Emergencies and PMBs: when your medical scheme must pay in full

Many members assume a scheme pays only up to its own rates and rules. For one important group of treatments the law says otherwise. These are Prescribed Minimum Benefits (PMBs), and emergencies fall inside them.

What counts as a PMB

PMBs are a set of benefits every registered medical scheme must cover, whatever option you are on. They include about 270 defined conditions, any emergency medical condition, and a list of common chronic conditions. The scheme must pay for the diagnosis, treatment and care of these conditions in full, without a co-payment or deductible, when the rules for using its Designated Service Providers (DSPs) are met.

The emergency rule

An emergency is a sudden and unexpected condition that needs immediate treatment, where delay would put your life in serious jeopardy or cause serious damage to a body function or organ. If you are treated for an emergency at a provider that is not the scheme’s DSP, because it was an emergency or no DSP was reasonably available, the scheme should still pay in full. That includes the related pathology, radiology and specialist accounts.

What to check on your statement

• Was the claim paid at 100% of what the provider charged, or only at a lower scheme rate?
• Is there a co-payment or a “shortfall” on an emergency or PMB item?
• Was the amount paid from your Medical Savings Account instead of the scheme’s own funds?
• Did the scheme give a reason code? Write it down, because it is the thing to challenge.

What to do next

1. Ask the scheme, in writing, to reprocess the claim as an emergency or PMB and to say which rule it relied on.
2. Ask your doctor or the hospital for a short note confirming the clinical emergency and the diagnosis code.
3. If the scheme will not change its decision, use its formal dispute process, then complain to the Council for Medical Schemes. See our guide on how to do that.

The official explanation of PMBs is on the Council for Medical Schemes website.