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Medical Aids South Africa | Medical Schemes | KeyHealth Medical Scheme

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Aspects of Medical Aids in South Africa

The history of medical aids in South Africa dates back to the 1980s. Although medical aid schemes did exist before then, it was only during the eighties that the healthcare schemes were streamlined. Once the benefits of belonging to one of the medical aids in the country became known, popularity grew quickly.

The earliest types of medical aid schemes were merely hospital cash plans rather than covers for payment of medical costs. By the nineties over 49 000 such policies were already sold. The modern version of medical aid, however, had its origins in fifties in the USA. Cover payments were made for major medical procedures. The original schemes in South Africa were available as group covers and open medical aids for individual membership only came later.

By the early nineties several South African insurance companies were selling medical policies. The Dreaded Disease policy was introduced and became part of life insurance policies. Medical aid as available from KeyHealth today is not insurance, but rather cover for day-to-day medical costs and also hospital costs. This simply means that the individual pays a monthly contribution to the Scheme and in return the Scheme pays the service providers used according to specified and agreed upon tariffs.

Medical Schemes Act No. 131 of 1998

Medical aids are regulated by the Medical Schemes Act No. 131 of 1998 not only for the protection of consumers, but also the medical professionals and service providers as well as schemes. According to the wording of the Act the business of a medical scheme is to undertake liability in return for a premium and to make provision for obtaining any relevant health service, grant assistance in defraying expenditure incurred and where applicable, to provide a relevant health service that can be the medical scheme or designated service providers in terms of an agreement with the medical scheme.

From the above description in the Act, it becomes evident that the modern medical aid provider doesn’t make a cash payment to the member when the member is hospitalised, but rather takes on the financial responsibility associated with such hospitalisation on behalf of the member.

Members and Dependants

According to the Act, a dependant of a member can be the partner, dependent children, spouse or immediate family where the member has taken on the responsibility of family care and support. The dependant can also be one as recognised under the rules of the particular medical scheme as eligible for receiving of benefits. The member is the person that has enrolled as member to a medical aid plan.

Note that a person may not be a member to more than one medical aid scheme and can thus also not submit a claim to more than one. A person cannot be admitted as a dependant of more than one member of a specific medical aid or as dependant of members from various schemes. In addition, a person may not accept benefits from any medical scheme of which he or she isn’t admitted as a dependant or a member.

Cancellation or Suspension

Membership of medical aids in South Africa can only be suspended or cancelled by the specific schemes if the members fail to pay the premiums within the allowable time period according to the rules of the particular schemes or fail to repay debt due to the medical schemes. Other grounds for suspension or cancellation include that of fraud or non-disclosure of material information.

It is essential to review the rules of a particular scheme to ensure compliance and to avoid any misunderstandings. KeyHealth offers comprehensive information to members and interested parties to ensure informed decision making regarding membership and the choice of a benefits plan.

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