Got a query?
You’ll most probably find your answer right here! We’ve put together the answers to all our most frequently asked questions.
What is the difference between Medical Scheme Rates and the rates charged by medical practitioners?
It is really important that you understand the difference between Medical Scheme Rates (MSR) and the rates charged by private providers.
MSR is the tariff determined by the Board of Trustees and is adjusted from time to time, following consultation with suppliers in the industry. On the Traditional and Traditional Plus (including SELECT) Plans, the Fund covers Day-to-Day Benefits at 100% of cost from PMSA, and then at 1 x MSR from PCB for the Traditional (including SELECT) Plan and at 3 x MSR from PCB for the Traditional Plus (including SELECT) Plan. Hospital Benefits and Supplementary Benefits are covered at 1 x MSR on all Plans.
However, medical practitioners are under no obligation to charge MSR. Due to the often substantial difference between MSR and the rates charged by medical practitioners, you should find out what rate your doctor charges, as you may be responsible for paying the difference between the two rates.
It is worth negotiating with the service providers since they are usually willing to reduce their service fee. By paying less, your benefits will last longer.
If I visit the Emergency Rooms (ER) at a hospital, will my costs be covered from my Hospital Benefits?
A visit to a hospital’s Emergency Room does not qualify to be paid from your Hospital Benefit, unless the incident is of such a serious nature that you are admitted to a ward in the hospital itself, for further treatment.
Furthermore, if you are transported to hospital by an ER24 ambulance (even though approved), and on examination you are found to be fit enough to return home, you will be responsible for arranging your own transport home.
When will elective procedures be regarded as PMB and therefore be covered under the Hospital and Network (including SELECT) Plans?
Under the Hospital and Network (including SELECT) Plans, elective procedures will only be covered in accordance with PMB. This means, for example, that procedures such as hip, knee, shoulder or elbow replacements will typically only be approved in the case of a fracture (normal wear and tear and arthritis of a joint would not qualify as PMB). Alternatively, an emergency admission where loss of limb has to be prevented will also qualify as PMB.
Can I claim for medical expenses incurred outside South Africa?
If you are injured or become ill while outside South Africa on holiday or business, you will be responsible for settling the account. You can claim the cost back from the Fund when you return.
Claims that are approved will be subject to the Fund’s Rules as if the treatment was rendered in South Africa. In other words,
the same exclusions, benefits and limits will apply.
Submit your original claim to firstname.lastname@example.org. The benefit will be paid according to the equivalent tariff and will be refunded to the member in Rands, at the exchange rate that applied on the treatment date. If you are intending to travel abroad, it is wise to take out additional medical cover. Your travel agent will be able to assist you with this.
What happens in the case of motor vehicle accidents?
Motor vehicle accident (MVA) claims have certain procedures, which must be strictly adhered to. The Fund will pay for claims related to such an accident, whether it qualifies as Prescribed Minimum Benefits or not. To help the Fund recover a portion of the millions of rands spent on claims related to motor vehicle accidents, members have an obligation to co-operate with the recovery process by disclosing all information relating to a possible third-party claim and to sign all the required legal documents.
You will also be required to sign a member undertaking, stating that you will pay the Fund back if you receive a settlement that includes money that the Fund paid on your behalf. If you are involved in a motor vehicle accident where a third party is liable, inform the Fund as soon as possible at 0860 100 076. Claims will be paid to the service providers (such as the hospitals and doctors concerned) up to the individual member’s limits.
Cases that are rejected by the Road Accident Fund will be covered by the Fund up to the individual member’s limits. However, a letter will be required from the Road Accident Fund stating that the claim has been rejected. Decisions will be made based on the Rules of the Fund.
If you decide not to institute a claim against a third party (for instance, if your injuries were not serious and did not result in long-term physical impairment or a treatment plan), you will be requested to cede your rights to claim against a third party to the Fund. This will allow the Fund to institute a claim directly, to recover the costs that were paid by the Fund
Does the Fund pay for claims in terms of the Compensation for Occupational Injuries and Diseases Act?
No, such claims are not covered by the Fund. Forms in respect of the Compensation for Occupational Injuries and Diseases Act should be completed by the treating hospital or medical practitioner and your Employer, and then submitted to the Compensation Commissioner. The Fund will not pay any benefits until the Commissioner rules that the injury does not fall under the Compensation for Occupational Injuries and Diseases Act.
How can I keep my medical costs low?
- Negotiate with your doctor to charge MSR or to give you a discount, if he or she has opted out of charging according
- Consider paying in cash and then claiming back, as many service providers offer discounts if they are paid in cash.
- Talk to your doctor about prescribed medicines. An alternative generic medicine may be as effective, and cost you much less. If you are too shy to approach the doctor, the dispensing pharmacist can do this for you.
- Try to avoid all unnecessary treatments. This is wasteful and costly to you and the Fund.
- If your doctor recommends a particular line of treatment and you feel uncertain about whether it is necessary, ask for a second opinion.
- If an operation is scheduled for the afternoon or evening, please arrange for the hospital admission after 12pm. That way the Fund will only pay for the afternoon (i.e. a half-day).
- If you are on the Savings, Traditional or Traditional Plus (including SELECT) Plan and require a non-PMB hip or knee replacement, you have to use the Fund’s Designated Service Providers, where available. If you do not use the DSP, you will have a compulsory R5 000 co-payment and may be liable for additional associated costs in excess of the Medical Scheme Rate. See page 80 for more information.
- Use pharmacy Preferred Providers, as these providers offer cost-saving options that will make your medical aid benefits last longer, through low medicine price and generic substitution, as well as not charging additional administration fees. You may obtain medicine from any other Pharmacy; however a co-payment may be applied. If a pharmacy charges more than the Fund’s approved rates (which will not occur at any of the contracted pharmacies) you will be liable for the difference.
What should I do if I suspect fraudulent activity against the Fund?
Unnecessary and fraudulent expenses are funded by you, the member, through increased contributions. In order to assist the Fund in combatting the impact of fraudulent claims, please:
- Check the accounts you receive from medical service providers for errors or inconsistencies,
- Check your member statement, SMS notifications and emails from the Fund to make sure that any claims that have been processed are correct and that there are no claims for services not provided,
- Report any suspicions of fraud by calling the Fraud Hotline on 080 111 4447, or emailing email@example.com.
- Examples of fraud scams are:
- A service provider putting in a claim for services that were never rendered.
- A service provider performing a procedure or giving treatment that is excluded by the Fund Rules, and then
- charging for it under a different code.
- A pharmacy providing generic medicine, but charging for the more expensive brand name.
If you suspect that a service provider, colleague or any other person or organisation may be engaged in fraudulent activities against the Fund, please contact the Fraud Hotline on:
Toll-free number: 080 111 4447
Fax : 086 672 1681
Callback No. (please call me): 072 595 9139
You can choose to remain anonymous.
When do I get my tax certificate from the Fund?
The Fund will mail or e-mail the tax certificate to you by June each year. Please keep this in a safe place for later use. The Fund only stores information relating to tax certificates for a period of 5 years.
Where can I obtain a membership certificate?
Contact 0860 100 076 to request a certificate. Alternatively, e-mail firstname.lastname@example.org.
How does my membership card work?
Your membership card (e-card) is available electronically on your smartphone. Whereas it is possible for someone to use your plastic membership card fraudulently, your e-card ensures that only you can use it. The e-card facility will initially run in parallel with printed cards.
Printed cards will only be phased out once we are satisfied that the e-card works well. However, you will still be able to request a plastic membership card from the Fund.
What can I do if I have an unresolved complaint against the Fund?
Please ensure that you follow the Fund’s internal escalation procedure before lodging a complaint with the Council for Medical Schemes (CMS).
- The Registrar of the Council for Medical Schemes is the regulator of the medical scheme industry. Any member or any person who is aggrieved with the conduct of a medical scheme, health professionals, private hospital or nurse, can submit a complaint to the Registrar’s Office.
- A complaint form is available on their website (medicalschemes.com).
- Complaints can be submitted through fax, e-mail or in person at the Registrar’s office. The Registrar’s contact details are as follows:
Customer Care Share call telephone number:
0861 123 267 or +27 12 431 0500
+27 12 431 7544
Council for Medical Schemes
Block A Eco Glades 2 Office Park
420 Witch-Hazel Street
- The Registrar’s Office will send a written acknowledgement of a complaint within 3 working days of its receipt, providing the name, reference number and contact details of the person who will be dealing with the complaint.
- In terms of Section 47 of the Medical Schemes Act, a written complaint received in relation to any matter provided for in this Act will be referred to the medical scheme. The medical scheme is obliged to provide a written response to the Registrar’s Office within 30 days.
- The Registrar’s Office shall, within 4 days of receiving the complaint from the administrator, analyse the complaint and refer the complaint to the medical scheme for comments.
Upon receipt of the response from the medical scheme, the Registrar’s Office will analyse the response in order to make a decision or ruling. Decisions / rulings will be made within 120 days of the date of referral of a complaint and communicated to the parties.
The Registrar’s Ruling and appeal to Council
- Section 49 of the Act makes provision for any party who is aggrieved with the decision of the Registrar to appeal such
- A decision. This appeal is at no cost to either of the parties.
- An appeal must be lodged within 30 days of the date of the decision. The operation of the decision shall be suspended pending review of the matter by the Council’s Appeals Committee.
- The secretariat of the Appeals Committee will inform all parties involved of the date and time of the hearing. This notice should be provided no less than 14 days before the date of the hearing.
- The parties may appear before the Committee and tender evidence or submit written arguments or explanations in person or through a representative.
- The Appeals Committee may after the hearing confirm or vary the decision concerned or rescind it and give another decision as they seem just.
The Section 50 Appeals process
- Any party that is aggrieved with the decision of the Appeals Committee may appeal to the Appeal Board.
- The aggrieved party has 60 days within which to appeal the decision and must submit written arguments or explanation of the grounds of his or her appeal.
- The Appeal Board shall determine the date, time and venue for the hearing and all parties will be notified in writing.
- Appeal Board shall be heard in public unless the chairperson decides otherwise.
- The Appeal Board shall have the powers which the High Court has to summon witnesses, to cause an oath or affirmation to
- Be administered by them, to examine them, and to call for the production of books, documents and objects.
- The decisions of the Appeal Board are in writing and a copy thereof shall be furnished to parties. A prescribed fee of R2 000 is payable for Section 50 Appeals.
What is the Credit Management Policy and its main objectives?
The Credit Management Policy is a policy put in place by the Trustees to ensure that debt owed to the Fund is collected timeously.