• Are you covered?

    tablet pic

    Belonging to a medical aid in South Africa can be costly with schemes increasing their rates annually and these increase percentages are sometimes higher than inflation. Due to these annual increases, members often opt to terminate their cover as they simply can’t afford the monthly contributions.  Those who can’t compromise belonging to a medical scheme will often turn to cheaper schemes with lower monthly premiums or remain with the same scheme and opt for a more cost effective plan.  Whatever the member decide, they remain under the impression that they will be covered by the scheme they belong to.  Medical cover varies from scheme to scheme and annually schemes will make changes to their benefits.  Some schemes have an annual limit on normal day-to-day medical expenses which include general practitioner visits, over the counter medication as well as limits on maternity cover, optometry, dental, specialist visits, scans, clinical psychology and many out of hospital expenses.  Although most medical schemes put a limit on out of hospital expenses and exclude coverage on certain conditions, their hospital cover is usually unlimited.  The risk of changing to a low cost medical scheme or cost effective plan could have more limits and exclusions than what you bargained for.  Does your medical scheme cover you for those unexpected health incidents that can be life threatening.

    When my mother-in-law had a severe heart attack on 16 April 2017 and was rushed to Life Kingsbury Hospital and later transferred to Rondebosch Medical Centre’s Cardiology Unit, we were confident that her condition would be fully covered by the medical scheme she belonged to. After the cardiologist and cardiothoracic surgeon performed an angiogram on her, the results determined that she needed urgent triple artery bypass grafting – in layman’s terms “triple bypass” surgery.  The medical scheme then refused to give authorisation for the surgery even after the cardiologist and the cardiothoracic surgeon submitted four letters motivating for authorisation, indicating the urgency of the surgery as her condition was deemed serious and life threatening. Her condition was listed under the 270 prescribed minimum benefit (PMB) conditions under the Medical Schemes Act 31 of 1998.  According to Regulation 8 of the Medical Schemes Act, all medical schemes are obliged to cover PMB conditions in full, irrespective of the medical scheme rate and limitations.  The medical scheme that my mother-in-law belonged to at the time of her being admitted to hospital indicated to us that they are PMB exempted.  This information was never disclosed in the annual member benefit booklet.  When we contacted the administrator of the scheme we were told that the fund manager was in procession of the scheme’s rules and that these rules are not made available to members.  The scheme argued that their hospital cover was limited and that members with prescribed minimum benefit (PMB) conditions should be transferred to a State facility for treatment of these conditions.  As a family we decided to lodge a complaint with the Council of Medical Schemes (CMS) in terms of Section 47(1) of the Medical Schemes Act 31 of 1998.  The CMS dealt with this matter swiftly, however they ruled in favour of the medical scheme indicating that they were indeed exempted from covering PMB conditions as it is a low cost medical scheme.  Our hands were basically tied and as a family we were given the option by the CMS to appeal the ruling.  We decided not to appeal as it could take up to 90 days for the CMS to rule on the appeal.  After contacting the cardiology units at both Groote Schuur and Tygerberg Hospital – both facilities could not accept my mother-in-law as a patient due to the usual capacity constraints.  State facilities also have a different scoring system to that of private hospitals; a patient’s age is taken into consideration as well as other medical circumstances before decisions are made to perform major operations.  As my mother-in-law is over 70 years old, admitting her to a State facility could not guarantee that the “triple bypass” surgery would be performed there.  During this time her health deteriorated and her treating cardiologist refused to discharge her as her condition was serious and sending her home was a health risk.  The longer she stayed in a private hospital, the cost escalated and we were afraid that her hospital limit would be exhausted. After spending 10 days in ICU at Rondebosch Medical Centre (with a daily rate of ±R10 000) a bed finally became available at Groote Schuur’s Cardiology Intensive Care Unit (CICU).  She was transferred and after a panel of doctors and professors met, they decided that the best option would be to insert a stent into the main artery to prevent her from getting another major heart attack.  With two arteries still being blocked, future grafting surgery are possible but for now she is on the road to recovery. Subsequently to this very stressful ordeal, my father-in-law (who was the main member) forced terminated their membership from the medical scheme and applied to another medical scheme.  We anticipated that the new medical scheme would impose a three month waiting period; however they were accepted as members of the new scheme as of 1 May 2017 with immediate cover on all PMB related conditions as well as unlimited cover of their chronic medication.  Luckily a three month waiting period was only imposed on all other medical expenses not related to PMB.


    So what should you be aware of when belonging to a medical scheme?

    • Know your medical scheme’s policy and if you don’t understand it make an appointment with their customer service representative, your broker or general practitioner to explain it to you.
    • Read the fine print in your benefit booklet and make sure that your medical scheme is not exempted from covering PMB conditions.
    • Treatment costs of PMB conditions are very expensive and for certain conditions these amounts can run into millions of Rands. Due to these high costs, medical schemes often don’t disclose this information to their members – especially if they are obliged by law to cover these conditions in full. Know your rights – as a member you have the right to know. If they are not exempted – your medical scheme should make the list of all 270 PMB conditions and 26 chronic conditions available to you. You can also find the list on the Council of Medical Schemes website – www.medicalschemes.com
    • Make sure that you understand the conditions under which your scheme will cover PMB conditions. Meaning they will cover the PMB condition in full if you go to their specified network of service providers – this would include specialists, hospitals, pharmacies and pathologists. Failure of not staying within this network of service providers will result in them not covering the PMB condition in full and you being liable for a co-payment.
    • Make sure that your condition is in fact PMB related and that your doctor uses the correct ICD code when submitting the claim to the medical scheme. Incorrect codes can result in your scheme not covering the condition.
    • Not all cancers fall under PMB. Cancers that originated in your solid organs qualify as a PMB. However this is very important to note – only if the cancer can be treated and has not spread beyond the organ in which it originated will it be covered under PMB. Secondary cancers (examples include bone cancer and secondary leukaemia) and non-treatable cancers does not fall under the PMB list.
    • Find out if your medical scheme has an oncology benefit and what the annual limit is. This benefit can be used should you be diagnosed with a secondary cancer. Also note this benefit might not fully cover surgery and treatment.
    • HIV and Aids is listed as a PMB condition and treatment should be covered in full.
    • If you have been diagnosed with any of the 270 PMB conditions listed and your scheme has not been PMB exempted but refuse to pay for the treatment; you have the right to lodge a complaint with the Council of Medical Schemes.


    To conclude, life is unpredictable and you never know when you might be admitted to hospital for a serious medical condition – so make sure that you have the right cover when you really need it. It is also good to have extra health insurance cover, like gap cover, critical illness cover and hospital cover – this extra cover does not replace your current medical scheme cover but can be used in conjunction with it. Stay healthy and stay informed!

    Leave a Reply