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SCHEMES ARE THREATENED BY EXCESSIVE CLAIMS

Medical schemes are being hit hard by excessive claims from members on high benefit options and Medicover's Principal Officer, Stephan Grobler, believes the relatively low premium increases levied by most medical aid funds in the past few years are a thing of the past.

He warns that, in future, the majority of members may pay dearly for the irresponsible actions of a few. He stresses, however, that the claims are not necessarily fraudulent, but rather consistent with a trend to get as much out of your scheme as possible - often without reason.

"It is extremely difficult to close loopholes that allow irresponsible use of medical aid benefits. So schemes have no choice but to increase their premiums to remain solvent."

He says Medicover has the advantage in this volatile climate of having maintained among the lowest premiums in the industry over a period of several years, while retaining some of the most generous benefits. "Our philosophy is to keep it simple, offering medical benefits without add-ons, frills or surprises. It has not only kept our annual increase below 10 percent for the past five years, but maintained and, in some cases, even improved benefits.

"While the industry trend has been to keep increases low, many schemes have slashed benefits at the same time."

He points to Medicover as one of the most stable medical schemes in the country, with reserves well in excess of the required levels stipulated by the Council for Medical Schemes.

"Our claims ratio has increased substantially in the past two years and we have taken several steps to reduce risk and keep our scheme sustainable. These include filters to reduce fraudulent claims from service providers and from members, as well as additional proof needed in certain categories of claims where there was previously room for manipulation."

The scheme is self-administered which, he says, means lower overheads and better control than outsourced administration, and therefore lower cost to the member.

"It also means efficient service carried out by people loyal to the scheme and transparency in the use of funds."

Specialist service providers manage dental and optometry benefits.

"This brings significant savings to the scheme and to members through checks and balances. Dental Information Systems manages our dentistry benefits and Opticlear has just been appointed to audit optometry claims among other benefits."

Grobler says that even if Medicover increased its premiums members would still struggle to find a more cost efficient scheme rand for rand.

"Our four plans cover all potential needs of members across the board and our two lower-cost options offer members hospital benefits, the prescribed minimum benefits, chronic care, dentistry, optometry and various others - for a price similar to a regular hospital plan."