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Health24.com | 20 medical scheme myths you should not believe

The world of medical schemes is a complicated one – and there are many myths and misconceptions doing the rounds. Below is the truth about some of these.

Myth: Medical schemes make a profit.

Fact: Medical schemes as such are not profit-making organisations. They might be part of bigger insurance companies, which do make a profit, but there are different laws governing insurance products and medical schemes. If a scheme registers a profit, it goes into the reserves of the scheme, and this belongs to the members. Medical schemes have trustees, not shareholders. Of the registered open medical schemes in SA, only 8 of the 23 achieved an operating surplus in 2015.

Myth: A scheme can refuse my application.

Fact. No it cannot. A scheme can make you pay a late-joiner penalty, and impose a general waiting period of three months or a condition-specific waiting period of no more than 12 months on a new member. But it cannot refuse your application if you can pay the membership contribution.

Myth: Medical inflation is higher in SA than elsewhere.

Fact: Medical inflation is a worldwide phenomenon. In SA, medical inflation, on average, has been 2% above CPI inflation over the last 16 years. High equipment and medication costs, the spiralling costs of private healthcare, overtreatment in the private sector, and the increase in lifestyle-related diseases all contribute to high medical inflation worldwide.

Myth: Medical insurance is the same as a medical scheme.

Fact: Medical insurance is not covered by the Medical Schemes Act, and functions more like an income-replacement product than medical cover. A medical insurance product pays you out for certain diagnoses, or a hospital stay – it does not pay your medical bills.

Myth: If my scheme gives 100% cover means I don’t have to pay in anything.

Fact: Not true. Schemes can cover you for 100% of the medical fund tariff, which may be considerably lower than the cost of the private hospital or private doctor. You could end up with a big co-payment.

Myth: A scheme can force me to use network hospitals.

Fact: No, it can’t. It can encourage you to do so by guaranteeing no co-payments from your pocket if you stay within the network. If you choose to use out-of-network hospitals or doctors (except in certain emergencies), the scheme can make you pay the difference, but they can’t force you to use certain healthcare services.

Myth: Pensioners pay a lower membership contribution.

Fact: No, that is not allowed. In many other spheres of life pensioners get a discount, but not for medical scheme contributions. In fact, it is illegal to let pensioners pay less. Traditionally pensioners are also high claimers on most medical schemes.

Myth: My employer has to subsidise my scheme contributions.

Fact: No, they don’t. The employer can, as part of your employment contract, require you to belong to a certain scheme, but they do not have to subsidise your contributions. If you work for the state, you might be lucky in getting a third of your contribution subsidised, but it is a privilege, not a right.

Myth: I cannot put my parents on my medical scheme.

Fact: If they are financially dependent on you, and you can prove it, they can join as adult dependants on your scheme.

Myth: A scheme can tell me which medication to use.

Fact: They can encourage you to use the medication on their medicines formulary. If you choose not to, you might have to pay the difference in cost, but they cannot force you to take a particular type of medication.

Myth: A scheme can exclude me from treatment for a pre-existing condition forever.

Fact: No, they can’t. They can only impose a 12-month waiting period for a pre-existing condition. If however, they find out that you did not disclose a pre-existing condition, you can be found guilty of fraudulent behaviour, and there might be penalties imposed because of that.

Myth: A hospital plan will only pay for in-hospital treatment.

Fact: Generally, yes, but all hospital plans also have to pay for the treatment of 25 chronic conditions. You might also be entitled to claiming for six-monthly GP visits to have your chronic prescriptions renewed.

Myth: I can change options whenever it suits me.

Fact. You can usually only switch options once a year in January on most schemes. This is done to streamline administration of things such as savings accounts, which are allocated on an annual basis. Nothing stops you from changing options every year.

Myth: A medical scheme cannot terminate my membership.

Fact: They can, if you are unable to pay the monthly contributions, or if you are found guilty of making fraudulent claims.

Myth: Complications from elective surgery are for my own account.

Fact: If you have cosmetic surgery, for which the medical scheme will not pay, and you get septicaemia after the operation, they will pay for the treatment of the infection, as that is a prescribed minimum benefit.

Myth: Once my benefits run out, that’s it for the year.

Fact: Even if your savings account is depleted, you are still covered for in-hospital treatment. You can also apply to your scheme for further ex-gratia payments for day-to-day treatment. These are evaluated on a case-by-case basis, according to certain protocols.

Myth: All cancer treatment is a prescribed minimum benefit.

Fact: Some cancers are PMBs, but certain cancers, when advanced, are not deemed treatable. Depending on your scheme, you can still claim for these from your oncology benefit, though. After this, many schemes will expect you to pay a portion of your treatment yourself – this depends on your scheme and the option you have chosen.

Myth: I cannot claim anything during the three-month waiting period.

Fact: You couldn’t buy a new pair of spectacles, but if you were in an accident, you could definitely get treatment at the nearest trauma unit.

Myth: Schemes take forever to settle claims, especially big ones.

Fact: The scheme has 30 days from receipt of the claim (with all the relevant information) to settle it. The only delays will be if there is information missing. You usually have until the end of the fourth month from the last date of your treatment to hand in claims. If schemes regularly miss the 30-day payment schedule, they are called to account by the Council for Medical Schemes.

Myth: The money in the savings account is yours.

Fact: It is yours in that it can only be used by you to pay for your medical expenses. But you cannot draw the money out in cash, or use it to settle the bill for co-payments. This money is carried over from year to year if you do not use the full allocation. It will only be paid out to you four months after you have left the scheme.

All images provided by iStock

Read more:

The cost of healthcare in South Africa

14 quick facts on medical schemes in SA

Medical schemes – the basics

(Sources: The Council for Medical Schemes; Alexander Forbes Health)

NEXT ON HEALTH24X

Health24.com | How watching porn can cause erectile dysfunction

Many young men who should be in their sexual prime are suffering erectile dysfunction as a result of watching pornography from an early age.

Prolonged exposure to porn, via the ease of technology, creates a demand for more extreme and “novelty” material in order to maintain arousal, to the point where sexual experiences with partners are no longer arousing.

Real sex ‘disappointing’

One international study in Behavioural Sciences, a medical journal, said the percentage of men below 40 who suffer erectile dysfunction has skyrocketed in the last 15 years, from between 2% and 5% to 30%.

The study was conducted by a team of US uroligists, neuroscientists and psychiatrists who analysed extensive neuroscientific research.

It said for those suffering with Porn-Induced Erectile Dysfunction (PIED), real sex registers as “disappointing” in comparison with porn, and there is great difficulty maintaining an erection.

Sheryl Rahme, addiction specialist at Changes Rehab Centre, said porn addiction mirrors addiction to drugs.

“With porn-induced erectile dysfunction… the urge to masturbate is not true libido – they are addicted to porn. They are addicted to seeking a fix and a temporary high.

“Porn can become your greatest need. If they have been using porn regularly to ‘get high,’ withdrawal can be as filled with agitation, depression and sleeplessness, as detoxing from alcohol, cocaine and other hard drugs.”

Cape Town-based Standing Together to Oppose Pornography (Stop) director, Clive Human, told Weekend Witness that those they were treating were “getting younger and younger”.

Effort and willpower

“We have kids in grade seven and early high school with compulsive masturbation. I do talks at schools and there’s an anonymous box for issues and questions and that’s how we get notified to many of the problems.”

He said Stop recommend no porn, masturbation or sex as an intervention strategy.

“They got erectile disfunction after a diet of porn and a person is just not as exciting. It takes about three months, sometimes six, to rewire the brain and for the damage to be repaired but that takes effort and willpower.”

He said a lot of the time young children look at porn out of curiosity, but abuse, loneliness and low self-esteem were other factors.

“Intervention can mean telling parents to restrict [children’s] access to phones or using adult content blocks.”

Human said teaching children about porn addiction should be part of the school syllabus.

Boys need to be warned

Board member of The Advice Desk for the Abused at UKZN, Dr Lubna Nadvi, said pornographic images can lead to sexual violence, especially toward women.

“The desire to obtain sexual gratification can often extend to beyond just viewing an image to actually wanting to carry out sexual acts against vulnerable persons without their consent.”

Nadvi said there needed to be an education campaign that warned young people, especially boys, that porn can lead to behaviours that perpetuate gender-based violence.

Researcher at the Wits City Institute specialising in gender and violence, Lisa Vetten, said porn could give young men a skewed view of what women wanted sexually.

She added: “If they are using porn to avoid dealing with actual women, that is a problem. They may lack the ability to be intimate.”

Read more:

Porn and sex addiction: an expert’s view

Your child watching porn?

9 to 5 pornography watcher

Health24.com | Medical scheme myths

The world of medical schemes is a complicated one – and there are many myths and misconceptions doing the rounds. Below is the truth about some of these.

Myth: Medical schemes make a profit.

Fact: Medical schemes as such are not profit-making organisations. They might be part of bigger insurance companies, which do make a profit, but there are different laws governing insurance products and medical schemes. If a scheme registers a profit, it goes into the reserves of the scheme, and this belongs to the members. Medical schemes have trustees, not shareholders. Of the registered open medical schemes in SA, only 8 of the 23 achieved an operating surplus in 2015.

Myth: A scheme can refuse my application.

Fact. No it cannot. A scheme can make you pay a late-joiner penalty, and impose a general waiting period of three months or a condition-specific waiting period of no more than 12 months on a new member. But it cannot refuse your application if you can pay the membership contribution.

Myth: Medical inflation is higher in SA than elsewhere.

Fact: Medical inflation is a worldwide phenomenon. In SA, medical inflation, on average, has been 2% above CPI inflation over the last 16 years. High equipment and medication costs, the spiralling costs of private healthcare, overtreatment in the private sector, and the increase in lifestyle-related diseases all contribute to high medical inflation worldwide.

Myth: Medical insurance is the same as a medical scheme.

Fact: Medical insurance is not covered by the Medical Schemes Act, and functions more like an income-replacement product than medical cover. A medical insurance product pays you out for certain diagnoses, or a hospital stay – it does not pay your medical bills.

Myth: If my scheme gives 100% cover means I don’t have to pay in anything.

Fact: Not true. Schemes can cover you for 100% of the medical fund tariff, which may be considerably lower than the cost of the private hospital or private doctor. You could end up with a big co-payment.

Myth: A scheme can force me to use network hospitals.

Fact: No, it can’t. It can encourage you to do so by guaranteeing no co-payments from your pocket if you stay within the network. If you choose to use out-of-network hospitals or doctors (except in certain emergencies), the scheme can make you pay the difference, but they can’t force you to use certain healthcare services.

Myth: Pensioners pay a lower membership contribution.

Fact: No, that is not allowed. In many other spheres of life pensioners get a discount, but not for medical scheme contributions. In fact, it is illegal to let pensioners pay less. Traditionally pensioners are also high claimers on most medical schemes.

Myth: My employer has to subsidise my scheme contributions.

Fact: No, they don’t. The employer can, as part of your employment contract, require you to belong to a certain scheme, but they do not have to subsidise your contributions. If you work for the state, you might be lucky in getting a third of your contribution subsidised, but it is a privilege, not a right.

Myth: I cannot put my parents on my medical scheme.

Fact: If they are financially dependent on you, and you can prove it, they can join as adult dependants on your scheme.

Myth: A scheme can tell me which medication to use.

Fact: They can encourage you to use the medication on their medicines formulary. If you choose not to, you might have to pay the difference in cost, but they cannot force you to take a particular type of medication.

Myth: A scheme can exclude me from treatment for a pre-existing condition forever.

Fact: No, they can’t. They can only impose a 12-month waiting period for a pre-existing condition. If however, they find out that you did not disclose a pre-existing condition, you can be found guilty of fraudulent behaviour, and there might be penalties imposed because of that.

Myth: A hospital plan will only pay for in-hospital treatment.

Fact: Generally, yes, but all hospital plans also have to pay for the treatment of 25 chronic conditions. You might also be entitled to claiming for six-monthly GP visits to have your chronic prescriptions renewed.

Myth: I can change options whenever it suits me.

Fact. You can usually only switch options once a year in January on most schemes. This is done to streamline administration of things such as savings accounts, which are allocated on an annual basis. Nothing stops you from changing options every year.

Myth: A medical scheme cannot terminate my membership.

Fact: They can, if you are unable to pay the monthly contributions, or if you are found guilty of making fraudulent claims.

Myth: Complications from elective surgery are for my own account.

Fact: If you have cosmetic surgery, for which the medical scheme will not pay, and you get septicaemia after the operation, they will pay for the treatment of the infection, as that is a prescribed minimum benefit.

Myth: Once my benefits run out, that’s it for the year.

Fact: Even if your savings account is depleted, you are still covered for in-hospital treatment. You can also apply to your scheme for further ex-gratia payments for day-to-day treatment. These are evaluated on a case-by-case basis, according to certain protocols.

Myth: All cancer treatment is a prescribed minimum benefit.

Fact: Some cancers are PMBs, but certain cancers, when advanced, are not deemed treatable. Depending on your scheme, you can still claim for these from your oncology benefit, though. After this, many schemes will expect you to pay a portion of your treatment yourself – this depends on your scheme and the option you have chosen.

Myth: I cannot claim anything during the three-month waiting period.

Fact: You couldn’t buy a new pair of spectacles, but if you were in an accident, you could definitely get treatment at the nearest trauma unit.

Myth: Schemes take forever to settle claims, especially big ones.

Fact: The scheme has 30 days from receipt of the claim (with all the relevant information) to settle it. The only delays will be if there is information missing. You usually have until the end of the fourth month from the last date of your treatment to hand in claims. If schemes regularly miss the 30-day payment schedule, they are called to account by the Council for Medical Schemes.

Myth: The money in the savings account is yours.

Fact: It is yours in that it can only be used by you to pay for your medical expenses. But you cannot draw the money out in cash, or use it to settle the bill for co-payments. This money is carried over from year to year if you do not use the full allocation. It will only be paid out to you four months after you have left the scheme.

All images provided by iStock

Read more:

The cost of healthcare in South Africa

14 quick facts on medical schemes in SA

Medical schemes – the basics

(Sources: The Council for Medical Schemes; Alexander Forbes Health)

NEXT ON HEALTH24X

Health24.com | SEE: Why people are freaking out about pictures of holes

A phobia is an irrational and persistent fear of certain objects or situations. Some people have an intense fear of snakes and others can’t stand the thought of public speaking.

But a small number of people have a fear of something quite unique: holes. It’s known as trypophobia and very little research exists on the condition. In fact, some researchers are referring to it as “the most common phobia you have never heard of”.

What is trypophobia?

For trypophobes, the sight of clusters of holes arranged in different formations can cause intense psychological or even physical reactions.

A 2013 study from the University of Essex found the disorder is widely documented by sufferers on the internet and that “the trypophobic objects had relatively high contrast energy at midrange spatial frequencies”.

According to National Geographic the term is not recognised by the American Psychiatric Association, and “mental health experts debate whether or not the affliction is a true phobia, with some opting more frequently to label it an idiosyncrasy, or unusual behaviour”. 

‘A wave of discomfort’

Even though the verdict is still out on whether it is a true phobia, the struggle is real for many sufferers. Tarryn Temmers, a content producer at Health24, is a self-diagnosed trypophobe. She says the phobia has been present for most of her life.

“I feel nauseous, a sensation that things are crawling on my skin and my head itches,” says Tarryn. “I feel extremely anxious when I get a glimpse of an image of a cluster of holes; I immediately have to look away. The fear comes over me like a wave of discomfort as soon as I am forced to look at the image.”

Tarryn thinks the condition should be recognised as a clinically diagnosable phobia. From a patient’s perspective this would mean that the condition will likely be covered by medical aids, more research will be done and official funding will improve the quality of treatment. 

“Professionals should be on board as this feels real and has real consequences.” A ‘clinically diagnosable’ condition means psychologists and psychiatrists can officially diagnose a patient with it using the Diagnostic and Statistical Manual of Mental Disorder (DSM). Currently phobias such as agoraphobia (fear of open spaces and social phobia (fear of social situations) are covered in the criteria mentioned in the DSM

Due to a lack of research it is unsure how many people in South Africa are suffering from the disorder, but anecdotally looking at the prevalence of phobias in general, Tarryn is one of many South Africans suffering from trypophobia. 

Why it happens

Researchers from the University of Kent say it is unclear why the condition exists, given the harmless nature of typical eliciting stimuli. Two of the theories being offered by scientists are:

1. Trypophobia is an evolutionary response to clusters that resemble the presence of parasites or infectious diseases. It reminds sufferers of diseases such as smallpox and measles and conjures up images of diseased people.

“This survival account is based on the notion that humans have been selected, via Darwinian principles, for their ability to notice poisonous organisms,” says Dr Geoff Cole  who co-authored the University of Essex study.

2. Potentially deadly animals such as spiders, snakes and scorpions have similar markings. For sufferers it’s natural to avoid any structures that resemble these lethal animals.

“We found that a range of potentially dangerous animals also possess this spectral characteristic,” said Cole.

“We argue that although sufferers are not conscious of the association, the phobia arises in part because the inducing stimuli share basic visual characteristics with dangerous organisms, characteristics that are low level and easily computed, and therefore facilitate a rapid nonconscious response.”

Treatment

Since there’s very little research on trypophobia, standardised treatment options are not available. Experts do, however, suggest Cognitive Behavioural Therapy (CBT).

CBT focused on abnormal and irrational thought patterns and is often used in treating other types of phobias. The study from the University of Kent suggests that CBT might also be effective in this case, even though it is still very experimental. 

Not for sensitive readers:

More images of what would typically illicit a sense of anxiety in somebody suffering from trypophobia can be found here

Read more: 

What is Social Anxiety Disorder?

Fear or phobia?

Spiders’ size exaggerated in minds of those who fear them

Health24.com | This is why you must take annual leave

If you check your pay slip, you should see a number that indicates the amount of leave days you have – but how often do you actually use that leave? And more importantly, how often should you take leave? 

Experts agree: take your annual leave and avoid burning out mentally and physically.

Think about all the devices you have access to – from your car to smart phone and computer. Have you ever noticed how they have the ability to idle or hibernate?  

“This function saves battery life,” explains clinical psychologist Dr Colinda Linde. “Think about the last time you had too many tabs, files or apps open on your computer, and how the device became sluggish.

“Humans are the same – if our bodies and minds are switched on in ‘work’ mode 24/7, it results in inefficient performance, exhaustion and errors, as well as mood changes such as becoming more sensitive, more reactive, less tolerant.”

The importance of taking annual leave

“It’s important for people to take time off. All the research shows that proper rest periods improve wellness, reduce stress and increase productivity,” says Shelagh Goodwin, general manager of human resources at Media24.

“Under South African labour law, it is mandatory for employers to give paid leave to employees.”

Goodwin says she can rest well over a long weekend, as long it comes with a complete change of scenery and she doesn’t check emails. However, she believes a proper break should be at least two weeks long. 

quote, Dr Linde, Colinda Linde

Patterns of annual leave

Is there a pattern you should follow when it comes to taking annual leave? Goodwin believes it depends on the individual. 

“It is best to take chunks, rather than a day here and a day there, but whether you choose to take two two-week holidays in a year or one four-week holiday is up to you. Personally, I’m a fan of two holidays a year – and I really feel it when I have not had a break in more than six months.”

If it is not possible to take regular leave throughout the year, you do need to make the time to take a break from “work mode”. Dr Linde says regular mini-breaks tend to work better as there is a periodic opportunity to recharge and reset.

Listen to your body. Not taking a proper break can lead to burnout. “Take holidays!” Goodwin urges. “It’s good for you and it’s good for your company.” 

She does caution that employers have the right to determine when your leave may be taken. “If it’s a bad time to take leave from an operational point of view, the employer may refuse to approve it.” 

Make sure you plan you leave around your company’s operational needs so that you can take a break when you really need it. 

Identifying burnout

“Burnout starts with feeling there is too much to do but somehow this is managed by skimping on sleep, social activity, and other ‘luxuries’ that get in the way of work,” says Dr Linde.

Then exhaustion sets in, along with mood and body symptoms, for example irritability, tearfulness, and inexplicable aches and pains, headaches and digestive issues. 

“In the beginning there is still an internal – and sometimes external – pressure to achieve, and willpower can keep you going along with very short breaks,” explains Dr Linde. 

“After a prolonged period, cynicism and lack of meaning sets in, along with more apparent mood, body and behavioural symptoms – you may need caffeine to get started in the morning, you develop sugar cravings and your sleep is impaired.”

Your performance starts to drop and mistakes occur due to fatigue, poor concentration and poor memory.

Planning your annual leave is the first step you can take to avoid burnout. Factors that contribute to burnout include high stress, a heavy workload, a lack of control over job situations, a lack of emotional support and long work hours. Over time, this will lead to physical wear and tear. 

Signs of burnout include: 

• Feeling of lack of control over commitments
• Loss of purpose
• Loss of motivation
• Detachment from relationships
• Feeling tired and lethargic
• Feeling that you’re accomplishing less
• Increased tendency to think negatively

Learning to switch off

Dr Linde says it takes time to shift from work mode into rest/play mode, especially mentally. “If it feels too difficult to shut down from work completely, especially if you run your own business and feel uncomfortable being away for too long you could compromise,” she says. “Be available for phone or mail contact once (or twice) daily, at a set time, and not for too long (30-60 minutes).”

do not disturb, switch off, unwind, resest

                                                                  iStock

At the end of that time, you need to shut off devices and keep away from work triggers until the next check-in time.

“You’ll be surprised at how quickly people will learn that they cannot access you outside the agreed times. They will adapt and learn to bring up the important matters at the time that they can contact you.”

Read more:

20 signs you’re on your way to burnout

Job burnout severely compromises heart

What is stress?