What Does Medical Aid Cover?
The nearly one hundred medical schemes
that operate in South Africa offer a myriad of plans that each has its own terms and conditions and that offer
Consumers are often confused about what exactly the nature of their cover is and how
to choose the most suitable plan.
The various medical schemes are regulated by the
Council for Medical Schemes, a statutory body that reports to the Minister of Health. This council has developed
certain rules and guidelines that must be followed by all medical schemes.
One of the most important rules that are obligatory for all schemes is the rule that all medical aid plans,
regardless of the price or aim, have to make provision for the cover of those conditions contained in the
Prescribed Minimum Benefits list. It may be helpful to keep the following in mind when evaluating plans that claim
to cover the conditions contained in this list.
- The Prescribed Minimum Benefits list (or PMBs
for short) set down by the Council for Medical
Schemes contains approximately three hundred conditions. These conditions include twenty seven
chronic conditions, a host of medical emergencies and about two hundred and seventy different diseases. The
cover offered by medical schemes must include the cost of all consultations, outpatient and in-hospital
procedures as well as medication.
- No medical aid scheme is allowed to pay for
the treatment of any of the conditions on the PMB with funds from the member’s medical savings account nor may
any scheme refuse to pay for such treatment.
- Members are obliged to provide their schemes
with full and accurate information when they submit claims. They also have the responsibility to adhere to the
terms and conditions stipulated by the scheme. In many cases prior authorization for treatment or
hospitalization is required and if this is not done the scheme has the right to reject the
- Schemes sometimes dispute claims because they
are of the opinion that the treatment received was not for a condition on the PMB. Members have the
responsibility to provide prove that the treatment was for such a condition and they have three years to do so.
In addition, schemes may be obliged to pay for initial unrelated treatment that later turns out to be for a
condition that is actually on the list.
- Members are responsible to make sure that
they are familiar with the regulations regarding the PMB. Many claims are rejected simply because they did not
contain the correct codes. The medical service provider should be able to help make sure that they claim is
correct in all regards.
- Medical schemes do not have to pay more than
the cost of treatment at a state medical facility.
- Members of schemes are obliged to make use of
Designated Service Providers if required to do so by their schemes. This means that it is obligatory to use a
medical service provider that is approved by the scheme. Members that fail to adhere to these conditions will
be held liable for the cost of treatment.
- Members that fail to adhere to the treatment
regime prescribed by a medical service provider may be held liable for the cost of the treatment and they may
even be refused further treatment benefits.
- Members must inform their medical schemes when they are diagnosed
with any of the conditions on the PMB list. In this way the scheme can respond to claims quicker and more
Hope this helped to explain the medical aid cover you can and should expect from
your medical scheme. © Medical Aid Plan
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