Understanding your medical aid’s oncology benefit

LIFE is unpredictable.

We all know that cancer is one of those conditions which can affect any one of us at any given time – for this reason it is very important to understand what your medical aid oncology benefits are.

Medical aid schemes are obligated by law to cover the diagnosis, treatment and care costs of any appropriate prescribed minimum benefit (PMB) condition, this regardless of which medical aid option you are on. Even a hospital plan must cover oncology to a PMB level of care – but what does this really mean when not all types of cancer are classified as PMB?

Essentially there are two types of cancer:

Cancer that affects non-solid organs and systems and;

Cancer of solid organs

In simple terms, cancer of solid organs is classified as a PMB if it has not spread to another organ in your body and is only affecting the organ of origin. There needs to be no evidence of any spread to other organs or incurable damage to the originating organ. Lastly, survival needs to be expected to be a minimum of five years or more, with the treatment prescribed having shown a high survival rate in other sufferers. Meeting these conditions means that your cancer is “treatable”.

If a solid-organ cancer does not meet the above-mentioned criteria, then it will be classified as a non-treatable cancer, which means it will not be classified as a PMB.

Non-PMB cancers are subject to the oncology benefits and limitations stipulated on your health plan by your medical scheme. If your medical aid option only covers cancer when classified as a PMB, this means that it will not cover “non-treatable” or “non-PMB” cancer.

When it comes to cancers of non-solid organs and systems, some are classified and covered as a PMB whether they meet the “treatable” definition or not. An example here would be leukaemia, lymphomas, multiple myeloma and chronic leukaemia.

Make sure you understand what your medical aid covers, a scheme which has a rand value attached to the oncology benefit generally has cover for oncology whether classified as treatable, non-treatable, PMB or non-PMB. These would be the options with a more comprehensive benefit. While an option which only covers to a PMB level of care will only cover oncology when treatable, or when they are one of the cancers of non-solid organs which are still qualifying as PMB.

It can all be very confusing and very overwhelming.

Your medical scheme can use protocols to manage your cancer whether PMB or not, they usually require that you register and pre-authorise to unlock the oncology benefits of your health plan – this will further clarify exactly what you are entitled to.

Iif you are uncertain of what your benefits currently are or would like assistance in choosing a medical aid which would best suit you and your family then please get in touch at or (041) 581-2509.

Also now consulting in Port Alfred, Eastern Cape.