Consumers would lodge significantly fewer complaints about their medical schemes if schemes communicated openly with them, as was required by the regulations under the Medical Schemes Act, Tembekile Phaswane, the senior manager for complaint adjudication at the Council for Medical Schemes, told a recent medical scheme conference.

In a presentation to the Board of Healthcare Funders conference in Cape Town, Phaswane said members’ lack of understanding of schemes’ terms and conditions led them to assume that their claims were being denied unfairly.

She said the main cause of disputes between members and schemes was inadequate communication about benefits. Every October or November, when schemes announce their contributions and benefit changes for the coming year, they draw members’ attention to any benefit enhancements. Benefit reductions, however, are not highlighted in marketing material. As a result, members become aware of these reductions only when they try to access benefits they have previously enjoyed, only to find they are no longer available.

The Council for Medical Schemes also receives a large number of complaints whenever a scheme changes its administrator, Phaswane said. Although schemes reassure members that switching administrators will not be disruptive, it is common for the change to result in the loss or corruption of membership data and in delays in the payment of claims.

Another source of complaints is members struggling to establish what they are entitled to from managed-care programmes. In many cases, the council finds that schemes either do not have a written protocol in place, as required by law, or refuse to provide members with details of this protocol, citing “intellectual property” or “scheme copyright”.

The law is very clear that schemes and administrators must inform members of the details of managed-care protocols, she said.

Phaswane said schemes should inform members what is meant by “an emergency medical condition”, because there is widespread misunderstanding of the difference between planned surgical interventions and emergencies.

She said many members and doctors were confused about the terms and conditions governing designated service providers (DSPs). If a condition is a prescribed minimum benefit (PMB), which schemes are obliged by law to cover in full, a scheme can dictate which facilities and which healthcare professionals the members must use if they want their costs covered in full. These facilities and professionals are known as DSPs. Members who want to use non-DSPs are liable for a co-payment.

The council receives many complaints about doctors who failed to disclose to members that they were not DSPs, Phaswane said. These doctors proceed with treatment knowing that a scheme would not cover the cost in full. When the scheme does not pay, they demand payment from the member. Phaswane said the council had reported these doctors to the Health Professions Council of South Africa.

She said the National Health Act obliged doctors to disclose their fees. Additional rules pertaining to ethical conduct for doctors require doctors to provide information about the costs associated with each treatment option and the alternatives available, so that you, as a member, can make an informed decision.

Phaswane said most members did not understand what constitutes non-disclosure. Schemes could help to overcome this problem by designing forms that prompted prospective members to fill in all the required information.

A core principle of insurance is that there must be full disclosure of the risks the insurer is taking on, because insurers have to price the risks appropriately, Phaswane said.

Two types of non-disclosure are common when people apply to join a scheme. The first is when you disclose information about only one pre-existing condition, not others. The second is when you transfer from one scheme to another, within 90 days, without fully disclosing existing conditions.

In either case, she said, a medical scheme would be entitled to cancel your membership..