Medical Aid Not Paying Claims?
(12 Possible Reasons)
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Is your medical aid rejecting and not paying all your claims?
Understanding medical aid rules is not easy. Plan rules are complicated and when much-needed claims go unpaid, on top of a high medical aid premiums, it can be very frustrating! Unfortunately, this is a concern that almost every member of a medical aid scheme experiences.While it's easy to blame medical aid systems, there could be issues beyond the claims processing itself.
There iare rules and processes guiding claim processes and they apply to the medical aid, you, and your healthcare provider.
These rules and processes can be difficult to understand, and you may need to deal directly with your medical aid or get assistance from a broker like us.
If you do not have a broker read this!
You should receive a monthly statement with reasons why a claim was not paid.
If you do not agree with the decision, read the plan brochure fully before you look for help.
And if you still feel aggrieved, you can contact the contact the Council for Medical Schemes.
Here’s more detail about their complaints procedure.
Here are 12 possible reasons why your claim may have been rejected:
1. Are your premium paid up to date?Did the last debit order run, and did your employer pay your premium on time?
2. Has the time to submit your claim expired?
Your scheme rules will dictate just how long you must submit a claim, generally before the end of the 4th month from the date of that account. Your account must be dated.
3. Have you used up your benefits for that treatment?
Most medical aids use a savings fund to pay out of hospital costs.
Other plans have set day-to-day benefits, or a certain amount payable per day.
There are also limits on certain benefits, like dentistry and glasses and if those are reached, you will need to self-fund further claims that year.
More expensive plans may have a safety net whereby, once your savings are spent and your claims have reached a pre-determined level (your threshold level), the scheme will pay all (or limited) claims for that year.
See: Have you spent your medical aid savings?
In-hospital only benefit plans, do not pay for out of hospital costs.
But, there is a plan that will pay in-hospital and dental costs!
If you need to investigate this plan, talk to me!
4. There is no referring doctor named on the specialist’s account.
With any specialist treatment, you must first be referred by a GP. This is to prevent members using a more expensive specialist first, when a GP might have been able to sort out the problem at a fraction of the cost. If there is no referring GP the claim will be refused.
5. The ICD-10 codes, for your treatment, are not valid.
Every specific treatment and condition has an ICD-10 code to identify it. All claims submitted must show a code, otherwise the account will not be processed.
6. Does your medical practitioner have a valid practice number?
Only medical practitioners registered with the Health Professions Council of South Africa will be paid by a medical aid and their practice code is proof of being registered. This code must be disclosed.
7. You must quote your member number on every claim.
No member number or an incorrect number and a claim is automatically refused.
Make sure a submitting doctor or specialist has your correct member details.
8. If you are treated for a non-PMB condition, the medical aid does not have to pay for it, should there be no benfits applicable.
Treatmentrs like cosmetic and obesity procedures are generally not covered and you will need to self-fund them.If you see a GP for a non PMB condition, that has no benefit, you self-fund it either from your savings or if those are used, yourself.
Always check with your scheme before you go for any expensive treatment!
9. Are you in a 3-month general waiting or a 12-month condition specific waiting period?
In this case, no claims will be paid. Check with your scheme or broker if you are a new medical aid member.
10. Your prescribed medication is not on the plan’s medicines formulary.
Plans have different medicines formulary (list of approved medication) and these determine which chronic medicines will be paid for. If it is not listed, you self-fund it. Ask your chemist for the generic medication – it can save you lots of money.
11. Did you pre-authorise your hospital treatment?
Elective hospitalisation and certain day-to-day treatments must be pre-authorised before being done.
And in an emergency, make sure the hospital contacts your medical aid.
No pre-authorisation and a claim will fail.
12. Did you use a listed provider?
Some plans require you to use listed providers or hospitals, who guarantee certain treatments with no co-payments.
If you do not use them, you can face a high procedure co-payment.
Are you aware that a portion of your medical aid premium is a broker fee?
Whether you use a broker or not, you still pay that fee!So, I urge you to use us.
It will cost you nothing extra, and we will help you with all these (and many other) medical aid concerns you may have.
Private healthcare providers can charge up to 500% of medical scheme rates.Medical aids add procedure co-payments as well.
These are significant concerns for medical aid members.
Protect yourself against these potential threats, by joining Cura's GAP or top-up insurance plan.
OR Zest GAP or top-up insurance plan.
This separate insurance will cover most in-hospital claim shortfalls and any co-payments. It is a vital safety net, ensuring you have adequate benefits for medical treatments without bearing the full burden of unexpected costs.
Protect yourself from soaring medical expenses by bridging the gap between medical scheme rates and the charges imposed by private providers.
Specialised Dental treatments can be extremely expensive!The costs of braces, root canal, implants and so on, can run into thousands of rand. Most treatments are done out of hospital, so are funded from your savings. That can result in less money available for other medical needs and family limits being used on one member only!
Dental treatment is something we all need and it is vital you consider the Best Dental Insurance Plan OR Most Affordable Dental Planin South Africa.
No Medical Aid or have a Hospital Plan only? This plan will help you meet the high costs of both normal and specialised dentistry!
Talk to me .... I am here to help you - at no charge!
Send me your questions and concerns. I'll answer them for you.
083 655 2164
You must consult the schemes/company product brochures and rules for comprehensive benefit descriptions.
We will offer you the best help at no cost!
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Last update:January 18, 2025
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