Medical Aid Refuses to Pay for Treatment Reasons and Recourse

Medical aids can refuse to pay for certain treatments and this is not considered unlawful. It is often the misconception of medical aid members in South Africa that once you have cover, you are then entitled to reimbursement for all your health related bills. Not so. Medical aid is a form of insurance that is there to offer financial protection when you need it most.

There are some medical services and products which are essential and then there are those which are non-essential. This is where the differentiation arises between treatments that are covered and those that are not. Remember a medical aid CANNOT refuse treatment, they can simply refuse to pay for the treatment. It is your democratic right to undergo the treatment of your choice, if advised by your doctor, and pay for it on your own.

Medical Aid Reasons for Refusing to Pay

There are two situations where medical aids refuse to cover treatment.

  1. The treatment may be non-essential meaning that it is either not a treatment that has conclusively been proven to be beneficial or it is a treatment that does not affect one’s health and lifespan.
  2. The medical expenses for the illness in question are a pre-existing condition and the stipulated waiting period is not over.

Non-Essential Treatments

Cosmetic surgery and related therapies are one example of non-essential treatments. Although it is conducted by medical professionals, like a plastic surgeon, the treatment is not a matter of life or death. Despite the psychological impact in some instances, medical aids often refuse to pay for these treatments. Special consideration may be given in cases following injury or burns but here as well it is largely at the medical aid’s discretion.

Another category of non-essential treatments are scientifically unproven therapies. This can range from alternative medicine to new and radical innovations in medical science that has not as yet been proven to be clinically effective. With regards to alternative medicine though, it is important to note that most South African medical aids pay for therapies such as homeopathy, acupuncture and chiropractic.

Conditions that Existed Before Membership

A pre-existing condition is one which existed prior to you joining a medical aid. In this regard the medical aid will refuse to pay for treatment and related medical services for the condition in question for up to one year. This is a means of protecting the scheme and its members from newcomers who may join the scheme only to drain resources and leave the medical aid.

Furthermore there may be an overall waiting period of up to 3 months for a new member who joins the scheme. In this case no medical expenses are covered by the scheme for the first 3 months irrespective of whether it is a pre-existing condition or not. Emergency medical treatment may be covered though irrespective of waiting period. However, it is important to note that these waiting periods may not apply if you move from one medical aid to another provided that your membership did not lapse at any time.

Recourse against Medical Aids

Medical aid policies are not infallible and sometimes refusal to cover treatment may be seen as being unfair. When misunderstandings or differences of opinions arise, medical aid members can take further action.

The first option for recourse is to discuss the matter with your medical doctor. In certain cases, a medical aid may reconsider covering the treatment in question if a medical doctor can provide valid reasons as to why the treatment is necessary. You can collect a motivation letter from your doctor and send it through to the scheme. Their medical panel will then reconsider the decision.

Should you need to take it further then you can speak to the Council of Medical Schemes, the authoritative body that regulates the operations of all medical aids in South Africa. This is not applicable for membership with hospital cash back plans and other medical insurance policies. In these cases, all questions and complaints have to be directed to the insurance ombudsman.

There are cases where some medical aids are quite unreasonable with their policies but this is largely due to call centre staff being ignorant about specific therapies. Rather look at taking up the matter further before making rash decisions such as changing medical aids or ending cover altogether.