Frequently asked questions
Please select the question below you’d like to find out more information on. Alternatively please feel free to contact us.
What is a co– payment?
Is membership of a medical scheme available to any person?
Can I belong to more than one medical scheme at the same time?
May a medical scheme refuse to admit my dependant?
If a member dies, will his registered dependants still be covered?
Must I give notice to the scheme in the event that I wish to terminate membership?
Am I entitled to benefits while serving notice of termination?
May a medical scheme determine contributions on the basis of individual high claims or provide for discounted or preferred rates in respect of a particular group of members/Clients for whatever reason?
What can I do if I am not satisfied with my current benefit option?
To what extent are the prescribed minimum benefits restricted?
What are the types of waiting periods?
i.e General waiting period of up to three months, Condition-specific waiting period of up to 12 months.
Within what period of time must my account for services of claim reach my medical schemes?
The account must be submitted not later than the last day of the fourth month following the month in which the service was rendered.
How do I know whether or not my scheme has paid and what amount has been paid in respect of a claim?
Payment of claims is regulated by the Act, which includes the dispatch to a member of a statement containing full particulars of the transaction, including the amount charged for every service and the amount of the benefit awarded for each service.
Within what period of time must the scheme pay my claim?
If the account or claim is correct and acceptable for payment, it should be paid within 30 days of receipts of the claim.
What is an ex-gratia payment and do I have a right to such benefits?
It is a discretionary benefit which a medical scheme may consider, normally when the member suffers undue hardship. Schemes are not obliged to make provision therefore in the rules and members have no statutory right thereto.
Is a provider of health care service entitled to charge more that the fees determined by medical schemes/ the tariff specified in the NHRPL?
May I participate in the operation of my scheme?
When does a government employee qualify for subsidy?
When am I allowed to change from option?
Only once a year, preferably in the beginning, and a motivation should be attached.
What is a late joiner penalty?
A penalty which may be imposed on a new member joining the scheme, if the member is over the age of 35 and cannot provide proof of sufficient previous membership to a medical scheme.
Information source: www.medicalschemes.org.za