The Council for Medical Schemes is probing SA’s two biggest medical schemes — Discovery Health Medical Scheme (DHMS) and the Government Employees Medical Scheme (GEMS) — following allegations that they are not paying their members claims in full. GEMS’s administrator Metropolitan Health is also under the spotlight due to a surge in consumers’ complaints last year. DHMS is SA’s biggest open medical scheme, and wields considerable market influence by virtue of its size and its consistent innovation. As an open scheme, it is available to anyone who can afford its fees and had 2.75-million beneficiaries in 2017, according to the Council’s 2017/2018 annual report. GEMS is a restricted scheme, limited to civil servants and their dependants. It is important not only because of its size — it had 1.8-million beneficiaries last year — but also because the government has proposed that all the schemes that currently cater for state employees be merged with GEMS as it implements National Health ...

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