Most asked Medical Aid Questions
1. How will I know what I am covered for and what I am not?
Your cover depends on the plan that you choose - different plans have different options. Our approach is to keep these clear and simple. Who wants confusion when lying in a hospital bed? Just phone 0219378300, give your name and if possible your membership number; the nurse-consultant will answer all your questions.
2. What are 'exclusions'?
When you apply to join a medical plan, it examines your and your family's medical history. The plan may decide not to bear the costs of a particular condition - what plans call "a pre-existing condition" which may incur a waiting period. This means that you have to carry those costs for the duration of the waiting period. Once the waiting period, which is anything up to 12 months, has expired you will receive cover for this condition.
Our primary responsibility is to members since their subscriptions have built up the fund/plan to what it is.
Declare any medical conditions in your application for membership. If you don't, if it appears and if we believe you were likely to have known about it, we won't meet its costs.
3. I'm looking for a new medical plan and can't be bothered to plough through a mass of detail to make a choice. Why shouldn't I use a broker?
Brokers offer you only a choice of plans that pay them commissions. Those that don't, like Cape Medical Plan, aren't on their list.. We prefer to deal directly with our prospective clients to ensure we know exactly the particular health (and financial) issues of the applicant. We avoid the possibility of misunderstanding inherent in using intermediaries. In this way, too, a member's fund go into health, not a middleman.
4. I trust my doctor and I'll trust his advice about the best plan for me.
Doctors offer medical advice and help but they are also business people. Trusting a medical opinion is different from a doctor's opinion in choosing a medical plan since this is also a financial decision. And since the business side of a medical practice may depend on medical aids, a doctor's judgment of the best plan may reflect what suits his business and not your health.
5. Why is private healthcare becoming so expensive?
First, the annual increases of private hospitals and medical specialists are major driver of rising costs of private health care.
Second, to meet statutory reserve requirements many medical plans have charged members more and offered less.
As a result of this, the number of people using private healthcare is shrinking. This means that fewer people pay more.
6. How does Cape Medical Aid contain price increases?
Cape Medical Plan is owned by it's members, we are self-administered and don't enter into contracts that will cost our members money. In addition to this our pre-quotes system helps us to assist our members with managing their medical expenses. If we are able to reduce costs relating to insured benefits, we are able to pass these savings onto our members, thereby reducing our annual increases.
7. How do I find out whether I am getting value for money i.e. how much of my subscription is going to health care?
If you think your medical aid may not be giving your value, tell them and ask for assurances, and see how they respond. If the response deals with their circumstances, your need as a member is not their primary focus.
You can also ask them to tell you what percentage of your subscriptions goes to administration not medical care, and how this compares to what they say are their two major competitors. More than 10 percent of your subscription going to admin should worry you.
8. If I am a dependant and my principle member dies, can I continue my medical cover?
With Cape Medical Plan, yes.
9. Am I allowed to join a medical aid regardless of my age or the condition of my health?
Legally you may not be refused membership. The terms of that membership will depend on your medical history, and the likely costs over time of any condition you may have. If you have a pre-existing condition, the approach of the medical aid will depend on its severity and thus the financial risk it stands for. Approaches could be to exclude that condition from cover, temporarily, or agree on a basis of shared risk and thus cost of cover, but only for an initial period of 12 months.
10. Why do you only have three plans?
Our plans cover the life stages, needs and means of our members and likely members. This view is based on continuing research.
Second, having many plans complicates matters for members and adds to administration costs. The cost often outweighs the benefits.
11. I am a man and you are expecting my subscriptions to cover all sorts of female-specific conditions./I am a woman and you expect my subscriptions to pay for all sorts of male-specific conditions. Can't I adopt a cafertaria approach and exclude the irrelevant?
The law forbids this. And the underlying principle of medical aid is sharing the cost of risk.
12. Can I use a hospital and doctor of my choice?
Yes. Our concern is your health as well as a healthy relationship between you and Cape Medical Plan. And healthy relationships involve freedom of choice.
13. What happens if I've been a member for a short period and suddenly develop a serious (and expensive) medical condition?
We're there for you. Speak to one of our nurse consultants who will help you plan what you need to do and how we will help.
14. I pay in money month after month, year after year, I take care of my health, and seldom claim. What do I get for all this?
Long-term protection and the peace of mind that goes with it. Bad things happen unpredictably.
15. Why do medical aid costs rise every year?
Inflation, a feature of the economic landscape, reduces the value of money. Particular factors make inflation in health care higher, hospital costs and medical practitioner's fees are among them. These fees and costs are not regulated by the state; and they affect medical plans and their members.
Different plans manage these costs differently. Our approach is to control costs as much as we can and to ensure that members know what they are getting at what price.
16. Health is a personal issue. Can I speak to a human being?
Cape Medical Plan has five nurse consultants and a customer care department for customer convenience. They understand about health, illness and medical aids: their job is to listen, understand and help.
17. I want the best medical aid cover for myself at a reasonable price: what must I do?
Tell us who you are, how old you are and what your and your family's medical history is and give us the name of your doctor.
Our efforts go into managing medical costs and ensuring that your subscriptions provide the cover you need and can afford. Your money is primarily for health and not expensive administrator costs or special offers.
18. All that matters about medical aid is price. Do Cape Medical Plan's plans cost less?
Separated from product and value, cost is meaningless. Some 140 medical aid societies offer 500 different medical plan options. The variety and complexity are so great that if you have a fair way of comparing them and their costs, we'll buy it from you.
19. Is Cape Medical Plan financially sound?
Yes and the following is why:
Our statutory solvency ratio is above average.
· We have one of the highest reserves - at R120 million - of any medical aid and this is members' money.
· In the last 10 years we have controlled our growth and physical expansion to balance service quality and size.
· Our exposure to loss of members to the new state medical aid, Gems, is minimal.
20. How do some medical plans manage to grow their reserves/solvency, while others don't?
All medical aids are legally obliged by law to have reserves of at least 25 percent of their total annual subscriptions. Some have yet to meet the target; until they have, if there was an epidemic, for example, their members' medical bills might not be met by the plan.
21. What can members do to try to understand and/or demystify the medical aid industry?
Insist on clarity not jargon and read as much as possible via newspapers and the internet, for example the Council for Medical Schemes website.
22. What is the general rule when trying to understand a complex service industry?