Charged above the scheme rate: what to ask your medical aid
Your scheme paid its own rate and left you the balance. What a scheme tariff shortfall means, and the questions to put to your medical scheme in writing.
The scheme says the provider charged more than the rate it pays, and it funded its rate only.
The wording to look for
- “above the scheme tariff”
- “scale of benefits”
- “100% of the scheme rate”
Questions to put to your scheme in writing
- What rate did the scheme pay for this service, and how is that rate determined?
- Is the treating provider party to a payment arrangement with the scheme, and on what terms?
- Does the scheme fund the full cost where the service is a Prescribed Minimum Benefit obtained from a designated provider?
- Please provide the tariff or scale of benefits the scheme applied to this claim.
Only you can answer these
- What your provider actually charged, from their own account.
- Whether you were told before the service what the provider would charge.
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.