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Board dismisses Discovery Health appeal

“On 31 October 2016, the Council for Medical Schemes Appeal Board dismissed the appeal lodged by the Discovery Health Medical Scheme (DHMS) regarding the issue of whether it is lawful for the rules of a medical scheme to make provision for the scheme to decline an application for reinstatement of membership for a certain period of time, or in perpetuity, in an instance where the scheme has cancelled such membership due to fraud or non-disclosure of material information by a member. The appeal followed an earlier ruling by the CMS Appeals Committee where the Committee ruled that a medical scheme is obliged to immediately re-accept a member whose membership has previously been terminated due to non-disclosure.”

“In its ruling, the Appeal Board found that, as an open scheme, the DHMS is subject to the open-enrolment principle as provided for in terms of the Act, which allows members to re-apply for membership to an open scheme where such membership had been terminated before, due to non-disclosure. In such an instance, the Act makes provision for the scheme to apply statutory waiting periods as provided for in section 29A to protect the scheme against abuse. Any person who has been without medical scheme coverage for a period of at least 90 days may receive a 3 month general waiting period and a 12 months condition specific waiting period which includes Prescribed Minimum Benefits (PMBs) conditions.”

Maybe it’s time for me to consider fishing for a living, for the sake of my sanity. I can understand that this may apply where there was a genuine omission in error, but why should an outright fraudulent act not be punished by exclusion? If it remains undetected, it is really to the detriment of honest members, and one of the reasons why we are already paying exorbitant fees for medical schemes. Perhaps my understanding is incorrect, but from my perspective, this comes down to condoning fraud.

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