A medical scheme consultant can help decipher your bill and explain why some costs are not paid by the medical scheme. Picture: 123RF/YETIYEAW
A medical scheme consultant can help decipher your bill and explain why some costs are not paid by the medical scheme. Picture: 123RF/YETIYEAW

Q: My dad contracted Covid-19 and was treated for it in a frail-care centre until his death. He was a member of a medical scheme but now our family has been presented with some hefty medical bills we were not consulted about. We were under the impression that the virus was a prescribed minimum benefit (PMB) and that the expenses would be covered.

Is it possible that he could have been given services such as an electrocardiogram and medicines that are not covered? If so, who is responsible for that cost? How do we know the medical scheme has paid what it should have? How can we know if they were right not to pay for the medicines? We have no idea what they were for. We trusted the centre and the medical team they contracted to treat him. 

Letter by e-mail

A: Jill Larkan, head of health-care consulting at GTC, responds:

Covid-19 is indeed one of the PMBs. The Council of Medical Schemes’s (CMS’s) latest PMB guidelines on Covid-19 say the benefit includes screening, testing, medical management including ventilation, rehabilitation and palliative care — a multifaceted, integrated approach to improving the quality of life of someone whose condition is terminal. And it can be given in a frail-care centre.

The World Health Organisation Global Outbreak Benefit, which the country’s largest medical scheme Discovery Health Medical Scheme has adopted, includes benefits for: 

  • A risk assessment.
  • A screening consultation.
  • The Covid-19 screening PCR tests.
  • Diagnostic and follow-up consultations for Covid-19-positive members.
  • Diagnostic and follow-up tests for Covid-19-positive members.
  • X-rays and scans.
  • Supportive medicines.
  • Accommodation in accredited isolation facilities.
  • A home monitoring device for at-risk Covid-19-positive members.

The CMS recommends that the primary health-care provider should submit an initial treatment plan to the medical scheme for pre-authorisation and provide weekly updates to allow the scheme to make informed continued funding decisions. 

The key questions you need answers to are: were the appropriate authorisations sought beforehand? Did a family member co-sign any documentation guaranteeing cover for expenses in excess of what the medical aid paid? Who cosigned for cover being provided to the deceased via the frail-care centre?

In view of the CMS’s recent Covid-19 guidelines, you could possibly ask the medical scheme to review the payment of all the claims pertaining to your dad’s treatment to see if this changes the way they have paid for any items.

You could also ask to speak to a consultant from the medical scheme to verify all/any outstanding costs with a view to understanding why they are not being met by the medical scheme.


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