Medical Aid. Do they really care??

[coells]

Focus on their own needs at the core of Momentum Health in 2015

Medical aids of today has come a long way from the old days where they just paid for your medical expenses. Today there is a huge focus on healthy living and preventative behaviour that all gets linked to fancy rewards schemes to motivate the members to engage in healthy living practises. They advise you to go for pre-screening for just about every condition possible from regular blood pressure tests to prostate check-ups and a whole long list more.

It came as a huge shock to me then, when I requested admission to a rehabilitation facility for a long standing drug addiction, that they declined the authorisation.

I should start by giving all the facts. I use to work in the financial industry and was a member of Bankmed for about 9 years up until 2010. At that time I lost my job as a result of my addiction. Oh, the work never new about my addiction, but my quality of work had deteriorated to a point where I was a liability to the company and hence they let me go. Then around middle of 2014 my partner got very ill and had to stay in hospital for more than a month and I realized that we can’t be without a medical aid started looking for a new medical aid. Due to the fact that Bankmed is a subsidiary of Momentum Health I decided to join them.

All the contracts were signed in middle September 2014 and the first premium deducted on 1 October 2014. Then during the festive season I engaged in very risky sexual behaviour whilst I was under the influence and had a HIV scare. To my great relief the second test came back negative, but it made me reflect on my live and my 15 year addiction to crystal meth. I decided that I need to make a change as my life was slipping away slowly whilst I was high every single day.
I immediately started looking into treatment facilities for drug addiction and after long deliberation decided on a facility that had a good reputation and was reasonably priced. The total cost would fall well within my benefit that Momentum Health said I have. To my great surprise the clinic phoned me this morning to advise me that the authorisation request has been rejected. The reason was because I have not been a member of the medical aid for 12 months.

I immediately got onto the phone to speak to Momentum because surely this is a mistake or misunderstanding of some sort. The call centre referred me to Ms Saksha who according to them is the person who deals with this type of authorization. Explaining to her my long history of addiction (15 years) and my close call of last year that lead to the decision to kick this destructive habit, I was shocked to just get a cold shoulder on the other side of the phone. I was told that the condition was pre-existing and if I had declared it on the application they would have excluded it for 12 months so they will not authorize it before October this year.

I was totally blown away. So Momentum would rather let me risk my life for another 7 months taking this destructive drug than approve a benefit that is part of the policy I am paying for every month? What has all of a sudden happened to healthy living and preventative behaviour? How much does Momentum really care about their members when “company policy” as she put it take precedence of somebodies health? Are all these healthy living schemes got anything to do with the members or is it all just there to try and increase the medical aid’s profits?

According to a Media Launch in September 2014
Focus on client needs at the core of Momentum Health in 2015
I beg to differ!

[HR Solutions]

Just a question. Yes good for you for kicking the habit, but medical aids are business people like a lot of us. I am on a medical aid - why should I pay a higher premium because some people (like yourself maybe) that is trying to kick a self induced habit and now needs to stop ? Because if everyone is allowed to just do anything and then claim from the medical aid our premiums would go up and up and up ..... Just my thought and answer to your question above and I think I have a valid point as much as you think you have a valid point.

PS somewhere along the line someone will pay for it and be penalised - why should it not be you ?

[Richard S]

I could not agree with HR more ..... and then there is the little matter of non disclosure on the application form.

[Justloadit]

Another reason for the 12month waiting period for expensive medical treatments, is to stop people from not being on medical aid, and when they need the expensive treatment, join the medical aid an claim for this treatment, at the expense of the other long term members.

So effectively the medical aid is also a type of long term savings for that future expensive treatment.

[coells]

Because if everyone is allowed to just do anything and then claim from the medical aid our premiums would go up and up and up .....

PS somewhere along the line someone will pay for it and be penalised - why should it not be you ?

Everyone is not just doing anything, it is part of the benefits that I pay for monthly same as you are paying for yours. Do I tell you what I think is something valid that you are allowed to claim for? No. It's not about if Momentum will pay, they will but will only do it in 7 months time. Someone is paying for it, me on a monthly basis....

[coells]

I could not agree with HR more ..... and then there is the little matter of non disclosure on the application form.

It's got nothing to do with non disclosure. I was never asked if I had an addiction problem and besides, when I joined up rehab was never even on the cards. It just wasn't something that I thought I would ever consider at the time.

[coells]

Another reason for the 12month waiting period for expensive medical treatments, is to stop people from not being on medical aid, and when they need the expensive treatment, join the medical aid an claim for this treatment, at the expense of the other long term members.

So effectively the medical aid is also a type of long term savings for that future expensive treatment.

I fully understand that, but it is not as if I have never had medical aid. I belonged to them for 9 years previously without any major medical claim. And the cost of the treatment would only be R 25 000.00. We are not talking about millions here. Yes, it is a lot of money, but taken that I pay my premium every month and it is part of the benefit I think it is within reason.

[adrianh]

Lets look at it from a totally different perspective. You spent a hell of a lot of money on your addiction....why should they foot the bill for you to kick your addiction? I can't think of any insurance on medical aid that will pay for self-inflicted harm, they have the right not to insure you against your own stupidity.

I also don't see how going to rehab could be considered to be medical treatment, should the medical aid pay for people who are addicted to gambling?

[HR Solutions]

If u paid for your addiction why can't you pay for your rehabilitation ?

You asked the question ..... Seems like u don't like the answers ....

[Houses4Rent]

Good for you to make that decision for starters. I know of someone who was an alcoholic, but never admitted it. Loads of people tried to help him including me even offering to pay for rehab, but he was in denial and a master of disguising it. One day suddenly we got a call that he passed away and nobody ever found out why. My feeling is that it was a bad mixture of medication and alcohol maybe. He was a very nice person looking after others more than himself and died far too young. So, I sincerely congratulate toy to your decision.

However I think its just rules anyway and its a business after all. Pre-existing conditions are often ruled out or at least have substantial waiting periods. And yes, I also think this kind of rule is there to protect long standing members.

The healthy living encouragement is not really because they care about their members, but because they care about their own viability and competitiveness. It has been proven that people who look more after them cause far lesser cost to the medical insurance.

Bottomline is rules are rules.

I am with Discovery Health since many years and am on top level of their Vitality Scheme. Once one understands how it works (takes some effort) one can greatly benefit of it especially when linked with their other products like Credit Card Life, Invest etc. I certainly get far more benefit that what Vitality costs me. So loads of members who do not use it properly pay for me. In other words, go out there, understand the systems and make them work for you.

[Pap_sak]

And although great you plan on kicking the habit - there is a 12 month exclusion period for obvious reasons. If there wasn't, I could join, get my R250,000 rand back op and leave a couple of months later - say 4 months @R3000 p/m - so cost me R12,000. And you think that is not only fair but this would be a viable business?

[coells]

If u paid for your addiction why can't you pay for your rehabilitation ?

You asked the question ..... Seems like u don't like the answers ....

You really should learn to think before you talk/type. It just puts your ignorance out there for everybody to see!

[coells]

And although great you plan on kicking the habit - there is a 12 month exclusion period for obvious reasons. If there wasn't, I could join, get my R250,000 rand back op and leave a couple of months later - say 4 months @R3000 p/m - so cost me R12,000. And you think that is not only fair but this would be a viable business?

If you have ever read the terms and conditions of a medical aid, all benefits are prorata. If you leave a month or two after your operation and only joined shortly before you are liable to pay the money back to the medical aid!

[coells]

Lets look at it from a totally different perspective. You spent a hell of a lot of money on your addiction....why should they foot the bill for you to kick your addiction? I can't think of any insurance on medical aid that will pay for self-inflicted harm, they have the right not to insure you against your own stupidity.

I also don't see how going to rehab could be considered to be medical treatment, should the medical aid pay for people who are addicted to gambling?

They will foot the bill but only in October this year so your whole argument is invalid. And yes, people with a gambling addiction can also go to rehab and the medical aid will pay for it. Please we need some intelligent debate here!

[coells]

Good for you to make that decision for starters. I know of someone who was an alcoholic, but never admitted it. Loads of people tried to help him including me even offering to pay for rehab, but he was in denial and a master of disguising it. One day suddenly we got a call that he passed away and nobody ever found out why. My feeling is that it was a bad mixture of medication and alcohol maybe. He was a very nice person looking after others more than himself and died far too young. So, I sincerely congratulate toy to your decision.

However I think its just rules anyway and its a business after all. Pre-existing conditions are often ruled out or at least have substantial waiting periods. And yes, I also think this kind of rule is there to protect long standing members.

The healthy living encouragement is not really because they care about their members, but because they care about their own viability and competitiveness. It has been proven that people who look more after them cause far lesser cost to the medical insurance.

Bottomline is rules are rules.

I am with Discovery Health since many years and am on top level of their Vitality Scheme. Once one understands how it works (takes some effort) one can greatly benefit of it especially when linked with their other products like Credit Card Life, Invest etc. I certainly get far more benefit that what Vitality costs me. So loads of members who do not use it properly pay for me. In other words, go out there, understand the systems and make them work for you.

Thank you! At least one person who is talking a bit of sense. I agree with you that you can get a lot more out of your medical aid in terms of extra benefits, which is what I am doing with the going to gym discounts on certain products etc. It just frustrates me that they can take such a blatant none caring position when somebody (in this case me) clearly needs and asked for their help. I suppose that’s what my partner means when he says I am too soft for running a business because I would have helped.