Medical Scheme Contract and Shariah Concern Review Checklist

A South African medical scheme is a regulated risk-sharing arrangement with rules, contributions, benefits and exclusions. A Shariah-conscious review should examine the actual contract and healthcare need rather than decide from the product label alone.

Educational information only: This is not medical, financial, legal or Shariah advice. Obtain personalised healthcare guidance and qualified regulatory and scholarly review.

1. Identify the scheme and option

Record the registered medical scheme, administrator, option, member number and effective date. Distinguish the scheme from brokers and managed-care providers.

2. Verify registration

Check the scheme and relevant broker information through the Council for Medical Schemes. Save the official result and date.

3. Record household healthcare needs

List members, chronic conditions, regular medicines, preferred providers and expected events privately. Avoid sharing unnecessary medical detail.

4. Review contributions

Capture employer and member amounts, income bands, dependants and annual changes. Reconcile payroll deductions to scheme statements.

5. Understand risk benefits

Record hospital, chronic, day-to-day and emergency benefits. Separate insured or pooled benefits from medical savings-account balances.

6. Review the medical savings account

Establish who owns the balance, how it is funded, what happens on exit and whether any return or deficit arises.

7. Check prescribed minimum benefits

Use current official information to understand applicable rules, networks and authorisation requirements. Confirm case-specific cover with the scheme.

8. Document waiting periods and exclusions

Record general and condition-specific waiting periods, late-joiner penalties and exclusions. Do not rely on a broker summary alone.

9. Review provider networks

Capture designated service providers, referral requirements, formularies and out-of-network consequences relevant to the household.

10. Understand claims and co-payments

Record authorisation, tariff, co-payment, shortfall and appeal rules. Keep example calculations for expected procedures.

11. Separate gap cover and insurance

Document any additional policy, insurer, premium and exclusions separately. Do not treat it as part of the medical scheme.

12. Record the Shariah question

Provide the scheme rules, risk-pooling structure, savings account and household need to a qualified scholar. Avoid turning a general opinion into product-specific approval.

13. Review alternatives fairly

Compare affordability, access, self-funding capacity and healthcare risk without inventing equivalent protection where none exists.

14. Plan complaints and emergencies

Record scheme, administrator and Council for Medical Schemes contacts. Keep authorisation and escalation routes accessible to adult family members.

15. Maintain the review register

• Scheme, option and registration

• Household needs and providers

• Contributions, benefits and exclusions

• Savings account and additional cover

• Shariah review and annual decision

Useful official starting points include the Council for Medical Schemes, its prescribed-minimum-benefit information and the Medical Schemes Act.

The completed file should show what the family needs, what the regulated option covers, what it excludes and which facts the Shariah review considered.