Top up cover? Complementary cover? Confusion reigns…

Among the more debatable topics arising out of the NHI Bill, now on its way to the National Council of Provinces for pre-Presidential approval is that under national health insurance, medical schemes may only offer “complementary cover”.

Taking the discussion further during the most recent Institute for Health Risk Managers
(IHRM) webinar, health sector legal expert Dr Debbie Pearmain reiterated that “complementary cover” in terms of the proposed legislation meant third-party payment for personal healthcare service benefits not reimbursed by the fund – “including any top up cover offered by medical schemes registered in terms of the Medical Schemes Act or any other voluntary private health insurance cover”.

“But this definition has flaws,” said Pearmain.

“What is ‘top up’ cover as opposed to ‘complementary cover’? And what are ‘personal healthcare service benefits’?”

Although the Bill refers to services not covered by the NHI Fund, it was not that simple, as
Pearmain pointed out. In the first instance, in the current context, for example, “top up” cover would mean gap cover…


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“Technically if schemes are allowed to provide ‘top up’ when you have the NHI benefits, the ‘top up’ cover is adding something of value to the NHI Bill which I don’t think the
Bill envisages. The more you think about it the more confused you get,” Pearmain
lamented, noting that the “weird term” personal health care service benefits
added to the confusion.

“Restricting medical schemes to ‘complementary cover’ may constitute denial of care for medical scheme members depending on how ‘personal health care service benefits are

Pearmain also noted that “complementary cover to services not reimbursable by the Fund
(Section 33 of the Bill)” contradicts the definition of complementary cover: “Proposed
amendments to the Medical Schemes Act (MSA) in the Bill,” she elaborated, “contradict
Section 33 of the Bill. So, if you amend the MSA, why is Section 33 necessary?

“If Section 33 is necessary, why amend the MSA?”

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