20 Claims Medical Aids will not pay for!

It is a truly fortunate patient whose medical scheme covers just about anything. Thank your lucky stars if you come across one.

There are certain things that any scheme is unlikely to foot the bill for. Legally, they don’t have to, and in order to remain solvent, most schemes need to draw the line somewhere. Although some things on the list seem obvious, these are all things for which people have tried to claim!

There are 26 chronic conditions (called Prescribed Minimum Benefits (PMBs)) for which all schemes have to foot the bill, but there are many other things left up to the discretion of the scheme.

Remember, too, that schemes have sub-limits, so even if they do agree to pay for something like substance abuse rehabilitation, the benefits won’t be endless. Also, all schemes have different regulations, so just check up what the small print says for yours. This is one time you really do have to take the half an hour and read the details.

Don’t be caught unawares by the medical aid’s possible refusal to foot the bill for the following things:

  1. Injuries sustained in professional and speed contests where medical assistance is available.
  2. Treatment for obesity – both medical and surgical
  3. Any costs incurred with regard to infertility treatment or contraceptive devices
  4. Operations, treatments or procedures for cosmetic purposes
  5. Any treatment at a service provider not registered with the Medical and Dental Council, the SA Nursing Council or the Homeopathic and  Associated Health Professions
  6. After hours consultation fees, unless it is an emergency
  7. Sunglasses
  8. Experimental treatment or procedures
  9. Unregistered medication (without NAPPI code)
  10. A telephone consultation with your GP
  11. Costs of appointment cancelled by members
  12. Examinations needed for insurance, visa or employment purposes
  13. The costs incurred if you donate an organ
  14. Hypnotherapy (some schemes will pay if it is done by a psychiatrist)
  15. Levies charged by service providers
  16. Procedures in hospitals if the fund’s case managers deem it unnecessary
  17. Treatment needed that is related to any breach of the law
  18. Treatment related to a self-inflicted injury or disease
  19. Travelling expenses for medical purposes, unless in an ambulance
  20. Holidays for recuperative purposes

Furthermore, do not the assumption that the medical aid will pay for everything else.

But if, as a member, you wake up in the middle of the night with acute appendicitis, or you break your leg falling down the stairs at work, you do have the assurance that you will be covered.



About Medinol:
Medinol is one of the few purpose-built practice management application to meet the unique needs of independent private healthcare providers. Today Medinol helps over 130 providers throughout South Africa run more efficient and profitable practices, while delivering outstanding patient care. As an on-premise software, Medinol and the data it manages, is fully under your control. This enhances your independence and privacy: what happens in your rooms, stays in your rooms. Medinol helps manage your patient information, generates your billings, submits your claims, control your outstandings, and get your accounts paid quickly. Medinol has been in operation since 1984 demonstrating its proven efficacy. Medinol’s mission is to help independent practices succeed in an ever-changing healthcare environment. More information can be found at http://medinol.co.za.


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Fudley Bezuidenhout Pr.Eng.
Founder and CEO
Email: info@medinol.co.za
Ph: 021-906-2296
Cell: 082-688-9610


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