My medical aid won’t pay all my medical bills

December 17, 2021

Think your medical aid pays all your medical bills? Think again.

In one example, Mr Jones, when contacted by debt collectors about a medical bill that was outstanding, got the fright of his life.

The bill went unpaid for years. Yet Jones was under the impression that the medical aid had already paid.

The bill was for an anaesthetist and so was someone that he hadn’t dealt with directly.

Upon asking for details from the debt collector, he discovered the truth about the debt.

Medical bills and the first rumblings of trouble

Medical bills

He did remember being in contact with someone about the debt. At the time, he had told them what he thought to be true, that the medical aid had settled the debt in full.

After all, the medical aid had authorised the surgery and made no mention of rejection. Jones considered the matter closed.

So why only now?

Mr Jones wanted to know why it had taken so long to contact him. Jones was also concerned that the medical aid had not received the bill. The medical aid had in fact, received the bill but only paid the portion related to standard medical aid tariffs.

What is the responsibility of the medical aid scheme?

The contract with the medical aid provider sets out the rules and regulations for payment.

However, the responsibility is on the member of the medical aid to ensure that claims arrive on time. It is also the responsibility of the member to determine what portion remains unpaid if any.

If payment is made according to the scheme’s rules, there is little recourse against them. Also, the period that has passed since the initial claim would make a new claim invalid.

What is your legal responsibility?

Legally speaking, it is your duty to pay the shortfall. This case is a little different in that nobody informed Mr Jones of the shortfall.

As so much time had elapsed since the initial invoice and the steps taken to recover the money, there is a strong case for non-payment of the debt under law.

This is not always the case, though, and you cannot rely on the passage of time as a defence against debt.

Non-payment of the debt is allowed when three years has elapsed since the last attempt to collect the debt. There are strict rules about non-payment, however.

The debtor must not have acknowledged the debt or made any payment arrangement regarding the debt in the three years.

The debtor will have to prove that they were not aware of the debt and the creditor will need to show what reasonable measures they took to recover the debt.

If the creditor applied for a judgement within the allotted time, the debtor could not claim the three-year clause.

At the end of the day, Mr Jones, in this case, may be lucky and let off, as not all accounts departments are as remiss as this one.

Leaving medical bills partially unpaid can have serious consequences.

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All info was correct at time of publishing