Profmed Healthcare for Professionals

A Member must notify the Scheme within thirty (30) days of any change of domicilium and/or banking details. The Scheme shall not be held liable if a Member’s rights are prejudiced or forfeited as a result of neglect to comply with the requirements of this rule.

12. TERMINATION OF MEMBERSHIP

12.1 “Voluntary termination of membership” - a Member may terminate his membership of the Scheme on giving one (1) calendar month’s written notice. All rights to benefits cease on conclusion of the last day of membership. Rule 8.3 will apply with regard to readmission as a Member;

12.2 A Member who resigns from the service of the participating employer shall, on the date of such termination, cease to be a Member and all rights to benefits shall thereupon cease, except for claims in respect of services rendered prior thereto.

12.3 “Death” - membership terminates on his death;

12.4 “Failure to pay amounts due to the Scheme” - if a Member fails to pay amounts due to the Scheme, his membership may, at the discretion of the Board, be suspended or terminated as provided for in these rules;

12.5 “Abuse of privileges, false claims, misrepresentation and non-disclosure of factual information” - the Board will exclude from benefits or terminate the membership of a Member or Dependant on the grounds of failure to pay any debts due to this Scheme; abusing the benefits and privileges of the Scheme by presenting false claims or making a material misrepresentation or non-disclosure of factual information, or committing any fraudulent act. In such event, he may be required by the Board to refund to the Scheme any sum which, but for his abuse of the benefits or privileges of the Scheme, would not have been disbursed on his behalf; and

12.6 A participating employer may terminate his participation with the Scheme on giving three (3) calendar months’ written notice.

13. CONTRIBUTIONS

13.1 The total monthly Contributions payable to the Scheme by or in respect of a Member are as stipulated in Annexure A;

13.2 Contributions shall be due monthly in advance and be payable by not later than the third day of each month. Where Contributions or any other debt owing to the Scheme, have not been paid within thirty (30) days of the due date, they shall be in arrears and the Scheme shall have the right to suspend membership and all benefit payments in respect of claims which arose during the period of default, and to give the Member and/or employer notice that if Contributions are not paid up to date within fourteen (14) days, membership may be cancelled;

13.3 The suspension of a Member from benefits in terms of these rules shall not affect the liability for the payment of Contributions falling due by or in respect of the Member during the period of suspension, in the event of the suspension being lifted;

13.4 In the event that payments are brought up to date, benefits shall be reinstated without any break in continuity subject to the right of the Scheme to levy a reasonable fee to cover any expenses associated with the default and to recover interest calculated from due date of payment at the prime overdraft rate of the Scheme’s bankers over the same period. If such payments are not brought up to date, no benefits shall be due to the Member from the date of default and any such benefit paid may be recovered by the Scheme;

13.5 When an employer undertakes to pay or pays a Member’s Contribution to the Scheme, that employer does so as agent of the Member concerned and not as a collection or other agent of the Scheme. Payment of Member’s Contribution to the Scheme shall take place only upon receipt of such payment by the Scheme, and not when such payment is made to the employer;

13.6 The Contribution to be paid by or in respect of a Member shall always be for a complete calendar month. If a Member dies or ceases to qualify for membership during a calendar month, membership, for the purpose of these rules, shall be deemed to terminate on the last day of that calendar month;

13.7 The Member shall supply to the Scheme all such evidence as may be reasonably required by the Board in order to determine the Income category of a Member when called upon to do so. Failure to comply with the requirements aforesaid will entitle the Scheme to base the Member’s Contribution on the maximum Income category which may be applicable;

13.8 All adjustments in the rates of Contribution arising from an increase or decrease in the number of Dependants are to be implemented on the first day of the following month. In the case of salary adjustments the Contribution is to be adjusted with effect from the month in which the salary adjustment occurs;

14. LIABILITIES OF A MEMBER

14.1 The liability of a Member is limited to the amount of his unpaid Contributions together with any sum disbursed by the Scheme on his behalf or on behalf of his Dependants which has not been repaid to the Scheme;

14.2 In the event of a Member ceasing to be a Member, any amount still owing by such Member is a debt due to the Scheme and recoverable by it;

14.3 The liability of the employer towards the Scheme is limited to any amounts payable in terms of any agreement between the employer and the Scheme.

15. CLAIMS PROCEDURE

15.1 Every claim submitted to the Scheme in respect of the rendering of a relevant health service as contemplated in these rules, must be accompanied by an account or statement as prescribed;

15.2 If an account, statement or claim is correct or where a corrected account, statement or claim is received, as the case may be, the Scheme shall, in addition to the payment contemplated in Section 59(2) of the Act, dispatch to the Member a statement containing at least the following particulars:

15.2.1 the name and the membership number of the Member;
15.2.2 the name of the supplier of service;
15.2.3 the final date of service rendered by the supplier of service on the account or statement which is covered by the payment;
15.2.4 the total amount charged for the service concerned; and
15.2.5 the amount of the benefit awarded for such service; and
15.2.6 the identification of each service by the use of the relevant code as stipulated in Chapter 2 of the regulations of the Act Section 5 clause (f).

15.3 In order to qualify for benefits, any claim must be submitted to the Scheme not later than the last day of the fourth month following the month in which the service was rendered;

15.4 Where a Member has paid an account, he shall, in support of his claim, submit a receipt;

15.5 Accounts for treatment of injuries or expenses recoverable from third parties, must be supported by a statement, setting out particulars of the circumstances in which the injury or accident was sustained;

15.6 Where the Scheme is of the opinion that an account, statement or claim is erroneous or unacceptable for payment, the Scheme must notify the Member and the health care provider accordingly within thirty (30) days after receipt thereof. The Scheme shall state the reasons why such claim is erroneous or unacceptable and afford such Member and provider the opportunity to return such corrected claim to the Scheme within sixty (60) days of the notice.

15.7 The account or statement contemplated in Section 59(1) of the Act must contain the following:-

15.8 No claim will be paid where a practitioner renders an account for services rendered by such practitioner to his Dependants, except for expense items paid to third parties, such as laboratory Costs;

15.9 Authorisation for Hospital events must be obtained prior to the date of that event. In the event of an after-hours emergency, authorisation must be obtained on the first working day after the admission; and

15.10 Treatment protocols and managed care tools can be applied to any event.

i	the surname and initials of the Member
ii	the surname, first name and other initials, if any, of the Patient;
iii	the name of the Scheme;
iv	the membership number of the Member;
v	the practice code number, group practice number and individual provider registration number issued by the registering authorities for providers, if applicable, of the supplier of service and, in the case of a group practice, the name of the practitioner who provided the service;
vi	the relevant ICD10 and any other diagnostic codes as may be required from time to time and such other item code numbers that relate to such relevant health service, and by using the ICD10 coding system in respect of the Chronic Disease List. Accounts submitted without ICD10 codes will be rejected for payment;
vii	the date on which each relevant health service was rendered;
viii	the nature and Cost of each relevant health service rendered, including the supply of medicine to the Member concerned or to a Dependant of that member; and the name, quantity and dosage of and net amount payable by the Member in respect of the medicine;
ix	where a pharmacist supplies medicine according to a Prescription to a Member or to his Dependant, a copy of the original Prescription or a certified copy of such Prescription may be requested;
x	where mention is made in such account or statement of the use of a theatre:- (a) the name and relevant practice number and provider number, contemplated in paragraph (v), of the medical practitioner or dentist who performed the operation; (b) the name or names and the relevant practice number and provider number, contemplated in paragraph (v), of every medical practitioner or dentist who assisted in the performance of the operation; and (c) all procedures carried out together with the relevant item code numbers contemplated in paragraph (v);
xi	in the case of a first account or statement in respect of orthodontic treatment or other advanced dentistry, a treatment plan indicating:- (a) the expected total amount in respect of the treatment; (b) the expected duration of the treatment; and (c) the initial amount payable and the monthly amount payable.