20 claims schemes don’t have to pay for


There are certain things that any scheme is unlikely to foot the bill for. Legally, they don't have to, and in order to remain solvent, most schemes need to draw the line somewhere. Although some items on the list might seem very obvious to you, the things listed below are all things for which people have really tried to claim.

There are 27 chronic conditions (called Prescribed Minimum Benefits (PMBs) ) for which all schemes have to foot the bill, as well as a further 270 medical conditions (listed as Diagnosis and Treatment pairs). Emergency care has to be provided for all members and their dependants, regardless of whether they are in a waiting period or not.

The Medical Schemes Act of 1998 determines what all medical schemes have to fund for their members. After that, your cover depends on the scheme and the option you have chosen.

Also remember that schemes have sub-limits, so even if they do agree to pay for something such as rehab, the benefits won't be endless. Although all schemes have to pay for PMBs, things such as certain dental procedures, have definite sub-limits. This is one time you really do have to take the time to read the details.

If you're on a medical scheme, or considering joining one, you need to read this article. This is by no means a comprehensive list, though.

Don't be caught unawares by your scheme's possible refusal to foot the bill for the following things:

  • Injuries sustained in professional and speed contests, unless they are PMBs
  • Wilfully self-inflicted injuries, unless they are PMBs
  • Treatment for obesity – both medical and surgical
  • While many schemes will pay for diagnostic tests to determine causes of infertility, they won’t pay for IVF (in-vitro fertilisation) or similar procedures
  • Operations, treatments or surgery purely for cosmetic reasons
  • Cost of services rendered by persons not registered as a professional in accordance with the Medical Schemes Act
  • After-hours consultations, unless it is an emergency and/or the condition is a PMB. If it is purely the patient’s choice and not an emergency, the after-hours consultation fee will be paid by the member
  • Sunglasses
  • Experimental treatment or procedures where insufficient proof exists of their effectiveness
  • Unregistered medication
  • Telephonic consultation with your GP, unless your scheme has a specific benefit for this
  • Costs of appointment cancelled by members
  • Examinations needed for visa, employment or insurance purposes
  • Hypnotherapy done by anyone other than a psychiatrist
  • Holiday for recuperative purposes
  • Transport of patients in anything other than ambulance services
  • Contraceptive devices
  • Treatment or operation for impotence, except for PMBs
  • Patent foods, including baby foods
  • Slimming preparations, toiletries and cosmetics

The law clearly prescribes what schemes have to fund for their members. Check the section called ‘Exclusions’ on your scheme’s brochures, just so you know what to expect.


-          Council for Medical Schemes; Medical Schemes Act 1998 (http://www.acts.co.za/medical-schemes-act-1998/);

-          Nasmed Medical Fund)      


(Updated February 2015)

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