How can I get advice about the cover of my medical scheme?

A medical scheme cannot prevent you from applying for scheme membership if you do not use the services of a broker, but using one is likely to be beneficial.

And it is likely that seeking advice will come at no cost to you, as medical scheme advisers are paid by medical schemes.

A good medical scheme consultant should:

  • Make sure that you have adequate coverage from a medical scheme and that you do not mistake a health insurance product for medical scheme coverage.
  • Saves you from researching many schemes and their options to find the right one, and provides valuable insights that you as a regular consumer may not know.
  • Do proper due diligence on any medical scheme recommended to you to ensure that the scheme is financially sound and that it is properly managed. He or she should also keep you informed if this changes.
  • Assess your care needs from the history of your medical expenses, the state of your health and your family and your future care needs. This could include, for example, future expenses if you are planning to start a family or are expecting a medical procedure. Your broker should reassess this if your health or family circumstances change.
  • Identify appropriate options within the recommended arrangements.
  • Determine the cost of your medical scheme membership – taking into account any late joiner penalty you may pay – and check with you if this is affordable. A loan penalty is an ongoing penalty applied to medical scheme contributions if a member joins a medical scheme after the age of 35, either for the first time or after a membership break. The fine that is imposed depends on how long the member has previously been a member of the scheme.
  • Update you at least once a year on any changes to options or benefits and advise you whether these changes make it worthwhile for you to change plans or options.
  • Contact the scheme for you if your claims are not paid or if there is a dispute.
  • How to access chronic medications.
  • Indicate any important exclusions or benefit limits you need to know.
  • Assist you with the application process, and point out the important medical history details you need to explain.
  • Advise you on whether you would benefit from gap cover. this is a short-term insurance policy that covers the shortfall between what your medical scheme pays and what a doctor costs to treat you in hospital. Some policies also have coverage for deficiencies in oncology benefits and treatment in casualties.

A good advisor will also inform you how the option works, including:

  • Any limits on hospitalization or other benefits for expenses associated with serious illness or hospitalization.
  • How your daily health care costs are covered;
  • Whether to use a network or specified list of hospitals, and which physician network to use for prescribed minimum benefits and other benefits. These are benefits that a scheme must provide by law, including cover for all emergencies, 271 life-changing conditions and 26 common chronic conditions.
  • Explain waiting times that may apply. These are periods in which you cannot claim a policy or a medical scheme for all or certain benefits.

Check your broker is legit

The Medical Schemes Act stipulates that scheme brokers and the brokers they work for must be accredited by the Council for Medical Schemes.

The municipality checks whether brokers are fit for the job and have the right experience to give advice.

Medical scheme brokers are also subject to the provisions of the Financial Advice and Intermediary Services Act and must therefore also be licensed as a financial services provider (FSP) or as a representative of a licensed FSP.

Your broker must also have a broker agreement with any medical scheme it recommends you join, and there must be a written service level agreement between the broker and the scheme.

In order to sell you a health insurance product, such as gap coverage, a health broker must be licensed as a financial services provider who can advise on short-term insurance policies.

What advice costs

Advice your broker gives you about joining a medical scheme is generally paid for by your scheme. The amount that can be paid to your broker through the scheme is set at 3% of your contributions up to a maximum monthly rand amount that is prescribed each year – currently just over R100 per month.

A broker can also be paid an additional agreed amount by you or your employer.

If your medical scheme broker stops providing a service to you, you can notify the scheme that you no longer want the broker’s services and the scheme must stop payments to the broker immediately.

If you take out gap cover insurance on the recommendation of a broker, the broker can earn commission of between 5% and 20% of your premiums. This is regulated under the Long and Short Term Insurance Acts.

You should be advised of this commission when you receive a quote from the broker.

Tip for choosing a broker

Brokers must contract with a medical scheme before they can give you advice on that scheme. Ask how many contracts your broker or broker has with the now less than 20 open medical plans. Your broker should be able to recommend at least three. Most An arrangement with membership that is limited to the employees of an employer, an industry or to members of a profession.” style=”color: rgb(0, 175, 173); cursor: pointer;”>limited medical plans do not use brokers or brokers.

How can I get advice about the cover of my medical scheme?

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