PMB versus normal benefits.
The same treatment can be funded very differently depending on which benefit it is assessed against. Here is the distinction.
Day-to-day benefits are what most people picture when they think about a medical scheme: a pool of cover for consultations, medication and routine care that runs down as it is used, and stops when it is finished.
Prescribed Minimum Benefits work differently. They are an obligation on the scheme rather than a pool of money, covering a defined set of conditions regardless of which option the member holds and regardless of whether their day-to-day benefits are exhausted.
Why claims land in the wrong place
A scheme assesses what it receives. If a claim arrives looking like an ordinary consultation, it is likely to be paid from day-to-day benefits, and once those run out the member is short. The treatment did not change. The category it was assessed under did.
Conditions still apply
PMB cover is not unconditional. Schemes apply the Regulations alongside their own registered rules, including arrangements about designated service providers and formularies. Establishing what applies to a specific claim means reading the scheme's rules, not assuming a general position.
This article is general information about healthcare administration in South Africa. It is not legal, clinical or financial advice, and it does not describe the rules of any particular medical scheme. Always check the position that applies to a specific claim.