Services Board as an overseeing body.

As mentioned previously, the key distinction between medical aid schemes and health insurance policies lies in the way ‘claims’ are processed. Health insurance policies usually provide for lump sum coverage for the instance that you may require medical attention. As with medical aid schemes, the relevant policy documents dictates under what circumstances the lump sum will be paid out. However, once paid out, the policy holder has complete discretion to pay for whatever medical treatment they deem fit for their relevant medical requirements.

How will cover for Covid-19 be determined?

The Council for Medical Schemes has set out guidelines in respect of Prescribed Minimum Benefits. These guidelines serves to ensure that medical aid members have access to certain minimum health services.

Upon the announcement of the nation wide lock-down in South Africa due escalating Covid-19 infections, the Council for Medical Schemes issued a circular classifying all Covid-19 cases as part of Prescribed Minimum Benefits.

The circular further indicated that medical aid schemes should cover the following:

• All consultations;
• All clinically appropriate diagnostic tests including Viral PCR;
• All clinically appropriate medication; and
• Costs of hospitalisation including all complications and rehabilitation.

It must be mentioned however, that medical aid coverage in respect of the above, will still be determined as per the usual guidelines and policies that each medical aid provider has established and agreed to with each member.

Therefore, it is of paramount importance that medical aid members consult their policy documents and medical aid providers to determine the scope of coverage for Prescribed Minimum Benefits.

The classification of Covid-19 treatment as a prescribed minimum benefit does not mean that a medical aid provider is obliged to pay for treatment where a member has failed to pay their membership fees.

Termination and disruption of medical aid cover will be dealt with in accordance with the usual policies set by each medical aid provider. Be that as it may, the aforementioned circular does appear to establish a heightened duty on medical aid providers, to properly investigate coverage interruptions or terminations under the current Covid-19 circumstances.

­­­­­Health insurance policies do not fall under the authority of the Council for Medical Schemes and are therefore not affected by the aforementioned circular. It would therefore appear that coverage and the extent thereof, in respect of any Covid-19 related medical treatment, will be dependent on the claim requirements of the relevant insurance policy.

It is therefore of utmost importance that health insurance policy holders consult their relevant policy documents and brokers to assess the scope of coverage allowed for Covid-19 treatment.

Conclusion

The Covid-19 pandemic and the resultant national lockdown has resulted in stringent hygiene protocols and quick business survival mechanisms being implemented.

Considering the very relevant increase in anxiety levels and global panic, it is important to make sure that the safeguards implemented to assist us in our most vulnerable positions, cater to our needs when required. Contact an attorney at SchoemanLaw for advice and to assess the scope of your cover.

Written by Raeesa Ebrahim Atkinson, Attorney, Schoeman Law