The Scheme offers you some unique opportunities not available to members who belong to open schemes (or even many closed schemes). This is especially valuable for members or their registered dependants who are diagnosed with cancer…

Open schemes usually apply strict conditions around the upgrading of plans during the benefit year. A well-known open medical scheme recently hit the headlines for not allowing a member to upgrade their Plan to access a new specialised drug for oncology, called Keytruda, which is covered only for members on their top plan at 75% of cost.

The Scheme’s main objective is breaking even and maintaining our solvency ratio, rather than making a profit, and we go out of our way to help members with oncology claims. For example, if you are a member of one of our lower-cost Plans that have more limited cover for oncology treatment, you will be allowed – on the diagnosis of cancer – to upgrade to a Plan that offers more comprehensive cover for oncology, including new specialised drugs. In 2018, five members benefited from this special arrangement.

Furthermore, whereas open schemes and even many closed schemes do not offer ex-gratia assistance, our Scheme helps a number of our members with high costs through this mechanism every year, following a carefully managed governance process. In 2018 we awarded an additional R3.5 million to help members with 115 high-cost non-oncology cases and 11 high-cost oncology cases. We also allowed five members to upgrade during the year to a Plan with higher oncology benefits when they, or one of their loved ones who are registered on the Scheme, were diagnosed with cancer.