By Clement Marumoagae
In South Africa, private healthcare is accessed through membership of medical aids, a privilege enjoyed by very few members of society. Generally, access to private health care constitutes part of employee benefits that employers make available to their employees. It is possible however, for any person with the necessary financial means to have access to non-employment linked medical aid scheme. Some employers are unable to provide their employees adequate access to medical cover by subsidising their contributions to medical aid schemes to which they are associated. Some employers partially subsidise their employees while others allow their employees to choose medical aid schemes of their own without subsidising them. All medical aids schemes that provide private healthcare in South Africa are regulated by the Medical Schemes Act 131 of 1998.
Generally, medical aid schemes must follow prescribed guidelines and rules to ensure that all their members receive proper and fair medical cover. The Medical Schemes Act provides the legislative framework within which medical schemes must operate with the view not only to be financially sustainable but also protect the interests of their members. One of the fundamental duties of medical aid schemes is to ensure that their members are treated fairly regarding the contributions they are expected to pay to these schemes, the benefits that they derive from them and access to healthcare when they fall sick. Medical aid schemes are registered on the assumption that they will treat their members fairly and would not unfairly discriminate against them on any of the arbitrary grounds such as race, age, ethnic origin, sexual orientation, disability, or gender.
Fairness should also be extended to medical aid schemes by members who are required to provide full, complete, and accurate material facts that will enable these schemes to conduct adequate risk assessment for their members which will determine payable premiums. The Medical Schemes Act allows medical aid schemes to cancel or suspend their members’ membership when they establish that such members failed to disclose material information. However, it is clear, as was demonstrated in, Steyn v Registrar of Medical Schemes 2021 (3) SA 551 (WCC), that at times, representatives of medical aid schemes who assist members to join these schemes may lead members not to disclose some information that medical aid schemes may use to reject claims when members lodge their claims. It is worth noting that part of treating members fairly is for medical aid schemes to ensure that they do not unreasonably reject members claims. The Supreme Court of Appeal in Regent Insurance v King’s Property (5/2014) [2014] ZASCA (176) 21 November 2014 reminded medical aid schemes that the legislature enacted legislation that precludes them from treating trivial misrepresentations and non-disclosures that are trivial, as grounds for rejecting claims. Medical aid schemes are not at liberty to reject claims without good cause as provided for in the Medical Schemes Act.
Should you have a medical aid scheme related dispute, and you believe that your claim was unreasonably rejected, feel free to contact us. Our team is sufficiently experienced in medical aid schemes and insurance related disputes. We can assist you to articulate and lodge your claim with the Council of Medical Schemes. Should you not be satisfied with the outcome of the Council of Medical Schemes processes, our team can assist you with further legal processes that you may be interested in pursuing at the Superior Courts.
