A number of medical aid members have submitted claims to Turnberry where medical aid administrators have not processed Prescribed Minimum Benefit (PMB) claims correctly, leaving the medical aid member with a balance on their accounts with their various in-hospital service providers. Should a condition be classified as a PMB the medical aid is obliged to settle the claims in full (subject to the rules of the medical aid and the Medical Schemes Act of 1998.
Should the medical aid company not meet it’s obligations for PMB ‘s we have detailed below the relevant sections of the Medical Schemes Act. for your reference.
Section 8(2) of the Medical Schemes Act of 1998. states the following:
“Any benefit option that is offered by a medical aid scheme must reimburse in full, without co-payment or the use of deductibles the diagnostic treatment and care costs of the Prescribed Minimum Benefit conditions.
Specified in Annexure A in at least one provider or provider network which at all times must include the public hospital system.”
Turnberry is a short term insurance administration company operating independently of any medical aid company. Turnberry has a liability for claims of policyholders in accordance with the policy benefits, as defined in the policy document issued, once the policyholder’s medical aid has met their legal responsibility.
Turnberry has no liability on claims listed as PMB ‘s and cannot operate or provide benefits applicable to a medical aid.
I can assure you that Turnberry strives to provide the best service possible to our clients. However, we are not in a position to pay claims which is the legal responsibility of a medical aid company We are also not in a position to enforce these legal responsibilities on a medical aid company. Should you have a PMB claim that has not been settled by your medical aid, please address these differences with them directly.
Turnberry Insurance Group
Executive Management Team