Your Medical Aid can’t Force you to go to a State Hospital for PMBs

    Going to a state hospital in South Africa can be likened to going to a funeral home and signing your own death certificate.

    Yes, there are one or two fairly well run state hospitals in South Africa, but generally they have the reputation of being understaffed, filthy, overcrowded, under-resourced and to be avoided at all costs.

    But what happens if your ‘reputable’ medical aid refuses to pay for a condition that is required by law to be fully covered? What happens if the rules of that medical aid prescribe that the particular treatment be carried out in one of these scary state hospitals?

    What are These Prescribed Minimum Benefits?

    PMBs are a set of specified benefits which make provision for members of different medical schemes to enjoy certain affordable minimum health services. These PMBs are a feature of the State Hospital for PMBsMedical Scheme’s Act, and medical schemes have to cover the costs related to the diagnosis and treatment of 25 chronic conditions, 270 medical conditions and any emergency medical condition.

    Even if you just have a hospital plan, you are still covered for the treatment of all 270 conditions if treatment takes place in a hospital.

    You CAN’T be Forced to Use a DSP, Usually a State Hospital

    A medical scheme can’t force you to use a designated service provider (DSP). You can’t be forced to go to a state hospital. But if you opt to not use the DSP recommended by your scheme without having a good enough reason, you may well be required to fork up a co-payment for the treatment of a PMB.

    Genesis Medical Scheme Protests

    Recently a certain medical scheme, Genesis, has taken the long journey through the courts about this matter of PMBs and state hospitals. According to the Council for Medical Schemes the application was rejected. The courts hold that there is no chance of success for Genesis and the costs were surrounding the issue were awarded to Genesis.

    Genesis Medical Scheme is not giving up on their wishes to have Prescribed Minimum Benefits done away with, and if they are successful, patients will suffer and their rights will be violated. There is confusion at the moment because a medical scheme can name a state hospital as a DSP for the treatment of certain PMBs if the member has reasonable access to such facilities and doctors. This has to be indicated in the benefit schedule of the medical scheme option.

    The Supreme Court of Appeal’s Fight for PMBs Continues

    Medical schemes can’t just escape their responsibilities surrounding PMBs by stating in their regulations that members must use state medical facilities for PMB treatments. This comes from the Supreme Court of Appeal.

    The case is by no means wrapped up but in the meantime, your medical scheme is obliged to pay in full for the bills that arise from treating a PMB condition. The exception comes about when the medical scheme has contracted with a healthcare provider and has stated in its rules that you must use that provider, but you opt to use a different provider.

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