7 Things You Need to Know When Making Your Medical Scheme Claims

Here are some tips to follow before making medical scheme claims.

  1. The South African Medical Schemes Act states that medical schemes must cover 300 medical conditions which it lists. These are what are referred to as PMBs or Prescribed Minimum Benefits. Included in these 300 conditions are 270 diseases, 27 chronic illnesses and all medical emergencies. If you suffer from any of the above, your medical aid scheme should pay the cost of treatment. Remember this when making medical scheme claims.
  2. Let’s say you make medical scheme claims. And then your medical scheme refuses to fund what you know is among those in the PMB list. Well then, your medical scheme must explain why. They also don’t have the right to pay for your treatment using money from your medical savings account. This is not legal.
  3. Let’s say your medical aid provider declared your case a non-PMB following your medical scheme claims. Then you should still entitled to claim compensation up to 3 years after the event. That is, if the condition qualifies as PMB.
  4. On the other hand, if your medical aid doesn’t have enough information about your condition at Understanding Medical Scheme Claimsthe time of your medical schemes claim, or if you did not obtain the necessary authorisations, your scheme is entitled to reject your claim.
  5. Since you can only catered for by your medical aid scheme after proving you’ve indeed suffered from a PMB condition, it is to your advantage to learn the PMB regulations. You should also know what you must do so that you can get treatment. For instance for your claim to succeed, the codes on it must be correct.
  6. Your medical aid scheme may not pay for it treatments over and above those in government health facilities. And in order to qualify to be treated for a PMB, you have to seek treatment in DSPs (designated service providers). If you are treated by a doctor or hospital not listed as a DSP, you will be expected by the medical scheme to foot some of the treatment cost yourself. The same goes for cases where you fail to follow the prescribed course of treatment, especially in the case of chronic illnesses.
  7. If you suffer from a chronic illness which will lead to your hospitalisation from time to time, your should register your condition with your scheme. This will allow them to pay your hospital admission fees automatically whenever you are admitted. Of course the condition has to be among the 27 in the PMB list.

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All info was correct at time of publishing