Always check your Scheme post!

Some of our Scheme communication is automated and as a result you may not always look at it in detail, as you might think that it is ‘just the statement’. Please always open your Scheme post and check if you need to act or respond. Here are some examples of Scheme correspondence and the consequences of not responding as requested.

Eligibility of a child dependant

In the January issue we explained how long a child can stay on the Scheme. If the Scheme determines that a member has a child that turns 24 in the current year, the member will receive a letter requesting them to prove the financial dependency or other criteria necessary for the dependant to remain on the Scheme. If this member does not reply, the dependant will be removed from the membership at 31 December of that year and cannot be reinstated.

Request for a Certificate of Existence

If our system picks up that you are a pensioner (over 65) and have not claimed for more than 6 months, we will send you a certificate of existence form and ask you to complete it and send it back to us. Do not ignore it, and ensure that you respond in time. Please also be aware that if your pension fund sends you a certificate of existence request, it has consequences for your Scheme membership if you don’t respond. If the pension fund does not hear from you, the fund will stop paying your Scheme contributions. If the Scheme does not receive your contributions, your membership on AMS will be terminated, according to the Scheme Rules. Once terminated, you cannot re-apply for membership.(see Medibrief article). Whether it is the Scheme or the pension fund sending you the request for a certificate of existence – please act on it.

Statements

Always check your statements and ensure that everything on the statement is correct.

  • Check if the claims listed are indeed for services that you have received.
  • Check if the claims have been paid or if further information or action is required.

Claims, and the payment thereof, are the responsibility of the member. Even if you have submitted a claim you still need to ensure that the claim was correctly paid to the provider or, if you had already paid the provider, directly to you. If the Scheme has not paid your claim, we will inform you about this on the statement. You will find a reason code explaining the short or non-payment and/or if further information or action is needed by you so the Scheme can process or pay the claim.

If you don’t respond within 60 days, the claim becomes stale and will not be paid by the Scheme. You are then responsible for the payment to the healthcare provider.

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