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In chronic medication are the medical aid allowed to charge…

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In chronic medication are the...
In chronic medication are the medical aid allowed to charge you +/- 25% of the cost of the Medication
Submitted: 8 years ago.Category: South Africa Law
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Answered in 42 minutes by:
7/1/2010
Lawyer: Mike Otis, Legal Advisor replied 8 years ago
Mike Otis
Mike Otis, Legal Advisor
Category: South Africa Law
Satisfied Customers: 2,161
Experience: B.Comm; LL.B; LL.M.
Verified
Dear Sir / Madam,

Thank you for your question.The answer to your question will be determined by the rules of your particular medical scheme and whether or not the particular chronic condition has been listed in terms of the Prescribed Minimum Benefits in the Medical Schemes Act. A list of the listed conditions can be found at the following link: http://www.medicalschemes.com/consumer/Rights.aspx#4

If the particular chronic condition is not listed, then the amount and conditions of cover are determined by the rules of your particular scheme.

If the particular chronic condition is listed, the scheme is obliged to provide cover for the treatment of the condition. Bear in mind that the scheme might not be obliged to pay for the diagnostic tests to determine whether the condition is present.

While the scheme is obliged to cover the treatment of a condition, it may in its rules require that you receive the required treatment from a so-called "designated service provider", failing which the scheme could decline to pay. The designated service providers, if any, will be listed in the rules of your scheme.

Moreover, if the particular condition is included in the list of Prescribed Minimum Benefits, the fund may also not make you pay for the treatment from your savings account or require you to co-pay for the treatment.

I would therefore advise that you check whether your particular chronic condition is listed in terms of the Prescribed Minimum Benefits and whether your scheme has any conditions, such as designated service providers, relating to the cover.

If you are still not satisfied with your scheme's handling of your condition, you may report the matter to the Council for Medical Schemes. The Council's contact details can be found on its website at http://www.medicalschemes.com/.

I trust you find the above in order.

Yours faithfully,

Edited by SALawGuide on 7/1/2010 at 8:45 AM EST
Mike Otis
Mike Otis, Legal Advisor
Category: South Africa Law
Satisfied Customers: 2,161
Experience: B.Comm; LL.B; LL.M.
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