How can I get advice on my healthcare cover?

A medical scheme cannot prevent you from applying for membership to a scheme if you do not use the services of a broker, but using one is likely to be beneficial.

And it is likely that seeking advice will come without cost implications for you, as medical scheme advisers are paid by medical schemes.

What a good adviser should do

A good medical scheme adviser should:

• Make sure you have adequate cover from a medical scheme and you do not mistake a health insurance product for medical scheme cover.
  
  
• Save you from having to research many schemes and their options to find the right one, and provide valuable insights that you as an ordinary consumer may not know.
  
  
• Do a proper due diligence on any medical scheme recommended to you to ensure the scheme is financially sound and that it is well managed. He or she should also keep you informed if this changes.
  
  
• Assess your healthcare needs from the history of your medical expenses, the state of your and your family’s health and your future healthcare needs. This might include, for example, you planning to start a family or anticipating any future hospital costs.  He or she would need to reassess this if your health or family circumstances change.
  
  
• Identify suitable options within the recommended schemes. 
  
  
• Determine the cost of your medical scheme membership – taking into account any late-joiner penalty you may pay – and checking with you if this is affordable.
  
  
• Inform you how the option works, including:
  • Any limits on hospitalisation or other major medical benefits;
  • How your day-to-day healthcare costs will be covered;
  • Whether you need to use a network or specified list of hospitals, and which doctor network you need to use for prescribed minimum benefits and other benefits; and
  • How you can access chronic medicine.
    
    
• Point out any major exclusions or benefit limits you should know about.
  
  
• Assist you with the application process, pointing out the important medical history details you need to declare.
  
  
• Explain any waiting periods that may apply.
  
  
• Up-date you on any option or benefit changes at least once a year and advise you on whether these changes make it worth your while changing schemes or options.
  
  
• Liaise with the scheme on your behalf when your claims are not paid or if there is a dispute.
  
  
• Advise you on whether you would benefit from gap cover.

Checking your broker is legit

The Medical Schemes Act stipulates that medical scheme brokers and the brokerages they work for have to be accredited by the Council for Medical Schemes.

The council checks that brokers are fit for the job and have the right experience to give advice.

Medical scheme brokers are also subject to the provisions of the Financial Advisory and Intermediary Services Act and should therefore also be licensed as a financial services provider (FSP) or be acting as a representative of a licensed FSP.

Your broker must also have a broker agreement with any medical scheme it recommends you join, and there must be a written service level agreement between the broker and the scheme.

In order to sell you a health insurance product, such as gap cover, a healthcare broker must be licensed as a financial services provider able to advise on short-term insurance policies.

What advice costs

Advice your broker gives you about joining a medical scheme is generally paid for by your scheme.

The amount your broker can be paid by the scheme is set at 3% of your contributions up to a maximum monthly rand amount that is prescribed each year – currently just over R100 a month.

A broker can also be paid an additional agreed amount by you or your employer.  

If your medical scheme broker stops providing a service to you, you can notify the scheme that you no longer want the broker’s services and the scheme must immediately discontinue payments to the broker.

If you take out gap cover insurance on a broker’s recommendation, the broker can earn commission of between 5% and 20% of your premiums. This is regulated under the Long and Short Term Insurance Acts.  

You must be advised of this commission when you receive a quote from the broker.