06 July 2011

Which conditions are covered?

The Regulations to the Medical Schemes Act in Annexure A provide a long list of conditions identified as Prescribed Minimum Benefits.


The Regulations to the Medical Schemes Act in Annexure A provide a long list of conditions identified as Prescribed Minimum Benefits. The list is in the form of Diagnosis and Treatment Pairs (DTPs).

A DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 270 PMB conditions should be treated. The treatment and care of PMB conditions should be based on healthcare that has proven to work best, taking affordability into consideration. Should there be a disagreement about the treatment of a specific case, the standards (also called practice and protocols) in force in the public sector will be applied.

The treatment and care of some of the conditions included in the DTP may include chronic medicine, e.g. HIV-infection and menopausal management. In these cases, the public sector protocols will also apply to the chronic medication.

Here is an example of a DTP as it appears in the Medical Schemes Act:

Code Diagnosis Treatment
109A Vertebral dislocations/fractures, open or closed with injury to spinal cord Repair/reconstruction; medical management; inpatient rehabilitation up to two months

The 270 conditions that qualify for PMB cover are diagnosis-specific and include a range of ailments that can be divided into 15 broad categories:

PMB category Example
Brain and nervous system Stroke
Eye Glaucoma
Ear, nose and throat Cancer of oral cavity, pharynx, nose, ear and larynx
Respiratory system Pneumonia
Heart and vasculature (blood vessels) Heart attacks
Gastro-intestinal system Appendicitis
Liver, pancreas and spleen Gallstones with cholecystisis
Musculoskeletal system (muscles and bones); Trauma NOS Fracture of the hip
Skin and breast Treatable breast cancer
Endocrine, metabolic and nutritional Disorders of the parathyroid gland
Urinary and male gential system End-stage kidney disease
Female reproductve system Cancer of the cervix, ovaries and uterus
Pregnancy and childbirth Antenatal and obstetric care requiring hospitalisation, including delivery
Haematological, infectious and miscellanous systemic conditions HIV/Aids and TB
Mental illness Schizophrenia
Chronic conditions Asthma, diabetes, epilepsy, Asthma, diabetes, epilepsy, hypothyroidism, schizophrenia, glaucoma, hypertension

No exclusions
Medical schemes often have a list of conditions – such as cosmetic surgery – for which they will not pay, or circumstances – such as travel costs and examinations for insurance purposes – under which a member has no cover. These are called exclusions. Exclusions, however, do not apply to PMBs. If you contract septicaemia after cosmetic surgery, for example, your scheme has to provide healthcare cover for the septicaemia part because septicaemia is a PMB. (Cosmetic surgery remains exclusion.) PMBs are concerned about the diagnosis; it doesn’t matter how you got the condition.

(Information from the Council for Medical Schemes)


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