Coronavirus in SA – Am I covered under my medical aid plan and gap cover policy?
Now that there have been confirmed cases of the COVID-19 virus in South Africa. You may be thinking, do I have enough cover?
What are prescribed minimum benefits?
Prescribed minimum benefits (PMB’s) are the set of defined benefits that medical scheme’s members have access to regardless of their plan option. According to the Medical Schemes Act of 1998, medical schemes must cover the costs related to the diagnosis, treatment and care of all PMB’s.
These PMB conditions must be paid for from the medical scheme’s risk pool and not from your savings account. Please ensure that you use your medical scheme’s designated service providers (DSP’s) to avoid being held liable for the cost of treatment in the form of co-payments.
Coronavirus and PMB treatment
At this time, the diagnosis and management of COVID – 19 infection is not included in the list of PMBs. However, most of the complications associated with the virus would be a PMBs.
A common complication from this virus is pneumonia and the PMB list includes “Bacterial, viral, fungal pneumonia” The diagnosis, treatment and care of this condition should be fully covered by medical schemes, provided you comply with your scheme’s rules. Meaning that by law, medical schemes are not permitted to fund PMB conditions from a member’s medical savings account.
What if my condition associated with the virus is not a PMB and there is an additional payment associated with the diagnosis and treatment?
If you are an existing member enjoying Ambledown gap cover, we will cover your in-hospital shortfalls or additional payments according to your policy and prevailing legislation. Further details on our various plans are available on our website, which you can access by clicking here.
The information relating to PMBs has been provided by the CMS (Council for Medical Schemes) and was correct at the time of publishing. Please click here to view or download the full document with additional information relating to Coronavirus.
As is always the case, our aim is to provide you with the financial security that should you or your family suffer an insured event, you will be covered, allowing you to focus on your or your family member’s recovery.
