With the cost of proper medical care, and in particular specialist treatments such as oncology being almost unaffordable to the average person, medical aid has become somewhat of a necessity to most South Africans. Although medical schemes offer different packages and benefits to suit the needs of their members, all schemes are required to provide Prescribed Minimum Benefits (PMB). But what are these and to which extent can medical schemes be held responsible to pay for elected procedures?

Jeff is diagnosed with a certain type of cancer which qualifies as a PMB condition. A comprehensive treatment plan is proposed by his oncologist, and his oncologist proceeds to schedule the procedure as Jeff is under the impression that his medical scheme offers “unlimited cover" for PMB conditions.

Jeff then notifies his scheme of the procedure and requests authorisation. On the morning of the procedure, the scheme informs Jeff that they will not be covering the specific procedure, and that they will only provide cover for treatment which is similar to that being provided and available in the public sector. Jeff, who is very sick and has built a relationship of trust with his oncologist, decides to proceed with the procedure proposed by his oncologist and pay for it from his own pocket. Can he after the fact force his medical scheme to reimburse him for the hefty expense incurred by him for his treatment, especially bearing in mind that this was the proposed treatment for a PMB condition?

The first thing of importance is that the Regulations to the Medical Schemes Act contains a schedule of PMB conditions, and schemes are required to pay in full for the diagnosis, treatment and care costs associated with a PMB condition, without any co-payment from the member. This however does not mean that schemes are liable to cover any treatment elected by the patient, nor are they obliged to settle specialist bills unconditionally.

Furthermore, schemes may employ appropriate interventions aimed at improving the efficiency and effectiveness of health care provision, including amongst others the requirements for pre-authorisation.

It is therefore of utmost importance to obtain pre-authorisation from the medical scheme before any treatment or care is commenced. But in the event of a scheme declining authorisation, is this decision final?

Schemes make use of certain treatment protocols and formularies in order to determine their generally employed methods of treatment and care, in accordance with the Regulations to the Act. This is usually equivalent to that offered in the public sector, although this may differ from one scheme to another. It is therefore a common occurance that your scheme will only cover a specific form of treatment, and not necessarily that which is being recommended by your oncologist.

The reality is that the obligation placed on schemes only entails that they have to provide treatment as described above. Unfortunately, this is where their obligation ends. However, this need not be where the road ends for you. The Act does make provision for individual cases where the treatment approved by your scheme might be less beneficial than another form of treatment which is not the standard treatment covered by your scheme. In these cases, the following avenues can be explored:

• Request your doctor or oncologist to submit a written motivation to your scheme to advise as to the reasons why the specific treatment is required.
• If the matter remains unresolved, you may lodge a formal complaint with the Registrar of the Council of Medical Schemes.
• If you are still dissatisfied with the Registrar’s ruling, an appeal may be lodged with the Council’s Appeal Committee.
• Any party that is aggrieved with the decision of the Appeals Committee may appeal to the Appeal Board.

Remember that at all times you are entitled to request to see your scheme’s treatment protocols, rules and exclusions, and this should be provided to you in an understandable language and manner.

It is very important to bear in mind that schemes are not obliged to pay in situations where pre-authorisation was not obtained. In a recent ruling by the Medical Schemes Appeals Committee, it was confirmed that a scheme cannot be forced to foot the bill where a member has proceeded with treatment without first obtaining pre-authorisation. This will obviously not be the case where a procedure was done in an emergency situation.

Does Jeff now have to bear the cost of his treatment due to failure to obtain pre-authorisation?

The requirement of pre-authorisation should be seen in the context of the purpose thereof, and this should not prevent schemes from at least providing treatment in line with that generally provided in the public sector. Jeff’s conduct does not defer from the fact that he indeed has a PMB condition and his scheme is obliged to treat such. The argument has been advanced that a member cannot be denied any reimbursement, however Jeff’s failure to obtain pre-authorisation limits his right to be treated without any co-payment, and in all probability a co-payment would be imposed.

Remember that should you find yourself in a position similar to that of Jeff, it is advisable to postpone the treatment if possible (your medical practitioner’s advice is essential here) and follow the procedure above in order to obtain authorisation from your scheme. If pre-authorisation is declined, it is advisable to seek legal assistance from an experienced legal practitioner in order to guide you through the procedure and assist you with the policy schedules and regulations.