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Benefits: Overview

There for you

Many people regard their medical scheme mainly as a way to help cover visits to the doctor or dentist, or to fund a new pair of spectacles. The monthly contributions then seem disproportionately high, and many medical scheme members (whatever scheme they belong to) complain that they are not getting value for money.

The first thing to understand is that a medical scheme is mainly there to help you when things go wrong. It’s comparable to your short-term insurance. You may go many years without claiming for anything, but when you’re burgled, it’s great to be able to claim for everything you’ve insured.

Likewise, members who are in accidents, develop cancer or need life-saving procedures are usually extremely relieved that they have a medical scheme to fall back on. And because the costs involved in these major medical events are often very high, this is where the benefit amounts are typically the highest, and where the Society spends most of its and, most importantly, your money.

During a typical member’s lifetime, there will be many occasions where the Society’s benefits would be extremely valuable. The “journey” below shows different life stages, and the type of healthcare challenges a member may face.


 

How to save money for the Society and make the most of your benefits

Remember that every member is in a sense a shareholder of the Society. This means everyone benefits from reasonable and responsible behaviour, as lower claims can result in lower contribution increases.

This is how you can save the Society – and yourself – money:

Maintain a healthy lifestyle, as prevention is always the better option.
Make healthier choices to avoid or better manage chronic lifestyle-related diseases.
Understand your responsibilities as a member, such as knowing and understanding your benefits, as well as the Society’s Rules, processes, and requirements (see more information later in this chapter).
Use the vaccines and screening tests offered as part of your Preventative Benefits to avoid certain illnesses and to identify potential chronic lifestyle diseases early.
Stretch your benefits by knowing how claims are covered, as well as where you are covered (see more information later in this chapter).

Use the Society’s Designated Service Providers (DSPs) or Preferred Providers (PPs) to avoid unnecessary co-payments. The Society’s DSPs and PPs are:

  • Network Hospitals (DSP);
  • Dis-Chem Pharmacies, Dis-Chem Direct, Cullinan Health & Home Pharmacy, the Namaqualand Pharmacy and Dr HA Burger in Springbok for the supply of medicine (DSP & PP);
  • ER24 for emergency transport (DSP);
  • PPN (Preferred Provider Negotiators) for optical benefits (DSP);
  • ICON (Independent Clinical Oncology Network) for oncology treatment (DSP); and
  • BBraun Avitum / E Owen & Partners for renal dialysis (DSP).
Ask for generic medicine whenever possible.

Consider paying in cash and then claiming back to get discounts.
If your doctor recommends a particular line of treatment and you feel uncertain about whether it is necessary, ask for a second opinion.
Think twice about undergoing elective surgical procedures. If you do need a surgical procedure that is not an emergency:

  • obtain pre-authorisation from the Society for the procedure;
  • use a Network Hospital;
  • get a quote from your doctor and other service providers such as the anaesthetist beforehand and check with the Society how much will be paid;
  • consider negotiating with your providers to charge (at least closer to) the amount covered by the Society; and
  • if an operation is scheduled for the afternoon or evening, arrange for hospital admission after 12pm.

Your responsibilities as a member

While the Society is accountable for member communication, you have a duty (and are accountable) to ensure that you remain updated regarding both the benefits provided by the Society and the developments affecting the Society, as well as to act responsibly in relation to the Society. Members’ behaviour (claiming patterns) has a direct impact on the total costs and therefore impacts your contributions and the future sustainability and viability of the Society.

Specifically, as a member you should:

  • Familiarise yourself with the Society’s benefit structure;
  • Use your benefits responsibly;
  • Ensure that your medical claims are submitted timeously (within 4 months from the date of service);
  • Adhere to the Society’s Rules;
  • Read all communication sent to you, attend Society information sessions as appropriate, refer queries to the Society for clarification and provide the Society with feedback if your information needs are not met;
  • Keep the Society up to date regarding any changes to your and your dependants’ membership status and details;
  • Check all accounts from service providers as well as your weekly and monthly member statements from the Society to make sure that all details are correct and that your claims have been processed correctly;
  • Obtain pre-authorisation from the Society before you are admitted to hospital or for any other procedures requiring pre-authorisation (but remember that authorisation does not confirm funding in full by the Society and that co-payments may still apply);
  • Ensure you are aware of the limits imposed on various benefits, for example prosthesis, when a hospital or any other authorisation is sought. The various limits are set for the year and will likely be exhausted after any one event. You may therefore be faced with high co-payments despite authorisation being granted in the case of any second similar major event in a one-year cycle;
  • Retain all your documentation received from the Society so that you can refer to it when necessary;
  • Keep your membership card in a safe place so that no one else can use it fraudulently;
  • Inform the Society of any changes to a beneficiary’s status that may result in the beneficiary no longer satisfying the eligibility conditions of being a dependant, in terms of the Society’s Rules;
  • If you suspect fraudulent activity in relation to the Society, please report such; and
  • Notify the Society of your cell phone number, valid postal and residential address, other contact details and email address and any changes to this information, to ensure that you receive Society-related correspondence and communication material.

 

Stretch your benefits by knowing how claims are covered

Remember that the Society operates on a not-for-profit basis. To understand how the Society covers various claims so that you can stretch your benefits, look at the following distinction:

DAY-TO-DAY HEALTHCARE HOSPITALISATION / MAJOR MEDICAL EVENTS
These claims are paid at the Society Recommended Price List (SRPL)* rate for the service rendered or benefit obtained.

If a provider charges more than the SRPL rate, the member will be liable for the difference between the SRPL rate and the rate charged by the provider.

Benefits are paid at various percentages of the SRPL rate – for example, a GP consultation at 90%, orthodontics at 75% and dentistry at 100%.
If you use a Network Hospital (and obtained pre-authorisation)

  • the hospital claim will be paid at the Negotiated Rate**; and
  • service providers’ professional fees will be paid at the Scheme Rate***, which is limited to 165% of the SRPL rate.


If you voluntarily use a non-Network Hospital (and obtained pre-authorisation)

  • the hospital claim, as well as service providers, will be paid at the SRPL rate, and you may have a sizeable co-payment.


If you do not obtain hospital pre-authorisation

  • you will be liable for a 30% co-payment on the total hospital account.


The above is a generalisation, to help you understand your benefits. There are also benefits paid at other rates (for example, in the case of medicine). Please see the tables in the respective benefits chapters for specific information on how various benefits are covered.

*SRPL rates
Aligned to medical aid industry practice, the Society has its own reference price list, the Society Recommended Price List (SRPL), according to which benefits are calculated and claims are paid. The SRPL is adjusted annually to take account of inflation and other changes.

**Negotiated Rate
This is the rate that the Society negotiates with Network (DSP) Hospitals for the direct payment of hospital accounts.

***Scheme Rate
This is the rate at which the Society pays benefits to all service providers for services rendered in Network (DSP) Hospitals and for defined in-room procedures. The Scheme Rate is 165% of the SRPL rate.

 

Where you are covered

Cover for benefits as outlined in this guide generally only applies within South Africa (also known as the Society’s Area of Operation), except in specific circumstances (see below). If you live in South Africa, you cannot claim benefits when you are outside the country. If you travel to other countries for work purposes, contact your Employer regarding cover.

If you travel on holiday outside South Africa, you should obtain your own private medical travel insurance.

Only in the following instances will cover be provided in Botswana and Namibia:

  • While members are employed by the Employer (or an Associated Employer) in Botswana or Namibia, such members and their registered dependants will be eligible for benefits in either of these countries; and
  • When members who are eligible for benefits in Botswana or Namibia retire and become pensioner members of the Society, they and their registered dependants will continue to enjoy these benefits for as long as they remain permanent residents of that country.

Other Benefits

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