What Does Medical Aid Cover?

South African medical schemes are required by law to confer Prescribed Minimum Benefits (PMBs) to their members, no matter what the circumstances. There are about 300 medical conditions that are defined in the South African Medical Schemes Act.

These include 270 sicknesses, 27 chronic illnesses and medical emergencies of all kinds. What is more, all medical aid schemes are obliged to cover the costs of all consultations, procedures, hospitalizations and medicines relating to these conditions.

These regulations were created in order to protect the members of these schemes and to assure peace of mind to them and their families. It is up to the medical aid company involved to explain why it will not pay for anything relating to the listed conditions. What is more, it is illegal for a medical scheme to pay for any of these expenses with money from the medical savings account of its members.

Different Health Conditions

It could be, however, that you are unable to furnish sufficient information about your condition when you put in a medical scheme claim or that you did not get the required authorization for consultations, treatment, hospitalizations, etc. in relation to your condition. In this case the medical aid may legally reject your claim

In the event that a medical scheme declares a condition as not qualifying for the PMBs, there is still a possibility that the medical scheme might be obliged to cover these costs. You have three years in which to claim these amounts, should the condition later be found to qualify for the prescribed minimum benefits.

In general, the onus is on you, the patient, to prove that you have a PMB condition. Without this proof the medical scheme will not cover your claim. For this reason you should familiarise yourself with the PMB regulations. Your medical scheme company will be able to supply you with all the information. One of the important ways to ensure a successful claim is to make sure that the codes are correct. Your medical provider will supply these.

Exceptions to Medical Aid Cover

With regard to the level of payment, your medical scheme is not obliged to pay for treatments etc. that are more expensive than those provided in government health facilities. In addition, in order to qualify for payment in terms of PMB regulations, you have to get treatment from Designated Service Providers (DSPs). Should you be treated in hospitals or clinics not listed as DSPs, or if you go to a non-DSP doctor, then it is likely that your medical aid will ask you to pay the difference out of your own pocket. The same applies to cases where you do not follow the course of treatment prescribed by the medical scheme, especially where a chronic illness is concerned.

It is of paramount importance to register your condition with your medical aid if you have a chronic illness that requires you to go to hospital from time to time. The medical aid will then pay your hospital admission fees automatically when you are admitted, which is very convenient. Naturally the chronic condition must be among the 27 in the PMBS list.