Resumen

NGOBENI, L M; MOROPENG, M L  y  THSEHLA, E. Prescribed Minimum Benefits complaints: A 5-year retrospective review. SAMJ, S. Afr. med. j. [online]. 2024, vol.114, n.6b, pp.4-8. ISSN 2078-5135.  https://doi.org/10.7196/SAMJ.2024.v114i6b.1007.

BACKGROUND. Medical schemes are required by the Medical Schemes Act No. 131 of 1998 to pay costs associated with the diagnosis, treatment, or care of a specified set of benefits known as Prescribed Minimum Benefits (PMBs). Medical scheme beneficiaries have the right to lodge complaints with the Council for Medical Schemes (CMS) when their claims are denied. OBJECTIVE. To determine and describe the pattern of PMB complaints received by the CMS from January 2014 to December 2018. METHODS. This was a cross-sectional study that utilised the CMS's clinical complaints database. Data for PMBs, complainants, medical scheme types, and reasons for payment denial were extracted. The CMS's lists of chronic conditions, PMBs, and registered schemes were used to confirm PMBs and to categorise schemes as either restricted (i.e. to members of specific organisations only) or open (i.e. to all South Africans). Extracted and coded data were analysed using SAS v.9.4 software. RESULTS. A total of 2 141 complaints were retrieved and 1 124 PMB complaints were included in the study. The median of PMB complaints per year was 225. Most of the complaints (43.6%, n=490/1 124) were lodged by members themselves. Non-communicable diseases constituted most of the PMB conditions that members complained about. Medicine and surgery were the services that were mostly denied full payment by medical schemes. Open medical schemes accounted for many (73.8%, n=830/1 124) of the complaints. CONCLUSION. Chronic conditions are the main diseases that medical scheme members complain about. Member education and clear definitions of PMBs should be prioritised by medical schemes and the CMS.

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