Picture: ISTOCK
Picture: ISTOCK

Your medical scheme is obliged to pay for certain prescribed minimum benefits (PMBs) that enable you to get the right treatment and protection from big medical bills.

PMBs cover medical emergencies, life- threatening conditions and certain common chronic conditions.

But the system isn't perfect. The Council for Medical Schemes reported in its latest annual report that it is investigating the country's two largest medical schemes, Discovery Health Medical Scheme and the Government Employees Medical Scheme, for failure to pay PMB claims in full as required under the Medical Schemes Act.

R54,000

The out-of-pocket costs incurred by a
medical scheme member in one year
to supplement his child’s PMB expenses

The South African Private Practitioners Forum (SAPPF), which represents several specialist doctor groups, said while there are specific problems with the PMB claims at these schemes, its members found 21,000 examples in one week from all schemes of PMB claims that were either not paid, short paid or paid from members' savings accounts in contravention of the Medical Schemes Act.

SAPPF consultant Johann Serfontein says even if half of the claims were submitted incorrectly or were justifiably disallowed by the scheme's rules, it is still a major issue.

In response, schemes say they do comply with PMB legislation, but that interpretation of PMBs is difficult and they try to contain costs to ensure cover is not abused and spent only on those who need it.

Schemes contract with designated service providers (DSPs) that you must use to enjoy full cover for PMBs. Schemes have an obligation to inform you of your DSPs.

Schemes are, however, entitled to draw up treatment protocols, including formularies (or lists of cost-effective medicines) for PMB conditions as long as the standards of care are not lower than those in public health-care facilities.

Dr Adri Kok, president of the Faculty of Consulting Physicians of SA, says your doctor should help you identify your condition as a PMB, but that you need to check if your scheme has a DSP and the treatment it will fund. It is your broker's responsibility to inform you of your scheme option's benefits, says Serfontein.

Without help, it can be a long and costly battle, as the father of a child who was diagnosed with lupus at the age of eight has discovered. Despite lupus being a PMB, his daughter's illness and claim rejections depleted his savings, cost him R54,000 in one year and brought him to the brink of a breakdown, the Discovery Health Medical Scheme member said.

Lupus is an autoimmune disease that attacks joints and vital organs such as the kidneys, lungs, brain and heart.

Discovery's PMB benefits for lupus include four consultations with specialists and a limited number of blood tests a year. The scheme only covers the cost in full of specialists on its specialist list.

The paediatrician and clinical haematologist in Durban who treated the child were not on the scheme's list, but there was no such specialist on its list in that city, the member said.

Medical Schemes Act regulations oblige schemes to pay in full for alternative providers if there is no provider within a reasonable distance, or if the provider is not able to treat you within a reasonable timeframe.

Dr Nozipho Sangweni, the principal officer of Discovery Health Medical Scheme, couldn't comment on the case as the member was unwilling to supply his membership number. She says if there is indeed no appropriate specialist in Durban on the scheme's list it will fund the specialist used in full.

Regular blood tests and consultations with other specialists to treat damage to the child's kidneys and eyes quickly exhausted the Discovery member's PMB benefits.

The child's doctor motivated for additional benefits provided for in the PMB regulations under the Medical Schemes Act for conditions that require alternative treatment or care beyond the standard benefits. The additional benefits were denied due to a lack of clinical information.

Sangweni says the scheme's treatment protocols and baskets of care are designed to cover about 80% of cases where the relevant disease is stable. If members need more than the basket of care, a "rigorous" clinical appeals process is available for members and their treating doctors to motivate for additional benefits.

Discovery Health told the member that the diagnostic codes the doctor put on his daughter's PMB claims were incorrect.

The PMB code of conduct obliges schemes to identify a PMB claim on diagnostic code, where possible. However, to confirm a PMB claim, schemes may need further information about the severity of the condition, other conditions you have, your age and your pathology or radiology results or how you have responded to treatment.

Sangweni says the administrator has specialist teams that can assist the treating doctor to resolve the issues around the codes that need to be used.

Your scheme may ask you to register on a chronic-disease programme to access benefits and your practitioner can be paid a fee for completing the relevant forms. Kok advises checking that this fee and any other PMB claims are not paid from your medical savings account as you may need your savings for other medical cover.

If you are not satisfied with your scheme's response, you are entitled to ask the Council for Medical Schemes' clinical unit to assist. If you don't get an immediate response you may have to risk being treated and then lodging a complaint.

Kok says members need to challenge scheme decisions with the same tenacity that Denise Ganas, the widow of hijack victim Nathan Ganas, had when she took on Momentum over the rejection of her claim.