CMScript 6 of 2024: Focus on Disclosures and waiting periods

This CMScript edition focuses on member rights and responsibilities regarding disclosure of medical information on membership applications and waiting periods for new members.

It is important for members of medical schemes to be fully informed about their rights and responsibilities to ensure they can effectively utilise their benefits and comply with the scheme’s requirements.

Here are some key points that members should be aware of:

Membership Rights

• Access to Information: Members have the right to receive detailed information about their medical scheme, including the benefits, exclusions, and the rules governing the scheme.
• Fair Treatment: Members should be treated fairly and without discrimination. This includes non-discriminatory practices in terms of age, gender, and health status.
• Claims Processing: Members have the right to prompt and fair processing of their claims. Any delays or issues should be communicated clearly.
• Complaints and Appeals: Members can lodge complaints or appeal decisions made by the scheme.
• Privacy and Confidentiality: Members’ personal and medical information should be kept confidential and only used for purposes directly related to their healthcare and scheme administration.

Membership Responsibilities

• Accurate Information: Members must provide accurate and up-to-date information when applying for membership and when there are changes to their personal circumstances.
• Adherence to Rules: Members must follow the medical scheme’s rules and guidelines, including those related to the submission of claims and notification of hospital admissions.
• Payment of Contributions: Members are responsible for paying their contributions on time to ensure continuous coverage.
• Utilisation of Benefits: Members should use the benefits responsibly, avoiding unnecessary medical procedures or services that could lead to increased costs for the scheme and other members.
• Reporting Changes: Any changes in personal details, such as dependents or contact information, should be promptly reported to the scheme.
• By understanding these rights and responsibilities, members can better navigate their medical scheme and ensure they receive the maximum benefits available to them.

Membership application and termination

Applicants and members of medical schemes have rights but also responsibilities as explained above.

The Medical Schemes Act, No. 131 of 1998 specify some of these rights and responsibilities.

Section 29 (1)(n) specifies that the terms and conditions applicable to a membership application may not be influenced by an applicant’s age, sex and past or present state of health. This means that you have the right not to be unfairly discriminated against or charged a higher membership fee based on:

• Race
• Age
• Gender
• Marital status
• Ethnic or social origin
• Sexual orientation
• Pregnancy
• Disability
• State of health

Section 29(2) states that your membership may not be cancelled or suspended except on the grounds of:

1. failure to pay, within the time allowed in the medical scheme’s rules, the membership fees required in such rules
2. failure to repay any debt due to the medical scheme
3. submission of fraudulent claims
4. committing any fraudulent act
5. non-disclosure of material information

Download the CMScript here