| Answer from scheme |
 |
Possible response |
|
Supporting provision |
| Your medical scheme does not cover this condition |
This condition is a PMB and should, by law, be covered.
Or: Although this condition is not a PMB, the information provided by the scheme led me to believe that this is covered? Could you please provide me with a copy of the specific scheme rule which excludes this condition from being paid for by my scheme? |
Regulation 8 to the Medical Schemes Act
Scheme rules, benefit brochures, etc |
| The medication / treatment you wanted, is not on the list used by the scheme / option you are on |
Yes, but I am entitled to appropriate care. This specific medication / treatment is the most appropriate for my condition. Exceptions from general lists are allowed, without me having to make a co-payment. Who do I contact to get this authorised?
If you get to that person, describe if you have had side-effects or if the treatment / medicine did not work or worked badly. Also indicate if you did try other medications/treatments which were on the list, but which did not work. In these cases the law says that you are entitled to an appropriate alternative which is not on the list, without co-paying. In some cases your doctor may have to write a motivation to be submitted to the scheme.
If you want access to the medication or treatment because it is better, a newer technology or because it would have lesser side-effects, etc – but you would have been ok on the medication / treatment on the list, you may say:
I am exercising my choice to obtain a different treatment / medication for my PMB condition. I will co-pay the difference in what you would have paid for, and what this medication / treatment costs.
|
Regulation 15H & 15I to the Medical Schemes Act
Regulation 8(5) |
| We looked at the motivation and have declined to pay for the treatment. |
Could you please provide me with reasons in writing as to why the motivation has been declined? Please also list the data sources you have used, and the names of the professionals who have evaluated to motivation. You can fax it to … or you can email it to … post it to … .
Please also provide me with the contact details of your Dispute Committee and the timeframes within which I have to lodge an appeal.
(This information you have to pass on to C4C, should you want us to help us with your case)
|
Administrative justice Regulation 15D to the Medical Schemes Act
Administrative justice |
| The scheme rules exclude paying for this treatment |
Please provide me with a copy of the specific rule which prohibits you form paying for this treatment. Also provide me with the rationale underpinning the specific interpretation of the rule which leads to this conclusion. |
Scheme rules have to be within the boundaries of the Medical Schemes Act |
