According to the law, there are certain medical conditions and emergencies that every medical aid must cover you for. These are called Prescribed Minimum Benefits (PMBs), and they were written into the Medical Schemes Act to ensure that members of medical schemes would not run out of benefits for certain conditions. These PMBs include about 270 medical conditions and 25 chronic conditions (you can view the official list from the Council for Medical Schemes here: https://bit.ly/37DnUYY).
In addition to these, each medical aid plan will have its own specific list of conditions that are covered. Always check your benefits with your medical aid provider and make sure you understand the rules. For example, most medical aids have a list of medications they cover. The scheme may say in its rules that it will cover you if your doctor prescribes a medicine on this list. If you decide that you would prefer a different brand of medication and this medication is not on the medical aid’s list of covered medicines, according to the scheme’s rules, they can refuse to pay for it. The same goes for other treatments.
The Act sets out what the schemes must follow when it comes to paying claims. For example, if you have any one of the chronic diseases listed, your scheme must pay for the diagnosis, treatment and care related to the condition. This means that your scheme must also pay for your consultations and tests related to your condition. They are not allowed to make you pay for any portion or co-payment on a prescribed minimum benefit (PMB) – unless you use a service provider (doctor) that is not on the medical aid’s list of services providers. If you do this, then the medical aid may charge you the difference between what their doctor charges and what your chosen service provider charges.
If you feel that your medical aid has acted unfairly in terms of the Act, you can lodge a complaint against them at the Registrar’s Office of the Council for Medical Schemes.
Tips:
- There are certain conditions every medical aid has to cover by law.
- If you disagree with a decision made by your medical aid, and are unsatisfied after speaking to them, you can lodge a complaint with the Council for Medical Schemes.
Source: Medical Schemes Act 131 OF 1998
If you have a query, follow us on our Facebook page and ask your question during our next Live Q&A (the first Thursday of every month).
* This is only basic advice and cannot be relied on solely. The information is correct at the time of publishing.