Picture: ISTOCK
Picture: ISTOCK

To Navi Smith* of Rivonia, it was an insignificant visit to her doctor about a urinary tract infection; she was prescribed antibiotics, which took care of the infection and its symptoms, and that was that.

But because she failed to disclose that visit in June when she applied for membership to Momentum Health a month later, her membership has been terminated by the medical scheme.

"Getting a UTI is like getting flu," says Smith, who received the termination letter last week.

"Nowhere was 'urinary tract infection' mentioned in the form's disclosure section," she says. "A layperson doesn't always understand medical diagnosis - we just take our meds and get on with life."

Momentum's application form states: "Failure to disclose pre-existing conditions could limit and/or exclude certain benefits or result in termination of your benefits."

Section 6.2.4 states: "In the last 12 months have you had any of the following: Diseases or disorders of the kidneys, bladder or reproductive organs, e.g. abnormal urine tests, kidney stones, nephritis, prostalitis, bladder infections or sexually transmitted disease?"

Smith ticked the "No" box, and that pen stroke has had dire consequences for her: Momentum rejected her doctor's requested authorisation for a CT scan - related to her recent pancreatic cyst diagnosis - and terminated her membership on the grounds of non-disclosure.

The termination, communicated in a terse letter, was effective from its inception date, July 1 2017.

Smith was a member of Momentum Health from 2013 until 2016, when she cancelled due to unaffordability. She applied to rejoin last July.

"Momentum could have rather placed an exclusion on urinary tract infections for a year instead of terminating my membership," says Smith, who has appealed against the decision.

"In any case, the cyst on my pancreas has nothing to do with my UTI."

It is a common misconception that the non-disclosure has to be linked to the claim event for a medical scheme or a life insurer to be able to repudiate a claim and cancel the membership or policy.

The scheme relies on the applicant's answers to assess the risk, so if the questions aren't answered correctly, that's referred to as pre-contractual misrepresentation.

And if the scheme finds out - an investigation is often carried out when a serious medical condition is diagnosed - it has the right to cancel the membership.

Medical schemes can't deny an applicant cover for a particular condition; they may only impose a 12-month waiting period, and for that specific condition only.

They may also not increase the contribution because of any pre-existing condition - contributions may only be based on a member's income or number of dependants, or both.

Waiting periods cannot be applied if the applicant has been a medical scheme member for more than two years, and if the applicant joins a new scheme within 90 days of leaving a previous one.

But this is what all medical scheme applicants must know before they fill in that form or brief their broker: the financial consequences of their membership being terminated far outweigh those of disclosing having been treated for a specific condition in the previous 12 months and then having a 12-month waiting period for that specific condition imposed.

Take your time

Members such as Smith don't have the option of requesting a waiting period for a condition after the scheme has discovered th eir nondisclosure at application stage.

So it's imperative that consumers take their time when filling in the medical history section of a medical scheme application form, and consult their personal records and their doctors to avoid leaving out any medical attention sought in the previous 12 months, however seemingly trivial.

Momentum Health says it is unable to disclose details relating to Smith, her medical condition or the circumstances around the case "in the public domain" to preserve client confidentiality.

"The scheme has, however, communicated with her directly and she has been provided with the process to follow to appeal the scheme's decision, should she wish to do so.

"Alternatively, the member has the right to lodge a formal complaint with the Council for Medical Schemes, which governs the medical schemes industry."

A Council for Medical Schemes' spokesman said in the 2016/17 financial year, the council dealt with 78 complaints from consumers whose medical scheme membership had been terminated due to non-disclosure of a pre-existing condition.

Momentum Health's head of marketing, Damian McHugh, says: "When it comes to failure to disclose a pre-existing condition, we don't test intent. In about 90% of cases it's a genuine oversight as opposed to a deliberate attempt to defraud the scheme, but the fact is that the non-disclosure impacts our ability to assess risk, whether it is related to the condition later claimed for or not.

"That pre-existing condition can go on to become massively expensive, medically, and we have to protect the interests of all our members."

*Not her real name

consumer@knowler.co.za

Please sign in or register to comment.