Medical Aid Chronic Condition Rip-Offs
Medical aids do their best to avoid paying medical claims. That’s the way the system is set up.
One of the most common medical aid rip-offs is to refuse to pay claims relating to conditions listed as Prescribed Minimum Benefits (PMBs) in the Medical Schemes Act.
There are about 300 of these. About 270 of these, if left untreated, would adversely affect your life. All medical emergencies are also included in the PMBS. There are also 26 common chronic conditions included in the PMBs and it is for these that medical aids are particularly fond of refusing to pay for.
Actually all medical schemes are obliged to cover the costs of diagnosis, treatment and care of all PMBs, with no co-payments from the patient – and expenses may not be paid from your medical savings account.
That doesn’t stop a lot of medical aids from refusing to pay for PMBs, especially common chronic ones, such as asthma – or they pay illegally from the patient’s medical savings account.
Here is the comprehensive list of the 26 chronic conditions covered in the PMB regulations:
- Addison’s Disease
- Bi-polar Mood Disorder
- Cardiac Failure
- Cardiomyopathy Disease
- Chronic Renal Disease
- Coronary Artery Disease
- Crohn’s Disease
- Chronic Obstructive Pulmonary Disorder
- Diabetes Insipidus
- Diabetes Mellitus Type 1 & 2
- HIV / AIDS
- Multiple Sclerosis
- Parkinson’s Disease
- Rheumatoid Arthritis
- Systemic Lupus Erythematosis
- Ulcerative Colitis
So how do you make sure that your medical aid scheme will cover your PMB claims?
• You have to KNOW YOUR RIGHTS in terms of the Medical Schemes Act
• You have to PROVE YOUR CONDITION is a chronic PMB. Your doctor or specialist will help you do this
• You must find out if your particular medical scheme requires to go about treatment in a PARTICULAR WAY in order for you to be covered (e.g. go to particular doctors or health facilities, use particular medicine, etc.)
• You must CLAIM IN A PARTICULAR WAY required by your medical aid scheme (e.g. using the correct codes is important. Your doctor or specialist will help with this.)
DON’T JUST CHECK INTO HOSPITAL – REGISTER YOUR CONDITION WITH YOUR MEDICAL AID FIRST
Medical aids are supposed to pay automatically for hospital admissions relating to PMBS but if you have one of the 26 chronic conditions they might expect you to register your condition with them before giving you the benefits.
Or sometimes there are additional benefits you could get for your chronic condition but you can only get them if you register your condition.
For example, recently LA Health medical scheme, which is administered by Discovery Health, rejected claims that a member with multiple sclerosis, a chronic PMB condition, submitted for the physiotherapy he needed.
So check with your medical aid before doing anything
And should you have a dispute with your medical aid about PMBs for chronic conditions, do not hesitate to lodge a complaint with the Council for Medical Schemes. You can find all the contact details here .