Focus on non-disclosure

Below is Information about non-disclosure

Why is non-disclosure investigated?

Open enrollment is a fundamental aspect of the Medical Schemes Act 131 of 1998 (the Act), which is designed to prevent medical schemes from engaging in risk selection practices. This provision allows any eligible individual to join any open medical scheme of their choosing without the threat of unfair discrimination. Specifically, Section 29(1)(n) of the Act prohibits medical schemes from discriminating against any member based on certain criteria, including age, gender, or their past or present health status. As a result, medical schemes are obligated to accept any applicant who seeks to join, without imposing risk ratings. To safeguard medical schemes against the risks associated with anti-selection, they are permitted to implement waiting periods. These waiting periods may include a general waiting period of three months and/or a specific exclusion period of twelve months for certain pre-existing conditions. Furthermore, Section 29(2)(e) of the Act allows for the cancellation of a membership contract if there is non-disclosure of material information. It is crucial for applicants to disclose any medical conditions for which they have received a diagnosis, treatment, or care within the twelve months leading up to their application. This disclosure enables the medical scheme to conduct a thorough risk assessment. However, it is also essential for members to declare all medical conditions, even those that may date back beyond twelve months or seem minor, such as menstrual cramps. Some conditions are chronic and ongoing, such as hypertension, which may not require treatment within the last year but still pose a risk. Medical schemes may impose a twelve-month waiting period or exclusion on pre-existing conditions to prevent individuals from joining solely to have their medical expenses covered for a specific health event and then leaving the scheme once those expenses are paid. If a member fails to disclose pre-existing conditions—whether intentionally or unintentionally—this can be classified as non-disclosure of material information, leading to termination of their membership. The legislation surrounding non-disclosure is vital for ensuring the long-term viability and sustainability of open medical schemes.

Non-disclosure process Members who apply for chronic registration, seek pre-authorization for any treatment or procedure, or register for any health management program within the first twelve months of joining Momentum Medical Scheme will be subject to the standard non-disclosure process. This process begins with an email sent to both the member and their financial adviser, notifying them that the standard non-disclosure process has been initiated and outlining the requirements. One of the key requirements is the completion of a Clinical History Form (CHF) by the member’s healthcare providers. The CHF is sent directly to the relevant healthcare professionals for their completion. During this period, any requests for authorization or admission will be placed on hold until the non-disclosure review is finalized. Upon receiving the completed CHF from the doctors, the details will be thoroughly reviewed to ensure that all pre-existing conditions and treatments have been properly disclosed. If non-disclosure is identified, the membership will be terminated, retroactively effective to the member’s join date, and any contributions made will be refunded. If Momentum Medical Scheme has paid out any claims during this time, the claimed amounts will be deducted from the contributions. Members who find themselves in this situation may re-apply to join the scheme, although they will be subject to full underwriting processes. Conversely, if members have declared all relevant information, the review will be concluded, and any pending authorizations will be released. In instances where the CHF is not received, the healthcare providers will be contacted up to five times as a reminder to submit the necessary information. The review cannot be completed until all CHFs have been collected. Therefore, it is advisable for members to communicate with their doctors to ensure that any outstanding information is provided promptly, allowing for a swift completion of the review and the release of any pending authorizations.

Who is liable for the cost to complete the Clinical History Form? Momentum Medical Scheme will cover the costs associated with the completion of the CHF. Once the completed forms are received, the doctor will be reimbursed for their services.

Important notes It is crucial for applicants to disclose all medical conditions, medications, treatments, and doctor visits, regardless of how minor or insignificant they may appear. Financial advisers play a key role in this process and must encourage applicants to provide as much detail as possible from the outset. They should ensure that all information shared by the applicant is included in the application, avoiding selective inclusion, especially if the adviser is assisting with form completion or capturing a web application. Additionally, applicants should disclose any anticipated treatments they expect to undergo upon joining the scheme. This is particularly important for individuals who are pregnant, planning to conceive within twelve months of joining, or those who are uncertain about their pregnancy status due to missed or irregular menstrual cycles. Such details must be clearly stated on the application form. The principal member, who is responsible for completing the application, must accurately share all relevant information regarding their dependents and verify this information with them before submitting the application. It is imperative that members carefully read all questions on the application form to ensure that comprehensive information is provided for themselves and their dependents from the beginning, which will help avoid any inconveniences later on. Members can also assist in the non-disclosure review process by encouraging their doctors to submit any required information as quickly as possible, thereby preventing unnecessary delays in finalizing the decision.