What is the difference between medical scheme rates and private provider rates?
- Medical scheme rates (MSR) are the rates determined by the Board of Trustees. MSR are generally lower than private provider rates.
- Private provider rates (PPR) are private rates charged by the service providers.
As PPR are substantially higher than MSR, patients generally have to make a co-payment (this is where the difference comes in), unless you are on the Platinum Plan (which provides cover at 3 x MSR for Everyday Services Benefit claims) or the Savings Plan (which pays 100% of cost for Everyday Services Benefit claims).
If you visit a practitioner who charges more than the rates covered by your chosen Plan, you will have to settle the difference directly with your practitioner. This does not apply to members of the Savings Plan, as any shortfall will be paid from their personal medical savings account, if they have funds available.
The Scheme pays only up to the benefit limit, as stated for each Plan, for both Hospital and Trauma Benefits and Everyday Services Benefits. The Scheme will therefore not pay the difference, even if you have not used up your annual sub-limit for a particular benefit.
What rules apply if I have been involved in a motor car accident?
In certain circumstances, you may not be covered by the Scheme for injuries resulting from a motor vehicle accident, as these medical expenses can be claimed from a third party.
If you are involved in a motor vehicle accident, you should consult an attorney to find out whether you have a claim against the Road Accident Fund.
If you have a valid claim, your attorney must submit an indemnity letter to the Scheme, in which case the Scheme will pay for your medical costs up to the available benefits. This will be done on the undertaking that the Scheme will be reimbursed once the claim is paid by the third party, in other words, the Road Accident Fund. (Batsumi is contracted by the Scheme to identify Road Accident Fund Claims and to liaise with your attorney and the Road Accident Fund to recover monies paid on your behalf for past medical expenses related to the accident.) You should always inform the Scheme when you claim from another source.
If the attorney determines that there is no claim against the Road Accident Fund, the Scheme will pay for the medical costs that were incurred as per the Scheme Rules.
How can I claim in terms of the Compensation for Occupational Injuries and Diseases Act?
In certain circumstances, you may not be covered by the Scheme for injuries resulting from an accident sustained in the workplace, as these medical expenses can be claimed from a third party. Claims in terms of the Compensation for Occupational Injuries and Diseases Act are not covered by the Scheme.
Forms for the Compensation for Occupational Injuries and Diseases Act should be completed by the treating hospital or medical practitioner and the relevant employer, and then submitted to the Commissioner of Occupational Injuries and Diseases.
The Scheme will not pay any benefits until the Commissioner rules that the injury does not fall under the Compensation for Occupational Injuries and Diseases Act.
What is the escalation process if I am unhappy with the service that I receive?
We understand that members expect reliable and efficient service from the Scheme at all times. To help you resolve medical scheme issues you may have, or have a complaint about service you received, please contact the Medscheme Call Centre on 0860 100 080 or via e-mail on firstname.lastname@example.org and provide the details of your complaint. The advantage of going through the Call Centre is that calls are recorded and trends can be picked up, allowing the Scheme to identify specific communication needs.
If you are not satisfied with the outcome, you are requested to make use of the following process to ensure effective and accurate resolution of your query.
|LEVEL 1||Request the assistance of an Escalation Consultant telephonically|
|LEVEL 2||Request assistance via email to email@example.com|
|LEVEL 3||Request the details of the Administration Manager or the Fund Manager to escalate to|
|LEVEL 4||Request the details of the Assistant Principal Officer|
|LEVEL 5||Request the details of the Principal Officer|
If, after following the procedure detailed above, you are still not satisfied with the outcome of the process, or you have not received a response within seven (7) working days, you may contact the Council for Medical Schemes’ Complaints Department:
Telephone: 012 431 0500
Fax: 012 431 0608
Send your complaint via the Council’s website: www.medicalschemes.com (follow the “Consumer Assistance – Complaints link”)
What can I do if I have a complaint against my medical scheme?
The Registrar of Medical Schemes is the regulator of the medical scheme industry. Any member or any person who is aggrieved with the conduct of a medical scheme, health professional, private hospital or nurse, can submit a complaint to the Registrar’s Office. However, the Registrar requires that members FIRST try to resolve any complaints with their medical scheme, before they contact the Registrar.
Once you have tried and failed to resolve a complaint with the Scheme, you may contact the Registrar to make a complaint. Complaints can be submitted through fax, email or in person at the Registrar’s office.
The Registrar’s contact details are as follows:
Council for Medical Schemes
Block A Eco Glades 2 Office Park
420 Witch-Hazel Street
Website address: www.medicalschemes.com – (on the landing page there is a quick links toolbar; click on the How to lodge a complaint link for further information.)
Telephone: 012 431 0500
Fax: 012 431 0608
Customer Care Share: 0861 123 267
Email address: complaints at medicalschemes.com
- The Registrar’s Office will send a written acknowledgement of a complaint within 3 working days of its receipt, providing the name, reference number and contact details of the person who will be dealing with the complaint.
- In terms of Section 47 of the Medical Schemes Act, a written complaint received in relation to any matter provided for in this Act will be referred to the medical scheme. The medical scheme is obliged to provide a written response to the Registrar’s Office within 30 days.
- The Registrar’s Office shall within 4 days of receiving the complaint from the administrator, analyse the complaint and refer a complaint to the medical scheme for comments.
- Upon receipt of the response from the medical scheme, the Registrar’s Office will analyse the response in order to make a decision or ruling. Decisions/rulings will be made within 120 days of the date of referral of a complaint and communicated to the parties.
THE REGISTRAR’S RULING AND APPEAL TO COUNCIL
- Section 49 of the Act makes provision for any party who is aggrieved with the decision of the Registrar to appeal such a decision. This appeal is at no cost to either of the parties.
- An appeal must be lodged within 30 days of the date of the decision. The operation of the decision shall be suspended pending review of the matter by the Council’s Appeals Committee.
- The secretariat of the Appeals Committee will inform all parties involved of the date and time of the hearing. This notice should be provided no less than 14 days before the date of the hearing.
- The parties may appear before the Committee and tender evidence or submit written arguments or explanations in person or through a representative.
- The Appeals Committee may after the hearing confirm or vary the decision concerned or rescind it and give another decision as they deem just.
THE SECTION 50 APPEALS PROCESS
- Any party that is aggrieved with the decision of the Appeals Committee may appeal to the Appeal Board.
- The aggrieved party has 60 days within which to appeal the decision and must submit written arguments or explanation of the grounds of his or her appeal.
- The Appeal Board shall determine the date, time and venue for the hearing and all parties will be notified in writing.
- Appeal Board shall be heard in public unless the chairperson decides otherwise.
- The Appeal Board shall have the powers which the High Court has to summon witnesses, to cause an oath or affirmation to be administered by them, to examine them, and to call for the production of books, documents and objects.
- The decisions of the Appeal Board are in writing and a copy thereof shall be furnished to parties. A prescribed fee is payable for Section 50 Appeals.
What do I do if I suspect fraudulent activity against the Scheme?
Unnecessary and fraudulent expenses are funded by you, the member, through increased contributions. You can contribute towards the fight against fraud by carefully and regularly checking your claims transactions and making sure that you have not been involved in a fraud scam without your knowledge.
Examples of fraud scams discovered by the Scheme have been:
- A service provider putting in a claim for services that were never rendered.
- A service provider performing a procedure or giving treatment that is excluded by the Scheme rules, and then charging for it under a different code.
- A pharmacy providing generic medicine, but charging for the more expensive brand name.
If you suspect that a service provider, colleague or any other person or organisation may be engaged in fraudulent activities against the Scheme, please contact the Fraud Hotline on 0800 112 811. This hotline is managed by an independent company, Tip-Offs Anonymous, and you can choose to remain anonymous. You can also email fraud at medscheme.co.za to report your suspicions.
When do I get my tax certificate from the Scheme and how can I request a copy of the tax certificate?
The medical scheme will email the tax certificate to you in May of each year.
You may email firstname.lastname@example.org to request a copy. Alternatively, log on to the secure website at www.medscheme.co.za and download your tax certificate or make use of the member self-help service.
Request a copy of your tax certificate
Where can I obtain a membership certificate?
You may email nedgroup.enquiries at medscheme.co.za
How can I replace or get additional medical scheme membership cards?
In line with the latest trends in the healthcare industry, Nedgroup Medical Aid Scheme has rolled out an electronic membership card with a One Time Pin (OTP) solution. This e-card offers you even greater peace of mind, as it will help ensure that your electronic membership card is accessed only by you. This process will run in parallel with the printed cards until we are satisfied that the process is flawless. If you require a printed membership card, contact Medscheme or email nedgroup.enquiries at medscheme.co.za
As a retiree, why am I entitled to maternity benefits when the Scheme could rather increase my other benefits?
In accordance with the Medical Scheme Act, all members registered on the same Plan must be provided the same benefit package. No differentiation of benefits is allowed based on age, gender or income.
It is therefore not permissible to remove this benefit from retirees’ benefits and ‘credit’ them with other, more age-related benefits.
What services are not covered by the Scheme?
There are certain services and procedures not covered by the Scheme, and these are known as exclusions. These exclusions apply in respect of all benefits other than the Prescribed Minimum Benefits. Unless otherwise authorised by the Scheme, no benefits will be granted in respect of any expenses or charges resulting from any of these services. A full list of excluded services and procedures is available from the Scheme upon request, but the following is given as an overview:
- All costs incurred for the treatment of conditions or injuries for which any other party may be liable
- Any injury that can be claimed from another source (such as a personal accident policy, the Road Accident Fund, Compensation for Occupational Injuries and Diseases Act, etc.) (Please refer to What rules apply if I have been involved in a motor car accident? earlier in this chapter for more information.)
- Injuries resulting from professional sport
- Investigations, operations or treatments for cosmetic purposes, artificial insemination, impotence or erectile dysfunction
- Examinations for insurance, employment, visas, pilot and driver’s licences
- Holidays for recuperative purposes
- Experimental treatments
The purchase of:
- patent medicines, vitamins and proprietary preparations
- applicators, toiletries and beauty preparations
- bandages, cotton wool and similar aids
- patented foods, including baby foods
- tonics, slimming preparations and drugs as advertised to the public
- household and biochemical remedies
- sunglasses and domestic remedies
- exercise equipment
- Unregistered medicines (in other words, those not approved by the Medicines Control Council)
- Orthodontic treatment for persons 21 years or older, excluding services required after trauma (applicable to all Plans)
- Sleep therapy