Although PMBs have been an integral part of the medical aid schemes landscape in South Africa for over a decade, members suffering the ill effects of chronic conditions are missing out on crucial benefits they are entitled to by law.
Much of the confusion arises from the fact that certain illnesses are not specifically stipulated in the list of chronic conditions compiled by the Minister of Health. The unpleasant autoimmune disorder, Graves disease, a trigger of hyperthyroidism, is a case in point.
What are PMBs?
Prescribed Minimum Benefits are defined illnesses or ailments – including medical emergencies – that are deemed to pose a threat to the medical aid members quality of life if left untreated.
According to the Medical Schemes Act, all medical aids in South Africa have a mandatory obligation to pick up the tab in full for the diagnosis, treatment and care of patients suffering a listed complaint.
When deciding whether a condition is a PMB, health practitioners may only look at the symptoms and not the cause.
A good example is that of cosmetic surgery, a voluntary surgery that is not a PMB and is seldom, if ever, covered by medical aids in South Africa. Should the patient, however, contract an infection as a result of the surgery, the medical aid scheme will have to pay for the diagnosis and treatment of the infection.
Independent financial consultants that provide medical aid comparisons of leading medical aids in South Africa generally provide a list of chronic conditions. If in doubt, explore your options online at www.medicalaid-quotes.co.za/chronic-cover.
What is Graves Disease?
Graves disease is a hereditary disease that activates the production of an excessive amount of thyroid hormones by the thyroid gland, a condition known as hyperthyroidism. Although listed chronic conditions include hypothyroidism an underactive thyroid neither Graves disease nor hyperthyroidism are specifically mentioned, although they are both deemed PMBs that have to be covered in full by your medical aid.
A medley of unpleasant mental, emotional and physiological symptoms, including the unsightly protrusion of one or both the eyes, accompany the non curable disease that affects over two percent of all women and rising numbers of black men and women in South Africa.
Treatments are both costly and erratic, with many patients undergoing one or more treatments before the disease is brought under control. The first line of attack is expensive anti-thyroid drugs that have to be administered for between six months and two years to be effective, incurring significant costs to uninformed medical aid members.
Radioiodine treatment or RAI is the next option and can cost anything between R5000 and R12 000, while the last alternative is the surgical removal of part or all of the thyroid gland, a major surgery that comes at an enormous cost.
Ensure your PMB Claims are not Rejected
Notwithstanding the fact Graves disease enjoys the protection of PMBs, albeit in a poorly, or non-existent, defined form, scores of loyal, fully paid up members of medical aid schemes in South Africa are seriously out of pocket.
Reports emanating from recent research indicate that only 15 percent of scheme members understand PMBs. Members are either paying for the treatment themselves, have had the claims paid out of their savings account or have resorted to the public health care sector for treatment!
The rule of thumb is: dont rely on your medical aid scheme to do the right thing, research your options online via medical aid comparison websites that provide live medical aid quotes together with relevant information on PMBs and the medical aid schemes that provide the best possible cover.