The FAIS Ombud this week issued a media release encouraging medical scheme members to lodge a complaint with her office if they believe they have been “financially prejudiced” by a healthcare broker’s advice.
The office lamented the fact that it receives “a negligible number” of complaints about medical scheme brokers, although it has the jurisdiction to investigate such complaints.
According to the office’s 2020/21 annual report, of the 10 552 complaints received, only 176, or 1.67%, concerned medical schemes/health insurance. Most of those complaints were about health insurance policies, so 176 complaints appeared to be “rather insignificant” considering that, in 2020, there were 76 medical schemes and about 8.8 million beneficiaries, the office said.
The reason for the low number of complaints in respect of medical schemes “is not entirely known”, and “one can only speculate” that beneficiaries are unaware that the FAIS Ombud can assist in investigating medical scheme-related complaints, according to the release.
The office used the example of gap cover to illustrate what a client should expect from a broker when receiving advice about his or her medical scheme needs.
According to the ombud’s office, brokers, during the needs analysis process, “often overlook” the risk that a prospective member will have insufficient hospital cover.
“When an FSP does not recommend that a prospective client consider the benefits of gap cover in relation to the limitations applicable to the recommended medical scheme, the FSP is leaving the client exposed to the potential financial prejudice, due to specialists charging in excess of the scheme tariff; expenses that form part of the procedure that the client may not be aware of, especially where the procedure is not in respect of a PMB; and co-payments for procedures in respect of illnesses such as cancer”.
The media release explains an insurance broker’s common-law obligations to his or her clients, which, to a large extent, are codified in the General Code of Conduct for FSPs and Representatives.
Therefore, says the office, when an FSP provides advice about a medical scheme, his or her duty is, first, to make a recommendation that is appropriate to the client’s needs and circumstances, and then to advise the client of the scheme’s material terms and conditions, including tariffs, exclusions and the use of designated service providers.
“The recommendation of a gap cover policy to mitigate any potential financial prejudice forms part of this duty to ensure that the client has peace of mind in knowing that, as far as possible, all risks have been addressed in the event of the client’s medical needs,” the office says.