The economic crisis is Zimbabwe has not only been felt by individuals but also by medical aid societies who are fighting to stay afloat. This has resulted in not only a war between medical aid societies and health care providers, but also a war between the former and their members.
Medical aid societies (MAS) are fully aware that laws are in place which they have to adhere to even in the light of economic hardships. But some of the MAS have chosen to ignore these laws that are there to protect the usually faceless and voiceless member who is at the mercy of MAS that are only looking for profits.
As the saying goes, “When elephants fight, it is the grass that suffers”. Individual members have borne the brunt of this on-going war through numerous shortfalls, denials of payment of claims, limited access to the wide array of service providers and of late, blatant discrimination versus their corporate members.
In order for one to understand the different challenges faced by members of MAS, one needs to understand the different groups that are provided for by the medical insurance companies.
Corporate Groups and MAS
The first is the corporate group which does not derive its name from the sector in which one works but rather from the elitist mind-set of those who have the benefit of having their medical aid covered in full by their employer or on some pro-rata basis. Such employers will choose the MAS they want to cover all their employees and depending on their policy, ensure coverage of spouses, children, other relatives and so forth.
MAS grossly benefit from this type of group because of the high numbers. The group is split in two when it comes to the waivers they get. Some medical insurance companies will give certain perks for companies with between 10 and 49 members and those with 50 plus members receive more perks. The perks range from waivers of waiting periods and decreased premiums, among other incentives.
Individuals and MAS
Those who are at the bottom of the pyramid and tend to have it harsh in every sense of the word, are the individual contributors. They pay the most at any premium level and are often looked at as a liability. This group is the one that most Zimbabweans tend to fall in when they are either unemployed, self-employed or have no medical benefits from their employer in part or as a whole. They are a group of social origin which is more or less at the ‘bottom’ yet they face the highest penalties for this. Increments often affect them the most since they do not have a representative body. Medical insurance companies place the burden of the perks they offer to the corporate group on these individuals at the bottom of the pyramid.
MAS and the Law
To get a more detailed insight, some provisions of the Statutory Instrument (SI) 330 of 2000 on Medical Services (Medical Aid Societies) Regulations together with Amendment SI 35 of 2004 will be addressed. The Amendment that was enacted in 2004 provides recourse for members of MAS when they believe there are unfair practices that are taking place. This is provided for in Section 16 and hence a member has the right to complain to the Ministry of Health and Child Care (MoHCC). The rectification of such an unfair practice ranges from the stoppage of the practice, to fines and even de-registration of the society. Therefore, it is important for members to know and learn that they are not at the mercy of their MAS as most societies would want them to believe.
One may sign a contract which states that they will abide by the rules and regulations of the MAS. However, the rules and regulations are subject to statutory instruments. Therefore members need to be aware that if it turns out that some of the fund rules are illegal, the contract either becomes voidable or void to the extent of the illegality. This means those clauses will not bind the individual.
Tired of Shortfalls
Everyone who has ever joined a MAS has an insurable interest. Even the employer who dangles this benefit to would-be employees does so to cover a rainy day. With how expensive health care currently is in Zimbabwe, one can only be happy to have an insurance umbrella for chronic illness, pregnancy, elderly parents, children or just themselves.
The current war that is going on between Health Care providers and MAS has grossly affected the individual with shortfalls. I remember the day when I was told by my MAS that I would never have to incur shortfalls yet now, that has become the order of the day. According to the Amendment of 2004, MAS are supposed to pay health care providers the gazetted tariff, and currently many are not doing so. This has resulted in health care providers placing the shortfall on the individual. This is illegal.
It is a common and very unfair practice which only takes reporting for it to stop. The result has been a backlash through increasing tariffs paid by individuals even though on the current tariff the service providers could have been paid. This is unfair and double-dipping which needs to be stopped as it grossly affects the income levels of members.
Discrimination Not Permitted
Another form of unfair practice is that of discrimination. This is defined as the unjust or prejudicial treatment of different categories of people, especially on certain grounds. Those who wrote the SI were well aware of the potential prejudice that often happens when MAS fight for profits over individuals.
Have you ever tried to join an open MAS such as CIMAS, First Mutual Health, TN Health, Altfin ( the list is endless) and been informed that you cannot join as an individual or that there is just a one-size-fits-all premium and no choice? If you have, that is a form of discrimination and should be reported immediately. Discrimination alone can result in a MAS being de-registered. Discrimination on the basis of being an individual is not permitted and being made to receive prejudicial treatment is a serious cause for concern.
Representation of Individual Members
According to section 10 of the SI, every MAS regardless of how it originated shall ensure that it has a constitution. This Constitution apart from other key issues should ensure that it includes the representation of individual members in voting power (Section 10b). This is mandatory and not a suggestion, hence every medical aid scheme should ensure that it informs members at the Annual General Meeting (AGM) and any special meetings. What many members have witnessed is the direct opposite: where only the shareholders are called and the individual members are relegated. This means that any decisions that grossly affect individual members are left to the fate of those who intend to profit from the medical aid scheme.
Medical aid schemes tend to ignore these provisions, claiming that they are registered as a private company and that they have a Memorandum of Articles and not a Constitution. This is a wrong interpretation since the company would have registered with the Ministry of Health and Child Care (MoHCC) as a MAS. Therefore the regulations that apply to MAS as given in the SI, apply to companies and individuals or trusts. A failure on their part to ensure that they have a constitution which includes the calling of individual member representation at AGMs and as part of the voting board, means that they are conducting illegal activities.
Having a company operating a MAS can be dangerous. On the one hand, they register and follow the necessary re-registration periods as a MAS but when it comes to accountability, they pull the ‘we are a company’ line. The fact that the registering body was initially a company does not change the fact that one of its subsidiaries is a medical society and should adhere to the same rules and regulations that are in place to protect its membership from unfair practice.
Waiting Periods and Waivers
According to Section 13 of the SI, the maximum initial waiting period for medical aid benefits should be three months. Many members have been made to wait anything from between 4-6 months just to get that initial prescription paid for as well as that long-awaited visit to a General Practitioner doctor. This is an unfair practice and ought to be reported.
MAS exploit a loophole which leaves ‘pre-conditions’ to the sole discretion of the MAS. Over the years, pre-conditions have been receiving more and more lengthy periods with the latest being a five-year waiting period. Listed below are other treatments which can be given a longer than 3 month waiting period:
(a) Medical treatment related to pregnancy
(b) The provision of spectacles or a prosthesis
(d) Cancer therapy
(e) Drugs for chronic illnesses
(f) Medical treatment in another country
Members should also be aware that a MAS may not impose any waiting period upon a new member admitted to a scheme that is equivalent to the one he previously participated in as a member of another society provided that the person who was a member of the previous society for a continuous period of at least two years applies for membership in the new society within three months after termination of his membership of the previous society. Hence you are not stuck with your MAS forever and no waiting period for anything should apply. If you have been made to wait for anything after having moved from another MAS with the characteristics provided above, then you can also report unfair practices.
What You Can Do
Members of MAS need to be aware of the provisions of the law so that they may be able to detect any unfair practices fairly quickly. They also need to know that MAS are not infallible but that this appearance of flawlessness will continue if they remain disempowered and ignorant of their own rights as members. There is also a need for individual members to come up with their own independent representative body aside from the internal board representation at medical aid level. This will provide pressure to societies that form solely for profiteering forgetting that they have been entrusted with funds from individuals.
The discrimination that exists between corporate and individuals needs to be done away with. The only difference between individuals and the corporate group is that they did not come from the same source hence it is discriminatory to place heavy financial burdens and poor benefits just because one joined as a single person or without a trailer of at least ten individuals. There is a stark difference between an incentive for joining as a group and discrimination for being an individual.
The Ministry of Health and Child Care needs to reform the Medical Aid Advisory Council which is an independent body that is supposed to regulate MAS. There is also need for a statutory instrument that gives powers to this authority so that MAS are called to task. The current SI already makes provision for individual members to be part of this council. Hence there needs to be pressure from individual members for the reformation of this council which started a few years ago but eventually “died” a natural death.
Individual members need to speak out. Therefore the next time you think that there has been an unfair practice by your MAS, do not just end by emailing or calling them in a frustrated voice. Report them to the Ministry of Health and Child Care, or you can email me on firstname.lastname@example.org or call and Whatsapp me on 0773 498 687 for more detailed information on how to file your complaint.
I would like to end by quoting Kubatana who always says “If you are not outraged, you are not paying attention!” Please, stand up and do something. Even the corporate members are feeling the pinch of cut benefits and being in a contract with a MAS that does not care about anything else except using your hard-earned money for their own profiteering.
If you are interested in being part of an individual member association pressure group, please contact me. Together we can make one individual make a difference!
Main image taken from www.mymedicalaid.za.org