Understanding Medical Scheme Coverage: What You Need to Know

It’s a rare and fortunate patient whose medical scheme covers nearly all healthcare expenses. If you find yourself in this situation, consider yourself lucky!

What Medical Schemes Typically Exclude

While many benefits are included, there are certain expenses that most medical schemes are unlikely to cover. Legally, they are not obligated to pay for everything, and to maintain financial stability, most schemes must set limits on their coverage. Although some exclusions may seem obvious, many individuals have attempted to claim these costs.

The Prescribed Minimum Benefits (PMBs)

All medical schemes are required to cover 26 chronic conditions known as Prescribed Minimum Benefits (PMBs). However, beyond these mandated conditions, many other treatments and services are left to the discretion of the individual scheme.

Important Considerations

Keep in mind that schemes often have sub-limits. For instance, while they may agree to cover substance abuse rehabilitation, the benefits may not be unlimited. Additionally, each scheme operates under different regulations, so it’s crucial to familiarize yourself with the specifics of your plan. Take the time to read the fine print—investing just half an hour can save you from unexpected surprises later on!

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

Important Assumptions About Medical Aid Coverage

It’s essential not to assume that your medical aid will cover every expense beyond the basics.However, if you find yourself in a medical emergency—like waking up in the middle of the night with acute appendicitis or breaking your leg after a fall at work—you can rest assured that you will have coverage for these critical situations.

Best Medical Billing Software in South Africa