South African medical aids accused of not paying up for benefits

Private practice specialists have complained to the Council for Medical Schemes (CMS) about South Africa’s two largest medical schemes – Discovery Medical Scheme and the Government Employee Medical Schemes (GEMS).

According to a report by  Times Select, the South African Private Practitioners Forum (SAPPF) claims that the two medical schemes are not paying for treatment for which they are legally obligated.

The CMS is now investigating whether Discovery and GEMS have failed to pay for Prescribed Minimum Benefits (PMBs) – with the SAPPF claiming that the two schemes have found ways to circumvent paying the full amount.

Following the investigation announcement, the SAPFF asked its members for examples of claims that had not been paid in full or at all.

It reportedly received more than 21,000 lines of unpaid claims in one week (representing every medical aid), indicating that that non-payment by medical aids was widespread, said SAPFF CEO Chris Archer.

Prescribed Minimum Benefits

Medical aids are required by law to provide all their members with a minimum level of mandatory cover, called Prescribed Minimum Benefits.

Prescribed Minimum Benefits covers treatment for 26 of the most commonly occurring ailments and over 270 other conditions.

Medical aid providers will pay medical bills on behalf of a member. This might include paying for hospitalisation, medical procedures, doctor’s consultations and certain medications.

According to the Council of Medical Schemes, the current Chronic Disease List (CDL) includes:

  • Addison’s disease
  • Asthma
  • Bipolar Mood Disorder
  • Bronchiectasis
  • Cardiac failure
  • Cardiomyopathy
  • Chronic obstructive pulmonary disorder
  • Chronic renal disease
  • Coronary artery disease
  • Crohn’s disease
  • Diabetes insipidus
  • Diabetes mellitus type 2
  • Diabetes mellitus type 1
  • Dysrhythmias
  • Epilepsy
  • Glaucoma
  • Haemophilia
  • Hyperlipidaemia
  • Hypertension
  • Hypothyroidism
  • Multiple sclerosis
  • Parkinson’s disease
  • Rheumatoid arthritis
  • Schizophrenia
  • Systemic lupus erythematosus
  • Ulcerative colitis

Read: These are your Discovery medical aid prices for 2019

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South African medical aids accused of not paying up for benefits