Coronavirus is yet to test the rules of medical schemes.

While it has been reported that a virus like COVID-19 would not usually be covered as a prescribed minimum benefit condition, where the virus amounts to an emergency condition then it will fall within the PMB legislation. In addition, to the extent that the virus results in medical consequences such as cardiac injury, the resultant condition may fall within the PMB provisions.

In the absence of COVID-19 being a PMB condition, the consequences for members of medical schemes are no different to when they have a flu virus.

In essence members who are hospitalised will have access to their hospital benefit at the applicable rate or will find that their medical savings have become depleted due to day to day use of doctors, pharmacists and importantly, screening.

Where medical scheme benefits are not sufficient to cover the costs associated with COVID-19, a member can make application for an ex gratia benefit, that is, payment of the costs at the discretion of the relevant scheme.

In addition to providing cover as set out in the rules of a scheme and the Medical Schemes Act, the board of a scheme must also take all reasonable steps to ensure that the interests of beneficiaries are protected. Given the highly contagious manner in which COVID-19 can spread, it may be argued that it is in the interests of beneficiaries to provide the care that is needed to infected persons to limit the spread, and that such cost of care must be provided on an ex gratia basis if not falling within the ambit of the rules or the PMB legislation.


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