How Do You Claim?

It is best to first phone your Medical Aid Scheme before your procedure or test to ensure that you adhere to their guidelines. Medical Schemes have a right to stipulate who their Designated Service Providers are.

A Designated Service Provider (DSP) is a healthcare provider (doctor, pharmacist, hospital, etc) that is a medical scheme’s first choice when its members need a diagnosis, treatment, or care for a PMB condition.

If you choose not to use the DSP selected by your scheme, you may have to pay a portion of the bill as a co-payment. This could either be a percentage co-payment or the difference between the DSP’s tariff and that charged by the provider you went to.

Medical schemes have to ensure that it is easy for beneficiaries to get to the DSPs. If there is no DSP within a reasonable distance of your work or home, then you can visit any provider, and the scheme is obliged to pay.

Schemes also have to ensure that the DSPs of their choice can deliver the services needed and without members having to wait unreasonably long. Where a DSP is unable to accommodate or treat a member, the medical scheme remains liable for all the costs of treating the PMB condition at a non-DSP.

The State’s healthcare facilities can be, but are not necessarily, DSPs. Before they can be listed as such, schemes have to make sure that their beneficiaries can get to the facilities and that the required treatment, medication, and care are available and accessible.

Treatment at DSPs can be handled in two ways:

1. Schemes can insist that you go to a DSP as soon as your condition is diagnosed, in which case they cover the costs from the start. Treatment at a DSP will be covered in full by the medical scheme under the PMB conditions when delivered according to scheme protocols and formularies.
2. If your benefit option allows for this, you can be treated by the doctor of your choice. If you choose to use a provider of your choice for these services, the scheme may apply a co-payment, as registered in their rules

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 be left 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.

Therefore, if you have problems with your medical scheme and PMB’s contact the Council for Medical Schemes for assistance. Their phone numbers are 012 431 0500 or 0861 123 267. Further details regarding PMB may also be found on their website – http://www.medicalschemes.com.

Contact IFAASA for guidance or an attorney may also be consulted to assist you with enforcing your rights against your medical aid scheme.