The What If's of PMBs
What if my condition is on the Chronic Disease List?
The Chronic Disease List (CDL) specifies medication and treatment for 25 chronic conditions that are covered in the section of the PMBs.
Defined treatment protocols or algorithms have been developed for CDL conditions. The algorithms, which have been published in the Government Gazette, can be regarded as benchmarks or minimum standards for treatment and have been developed in consultation with service providers and other entities. This means that the treatment your medical aid scheme provides for must not be inferior to the algorithms. If you have one of the 25 listed chronic diseases, your medical scheme has to cover medication as well as doctors’ consultations and tests related to the diagnosis and management of your condition. A patient has three years to claim from their medical scheme for monies incorrectly taken from medical savings account, day to day expense plans or rejected should the diagnosis eventually fall within the ambit of one of the PMB diseases. The scheme may make use of protocols, formularies (lists of specified medicines) and Designated Service Providers (DSPs) to manage this benefit but may not bypass the algorithm provided for in the Medical Schemes Act.
What if my medical scheme refuses to cover treatment?
Medical schemes often reject payment for the diagnosis and treatment of PMB’s and unless you, as the member, challenge their decisions the claims will remain unpaid. However, you don’t have to champion this cause by yourself. The Council for Medical Schemes (CMS) was established to supervise medical schemes in South Africa. In this role, their first priority is to protect the rights of consumers (members) and to ensure that you are treated fairly. If you have problems with your medical scheme and PMBs contact the Council for Medical Schemes for assistance. Further details regarding PMBs may also be found at www.medicalschemes.com. An attorney may also be consulted to assist you with enforcing your rights against your medical aid scheme. Empowering your self with knowledge that will ensure the best quality of life possible is part of managing the emotional burden of a disease!