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Medical Aid Schemes

The nation’s health is probably Government’s top priority – and the cost, both to it and the economy, of health care is well documented. Recently, there has been much media exposure afforded Government’s planned NHI – the National Health Insurance, and debate has continued about its pros and cons.

The Medical Schemes Act 19981 governs private health care – in other words, ‘medical aid’. The purpose, amongst others, is to protect the interests of members of medical aid schemes by regulating and controlling the activities of companies offering medical aid. Unfortunately, fraud against these medical aid schemes does occur.

A. Members

  1. Any person who falsely claims for the payment of any benefit under a medical aid scheme commits a criminal offence.2

  2. Any person who knowingly submits some fact to a medical aid scheme, which will be used in determining his entitlement to a benefit, and which fact is false, commits a criminal offence.3

  3. It is also an offence not to disclose information about an event, or occurrence (which will affect your right to receive any benefit) in order to obtain some benefit to which you would not otherwise be entitled.4

  4. It is an offence to be a member of more than one medical scheme, or the dependent of more than one member.5

  5. It is even a crime to claim, or accept benefits from a scheme of which you are not a member.6

B. Medical practitioners

  1. It is a crime to render a false statement, account or invoice knowing that it may be used by someone to claim any benefit from a medical aid scheme.7

C. Medical aid schemes

  1. To carry on business as a medical scheme, you must be registered in terms of the Act. It is an offence to do otherwise.8

  2. It is a crime to use a name for your business which is likely to give the impression that it is a medical aid scheme if you are not registered.9

  3. It is also an offence to market, advertise, or promote your business in a way which is likely to create the impression that it is a medical aid scheme, unless you are registered.10

  4. Advertising or promoting a medical aid scheme in a way likely to create the impression that membership depends upon buying some other product, benefit or service is forbidden, and it is an offence to do this.11

  5. It is an offence for a medical scheme to carry on any business other than that of a medical scheme.12

  6. No person may provide any service or advice concerning admission to a medical scheme, or its benefits or services unless he is accredited by the Council for Medical Schemes13 as a broker.14 15

  7. A medical scheme may not compensate a broker other than by paying the prescribed commission, under the circumstances established by the Minister of Health in regulation, and it is an offence for it to do otherwise.16

  8. It is also an offence for a broker to receive compensation for providing broker services other than from a medical scheme, a member (or prospective member) or his employer, or if he is employed by another broker.17

  9. It is an offence for a medical scheme to use or refer to itself by a name other than the name under which it is registered.18

  1. As amended; the most recent amendment was effected by Act 11 of 2013. An intended amendment by way of Act 45 of 2013 has not yet been put into place. 

  2. Section 66(1)(b). 

  3. Section 66(1)(c). 

  4. Section 66(1)(d). 

  5. Section 66(1)(1) read with section 28(a) and (b). 

  6. Section 66(1)(a) read with section 28(c). 

  7. Section 66(1)(e). 

  8. Section 66(1)(a) read with section 20(1). 

  9. Section 66(1)(a) read with section 21. 

  10. Section 66(1)(a) read with section 22A. 

  11. Section 66(1)(a) read with section 21A(3). 

  12. Section 66(1)(a) read with section 26(ii). 

  13. The Council of Medical Schemes is situated at Hadefields Office Park, Block E 1267, Pretorius Street, Hatfield. 

  14. This does not apply in the case of an employer giving advice to employees, or a trade union representative to its members. 

  15. Section 66(1)(a) read with section 58(1) and section 65(1) 

  16. Section 66(1)(a) read with section 65(2)–(5). 

  17. Section 66(1)(a) read with section 65(6). 

  18. Section 66(1)(a) read with section 23(2).