Financial Mail, through its Currency publication, quoted Curemed Advisor Martin Janse van Rensburg in an April 2026 feature on Prescribed Minimum Benefits, the legally mandated cover that every South African medical scheme must provide. Martin, who leads the Curemed Pretoria branch, explained why many members still face large out of pocket bills even though these benefits exist to protect them.

What the article covered

Prescribed Minimum Benefits set a baseline of care that every medical scheme must provide, regardless of the plan a member chooses. They cover emergency treatment, 271 serious diagnoses and 26 chronic conditions, from heart attacks and cancers through to severe mental health conditions. They were designed to guarantee access to a minimum level of care regardless of a member health profile.

Financial Mail reported that in 2024 medical schemes spent about R135bn on these benefits, roughly 52 percent of the total healthcare spend of R259bn. Most of that money went to acute, in hospital events, with cardiovascular and oncology cases dominating and the top four disease groups absorbing close to 70 percent of diagnosis and treatment costs. In other words, a relatively small number of catastrophic events shapes the economics of the whole system.

Martin Janse van Rensburg told Currency that understanding these benefits is one of the most important, and most misunderstood, parts of medical scheme membership. As he put it, PMB cover is diagnosis driven, not symptom driven, which means benefits apply only once a condition has been formally diagnosed and the relevant clinical criteria have been met.

To access full 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 designated service provider. ICD-10 codes are critical, because an incorrect or incomplete code can send a claim to the wrong benefit pool or cause it to be rejected. Members who believe their rights have not been honoured can lodge a formal complaint with the Council for Medical Schemes.

The practical takeaway from the feature is that these benefits protect members, but their value is only fully realised when members understand how to access them correctly. Informed members who are supported in applying the rules are far less likely to face unexpected out of pocket costs.

Why this matters for medical scheme members

Shortfalls and co-payments linked to how benefits are applied are one of the main reasons members turn to independent advice and to Gap Cover. An independent Curemed Advisor can help make sure the correct diagnosis codes are submitted, that a designated service provider is used where required, and that the right process is followed, then check whether Gap Cover would close any remaining shortfall. You can read our complete guide to Gap Cover in South Africa, compare options on our medical aid comparison page, or see the full list of medical schemes.

About Martin Janse van Rensburg

Martin Janse van Rensburg is a Sales Manager and Financial Advisor at Curemed who specialises in medical aid and leads the Curemed Pretoria branch. His comment for Financial Mail reflects the day to day work of helping members understand their cover and apply it correctly. Read more on his Curemed profile.

Read the original article

The full feature is available on Financial Mail: R135bn later, members still face huge medical bills.

Reviewed by Roxanne Hurter-Ehlers, Director of People and Governance.