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Medical Schemes and their Importance Explained

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Medical Schemes and their Importance Explained

Medical schemes in a variety of forms and under different titles are to be found worldwide.  There are around a hundred in South Africa alone where, in common with many other countries, the overburdened state health facilities have led typically to long waiting lists and curtailed services. In turn, this has seen a rapid expansion of the private healthcare sector. In parallel, the urgent need by a growing number of the nation’s citizens for financial assistance to cope with the much higher costs of undergoing private treatment has also fuelled substantial growth within the healthcare insurance industry.

Locally, medical schemes are required to be non-profit and are now mandated by the Department of Health to provide certain prescribed minimum benefits. This provision means, for instance, that those with chronic illnesses, such as diabetes, asthma, cancer, HIV/AIDs and twenty-one other conditions, may not be excluded from membership and must receive full cover for all costs relating to their condition.

Over and above these compulsory provisions, routine treatment in the form of surgery, dentistry, optometry, maternity and medications are covered in accordance with pre-agreed percentages and limits. In return, members must pay a monthly premium which, in turn, must be approved by the Council for Medical Schemes (CMS).

The nation’s fund managers have been required to devise increasingly innovative ways by which to meet rising healthcare costs, while simultaneously attempting to maintain affordable premiums. The result has been a wide diversity of products that vary not just in terms of their price, but also in the precise combination of benefits that they offer. This diversity has required prospective members to conduct careful comparisons, both of the various medical schemes and their individual product range, before making a commitment.

With regards to the importance of this form of cover, it has been estimated that perhaps as much as ninety-five percent of the private healthcare sector’s annual income originates from these specialised insurers. Moreover, the vast majority of patients could not meet the cost of their treatments without the aid of one of these vital medical schemes.

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