Medical Schemes Members Have Rights:

1. The right not to be unfairly discriminated against on the basis of:
   Race, Age, Gender, Marital status, Ethnic or social origin, Sexual orientation, Disability, State of health, etc.
2. The right to join a medical scheme of their choice.
   Anyone can join an open medical scheme as long as they can afford the contribution and provided your employer does not require you to join a specific scheme. Employer-based schemes must accept every applicant in the relevant employee grouping as defined in the Schemes Rules.
3. The right to acquire cover for dependants:
   Dependants are defined in the Schemes Rules as a member’s spouse or partner who is not a member or a registered dependant of a member of another medical scheme, a a member’s natural child, or a stepchild or legally adopted child or a child in the process of being legally adopted or a child who has been placed in the custody of the member or his spouse or partner and who is not a beneficiary of any other medical scheme.
4. The right to as a dependant, to continue membership
   After the death principal of member, dependants must be covered until they choose to leave the scheme or to join another scheme, as long as they can afford the contributions.
5. The right not to be charged more because of OLD AGE or ILL HEALTH.
   Contributions can only be based on income and the number of dependants.
6. The right to at least a Basic Set of Benefits, called the Prescribed Minimum Benefits (PMBs).
   As a minimum, schemes must offer the PMBs at cost, for diagnosis, treatment and care, in terms of the PMB protocols.
7. The right to have claims paid timeously
   A medical scheme must, subject to the rules of the scheme, pay to a member or health care provider any benefit  owing within 30 days of the claim being received
8. The right to receive regular statements
   In addition to paying an account, a scheme must furnish the member with statements detailing  the name of the provider, date of service rendered, total amount charged, amount of benefit paid.
9. The right to rectify erroneous claims
   If a medical scheme believes that an account or claim is incorrect or unacceptable, it must inform the member with reason, within 30 days of receipt, and allow the member with the opportunity to correct and resubmit the account or claim.
10. The right to participate in schemes governance
    All trustees on CompCare must be elected by members from amongst members to serve terms of office of 4 (four) years each . Members must attend Annual General Meetings which must be held once a year by no later than 31 July of each year where members may voice opinions and present motions.
11. The right to access to scheme information
    A scheme must furnish a member with information, on demand with a copy of the Schemes rules and annual financial statements.
12. The right to advance notice of change in contributions, benefits or any other condition affecting membership.
13. The right to confidentiality of medical information pertaining to the diagnosis, treatment or health status of any member or dependent.
14. The right to obtain proof of membership
    A scheme must issue to each member written proof of membership including:
    • Date of entitlement to benefits
    • Details of any condition-specific waiting period or general waiting period
    • If applicable, details of limitations on health care providers.
15. The right to complain
    When a member is dissatisfied with a service from a medical scheme, it is his/her duty to express this dissatisfaction to the medical scheme so that the latter can rectify or resolve the issue satisfactory. Always follow the proper complains procedures as explained in this manual.

Members have a duty to:

• Be open and honest
• Not to submit fraudulent claims
• Not to commit fraudulent acts, e.g.: buying sunglasses, toiletries, AMC pots on medical scheme account
• Disclose any material information on request fill out the health history form open and honestly
• To pay contributions timeously
• Directly to a medical scheme not later than 3 days after the payment becomes due.

Limitations on member rights:

Member rights are limited insofar as Schemes Rules define benefit limits.

Subject to the Act and Prescribed Minimum Benefits, Scheme Rules may restrict benefits covered and limit amounts payable in respect of particular benefits. For example Some options can cover 100% on all benefits; another only covers 60% of benefit the member than pays the outstanding 40%.

Member rights are limited insofar as manage care interventions may be applied.

Schemes rules may provide for various interventions designed to promote cost-effectiveness and appropriateness of service, e.g. preauthorisation for certain expensive benefits.

Member rights are limited insofar as late claims rejected.

A Scheme may refuse to pay a claim that is submitted 4 months after the last date of service rendered, as stated on the account, or the date on which the account was returned for correction.

Member rights are limited insofar as membership of, and claims against, more than one Scheme is prohibited.

No person may:

• Be a member of more than one scheme
• Be a dependant of more than one scheme, e.g. a child cannot be registered on both parent medical schemes
• Or cannot claim against more than one scheme this can be regarded as fraud

Member rights are limited insofar as frequency of change of benefit options may be limited.

A scheme may restrict change between options to the beginning of a year, with 3 months notice.

Member rights are limited insofar as waiting periods may be applied.

On admission to membership a scheme impose a:

• 3 month general waiting period
• 12 month condition-specific waiting period, or
• A Waiting period on certain PMB’s

Except:

1. A child born to a member who is registered on the Scheme within 30 days of birth
2. Change between benefit options as allowed once a year with effect from 1 January of the next year
3. Termination of membership due to employment or employer changing schemes.