1 reviews | Active since May 2018
Why Genesis???
After my father had a heart attack , he was admitted to a private hospital by his MD , whereupon he was sent to ICU , genesis refused to give an authorization number for his emergency surgery , we had to pay cash for him to get treated , everything we had . After two days they gave authorization , whereupon my dad received a triple bypass , blessed are we that it was a success ! The hospital refunded us fully after the successful authorization ! Now a month after the surgery Genesis cancelled with immediate effect my parents’s medical aid fund , saying they will pay back all paid premiums up to date , because he didn’t disclose he had a DVT in 2012 after back surgery . As far as we understand a heart attack is a PMB disclosed in the medical aid Act ! According to all his medical advisers (doctors) there was no relevance between 2012 DVT and the heart attack as per written explanations by various surgeons and MD’s . WHY would Genesis Medical Scheme terminate them ???
Dear Mieke
We appreciate the nature of your enquiry and wish to provide some supporting information on this matter, as decisions like this are never taken without thorough investigation and careful consideration.
New applicants to a medical scheme are always required to disclose their current and previous medical history in terms of symptoms, conditions and / or treatment received. From this information the medical scheme will then assess its risk profile and may impose certain general and / or condition specific waiting periods. This is done to protect current members of the scheme from new members who may purely join a scheme to claim for a certain event – for example, if they need an operation, and then leave the scheme again before they have made any meaningful contributions to the risk pool of the scheme (an act referred to as anti-selection). Anti-selection prejudices other members who are contributing to the scheme on an ongoing basis and then have to carry the cost of those members who anti-select. In addition, the medical scheme is able to identify any possible future risk that the new membership may pose in later years.
In your father’s instance, whilst the omission of certain important information from his application form may well have been innocent and unintentional, the fact of the matter is that not all material information was available to the Scheme at the time the underwriting criteria for his membership was decided upon. In your post you state that there is no connection between the failure to disclose DVT and the current condition. This is not the test app**** by the courts. Every member has a duty in law to make a full and honest disclosure of his/her medical history when joining the scheme. The failure to disclose a condition that may not manifest itself again is irrelevant.
In instances of non-disclosure of material information, medical schemes have the right in terms of the Medical Schemes Act to cancel a membership. The Act even makes provision for offenses like this on conviction to a fine, or to imprisonment.
Further to this, the courts have held that it is not for the insured (or his / her doctors) do decide what is relevant or not. It is the sole right of the insurer, in this case the medical scheme, to decide what information is relevant or not.
The Board of Trustees has a broader responsibility to the entire membership of the Scheme as a whole, particularly those applicants who fully declare details of all previous medical conditions when joining the Scheme and who were subject to the Scheme’s normal underwriting criteria.
Non-disclose of material information is a big problem in our industry and it is a topic that is often discussed in the media. It is never easy when this happens, especially when it happens to someone close to you. The reality on the side of a medical scheme is however that they have to apply their Rules consistently, as all other members are shareholders of a medical scheme and are directly affected by the Scheme’s application and management of risk.
We recently published two articles on this topic on our website:
https://www.genesismedical.co.za/industry-news/medical-scheme-non-disclosure-a-risk-never-worth-taking-part-1/
https://www.genesismedical.co.za/industry-news/medical-scheme-non-disclosure-a-risk-never-worth-taking-part-2/
Yours sincerely
GENESIS MEDICAL SCHEME
Dear Mieke
We appreciate the nature of your enquiry and wish to provide some supporting information on this matter, as decisions like this are never taken without thorough investigation and careful consideration.
New applicants to a medical scheme are always required to disclose their current and previous medical history in terms of symptoms, conditions and / or treatment received. From this information the medical scheme will then assess its risk profile and may impose certain general and / or condition specific waiting periods. This is done to protect current members of the scheme from new members who may purely join a scheme to claim for a certain event – for example, if they need an operation, and then leave the scheme again before they have made any meaningful contributions to the risk pool of the scheme (an act referred to as anti-selection). Anti-selection prejudices other members who are contributing to the scheme on an ongoing basis and then have to carry the cost of those members who anti-select. In addition, the medical scheme is able to identify any possible future risk that the new membership may pose in later years.
In your father’s instance, whilst the omission of certain important information from his application form may well have been innocent and unintentional, the fact of the matter is that not all material information was available to the Scheme at the time the underwriting criteria for his membership was decided upon. In your post you state that there is no connection between the failure to disclose DVT and the current condition. This is not the test app**** by the courts. Every member has a duty in law to make a full and honest disclosure of his/her medical history when joining the scheme. The failure to disclose a condition that may not manifest itself again is irrelevant.
In instances of non-disclosure of material information, medical schemes have the right in terms of the Medical Schemes Act to cancel a membership. The Act even makes provision for offenses like this on conviction to a fine, or to imprisonment.
Further to this, the courts have held that it is not for the insured (or his / her doctors) do decide what is relevant or not. It is the sole right of the insurer, in this case the medical scheme, to decide what information is relevant or not.
The Board of Trustees has a broader responsibility to the entire membership of the Scheme as a whole, particularly those applicants who fully declare details of all previous medical conditions when joining the Scheme and who were subject to the Scheme’s normal underwriting criteria.
Non-disclose of material information is a big problem in our industry and it is a topic that is often discussed in the media. It is never easy when this happens, especially when it happens to someone close to you. The reality on the side of a medical scheme is however that they have to apply their Rules consistently, as all other members are shareholders of a medical scheme and are directly affected by the Scheme’s application and management of risk.
We recently published two articles on this topic on our website:
https://www.genesismedical.co.za/industry-news/medical-scheme-non-disclosure-a-risk-never-worth-taking-part-1/
https://www.genesismedical.co.za/industry-news/medical-scheme-non-disclosure-a-risk-never-worth-taking-part-2/
Yours sincerely
GENESIS MEDICAL SCHEME