Your scheme said no. Ask it why, in writing.

Pryse does not decide whether a medical scheme was right to reject a claim. It sets out what the scheme’s stated reason means, and the questions the scheme can be asked to answer in writing.

Reasons South African medical schemes give

• Not treated as a Prescribed Minimum Benefit · The scheme says this service does not fall within the Prescribed Minimum Benefits.
• Provider was not a designated service provider · The scheme says the provider you used is not one it designated for this service.
• Pre-authorisation not obtained · The scheme says it did not authorise the service before it was rendered.
• Medicine not on the formulary · The scheme says the medicine claimed is not on the list it funds for your option.
• Benefit exhausted · The scheme says the benefit this claim would have been paid from is used up.
• Sub-limit applied · The scheme says a specific per-item, per-person or per-family cap applies to this claim.
• Co-payment or deductible applied · The scheme says part of the cost is yours to pay under its rules.
• Charged above the scheme rate · The scheme says the provider charged more than the rate it pays, and it funded its rate only.
• Treated as an excluded service · The scheme says its rules exclude this kind of service from cover.
• Waiting period applied · The scheme says you were still inside a waiting period when the service was rendered.
• Condition not registered for chronic benefits · The scheme says the condition was not registered with it for chronic cover when the claim was made.
• Claim submitted late · The scheme says the claim reached it outside the period its rules allow.

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