Know your scheme's PMBs


A medical aid plan is often considered to be one of the most complex products you’ll ever purchase. To curb waste and maximise benefits, it’s therefore important to carefully read the terms and conditions of the option you choose. Maximising your benefits will ensure that they last longer and possibly cover more beneficiaries in the process. So says Dr James Arens, Clinical Operations Executive at Pro Sano Medical Scheme.

Inevitably there will be limits and exclusions – and the more basic (and cheaper) the plan, the more limits and exclusions there will be. Only the legislated Prescribed Minimum Benefits (PMBs) will be paid in their entirety. The PMBs comprise a set of designated conditions and treatments that all medical schemes are legally obliged to fund in full.

Dr Arens suggests some strategies you can employ to familiarise yourself with the benefits in order to manage them better and make them last longer:

  • A starting point is for someone from the scheme (or your broker) to explain them thoroughly, as well as guide you on how to read your statement. Monitor your statements closely in order to keep track of actual doctor visits and procedures - and report any irregularities to the scheme, which is not always in a position to determine exactly what transpired in the consultation room or hospital. This is why the member needs to play an active role in preventing potential abuse of benefits.
  • For hospitalisation or expensive procedures it is safer (and mandatory by most schemes) for members to call in for formal authorisation for the admission or procedure. The authorisation department validates the procedure codes against the diagnostic codes to ensure that members only pay for what national and international standards, and guidelines deem appropriate. I can’t underscore enough how important it is for members to call in personally to get first-hand information on any disclaimers and exclusions, so you know in advance whether you will be liable for an excess.
  • If for some reason you are not comfortable with the doctor’s diagnosis or treatment strategy, you might want a second opinion - particularly in the case of serious conditions that may require additional money from you. The scheme can facilitate this. Further to a written request, schemes may allocate additional benefits in the form of what is known as ‘ex-gratia’ funding. Enquire if your scheme has such a written policy so that you know when you may apply for such assistance.
  • Before embarking on a new battery of medical tests, always inform your doctor where and when you had your most recent ones done. You are entitled to all your clinical records from previous doctors.
  • You should always be aware that the benefits allocated are being paid for with your own money and should therefore be managed as such. Abusing benefits ultimately results in higher premiums – not only for you, but for all the other members of the scheme.

By assuming a more active role in your interaction with service providers and the medical scheme, you will maximise your benefits honestly,” concludes Dr Arens.

 Issued on behalf of Pro Sano by The Riverbed Agency

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