Medical schemes turn people away with “your benefits are finished” far too often, when the law actually says they may not do that for a Prescribed Minimum Benefit. So I built a small tool to help you check where you stand before you accept a no.
You can type in your condition, or browse the common conditions by category (heart, cancer, kidney, mental health and so on), and it tells you whether it is one of the 26 Chronic Disease List conditions, one of the roughly 270 other PMB conditions, or a medical emergency, and then exactly what your scheme must pay for by law.
A few things it covers that catch people out.
A PMB must be paid from the scheme’s risk pool, not from your medical savings and not from your day to day benefits.
A PMB cannot run out, so a scheme may not refuse it because you have reached an annual or plan limit.
You get the full benefit with no co-payment when you use the scheme’s designated provider and its medicine list, and in a real emergency you may go to any hospital.
There is also a short “is your scheme short-changing you?” checklist that flags the specific rule a scheme may be breaking, and the steps to complain, first to the scheme in writing, then to the Council for Medical Schemes, which is free and can order the scheme to pay.
One honest note. The tool cannot list every single PMB condition, there are about 270, so if your condition is not found it says so clearly and points you to the official CMS list and your scheme, it never tells you that you have no claim.
Try it here: Medical Aid PMB & Chronic Cover Checker (SA)
This is general information, not legal or medical advice. If you have ever fought a scheme over a PMB, I would like to hear how it went, and whether anything here is unclear or worth adding.