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councilmedicalschemesBusinessLive reports that the Council for Medical Schemes is probing SA’s two biggest medical schemes following allegations that they are not paying their members claims in full.  

Under the spotlight are Discovery Health Medical Scheme (DHMS) and the Government Employees Medical Scheme (Gems), as well as Gems’ administrator Metropolitan Health due to a surge in consumers’ complaints last year.  The inspections into the schemes are in terms of section 44 of the Medical Schemes Act, Stephen Mmatli, head of compliance and investigations at CMS, said on Wednesday.  An inspection into DHMS and its administrator Discovery Health was initiated following allegations that members’ claims for Prescribed Minimum Benefits (PMB’s) were not being paid in full, in contravention of the Medical Schemes Act.  PMB’s are the basic basket of healthcare benefits that all schemes must provide to all their members.  DHMS said it had fully co-operated with the inspector during the process, which was not yet complete.  The inspection into GEMS was triggered by allegations that it was not paying PMB claims in full, and a sharp increase in member complaints during the course of 2017.  GEMS principal officer Guni Goolab declined to comment on the inspection as it had yet to be finalised.  Mmatli said investigations were also underway into two smaller schemes, Resolution Health and Bonitas Medical Fund, over certain other issues.

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