GEMS in trouble?

Should GEMS Patients be Treated With Circumspection?


Unlike other medical schemes, it has never made use of the underwriting provisions in the Medical Schemes Act designed to protect schemes from “anti-selection”, a phenomenon in which people only join up when they get sick or anticipate big health bills.

The Act allows schemes to impose a late joiner penalty on people who have never previously belonged to medical schemes, a three-month waiting period in which the new member pays contributions but cannot claim, as well as a 12 month-exclusion on pre-existing medical conditions.

GEMS principal officer Guni Goolab is quoted in the report as saying that beneficiaries who entered and left GEMS in the same year had triple the hospital admission rate of other members.

There were 8,591 such beneficiaries last year, who had a hospital admission rate of 72%: they contributed R30m yet claimed R149m from the scheme, he said.

Discovery Health, one of SA’s biggest medical scheme administrators, said in the report it too was concerned about an increase in hospital admissions, particularly in regions where new hospitals had opened.

Noach said in the report that Discovery Health and its biggest client Discovery Health Medical Scheme had recently met doctors and private hospitals to make them aware of their concerns.

Neither GEMS nor the Council of Medical Schemes are willing or able to dispel the rumours that it is in financial difficulty , writes Bronwyn Nortje in Business Day.

Nortje writes that along with very real concerns around the financial health of the scheme and the effect of higher contribution increases and benefit changes on its members, GEMS’ persistently low solvency issue also raises questions about the conduct of the council.

“This raises the question why other large schemes, such as Discovery, are forced to adhere to the requirements of the Medical Schemes Act, while Gems is given endless extensions.

“Despite at the time having a solvency ratio of twice what Gems currently has, the registrar for medical schemes rejected Discovery’s plan to restore its solvency levels and told the scheme to shape up or ship out.



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