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:
- Injuries sustained in professional and speed contests where medical assistance is available.
- Treatment for obesity – both medical and surgical
- Any costs incurred with regard to infertility treatment or contraceptive devices
- Operations, treatments or procedures for cosmetic purposes
- 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
- After hours consultation fees, unless it is an emergency
- Experimental treatment or procedures
- Unregistered medication (without NAPPI code)
- A telephone consultation with your GP
- Costs of appointment cancelled by members
- Examinations needed for insurance, visa or employment purposes
- The costs incurred if you donate an organ
- Hypnotherapy (some schemes will pay if it is done by a psychiatrist)
- Levies charged by service providers
- Procedures in hospitals if the fund’s case managers deem it unnecessary
- Treatment needed that is related to any breach of the law
- Treatment related to a self-inflicted injury or disease
- Travelling expenses for medical purposes, unless in an ambulance
- 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.