FAQs
We answer the most frequent questions posed to our call centre:
GENERAL INFORMATION
MEMBERSHIP
WAITING PERIODS
LATE JOINER PENALTIES (LJPs)
CONTRIBUTIONS
BENEFITS
SAVINGS
CLAIMS AND PAYMENT OF ACCOUNTS
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GENERAL INFORMATION
When did the Medical Schemes Act come into operation?
The Medical Schemes Act 1998 (Act 131 of 1998) came into operation on 1 February 1999. Regulations were introduced by Government Gazette No. 20556 dated 20 October 1999, with effect from 1 November 1999 and 1 January 2000 respectively.
How may members ascertain what their obligations are to the Scheme and what their rights, benefits, contributions and limitations are from time to time?
A member is entitled to request copies of the Scheme Rules, financial statements, and annual reports upon payment of a reasonable fee for such documents. On admission to membership, medical schemes are obliged to furnish members with a summary of the registered rules, which comprise reciprocal rights, and obligations of both the Scheme and members and all benefit options and relevant contributions.
Selection of medical schemes and benefit options
- Ensure that the Scheme is duly registered in terms of the Medical Schemes Act 131 of 1998. The names, addresses and telephone numbers of all registered schemes are published on the website of the Council for Medical Schemes www.medicalschemes.com. The list is furthermore published annually in the Government Gazette for general information. The office of the Registrar will also provide you with information on registered schemes.
- Request information about benefits, contributions, limitations and exclusions from your selected scheme.
- If you do employ the services of an agent or broker (intermediary), ensure that he/she is accredited by the Council for Medical Schemes and that your selection of a scheme is based on informed consent. To ascertain whether a broker is accredited, prospective members should insist that brokers produce proof of accreditation with the Council and/or verify their broker accreditation status on the Council's website.
- Request the latest financial statements and annual report of the Scheme to establish their financial position. These reports are available in the Council's Annual Report.
Is membership onto a medical scheme available to any person?
Yes, except for restricted membership schemes, for instance, where a particular employer, profession, trade, industry, calling, association or union has established a scheme, exclusively for its employees or members.
Can I belong to more than one medical scheme at the same time?
No. It is illegal.
Can a minor become a member?
Yes, with the assistance of their parent(s) or guardian, provided that they pay the relevant contributions on behalf of the minor.
May a medical scheme refuse to admit my dependant?
No, in terms of the Medical Schemes Act, no medical scheme may refuse to admit persons who are dependent on a registered member. A member's dependants are his/her spouse or partner, child under the age of 23 or older and a child who is dependent upon the member due to a mental or physical disability; immediate family in respect of whom the member is legally liable for family care and support and such other persons who are recognised by the Scheme as dependants. The Scheme require proof of such dependency and appropriate additional contributions in respect of such extended cover must be expected.
Must a prospective member apply for membership of a medical scheme through a broker?
No, there is no such provision in the Act. One can apply directly to the Scheme or opt to use the services of a broker (intermediary).
If a member dies, will his registered dependants still be covered?
Yes, without any break in membership and provided contributions are paid. It is important to inform the Scheme if one chooses to discontinue membership.
Must I give notice to the Scheme in the event that I wish to terminate membership?
Yes, the notice period stipulated in the Rules must be complied with.
Can the Scheme terminate my membership in the case of retrenchment, redundancy or retirement?
Closed schemes may terminate your membership in the case of retrenchment and redundancy, but not in the case of retirement. Open schemes may not terminate your membership in any of these events and you may continue your membership provided contributions are paid.
When may the Scheme terminate or suspend my membership?
Only on the grounds of failure to pay membership fees timeously or other debts owing to the Scheme, submission of fraudulent claims, committing other fraudulent acts, or the non-disclosure of material information.
What restrictions may a medical scheme impose on an applicant?
Late joiner penalties and waiting periods.
What role does my employer play in my relationship with the Scheme?
The employer may determine whether or not the employees are entitled to belong to one or more scheme or whether the employees have total freedom of choice of scheme. The employer also determines, generally within the framework of conditions of service, negotiations between the workforce and organised labour, such as trade union/personnel organisations or staff, what level of subsidies will apply to different categories of employees or in general. Therefore, employers are not admitted to membership but they play an important role in collecting contributions and ensuring payment thereof to the Scheme.
Is the Scheme entitled to cancel my membership when the employer fails to pay the membership fees?
Yes, since the employer pays the contributions on behalf of its employees and the Scheme is contracted with the member. The Scheme must give the employer and/or member written notice that if the contributions are not paid up within the period stipulated in the Rules, membership may be cancelled.
What does a waiting period mean?
A period during which contributions are payable without the member being entitled to benefits.
What are the types of waiting periods?
There are two kinds of waiting periods: general waiting period of up to three months; and condition-specific waiting period of up to 12 months.
When do waiting periods not apply?
- In respect of PMBs, if the services are rendered by state hospitals or designated providers.
- A child dependant born during the period of membership.
- A member moving between benefit options unless he has to complete the remaining period of a previously imposed waiting period.
- When an individual has to transfer to another scheme due to a change of employment.
- In instances where an employer changes the medical scheme under which the employees are registered with effect from the beginning of the financial year.
Can a medical scheme impose a condition-specific waiting period on pregnancy?
Yes, in those instances where the person was a beneficiary of a medical scheme up to 24 months.
What is a LJP?
It is a penalty by way of additional contributions, imposed on persons joining a scheme late in life i.e. an applicant who is 35 years of age or older, who was not a member of one or more medical schemes as from a date preceding 1 April 2001 without a break in coverage exceeding three consecutive months since 1 April 2001.
May pensioners' contributions be less than that of other members?
No, contributions to a medical scheme may only be based upon a member's income and/or the number of his/her dependants.
May medical schemes determine the contributions of retirees on their income immediately prior to retirement as a subsequent deemed income or salary?
Yes, unless proof of a reduced income is submitted to the Scheme.
May a medical scheme determine contributions on the basis of individual high claims or provide discounted or preferred rates in respect of a particular group of members/clients for whatever reason?
No, contributions may only be based on a member's income and/or the number of his/her dependants, or both. The contributions apply universally to all members who are enrolled and their dependants.
If I do not claim from my medical scheme, may I receive a no-claim bonus or rebate?
No, the Act prohibits the payment of bonuses, rebates or refunding of any portion of contributions other than in respect of savings accounts in certain circumstances.
On what basis may contributions vary?
Only in respect of the cover provided. Different benefit options are priced differently depending on the level of cover afforded.
If the Rules of the Scheme so provide, children may be charged a reduced contribution.
May my medical scheme call upon me for increased contributions with retrospective effect?
No, in terms of the Act a medical scheme must give members advance written notice of any change in contributions and benefits or any other condition affecting membership.
Must my employer subsidise my contributions to the medical scheme?
No, subsidies are conditions of employment and the Act does not address such conditions.
Am I entitled to benefits while serving notice of termination?
Yes, until the last day of membership provided that contributions are paid.
How do I know which benefit option to select?
Ensure that you understand how the benefit options operate and elect according to your healthcare needs and what you can afford. The registered rules of medical schemes fully disclose detailed information regarding the relevant benefits and contributions. It is essential that you obtain the Rules of the Scheme or a summary thereof to verify all information relevant to enable you to make an informed choice.
What is a deductible?
It is a portion of the cost for which the member is responsible.
May a medical scheme request pre-authorisation or second opinions in respect of certain benefits?
Yes, except in an emergency where pre-authorisation should be obtained as stipulated in the Rules.
What can I do if I am not satisfied with my current benefit option?
Instead of changing schemes and being faced with waiting periods, a member can either buy up in order to get better benefits or buy down for less contributions. This option is available annually.
What is an ex gratia payment and do I have a right to such benefit?
It is a discretionary benefit which a medical scheme may consider, normally when the member suffers undue hardship. Schemes are not obliged to make provision thereof in the Rules and members have no statutory right thereto.
I need to go into theatre to have a general anaesthetic for dental surgery. Why would I not be issued with a pre-authorisation number?
A pre-authorisation number is not applicable as this type of surgery is excluded from your risk benefits. The benefit on dental surgery would be at the NIMAS rate subject to day-to-day/savings funds. Dental surgery is not covered on the the Core Option.
Please could I have details of the maternity benefits offered by NIMAS?
All visits to your gynaecologist prior to the birth would be subject to the day-to-day/savings funds. A pre-authorisation number for the birth would need to be issued by our hospital pre-authorisation department. Please contact them at least one month prior to the expected delivery date of the baby. In cases of an emergency, the hospital/practise would contact NIMAS directly. (Note: NIMAS does not cover for hospitalisation in private wards). Only hospitalisation benefits are covered on the Core Option.
Why do I have to pay a portion when I collect my chronic medication?
If you buy your medication from a pharmacy contracted to NIMAS and use medication listed on the formulary there would be no extra cost.
Do I have any cover whilst travelling overseas on holiday?
Benefits would only be allowed for unplanned treatment that is clinically essential while the member or dependant is overseas. Benefits are not available in cases where the member (or dependant) proceeds beyond the borders of South Africa for treatment of any condition. The member must pay any claims incurred and obtain a fully detailed account for submission to NIMAS. NIMAS will reimburse in accordance with the benefits and Rules of NIMAS.
I have had contact lenses/glasses last year - I need to replace my contact lenses/glasses. Can I use my day-to-day funds?
No, the optical benefits are applicable only every two years and only refundable subject to the optical benefits limit. Optical benefits are not covered on the Core Option.
My frame/one of my lenses have broken. Can I use my day-to-day funds to replace it?
This type of benefit is only refundable to the member subject to available savings.
Does my medical scheme option cover me 100% for treatment in hospital?
Each option has different benefits applicable to treatment in hospital. It depends on how the practitioners treating you, set their fees. NIMAS pays 100% of the NIMAS rate on the Core, Classic, Millennium and Supreme options. On the Supreme Option, the surgeon, anaesthetist and admitting practitioner's fees are covered at 150% of the NIMAS rate.
Please note that, any requests for non-emergency procedures need to be submitted to NIMAS at least three working days prior to the date of admission to allow time for requesting/receiving/assessing motivations (where necessary). This will ensure that both the hospital and the patient are aware of the benefits before the costs are incurred. In the event of an emergency admission, you, the hospital or practice would need to contact NIMAS to get pre-authorisation.
I was in hospital and needed to be taken to another hospital for tests. Why is the return trip not covered?
The inter-hospital transfer of the member shall be limited to one one-way upgrade transfer to the facility able to provide the therapeutic interventions. Any return trip that is undertaken will not be covered under this agreement. All arrangements for the transfer of the member/dependants must be pre-authorised by the ER24 call centre. However, under extreme circumstances, ER24 will phone NIMAS for approval for the return transfer. If this is not approved, the cost of the return transfer will not be covered by NIMAS.
Please note that any inter-hospital transfers requested due to convenience or unavailability of any other modes of transport will be due by the member.
Will I receive my full savings allocation for the year if I choose an option with a savings plan?
Yes, you will receive the full amount of savings upfront from the month you join the Scheme.
What happens if I leave the Scheme during the course of the year and I have spent all my savings?
Your amount owing will be claimed back from your account based on how much you have spent.
What happens to my savings if I join an option without savings?
Legally the Scheme cannot retain your savings and will refund these amounts within four months from the change.
May credit balances in my personal savings account be withdrawn in cash?
Only when you terminate your membership of the Scheme or a benefit option, without joining another medical scheme or benefit option without a savings component.
May contributions be paid out of my savings account?
No, except on termination of membership. Funds in the savings account may be used by the Scheme to offset any debt owed by the member which would include contributions.
Can deductibles in respect of PMB benefits be paid out of my savings?
No, the Act specifically prohibits this.
CLAIMS AND PAYMENT OF ACCOUNTS
Within what period of time must my account for services or claim reach my medical scheme?
The account must be submitted no later than the last day of the fourth month following the month the service was rendered.
How do I know whether or not the Scheme has paid and what amount has been paid in respect of a claim?
Payment of claims is regulated by the Act, which includes the dispatch to a member of a statement containing the full particulars of the transaction, including the amount charged for each service and the amount of the benefit awarded for each service.
Within what period of time must the Scheme pay my claim?
If the account or claim is correct and acceptable for payment, it should be paid within 30 days of receipt of the claim.
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