Last reviewed: September 2026. We review our guides regularly to keep them accurate.
By Martin Janse van Rensburg, Sales Manager and Financial Advisor at Curemed. Reviewed by Roxanne Hurter-Ehlers, Director of People and Governance.
Oncology cover is the medical scheme benefit that pays for cancer treatment. Every scheme must pay in full for cancer that qualifies as a Prescribed Minimum Benefit, at a defined level of care, through its designated providers. Full cover stops where treatment falls outside that level of care, where a threshold is reached and payment drops to a percentage, or where a provider charges above the scheme rate.
In short
- Cancer that qualifies as a Prescribed Minimum Benefit must be paid in full, at a defined level of care, through the designated provider of the scheme.
- Above that level, Discovery Health thresholds run from R250 000 to R500 000 per rolling 12 months, then 80% of the Discovery Health Rate.
- Providers may charge above the scheme rate, and the balance is billed to the patient.
- Some Gap Cover products pay oncology co-payments, but wording differs materially and the scheme must contribute first. The regulatory limit is R226 881.03 per insured person per year from 1 April 2026.
What does the Medical Schemes Act guarantee for cancer treatment?
Prescribed Minimum Benefits arise under the Medical Schemes Act 131 of 1998, listed in Annexure A to the General Regulations as Diagnosis and Treatment Pairs. Cancer sits there, not on the Chronic Disease List: treatable prostate cancer is code 953L, with a treatment component of medical and surgical management, which includes chemotherapy and radiation therapy, and treatable breast cancer is code 950J.
Regulation 8(1) is direct. It requires that:
any benefit option that is offered by a medical scheme must pay in full, without co-payment or the use of deductibles, the diagnosis, treatment and care costs of the prescribed minimum benefit conditions.
General exclusions do not apply to PMBs, and entitlement concerns the diagnosis, not how the condition was acquired.
Regulations 8(2) to 8(5) attach conditions. A scheme may require its Designated Service Provider (DSP) and charge a co-payment if you voluntarily use a non-DSP, but not where the service was involuntarily obtained, for example where no DSP is within reasonable proximity. It may apply pre-authorisation, protocols and formularies, and charge a co-payment if you knowingly decline a clinically appropriate formulary medicine. Such co-payments must appear in the scheme rules, may never be 100% of the cost and may not come from savings.
Level of care is the other boundary: defined, not unlimited, and benchmarked on public sector protocols. The Council for Medical Schemes gives prostate cancer examples: robotic assisted laparoscopic prostatectomy is not PMB level of care, and brachytherapy with permanent low dose radiation is PMB level of care while temporary high dose radiation is not. See our guide to how Prescribed Minimum Benefits work on every medical scheme option and the Council for Medical Schemes PMB resources.
How does an oncology threshold work on a medical scheme?
Above PMB level of care, many plans fund cancer treatment up to a Rand threshold, after which the scheme pays a percentage and the member pays the rest.
How does the Discovery Health Oncology Programme work in 2026?
The Discovery Health Medical Scheme Oncology Programme runs on a 12-month rolling cycle, not a calendar year. Within the threshold, approved treatment is covered up to 100% of the Discovery Health Rate (DHR).
| Plan | 12-month threshold | After the threshold |
|---|---|---|
| Executive, Classic Comprehensive | R500 000 | 80% of DHR. Extended Oncology Benefit pays a closed list of medicines at 100%. |
| Classic Smart Comprehensive | R375 000 | 80% of DHR. No Extended Oncology Benefit. |
| Priority, Saver, Smart Saver, Smart, Core | R250 000 | 80% of DHR. |
| KeyCare series | No Rand threshold | PMB treatment covered. |
| Active Smart | Threshold not available | PMB treatment covered by law. |
Past the threshold, Discovery states that it will cover approved treatment up to 80% of the Discovery Health Rate (DHR) for the remainder of the 12-month cycle. PMB treatment stays at 100% of the DHR with a network provider, and using the pharmacy DSPs for approved oncology medicine avoids a further 20% co-payment.
Take Naledi on Classic Saver. Once approved treatment passes R250 000 in her cycle, a non-PMB item billed at R10 000 at the DHR is paid at R8 000 and she pays R2 000, plus anything charged above the DHR.
How does Bonitas structure cancer cover in 2026?
Bonitas Standard and Standard Select carry identical cancer benefits, subject to registration on the Oncology Management Programme.
| Benefit | 2026 limit or rule |
|---|---|
| PMB cancer treatment | Unlimited. 30% co-payment if a DSP is not used. |
| Non-PMB cancer treatment | R280 100 per family. Once reached, 80% at a DSP and no cover at a non-DSP. |
| Brachytherapy | R63 110 per beneficiary. |
| Specialised drugs, including biologicals | R164 100. |
| MRI and CT scans | R34 020 per family. R1 860 co-payment per scan event, except for PMB. |
| In-hospital specialists | Network in full at the Bonitas Rate. Non-network at 100% of the Bonitas Rate, balance to the member. |
After the R280 100 non-PMB limit, a family still receives 80% at a DSP but nothing further at a non-DSP, which matters for Gap Cover below.
Why do cancer bills exceed what the scheme pays?
Even inside a threshold, 100% of the scheme rate is not 100% of the bill. Centralised tariff negotiation between the South African Medical Association and the Board of Healthcare Funders ceased after 2003 following competition authority intervention, leaving each scheme to set its own rate and each provider its own fee.
The Competition Commission Health Market Inquiry reported in September 2019 that where a professional charges above the scheme tariff, the higher rate is generally collected from the patient, who is liable for any portion not covered by the scheme. The Inquiry called this balance billing. The same mechanism drives the self-payment gap on medical aid, where a member funds claims directly for a period.
What can Gap Cover do about an oncology shortfall?
Gap Cover is short-term insurance under Part 7 of the Regulations under the Short-term Insurance Act 53 of 1998, known as the Demarcation Regulations. Regulation 7.5(1)(c) requires the marketing of every such policy to carry this statement.
This is not a medical scheme and the cover is not the same as that of a medical scheme. This policy is not a substitute for medical scheme membership.
Benefits are capped by regulation at R226 881.03 per insured person per year from 1 April 2026, per the National Treasury Annexure B escalation table.
Some Gap Cover products carry a specific oncology co-payment benefit that responds when the cancer benefit of a scheme is exhausted and a percentage co-payment is imposed, such as the 20% after a Discovery Health threshold. Terms, sub-limits and exclusions differ materially between insurers and between tiers, and these benefits are typically gated on the treatment not being PMB-funded and on following the registered treatment plan of the scheme.
Gap Cover tops up a scheme payment. One insurer states expressly that if the scheme limit was used up before the claim event and the scheme contributes nothing towards the benefit, the policy will not pay, which is the Bonitas non-DSP situation above. Our complete guide to Gap Cover in South Africa explains how to compare wording.
How do you keep your own share of the cost down?
- Register on the oncology programme of your scheme and obtain pre-authorisation for each stage.
- Ask the scheme in writing which treatment is PMB level of care, and use the oncology DSP, network hospital and DSP pharmacy.
- Ask each provider before the first appointment whether they charge at the scheme rate.
- Check your Gap Cover policy for an oncology co-payment benefit, and follow our guide on how to claim from Gap Cover.
A Curemed Advisor can compare the oncology benefit on your option with alternatives, check the designated providers in your area, and read your Gap Cover wording alongside your plan, with no obligation.
Benefit details differ by scheme, plan and policy. Figures are those published by Discovery Health, Bonitas and National Treasury for 2026; confirm your own plan rules. Gap Cover is short-term insurance and not a medical scheme.
What else do members ask about oncology cover?
Can I join a medical scheme after a cancer diagnosis?
You can apply. Waiting periods are imposed under section 29A of the Medical Schemes Act 131 of 1998. If you were not a beneficiary of a medical scheme for 90 days or more before applying, a general waiting period of up to three months may apply, and Prescribed Minimum Benefits may be excluded during it.
Can my medical savings account pay for cancer treatment?
Not for Prescribed Minimum Benefits. The Council for Medical Schemes states that PMBs cannot be paid from a medical savings account, and a scheme may not recover a PMB co-payment from savings. Savings can fund items outside the oncology benefit, such as the one wig Discovery Health funds up to R5 000 a year.
Is it safe to switch medical schemes in the middle of treatment?
It is possible, but timing matters. A new scheme may impose waiting periods under section 29A, and each scheme runs its own oncology programme, threshold and designated providers, so a registered treatment plan is not automatically carried over. Do not resign until the new membership is confirmed in writing.
What should I do if an oncology claim is rejected?
Ask for the reason in writing and check whether the treatment was registered and pre-authorised, whether it is PMB level of care, and whether a designated provider and formulary medicine were used. If the scheme maintains its decision, use its internal dispute process and then the Council for Medical Schemes.
How does a broker help with cancer cover?
A broker, or Advisor, compares how each plan treats cancer before you need it: the oncology threshold, what is paid after it, the designated providers near you, and how your Gap Cover policy responds to an oncology co-payment. During treatment an Advisor can help with registration, pre-authorisation queries and claims.
Martin Janse van Rensburg
Sales Manager and Financial Advisor | Curemed Health and Wealth Consultants
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