Medical Scheme Claims and Prescribed Minimum Benefits

When making medical scheme claims in South Africa there are a few very important things to remember. These seven points are perhaps the most pertinent:

1. In South Africa, the law requires medical aid providers to make provision for certain that they will pay the total costs for some three hundred medical conditions. These are called the Prescribed Minimum Benefits (PMBs for short). This list includes all medical emergencies, certain diseases, and many chronic ailments. Any member of any medical plan must be covered in full when suffering from any pathology or disease listed in the South African Medical Schemes Act.

2. Underwriting companies should be reported immediately if they refuse to pay medical scheme claims for treatment related to any condition on the PMB list. They are also not permitted to use funds from any type of medical savings account to pay for such treatment.

3. If the underwriter refuses to pay medical scheme plans for treatment because the illness is not on the PMB list, compensation can still be claimed for up to three years later if the condition was later declared to be on the list after all.

4. When making a medical scheme claim, one should do everything possible to provide their insurers with as much information as is possible when they lodge medical scheme claims. It is also extremely important to follow the rules and to obtain prior authorizations where necessary and required according to the policy’s terms and conditions. If this is not done, the insurer can legally refuse to acknowledge or approve the claim. Most medical aid schemes have an emergency claim phone line. Make use of it to make sure you are going about your claim in the correct way.

5. It is vital to study the PMB list very carefully and to make sure that each and every condition is fully understood. Patients should also make sure that they know exactly what is required from them in order to qualify for full cover and treatment. The importance of being informed simply cannot be overemphasized. Affordable health care requires all parties to fulfill their roles and to follow the rules. This includes the medical schemes sticking to their part of the bargain.

6. In many cases medical schemes or hospital plans require the client to make use of designated service providers (or DSPs for short). If the patient ignores these rules, the service provider is entitled to refuse the claim. In the case of treatment for chronic illness, patients are required to follow the prescribed treatment plan and if they fail to do so, their claims may also be refused legitimately.

7. If you suffer from a chronic condition that requires you to be hospitalized from time to time, it is vitally important to register this condition with the insurer. Care should be taken to specify the condition as one that appears on the PMB list. By registering the condition, your medical scheme claims will be paid without delay whenever you are admitted to the hospital, and it would not even be necessary to lodge medical scheme claims. © Medical Aid Plan