Angela Drescher Case Summary

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SUBMISSION SUMMARIES
Angela Drescher
The key issues raised by Angela Drescher in her oral submission are centred on PMBs, the lack of knowledge that medical aid scheme holders have, scenarios based on real life issues on people whose benefits were not approved to cover their illnesses and that the CMS is not fulfilling its role to protect and represent the interests of the medical scheme member. According to her submission, a PMB is a minimum cover that one receives in a government hospital, according to state hospital protocols, two-hundred and seventy illnesses are covered by the PMB. These benefits are listed or prescribed in the Medical Schemes Act, additionally, anyone on a medical aid cover has to have access to such benefits. Angela
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Her complaint was based on the failure of the psychiatrist in informing her whether or not her son’s illness is covered by PMB. Angela laid a complaint to the Department of Health on whose responsibility it was to inform the patient that the condition diagnosed is a PMB. No further answer was sent to her from the 15th of March to date. A follow up is required on this matter.
Angela does not believe that the PMB code of conduct is widely used by most of the medical schemes and that it is a live document that is being addressed continuously.
In response to Angela’s question, Craig Burton Durham said schemes have a legal obligation to inform members proactively of their benefits and where the scheme rejects a PMB claim, it has to give reasons.
Her recommendations include the communication of PMB information to be in clear, plain language, be readily available and be updated and communicated whenever changes are made. Registration of PMB coverage must be accessible and available to providers and members, including the location and contact details of designated service

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