Mental Health Conditions And Medical Schemes – What’s Covered?



South Africans are largely considered to be resilient – we’ve weathered a pandemic, political instability, rampant unemployment, water issues and load shedding.



However, when it comes to mental health conditions, many suffer in silence, and may forgo a diagnosis, or fail to address the issue. According to the South African Depression and Anxiety Group (SADAG), one in three South Africans will suffer from a mental illness at some point in their life.

In many cases, anxiety over finances leads to depression and even suicidal thoughts.

“Some people struggle with handling money because of mental illness, while others experience deep depression due to retrenchment, a gambling addiction, or struggling to pay back a mountain of debt,” says Shafeeka Anthony, Marketing Manager of Established 16 years ago, this website helps South Africans to be more informed about handling their personal finances. 

“Research by the Organisation for Economic Co-operation and Development has shown that, across countries, the mental health of unemployed people and those experiencing financial insecurity is worse than that of the general population. This trend pre‑dates Covid-19, but the pandemic has accelerated it.” spoke to health professionals to discover which mental health conditions tend to be covered by medical aid, and what this cover entitles you to.

Prescribed minimum benefits

All medical schemes in South Africa, irrespective of the plan or option, are legally obliged to treat patients for the 271 Prescribed Minimum Benefit (PMB) conditions determined by the Council for Medical Schemes. PMBs are conditions that warrant continuous care to improve members’ health, and the list includes certain mental health conditions.

All medical scheme members are entitled to in-hospital treatment and medical management for these conditions, says Jarrod Higgs, advisor sales team leader at Bestmed. However, it’s important to note that different providers have different approaches to treatment.

“There are various types of diagnoses that one has to recognise and treat, and for each diagnosis, there are numerous treatment plans to consider,” says Dr Noluthando Nematswerani, Head of the Centre for Clinical Excellence at Discovery Health. “The extent of cover depends on the member’s plan, the diagnosis, and the severity of that diagnosis.”

Which mental health disorders are covered?

Higgs notes that medical scheme members can receive specific care in-hospital for particular mental health disorders such as anxiety, acute stress, delusions, psychosis, and affective disorders such as schizophrenia, and bipolar or depressive disorders.

“In addition, they can be admitted to hospital or sub-acute facilities as a result of the abuse of alcohol or chemical substances,” he says.

In addition, up to 15 outpatient psychotherapy sessions are included per year under the PMB provision, for more than 40 major affective disorders, including schizoaffective-, bipolar affective- and recurrent depressive disorders.

There are also 27 chronic disease list conditions that are covered. To register a chronic condition, members require a valid diagnosis by a psychiatrist or psychologist, says Higgs.

“As it stands, the only mental illness conditions that are mandatory for a medical scheme to cover in this list of 27 are schizophrenia and bipolar mood disorder. Other conditions, such as major depression, are usually only covered by medical schemes on more comprehensive options, with certain limitations. For example, there may be a rand limit, or a portion of the treatment cost that will be covered.”

Who qualifies for treatment?

Anyone is covered in terms of PMBs, but if you require prolonged treatment you must register for the mental health programme offered by your medical scheme.

Compared to the day-to-day benefits members receive, the mental health programme offers more comprehensive benefits, says Michelle John, a medical aid and gap cover broker at Cooke Fuller Group.

What many members don’t know is that a medical broker can advocate for additional benefits on a member’s behalf – and will often succeed in securing them.

“Members are not always familiar with the rules, or with their rights,” says John. “Even members on lower-priced plans are entitled to receive extensive benefits with and without PMB – but bear in mind that the level of in-hospital care will depend on the diagnosis justifying admission.”

How does gap cover help?

John says that gap cover – an insurance product – is particularly useful, as many specialists charge above medical aid rates.

“They honour only in-hospital treatments – and even then, some can charge up to 500% of the scheme rate,” she warns. “While your medical aid may provide 100% cover, you will still be liable for the shortfall. On the plus side, your medical scheme will inform you beforehand if a specialist is not contracted to their network or charges higher rates.”

Can I join a medical scheme with a pre-existing mental health condition?

John says you can join, but there’s a three-month waiting period before you can claim,  if you haven’t been diagnosed and you’re not on chronic medication – that is, medication you take every day for the foreseeable future.

If you have a diagnosis, you must disclose this when you apply to join a scheme. There will then be a 12-month waiting period before you can claim for your condition.

Seeking medical and financial help

Health professionals encourage you to avoid self-diagnosis and to rather seek professional help for mental conditions as soon as possible. 

If money troubles are a contributing factor, and causing you deep distress, don’t delay either, says Anthony. “Many people are unaware that debt counselling, for example, is available if you are struggling to meet your financial obligations.

“This process involves a debt counsellor assessing a client’s outstanding debt and implementing a restructured payment plan. This is done by negotiating lower interest rates with credit providers, and extending the debt repayment terms.

“Debt consolidation, on the other hand, is a form of debt refinancing aimed at simplifying multiple debt repayments. It involves taking out a new loan and using it to settle your outstanding debt. This will then leave you with a single monthly instalment with a reasonable interest rate.”

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