PMBs and cancer
Some medical aid plans provide cancer treatment for “PMB cases only”. Most cancers are considered PMBs, and therefore you are funded for out-of-hospital treatment for cancer under the PMB legislation, even if you are on a hospital-only plan.
However, there are some limitations. For starters, only treatable cancers are considered PMBs. According to the government notes:
In general, solid organ malignant tumours (excluding lymphomas) will be regarded as treatable where:
i) they involve only the organ of origin, and have not spread to adjacent organs
ii) there is no evidence of distant metastatic spread
iii) they have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example brain stem compression caused by a cerebral tumour) or another vital organ
iv) or, if points i. to iii. do not apply, there is a well demonstrated five year survival rate of greater than 10% for the given therapy for the condition concerned
If your scheme covers only PMB cancer and your cancer does not meet the above criteria, it will probably not be covered.
Chemotherapy and bone marrow transplantation
In addition, there are specific criteria for tumor chemotherapy with bone marrow transplantation:
Tumour chemotherapy with or without bone marrow transplantation and other indications for bone marrow transplantation. These are included in the prescribed minimum benefits package only where Annexure A explicitly mentions such interventions. Management may include a first full course of chemotherapy (including, if indicated, induction, consolidation and myeloablative components). Where specified in terms of Annexure A, this may be followed by bone marrow transplantation/rescue, according to tumour type and prevailing practice. The following conditions would also apply to the bone marrow transplantation component of the prescribed minimum benefits:
i) the patient should be under 60 years of age
ii) allogeneic bone marrow transplantation should only be considered where there is an HLA matched family donor
iii) the patient should not have relapsed after a previous full course of chemotherapy
iv) (points i. and ii. shall also apply to bone marrow transplantation for non-malignant diseases)
(Note: “Annexure A” is this list“)
The prescribed minimum benefits include solid organ transplants (liver, kidney and heart) only where these are provided by Public hospitals in accordance with Public sector protocols and subject to public sector waiting lists.
Changing plans due to a cancer diagnosis
You can change plans within the same scheme and not have new waiting conditions applied. Some schemes allow you to upgrade immediately to a higher plan if you are diagnosed with a life-changing condition. Other schemes only allow the change on January 1.