⚖ The Advocate
Health Rights

Your Medical Aid Can Exclude Your Chronic Condition — It Is in the Contract

A medical aid scheme denies a member's chronic medication or treatment claim, claiming the condition is excluded from their plan.

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The Situation

What They Said

“Your plan does not cover chronic medication. The exclusion is in your contract. We suggest you upgrade to a more comprehensive plan if you want that covered.”
A medical aid member — or their parent, spouse, or employer — receives a rejection letter from the medical scheme denying claims for chronic medication or ongoing treatment for a condition such as diabetes, hypertension, asthma, epilepsy, or depression. The scheme claims the treatment is excluded from the member's plan and that the contract permits this exclusion.
The Fallacy

Contract as Override — Suppressing a Statutory Right Through Policy Language

The medical scheme presents the plan contract as the final word on what is and is not covered. But the Medical Schemes Act creates a category of benefits — Prescribed Minimum Benefits, or PMBs — that all registered medical schemes must cover regardless of plan level or contractual exclusions. The list of conditions covered as PMBs includes 25 chronic conditions on the Chronic Disease List (CDL) and 270 diagnoses. If a member's condition appears on these lists, the scheme cannot lawfully exclude it — no matter what the contract says. The contract exclusion is void to the extent it purports to override the PMB obligation.

What the Law Says

Your Legal Foundation

Medical Schemes Act 131 of 1998
Section 29(1) — Prescribed minimum benefits
“A medical scheme must make provision for the payment of benefits in respect of the diagnosis, treatment and care costs of prescribed minimum benefit conditions, as defined in regulations. These benefits must be provided to all members regardless of the benefit option they are enrolled on.”
Every registered medical scheme in South Africa — regardless of plan level — must cover Prescribed Minimum Benefits. A member enrolled on any plan, including the cheapest option, must have their PMB conditions covered. A scheme that denies PMB claims on the basis of plan-level exclusions is acting unlawfully.
Regulations to the Medical Schemes Act (Government Gazette 20556 of 23 August 1999, Regulation 8)
Regulation 8 and Annexure A — Chronic Disease List (CDL) conditions
“The Chronic Disease List comprises 25 medical conditions for which prescribed minimum benefit treatment must be made available by all registered medical schemes. These include: Addison's disease, Asthma, Bipolar mood disorder, Bronchiectasis, Cardiac failure, Cardiomyopathy, Chronic obstructive pulmonary disorders, Chronic renal disease, Coronary artery disease, Crohn's disease, Diabetes insipidus, Diabetes mellitus types 1 and 2, Dysrhythmias, Epilepsy, Glaucoma, Haemophilia, Hyperlipidaemia, Hypertension, Hypothyroidism, Multiple sclerosis, Parkinson's disease, Rheumatoid arthritis, Schizophrenia, Systemic lupus erythematosus, and Ulcerative colitis.”
If a member's chronic condition appears on this list, the medical scheme must cover the diagnosis and treatment — at cost of the prescribed minimum benefits treatment — regardless of the member's plan. Hypertension, diabetes, asthma, epilepsy, and depression-related diagnoses that fall within bipolar or schizophrenia categories are explicitly covered.
Constitution of the Republic of South Africa, 1996
Section 27(1)(a) — Access to health care services
“Everyone has the right to have access to health care services, including reproductive health care.”
The constitutional right to access health care is the foundation on which PMB obligations are built. A medical scheme that is registered to provide health cover and then denies cover for a condition that the law mandates must be covered is undermining a constitutional right. The Council for Medical Schemes exists to enforce PMB compliance.
What Scripture Says

God's Word on This

3 John 1:2 (NET)
“Dear friend, I pray that all may go well with you and that you may be in good health, just as it is well with your soul.”
Scripture values the health of the whole person — spiritual and physical. Systems of care that deny treatment to people who need it most are opposed to the vision of human flourishing that both faith and good governance are meant to support.
Luke 10:34 (NET)
“He went up to him and bandaged his wounds, pouring olive oil and wine on them. Then he put him on his own animal, brought him to an inn, and took care of him.”
The Good Samaritan does not ask the injured man about his plan level or whether his condition is covered. He provides care regardless. The PMB obligation written into law reflects this same principle: a person in medical need deserves treatment, not a rejection letter.
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You Know the Law — But Do You Know What to Say?
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What They'll Say Next

Common Counter-Arguments

After you respond, they may push back with these arguments. Members get the full rebuttal for each.

They might say: “Your condition is covered, but only at the generic medication level — we will not pay for the brand name your doctor prescribed.”
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They might say: “You must use our Designated Service Provider (DSP) for PMB treatment. Since you did not, we will not pay.”
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They might say: “Your condition is not on the Chronic Disease List — it is similar but not the same as a listed condition.”
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