Coping with soaring cost of medical aid

It is advisable to check that expensive scans you will need during pregnancy are covered. / 123RF
It is advisable to check that expensive scans you will need during pregnancy are covered. / 123RF

Medical scheme contributions will increase by approximately 7.75% on average this year and many schemes are passing an increasing amount of risk of paying for healthcare services on to you.

This is according to Jill Larkan, the head of healthcare at GTC, who calculated the average increases on nine large medical schemes.

If your salary has gone up by less than the increase in your medical scheme contributions, you may find the increased contributions an additional financial burden and may be looking to move to a cheaper option, known as buying down.

If you are thinking of buying down, make sure you check these benefits before you do: 100% cover does not mean you are covered in full.

Cheaper schemes pay specialists who treat you in hospital at lower rates, which means you need to seek out those rare doctors who do charge lower rates, or, if your scheme has doctors in a network that charge the scheme rate, use one of them.

If a scheme says it offers cover for procedures in hospital at 100%, this only means it pays the tariffs your scheme has drawn up. It does not mean your scheme will pay 100% of the costs a specialist charges to treat you in hospital, Larkan says.

If your specialist charges more than your scheme pays - between one-and-a-half to five times the tariff is common - you will have to pay the balance yourself. You can also take out short-term insurance, known as gap cover, to cover the difference in the rates.

Low medical savings

Many medical schemes offer cover for less serious out-of-hospital visits to a doctor and for optometry, medicine and dentistry through medical savings accounts.

Larkan says these accounts allow medical schemes to limit the amount they have to pay out. Once your medical savings account is depleted, you have to pay for the costs out of your own pocket, she says.

Always check how much you will contribute to your medical savings account for the year and how this compares to what you typically spend on out-of-hospital costs for the year.

If you know the contributions are too little, but can't afford a more expensive medical scheme option, set aside an amount each month in a separate savings account that you only use for medical expenses not covered by your scheme.

Chronic medicines

Many medical schemes, and especially the cheaper ones, specify the pharmacy you must use to get medicines for a chronic (ongoing) condition such as high blood pressure or cholesterol, Larkan says.

This limits the costs for your scheme. If you use a different pharmacy, you will have to pay the difference in cost out of your own pocket.

Cheaper medical schemes typically have lists of approved medicines or formularies with cheaper generic medicines. They will only pay for the cost of those medicines and not more expensive ones.

They are also unlikely to cover chronic medication for conditions that they do not, by law, have to cover.

Cancer benefits

Cancer benefits are typically trimmed down as you move to cheaper options. Check that expensive scans you may need are covered and that there is a substantial benefit to cover expensive oncology medicines. If you need to accept a lower annual benefit limit for cancer to reduce contributions, check if you have severe illness cover.

Cover for big ticket items

Larkan says if you are anticipating any big medical events for the year ahead, such as childbirth, or decisions to have significant elective operations or even special dental treatment, you need to check how the scheme will cover the procedure, and possibly an extended hospital stay, the cost of specialists and aftercare.

Cheaper schemes tend to limit cover for expensive procedures such as organ transplants or to only offer cover in state hospitals. Also check the cover for artificial eyes and limbs as well as appliances such as wheelchairs, because these can be very expensive.

Ambulance and emergency services

Make sure you are covered for emergency ambulance services, including emergency evacuation. Be aware of which emergency ambulance service your medical scheme covers.

Who to call when you've been ripped off by a financial services provider

It should give you comfort to know that the financial services sector in South Africa is highly regulated.

Not only do we have good laws in place to regulate what is sold, how and by whom, but we also have a host of statutory
regulators and ombudsmen for just about every aspect of financial services.

The flip side, however, is that it can sometimes be tricky for you to figure out which regulator or ombudsman you should complain to.

For example, if your car was stolen and your insurer has rejected your claim on the basis that you didn't have a vehicle tracking device installed - this being something that your financial adviser failed to alert you to - you might be confused to discover that the Ombudsman for Short-term Insurance can't resolve your complaint.

The appropriate ombudsman is the FAIS Ombud, also known as the Ombud for Financial Services Providers, who deals with complaints relating to the rendering of advice.

If an adviser recommends a product to you, he or she must advise you of the conditions relating to the use of that product.

The Sowetan Money team has compiled the following list of ombuds and regulators for your easy reference.

As a rule of thumb, you need to try and resolve your complaint with the financial adviser or institution first.

If you're not satisfied with the outcome, you can then take your complaint to the appropriate ombud or regulator, where it will be assessed at no cost to you.

The Ombudsman for Banking

Services Ombud: Reana Steyn

Call: 0860-800-900

Email: if you have a complaint about your bank

The Credit Ombud

Ombud: Nicky Lala-Mohan

Call: 0861-662-837

Email: if you have a complaint about a credit bureau or concerning a credit agreement.

National Credit Regulator

CEO: Nomsa Motshegare

Call: 0860-627-627

Email: if you have a complaint about a credit provider or if you have a complaint about a debt counsellor.

FAIS Ombud / the Ombud for Financial Services Providers

Ombud: Noluntu Bam

Call: 012-470-9080 or

Email: if you have a complaint about a financial adviser or a company that has given you bad financial advice.

Financial Services Board

Executive officer:
Adv Dube Tshidi

Call: 0800-110-443

Email: if you have an investment-related complaint about a company that is not a bank.

Ombudsman for Long-term Insurance

Ombud: Judge Ron McLaren

Call: 0860-662-837

Email: if you have a complaint about a life assurance company.

Council for Medical Schemes

Acting chief executive and registrar: Dr Sipho Kabane

Call: 0861-123-267

Email: if you
have a complaint about your medical scheme.

Pension Funds Adjudicator

Adjudicator: Muvhango Lukhaimane

Call: 012-748-4000 or

Email: if you have a complaint about your pension or provident fund, or the trustees of the fund, or the quantum of a benefit paid from your retirement annuity fund.

Ombudsman for Short-term Insurance

Ombud: Adv Deanne Wood

Call: 0860-726-890

Email: if you have a complaint about the insurer of your car or possessions.

Tax Ombud

Ombud: Judge Bernard Ngoepe

Call: 0800-662-837

Email: if you have an administrative or procedural complaint against SARS. If you have a complaint about a tax practitioner, you must complain to the individual's professional body.

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