R135bn later, members still face huge medical bills

South Africa’s medical schemes now spend more than R135bn a year on prescribed minimum benefits (PMBs) – legally mandated cover that accounts for more than half of all healthcare payouts. The protection is real – but getting the rules wrong can still leave members with crippling out-of-pocket bills.

PMBs set a baseline of care that every scheme, regardless of plan, must provide: emergency treatment, 271 serious diagnoses and 26 chronic conditions. The list spans everything from heart attacks and cancers to appendicitis and severe mental health conditions. But its breadth masks how concentrated the spending is – and how technical the rules governing access have become. For members, the difference between full cover and a large bill often comes down to details.

PMBs were designed to prevent discrimination based on health status. As the Council for Medical Schemes (CMS) noted in its 2016 review, they remove the ability of schemes to separate “insurable” from “uninsurable” individuals. In effect, they guarantee access to a minimum level of care, regardless of a member’s risk profile.

Curemed Health & Wealth Consultants’ head of its Pretoria Branch, Martin Janse van Rensburg, tells Currency that understanding PMBs is one of the most important, yet often misunderstood, aspects of medical scheme membership in South Africa.

“A key point many members are unaware of is that PMB cover is diagnosis driven, not symptom driven,” he says. “This means that benefits apply only once a condition has been formally diagnosed and the relevant clinical criteria have been met.”

A safety net that swallows half the budget

In 2024, medical schemes spent R135bn on PMBs – 52% of the total healthcare spend of R259bn. More than R110bn of that went to acute, in-hospital diagnosis-and-treatment (DTP) events: the high-cost interventions associated with severe, often life-threatening conditions.

Nearly 80% of PMB expenditure is concentrated in these acute phases of care. In practice, PMBs are driven far more by hospital events than by routine or primary care.

Four disease groups, 70% of the bill

Though PMBs cover 271 conditions, spending is heavily concentrated.

Cardiovascular cases – including heart attacks, bypass surgery and angioplasty – dominate, with costs escalating from admission through specialist care and intensive care. Oncology follows, where hospitalisation, chemotherapy, radiation and increasingly expensive biologic therapies drive costs. 

Trauma cases – from car accidents to severe injuries – add another layer of high-cost interventions, often involving multiple surgeries and prolonged ICU stays. Neurological, respiratory and orthopaedic conditions round out the major cost drivers.

Together, cardiac and cancer cases account for close to half of all DTP spending. The top four disease groups absorb 70% of total DTP costs. A relatively small number of catastrophic events, in other words, shape the economics of the entire PMB system.

Inside the ICU

Intensive care is the system’s most powerful cost multiplier. Patients with severe cardiac, trauma, respiratory or neonatal conditions require specialised equipment, constant monitoring and high staff-to-patient ratios. Daily ICU rates can run into tens of thousands of rand. A single high-acuity admission – once specialist fees, procedures, diagnostics and extended stays are included – can easily reach hundreds of thousands of rand.

This is what drives the headline number. It is not the breadth of conditions covered, but the cost of treating the most critically ill patients.

Courts, complaints and complexity

That complexity is not theoretical – it shows up consistently in complaints data.

A 2019 study in the South African Medical Journal, analysing more than a decade of CMS appeals, found that roughly 40% of all complaints received by the regulator related to PMBs, with cancers and emergency conditions accounting for a significant share. 

A 2024 study in the same journal, which reviewed five years of complaints to PMBs, again highlighted the need for clearer definitions and better communication between schemes, providers and members.

The system has also been tested in court. In a long-running dispute, Genesis Medical Scheme challenged how PMBs should be paid – specifically, whether schemes could limit payouts through their own tariffs or benefit rules.

The Supreme Court of Appeal found that PMBs must be paid “in full”, reinforcing that schemes cannot simply cap benefits below the actual cost of treatment. Schemes are still permitted to use designated service providers, however, and in non-emergency cases, members who choose providers outside these networks may face co-payments.

What members should know

For members, the implications are practical – and often overlooked.

To access full PMB cover, three conditions generally need to be met: the diagnosis must appear on the official PMB list, the treatment must match the defined benefit, and – except in emergencies – care should be obtained through the scheme’s designated service provider.

ICD-10 codes are critical. An incorrect or incomplete code can result in a claim being paid from the wrong benefit pool – or rejected altogether. Ensuring that treating doctors submit accurate diagnoses and that supporting test results are provided to the scheme can make a material difference.

Members who believe their PMB rights have not been honoured can lodge a formal complaint with the CMS.

PMBs are one of the most important consumer protections in South Africa’s healthcare system. They guarantee access to treatment for serious conditions, regardless of a member’s plan. But they are not automatic. The rules are technical, the system is complex, and small administrative missteps can have large financial consequences.

PMBs do not guarantee unrestricted access to any provider, unlimited benefits, or automatic approval without clinical review. Scheme rules still apply, and members often need to follow specific processes to access PMB treatment. This is where guidance becomes essential.

“In our experience, members who are informed about PMBs and supported in applying them correctly are far less likely to face unexpected out-of-pocket costs,” says Curemed’s Janse van Rensburg. “Ultimately, PMBs are designed to protect members, but their value is only fully realised when members understand how to access them correctly.”

Understanding how PMBs work – and where they don’t – is often the difference between full coverage and a bill arriving when it’s least expected.

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