Claim cut by a sub-limit: what to ask your medical scheme
Your scheme says a specific cap applies to this kind of claim. What that means, and the questions to put to your medical scheme in writing.
The scheme says a specific per-item, per-person or per-family cap applies to this claim.
The wording to look for
- “a sub-limit applies”
- “annual limit”
- “per-family limit”
Questions to put to your scheme in writing
- Which sub-limit was applied, and where is it published for my option?
- How much of that sub-limit had been used before this claim, and by which claims?
- Does the sub-limit apply where the service is a Prescribed Minimum Benefit, and how was that assessed?
- Please provide the benefit schedule showing that sub-limit for the current year.
Only you can answer these
- Whether other members of your household have claimed against the same limit.
Paste your rejection notice and build the letter. It is read on your own device and never uploaded.
See every reason a South African medical scheme gives.
Pryse is not a law firm and does not act for you. Nothing here is a determination of your rights or legal advice, and no registered scheme rule is quoted. The questions ask your scheme to provide its own.