Your rights under medical schemes Prescribed Minimum Benefits

The South African National Consumer Union (Sancu), who has recorded a surge in medical aid complaints, is urging South Africans to know their rights when it comes to the Prescribed Minimum Benefits (PMB) covered by medical schemes.

“Consumers seem to be ill-advised on this extremely important issue,” Sancu vice chairperson Ina Wilken-Jonker told Health24.

She said medical schemes should be obliged toward their members and fully disclose all PMB conditions, which consists of a list of chronic conditions, medical emergencies and a further list of 270 conditions.

PMB is a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected.

This means that there is a list of 270 medical conditions and 25 chronic conditions for which every scheme has to cover the diagnosis, treatment and care, whether someone is on a low-cost hospital plan, or a comprehensive high-cost medical scheme option.

The aim of the PMB is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable, according to the Council for Medical Schemes.

There are two main reasons why PMBs were created:

To ensure that medical scheme beneficiaries have continuous healthcare. This means that even if a member’s benefits for a year have run out, the medical scheme has to pay for the treatment of PMB conditions.
To ensure that healthcare is paid for by the correct parties. Medical scheme members with PMB conditions are entitled to the specified treatments and these have to be covered by their medical scheme, even if the patients were treated at a state hospital.

Wilken-Jonker pointed out that Sancu receives numerous complaints from consumers who are not aware of the benefits derived from PMBs.

“For members to ensure they get the benefits they are entitled to, they have to know what these benefits are.”

Consumers in South Africa are protected by the Consumer Protection Act No 68 of 2008, which came into full force on the 1st April 2011.

“One of the basic rights of consumers are the right to be informed. Nobody can take decisions or make informed choices if they don’t have the necessary information,” said Wilken-Jonker.

“Medical schemes must remember that their members are the people who are responsible for the existence of the scheme and should be treated fairly and with respect.”

Sancu said that consumers should take note that the Council for Medical Schemes recognises that Schemes have a legal obligation to inform members pro-actively of the benefits they are entitled to if the member for example, qualifies as a PMB, without realising they do.

“One of the most basic rights of consumers is the right to be informed. Medical Schemes have no right to deny you access to the 270 conditions”.

The organisation said conditions treated under the PMB should be paid from the risk pool of schemes and not from the savings pool.

“The excuse that the PMB system is too complex to divulge to consumers is unacceptable”, it added.

Health24