by Ayanda Tshazi
date 14 April 2016
Having worked in the medical aid industry for 2 years I can confidently sum the industry up in one word that it embraces and uses to self-define – scheme (also read, sham / money making scam). The best any medical aid is hoping for is that members will contribute faithfully and timeously every month, and never need to withdraw from it. The fine print and conditions attached to medical schemes are many times unethical and sometimes even outside the law. For example, until a recent case of investigative journalism from “Speak Out”, medical schemes were not providing information on Prescribed Minimum Benefits (PMB). And in fact, if you do not know that your condition is a PMB and neglect to claim for it as such, many times it will be charged as a regular benefit – which means you run the risk of using up your benefits for something medical aids are obliged by law to pay for no matter the cost. That’s because the law makes provision for basic cover that any member of any medical aid must be absolutely covered for. An example of a PMB is an emergency – for instance a vehicle accident. It doesn’t matter that you have used up all your medical aid monies; if you are a member of a medical aid you cannot be refused treatment for an emergency. But you’d be surprised at the great lengths medical aid schemes can go to in trying to get out of their PMB obligations.
A case in point is the Veroney Judd Stevens case, whose story was recently on Timeslive (What Price for a Life, 4 April 2016), who had breast cancer (a PMB condition). She was refused treatment by her scheme until after a year. By that time the cancer had spread to her brain. Once cancer spreads to other parts of the body it stops being a PMB condition and PMB obligations fall away for the medical aid. Just last week I visited a friend in hospital with stage 4 cancer. Her treatment was delayed by 3 days because the medical aid was unsure why she had been hospitalized – this after they approved her treatment. If it sounds like the medical aid is hoping for the worst to happen so that they don’t have to pay for treatment, then you’re probably not too far off the mark.
By right, all insurance (medical aid is a financial / insurance service much like car or household insurance) thrives on the hope of contributions outweighing claims. A portion of contributions (pegged at 25% by law) is kept in reserves and redirected to investments so it can make more money and supposedly keep the scheme financially viable. I say supposedly because many times those investments are not actually cashed out in order to make the medical aid function properly; that is, to fund the medical needs of members. No. Instead medical aid boards like to see the money swell and make returns. I don’t know for what because medical aid schemes are by law NOT FOR PROFIT. Which makes the business models of shareholder beholden schemes such as Discovery Health and Momentum, very interesting, from a legality point of view.
In the meantime, what many don’t know is that the bulk of the population actually don’t even need medical aid. Anyone under the age of 35, who is healthy and does not have a chronic condition, will mostly use the doctor for the odd flu or allergy. We have been wrongly conditioned to depend falsely on medical insurance. We are also overly dependent on western forms of medicine that are not necessarily best suitable for our health and pockets. I have recently been effectively cured of sinuses by a traditional healer from a not so distant rural village. No expensive or invasive procedures – just one inhalation and about 20 sneezes. I was only asked to make a donation that I could afford.
Very good advice from a homeopath has just about cured my partner of diabetes. Now that’s something you will never hear from a western doctor who sees you as a long-term patient (read cash cow) once you’re diagnosed with a“chronic” condition. How many of us know of or have heard of a traditional healer who fully recovers stroke victims? That’s something the western practitioners are not able to even claim is possible. Yet our homes and communities are littered with real life testimonies of how effective traditional medicine sometimes is.
More importantly, if we exercised our constitutional right to access quality healthcare, then we would not only eliminate the market for medical aid, but we would all have an holistic healthcare system that integrated the best of traditional, alternative and so called mainstream medicine. For one, western doctors could learn a lot from traditional healers who make a decent living, share the same standard of living with their clientele and take for their services only that which the patient can afford or thinks is worth the service. All healthcare providers would look at their patients as humans and learn something about the meaning of service.
Western medicine is not our only option. And it is certainly not always worth the expense it comes with. One of the reasons the NHI is not going to see the light of day is because it would take away the control of the costs from the few practitioners and pharmaceuticals who are holding the rest of us at ransom with enormous costs to treatment. While government must work to deliver access to healthcare to all citizens, one way of balancing the scales is by using our numbers and redirect our monies and bodies to the effective alternatives and thereby change western medicine from mainstream to just another option to healthcare. We have the power to bring down medical costs, along with western medicine arrogance.