South Africa has a complex private health sector, with up to 16% of the population making use of a Medical Scheme via a paid membership to access their healthcare needs.
As Medical Scheme members and beneficiaries, we, the patients, are obliged to engage with our Medical Schemes via their processes and procedures. This is both fair and reasonably regulated.
But what happens when your Medical Scheme disagrees with your healthcare provider on what care is required? For example, your provider prescribes a certain medication, but your Medical Scheme insists that another one, included on THEIR list of approved meds, is the better option? Or, perhaps you require a procedure or surgery, but they disagree?
This is where the dispute resolution process begins. So, what does that actually look like?
Whilst we can't speak for everyone, I, as the CEO of Rare Diseases South Africa, have had some experience in this regard during my decade of advocating for rare disease patients. To be honest, it usually isn’t very pretty!
So - what have I learnt?
It is important to exhaust all the internal processes of your Medical Scheme before you can take the matter further.
Council for Medical Schemes (CMS) is the regulator, , and effectively the ombudsman, for Medical Scheme members. But - they have limited resources, and have lost the required clout to set firm precedence and enforce rulings.
Applying constant pressure on both fronts is critical. File 13 at both the CMS and Medical Schemes is a big, dark abyss of little to no communication.
The Schemes and the Scheme Administrators are not the same thing (more on this in another blog).
So, what are the timelines from start to finish when initiating a dispute? LONG....
0-2 weeks - Initial Application: With any request for authorization, an initial submission must be made to the Medical Scheme. This can take an average of 14 days until feedback is provided.
2 weeks - 3 months - Review/Internal Dispute Committee: · If your treatment is declined, and a review is requested, requiring evaluation by an internal committee, a wait of up to three months can be expected. Why? Well, internal committees of some Medical Schemes only meet that often. It is imperative that you get a firm commitment (in writing!) on the complaint review date when making the request - because often, these cases "are forgotten" and excluded from the committee meeting agenda, leaving you like a kid in the playground waiting for the roundabout to stop so you can get on it.
And as specified by CMS: "It is however very important to note that a prospective complainant should always first seek to resolve complaints through the complaints mechanisms in place at the respective medical scheme before approaching the Council for assistance." Hence the need to exhaust all the internal processes of your Medical Scheme first!
Month 3-9 - CMS Complaint: What is the process? Complete the online application form and submit your complaint. Who can lay a complaint? Any beneficiary or any person who is aggrieved with the conduct of a medical scheme. What can you complain about? The Council for Medical Schemes governs the medical schemes industry and therefore your complaint should be related to your medical scheme. What is the turnaround time? Section 47 of the Medical Schemes Act 131 of 1998 provides that rulings in relation to written complaints needs to be finalised within 120 working days after receipt of all the relevant documentation/ evidence, except when the investigation is complex (queue most cases that involve needing to access a costly / innovative or fairly new technology or intervention), then the Registrar will endeavour to keep complainants updated of developments and reasons for delayed resolution.
Note: The Registrar is may only issue rulings or directives within the scope of the Medical Schemes Act. The following forms of relief cannot be made by the Registrar:
Award punitive damages or compensation for delays, pain and suffering;
Order full refund of contributions, unless provided for in the registered rules of a medical scheme;
Direct payment of health expenses which are lawfully excluded from benefits in terms of the Act;
Payment of interest;
Dismiss or discipline employees of a regulated entity.
Month 9-12 - Appeal notice period: · As is the case with any legal process, the opportunity to appeal the CMS ruling exists. An appeal lodged under Section 48 must be in the form of an affidavit, within three months after the date on which the decision was made. The CMS may condone late submission of an appeal, on good cause shown.
My experience is that the more expensive the treatment, the longer the Scheme will wait to finalise their appeal notice. Why? In my opinion, because every day the process is delayed, is a day they save on paying for the treatment?
Month 12-whenever - Waiting for the appeal hearing date: This is where things get interesting. To our knowledge, and confirmed by our experience, the Medical Schemes Act does not mandate the timeframe in which an appeal must be heard. So, whilst the appeal has been noted, the process can take OVER ONE YEAR for the matter to be heard.
As an example, we (RDSA) are currently assisting a patient who has waited 15 months from the date of the CMS ruling until today, when finally, after sending formal legal correspondence insisting the matter be set down, that we finally have a date for the end of August this year. This is 15 months from 30 March 2021 (date of Ruling) until today, 7th July (date notice of set down was provided) to 30 August 2022 (date matter will actually be heard).
That is a total of 518 days a sick patient has not only had to wait for her "day in court", but that she has remained untreated, in pain, and deteriorating.
First Whenever to the Next Whenever - Waiting for a ruling: · So after having gone through this entire process, very often remaining untreated due to being unable to afford the out of pocket expenses, you are required to wait for the ruling to be finalised, and circulated. On more than one occasion we have waited for six months for this ruling, because the Act doesn't mandate this timeframe.
It is only at that point, that your treatment will be enforced, provided the Scheme chooses not to appeal via a section 49/50 appeal, which starts the last 2 processes (potentially another 60 days plus a first "whenever") again.
So what are we going to do about it?
We, as a collective medical aid members, need to band together, find our voice through the #DearMinisterOfHealth movement, and request that the Minister of Health, as the Constitutionally appointed custodian of all healthcare related matters within South Africa, provide oversight and support to the CMS to: 1) effectively and efficiently fulfil its responsibilities to Medical Scheme members with disputes about the conduct and decisions of their medical scheme, and 2) that the necessary resources are provided to the CMS to enable it to fulfil this mandate.
How will we do it?
Alone we whisper, Together we Roar!
Written by Kelly du Plessis, Founder and CEO of Rare Diseases South Africa
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