In honour of Breast Cancer Awareness Month this October
October is Breast Cancer Awareness Month — a time to promote early detection, support patients, and highlight the many challenges they face. One of the most distressing situations for any patient is when a medical aid refuses to pay for treatment. Whether it’s chemotherapy, surgery, or medication, a denial can feel devastating. But it’s not the end of the road.
Under South African legislation, medical schemes are legally required to fund certain cancer treatments. Knowing your rights can empower you to challenge an unfair denial and get the care you deserve.
Your legal right to cancer treatment
South African patients are protected under the Medical Schemes Act 131 of 1998, which guarantees coverage for certain conditions known as Prescribed Minimum Benefits (PMBs).
For breast cancer, PMBs include:
- Consultations with oncologists and specialists
- Diagnostic tests and imaging
- Surgery and post-operative care
- Chemotherapy and radiation
- Access to registered oncology medications
Even if your plan has benefit limits or exclusions, PMB conditions must still be covered in full. A scheme cannot lawfully refuse to fund essential breast cancer treatment that falls under PMBs.
Relevant legal cases
- 2015 case: The SCA ruled that scheme rules cannot override statutory obligations for PMBs. Even if internal rules limit coverage, treatment for PMB conditions must be paid in full.
- 2021 case: A medical aid was not permitted to shift the cost of PMB treatment to a member’s day-to-day benefits. PMBs must be paid from the scheme’s risk pool in full.
- 2024 case: The High Court found that the failure to provide timely oncology services was unlawful and unconstitutional under section 27 (right of access to health care). This reinforces patients’ rights to essential treatment.
Common reasons medical aids give for denial
- “Treatment exceeds benefit limits”
- “The doctor is not in-network”
- “No pre-authorisation was obtained”
- “Alternative treatment options exist”
While these reasons may sound valid, many are not legally defensible when PMBs apply. The law prioritises patient access to life-saving care over administrative technicalities.
Steps to take if your medical aid denies cancer treatment
Step 1: Request a written reason
Ask your medical aid to explain the reason for the denial in writing. This is your starting point for appeal.
Step 2: Review whether PMBs apply
Check the Council for Medical Schemes (CMS) PMB list to confirm whether your treatment is a prescribed minimum benefit. Most breast cancer treatments are.
Step 3: Lodge an internal appeal
Medical aids must have an internal appeal process under the Act. Submit medical reports, oncologist recommendations, and proof that the treatment is clinically necessary.
Step 4: Escalate to the CMS
If your appeal is rejected, you can lodge a complaint with the Council for Medical Schemes. The CMS can investigate and compel the scheme to provide cover if your rights were infringed.
When to seek legal assistance
If your medical aid:
- Continues to refuse PMB-related treatment,
- Delays payment without justification, or
- Causes harm due to treatment interruption,
you may need to consult a medical aid dispute attorney. Legal action can include reviews of the scheme’s decision or, in some cases, claims for damages if the denial caused harm.
Practical tips for patients
- Keep detailed records of all correspondence and authorisations.
- Obtain pre-authorisation before starting treatment, where possible.
- Ask your oncologist to reference PMB codes in treatment plans.
- Seek legal advice early if you face resistance from your medical aid.
No patient should have to fight two battles — one against cancer, and another against their medical aid.
If your medical aid has denied or delayed cancer cover, contact our offices for legal guidance. You have rights, you have options, and you are not alone in standing up for them.