Declined medical benefits under scrutiny in new book

Johannesburg medical orthotist and prosthetist Roger Wolfson claims medical aid members aren’t always getting the Prescribed Minimum Benefits (PMBs) the schemes are required to give them by law. 

So strong are his views, he has written a book about it, The PMB Coach, published as an eBook at the end of 2025. 

“Ninety percent of patients don’t know they are due PMBs,” says Wolfson. “Medical aids don’t necessarily tell them, and so the law is effectively hidden. Patients often discover PMBs only after serious financial loss, usually through word of mouth or crisis.” 

Medical aids dispute Wolfson’s claim.  

PMBs are a feature of medical aids that cover the costs related to the diagnosis, treatment, and care of emergency care conditions, a list of 271 medical conditions, and 26 chronic conditions, according to the Council for Medical Schemes. They are intended to ensure that members have cover for life-threatening emergencies and certain chronic illnesses, regardless of their benefit option. 

When deciding whether it is a PMB, the doctor is meant to look at the symptoms and no other factor, such as how the injury or condition was contracted, according to the council. 

“My book explains PMBs in plain language,” Wolfson says, “and gives patients practical tools: call-centre scripts, so agents can’t deflect; appeal and complaint templates to the medical aid; then the Council for Medical Schemes; and finally escalation to the Parliamentary Health Portfolio Committee. It is about empowering patients to enforce a law that already exists.” 

Wolfson says it is one of the most contested areas of private healthcare. He draws on decades of clinical practice to argue that patients are frequently left with unexpected bills for treatment that should be covered. His interest in the subject grew out of repeated funding disputes involving orthotic devices, post-operative care, and rehabilitation. 

His argument is that many members don’t know when their condition qualifies for these benefits and therefore don’t challenge funding decisions. “The patient signs the forms and is liable, so the patient needs the tools to deal with the system,” he says. 

His book is structured as a practical manual that explains how to check diagnostic codes; confirm whether a condition qualifies as a PMB; and follow formal dispute processes when claims are rejected or paid from savings. 

Wolfson believes funding disputes arise most often on lower-cost hospital plans, where members assume that hospitalisation automatically means full cover. In his experience, the initial procedure is often paid for, but related treatment such as follow-up consultations, rehabilitation, or assistive devices are contested. 

He says this additional care forms part of the original treatment episode and should therefore be funded. He also argues that authorisation processes place the burden on patients and their families at a time when they are least equipped to manage it. “Often the member is in hospital and someone else has to deal with the administration. That person needs to know what to ask and what to check,” he says. 

The SA Jewish Report asked a number of medical schemes to respond to this issue. GEMS, Bonitas, Momentum, and Fedhealth said they would respond, but didn’t by the time of publication. They did however deny claims of not paying PMBs. The only scheme that made a real effort to respond in detail was Discovery Health, which rejected the suggestion that valid PMB claims were routinely not paid. The scheme said it funded PMBs in line with the Medical Schemes Act and the regulations governing PMB level of care. Payment depended on whether treatment met the defined clinical criteria and whether scheme rules, including the use of designated service providers where required, had been followed. 

Discovery also disputed allegations that South African medical schemes in 2024 rejected a total of R40 billion worth of PMB claims, saying these included a range of categories and claims that fall outside scheme rules and couldn’t automatically be attributed to PMB funding. 

Wolfson acknowledges that schemes do pay many claims but says disputes are often resolved only after members challenge the initial outcome. “Most of the time, after a bit of a fight, they do get their money,” he says. 

Discovery Health says members who believe a PMB hasn’t been funded correctly should first query the decision with the scheme and, if necessary, use the internal complaints and appeal process. Unresolved disputes can be referred to the Council for Medical Schemes. 

After years spent fitting prosthetic limbs and orthotic devices to restore mobility, Wolfson now views access to funding as another stage of a patient’s recovery. “This is about understanding your rights and being able to use them.”