Some medical aid plans, especially entry-level ones, cover “PMB-only” for cancer benefits. What does this mean?
A “PMB-only” benefit means that the medical aid will provide the minimum level of care that is required by law. Very often that “minimum” level of care is more than adequate to treat the condition. Where there is a dispute as to what the minimum level of care should be, the patient has to receive at least the same level of care that would be offered in a State facility.
Note! Medical schemes can compel you to use State facilities for the treatment of some PMBs, including cancer. These restrictions are usually stated in the benefit brochure for your plan. If you are not sure what your plan requires, you can find your medical aid plan and benefits here, and confirm with your scheme or broker.
Which cancers fall under the PMB rules?
Most treatable cancers are considered PMBs, and therefore a private medical aid patient is covered for out-of-hospital treatment for most cancers, even if on a hospital-only plan.
What is a “treatable cancer”?
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 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“)
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.