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All medical schemes have a list of medicines, treatments and procedures which they will not pay for. This is because funds that are available for healthcare are not unlimited. Items that are not medically necessary or fall outside of accepted medical practice are a risk to the funds available to members who need essential proven healthcare services. Therefore, to ensure that all members have fair and equitable rationing in healthcare cover, GEMS has limits to the items and treatments we will cover.
Items or procedures that are not covered at all are called Scheme exclusions.
All Scheme exclusions are listed in detail in Rule 16 and Annexure E of the Scheme Rules. The Rules indicate that "all costs are
excluded when members undergo procedures or receive devices or prostheses that are Scheme exclusions". You must make sure
that the procedures, treatments or medicine you receive will be paid for before obtaining them, as excluded services or items will not be paid for by GEMS. You will then be responsible for paying those costs.
Exclusions versus PMBs
Exclusions may not apply to Prescribed Minimum Benefits (PMBs). For example, if a member contracts septicaemia after cosmetic
surgery (which is a Scheme exclusion), GEMS will still provide healthcare cover for the septicaemia because it is a PMB. PMBs
concern the diagnosis and it doesn't matter how you got the condition.
Examples of excluded items, which GEMS does not pay for, include:
0860 00 4367 (Call Centre) enquiries@gems.gov.za More Contacts >
