MEDICAL FUNDS AND OPTOMETRY

 

Why is my co-payment so high?

 

This is the single most common question my staff and I are confronted with daily in our practice. Many medical aids contribute to this as they advocate “100% optical benefit within a two year cycle”. The reality is far from this…

 

Firstly, most funds cleverly only acknowledge one aspect of your visual system namely refractive error, i.e. short-sightedness, far-sightedness and presbyopia. (poor vision at near over 40) Most commonly refractive changes happen gradually over a period of average two years hence this way of thinking.

 

In many cases a new correction is required way before a two year cycle has elapsed because of:

 

 - Rapid gain in length seen with teenagers

 - Sudden onset of systemic conditions like Hypertension and Diabetes

 - Change in working environment putting strain on eyes, ex. suddenly required to work on a computer most of the day

 - Pathology in eye like Cataracts

 

This list goes on and on but most funds will still not provide full cover in these instances as these are exceptions rather than the rule.

 

Secondly, as a primary eye care practitioner I see patients every day with foreign bodies (mostly metal from grinding), general inflammation and infections. These symptoms require prompt investigation and action. As most funds still adhere to the “optical benefit every two years” way of thinking, they are oblivious to the need for these services and will simply not cover it at all.

 

Thirdly, as far as Optometry services are concerned, most funds disregard any specialized investigation like pupil dilation, threshold perimetry, corneal topography, gonioscopy and cycloplegic refractions to name but a few. These are done to better assess the health of your eyes appose to merely determining a refractive error for spectacles. Many Optometrists regretfully don’t perform these as the funds don’t cover it.

 

Fourthly, when it comes to optical products the funds will cover the bare minimum. Consider this analogy:

 

You pay a premium each month for transportation once every two years from Johannesburg to Cape Town. When you eventually decide to “claim” your ticket, they give you a bicycle, sometimes one without a seat! You are upset and never expected manual labour but they tell you that for a small surcharge they will upgrade it to a motorcycle. A motorcycle just won’t suffice as the weather is dismal.

 

Now for a ridiculous additional amount, more that the cost of the bicycle and motorcycle combined you can get an entry level motorcar, no radio, air-conditioning or power-steering. Ludicrous, you anticipated a motorcar with all the bells and whistles for your monthly premium.

 

Most funds do not cover specialized services, designer frames, premium lenses or lens enhancements, but it surely makes your “journey” easier.

 

If however you prefer not to take the “motorized” option, i.e. no co payment, heck, that is your prerogative and we will include a bell for your bicycle at no cost.

 

ERMELO

PR NO: 0158569

Dros Centre, Ermelo, South Africa

Tel: 017 811 2363

Fax: 017 811 2386

E-mail: info@lzoptometrists.co.za

BETHAL

PR NO: 0413569

Spur Centre, Bethal, South Africa

Tel: 017 647 2820/2805

Fax: 017 647 1391

E-mail: info@lzoptometrists.co.za

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