If you’re a member of a medical scheme, you probably know the mantra by now: You must notify your scheme by mid-December of any changes, because if you don’t, you’re restricted to the plan you’re on for the following year.
Most medical schemes allow members to downgrade plans during a year, but if you want to upgrade, because, for example, you’re pregnant and would prefer a slightly more comfortable birthing experience with a private suite, an extra bed for your partner and no distractions, that will come out of your own pocket because most medical schemes do not allow it.
The issue was raised in a recent Cape Times story about a Hermanus father, who had been with Discovery Health Medical Scheme for more than a decade and was diagnosed with a melanoma. The scheme wouldn’t allow him to upgrade to a better plan, thereby allowing him to benefit from better - and costlier - treatment.
Discovery Health chief executive Jonathan Broomberg explained: “All plans on (our) medical scheme cover all cancers, including this patient’s condition.
“However, the plans vary considerably in terms of which medications are covered for cancer.”
Discovery Health’s data indicate that cancer cases increased by more than 45% between 2011 and last year, with almost 8 500 new cases last year. The scheme has seen an increase in treatment costs of more than 100%, from R1.5 billion in 2011 to more than R3.5bn last year.
With such an increase in cancer alone, the burden on the scheme is significant.
From October to December, cancer was the leading death-related claim, with almost R153 million paid out in that quarter alone for Discovery’s clients.
Allowing members to upgrade during a year would overburden the scheme. Broomberg said Discovery’s rules prohibited any upgrades of plans during the year.
“This long-entrenched rule is important to prevent anti-selection. If the scheme allowed mid-term upgrades, the implication would be that all members would downgrade to the cheapest plan, with the lowest benefits, and then only upgrade as and when they need the benefits.
“This would have a negative impact on the long-term sustainability of the scheme and would increase premiums for all members. The scheme applies these rules in a consistent way to all members.”
Anti- or adverse selection is an insurance-sector term describing how market participation is affected by disproportionate information. It happens when, for example, people join a medical scheme with the sole purpose of being treated for a condition they already suffer from, without informing the scheme that they have a pre-existing condition.
Essentially, you’re bilking the scheme, and it is to the detriment of others, because the kitty is only so big.
As Jeremy Yatt, the principal at Fedhealth, says: “Anti-selection means that you know you are sick and would prefer to pay less.
“What you are doing is selecting against a scheme. For example, if I know I need a knee operation and I am not on a scheme, and I join to get the cover.
“In a medical scheme, it’s not fair towards the other members - we all belong, pay a contribution rate, like a stokvel. We call it paying into a medical aid community.”
But Fedhealth has been quietly allowing its members for the past decade or so to upgrade during the year - with a proviso.
All medical schemes write their own rules: “Most medical aids say you can upgrade only at the end of the year. We allow you to change when you need to do. And it doesn’t have a harmful effect on the scheme,” Yatt says.
Fedhealth will allow upgrades only within 30 days of the diagnosis.
“If, for example, you’re diagnosed with cancer and the doctor wants to give you a specialised biologic treatment, but you wait If you come to us three months later and ask for it, we will decline,” Yatt says.
“We believe Fedhealth has a benefit that is unique - by allowing members to upgrade to a higher option.”
With cancer diagnoses on the rise worldwide, knowing the contents of your medical scheme’s policy on upgrading is critical because if a high-end treatment could save your life, and it’s attainable, you want to have options.
You do not want to be told you’re on a hospital plan and qualify only for a certain “entry-level” range of treatment.