South Africa · Medical Aid Members Only

You have PMB rights.
Know what you're owed.

Facing an amputation — your own, or someone you love — is one of the most disorienting moments life can deliver. There is grief, there is fear, and there is an avalanche of medical decisions to make. On top of all of that, you are expected to navigate a medical aid system that buries your legal entitlements in benefit guides nobody reads.

This site exists to change that. South African law — the Medical Schemes Act 131 of 1998 — guarantees you a set of Prescribed Minimum Benefits (PMBs) that your scheme cannot legally deny you. For amputees, this means access to prosthetic care regardless of which plan you're on. But knowing the right exists and knowing how to claim it are two very different things.

The right prosthetic limb is not a luxury. It is the difference between mobility and confinement, between safety and falling, between returning to your life and watching it narrow. Being informed is the first step. Asking the right questions is the second. This guide helps you do both.

This is an independent, non-commercial information resource for South African medical aid members. It is not affiliated with any medical scheme. Data is sourced from published scheme benefit guides and is updated annually. Always verify current benefits directly with your scheme before making treatment decisions.

PMB Explained

What Prescribed Minimum Benefits actually are — and how to use them.

What is a PMB?

A Prescribed Minimum Benefit is a set of conditions and treatments that every registered South African medical scheme must cover — regardless of your plan, your savings balance, or what your benefit guide says. PMBs are defined by law under the Medical Schemes Act 131 of 1998 and cover approximately 270 medical conditions, including amputation.

What this means for amputees

  • If your amputation is linked to a PMB condition — trauma, diabetes, vascular disease, or cancer — your scheme must cover your prosthetic care at the prescribed level of care
  • Your scheme cannot apply a rand limit or co-payment to a PMB, provided you follow the correct protocols
  • The relevant PMB condition codes for amputees are: 901H (traumatic amputation), 915E (diabetic complications) and vascular/oncological codes
  • PMBs are paid from risk funds, not your savings or day-to-day benefits — your scheme cannot argue that your benefit has run out
  • Your prosthetist can assist with the documentation and motivation required

The one catch

The phrase "subject to protocols" is where most claims go wrong. Your scheme has the right to prescribe how your PMB is treated — which means they can require you to use specific providers, follow pre-authorisation processes, and provide clinical motivation. If you bypass these protocols, the PMB protection can fall away. Always get pre-authorisation before any prosthetic fitting.

How to Claim Your PMB — Step by Step

1

Confirm your amputation qualifies as a PMB condition

Speak to your surgeon or GP. Ask them to confirm the ICD-10 code for your amputation and whether it links to a PMB condition. Common codes: traumatic (S48, S58, S68, S78, S88, S98), diabetic vascular (E11), peripheral vascular disease (I70–I79).

2

Contact your medical scheme's PMB department

Phone your scheme and specifically ask for the PMB team or chronic/managed care division. Say: "I need to apply for PMB cover for a prosthetic limb following amputation." Request the PMB application forms.

3

Complete the PMB application forms

Three parties must provide input: You (member section), your doctor or surgeon (clinical motivation — diagnosis, treatment necessity, prognosis), and your prosthetist (device specification, quotation, NAPPI codes for all components).

4

Submit and track your application

Submit everything together — incomplete applications cause delays. Note your reference number. Your scheme is legally required to respond within 60 days. Follow up at 30 days if you have not heard back.

5

Obtain pre-authorisation before your fitting

Once approved, your scheme will issue a pre-authorisation number. This must be in place before your prosthetist begins fabrication. No exceptions. Without it, your claim can be rejected.

6

Proceed with fitting and claim

Your prosthetist submits the claim to your scheme using your pre-auth number, the NAPPI codes for all prosthetic components (socket, liner, foot/knee, adapters), and the ICD-10 diagnosis code. Keep copies of everything.

7

Appeal if you are refused

If your PMB claim is denied, you can appeal — first to your scheme's internal appeals process, then to the Council for Medical Schemes (CMS): 0861 123 267 or complaints@medicalschemes.co.za. A valid PMB refusal is rare. Most denials are procedural and reversible.

Your Scheme

Select your medical scheme and plan to see what your benefits look like — and what to watch out for.

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Select your scheme above to see your prosthetic benefits and PMB entitlements.

Bonitas
Bestmed
Discovery
Fedhealth
GEMS
Medihelp
Momentum
External Limb Benefit Limits — Confirmed Figures Across Schemes

Standard benefit limits for external prosthetic limbs (pre-PMB). Figures shown are per the plan indicated. PMB coverage is legally unlimited across all schemes — this chart shows the standard benefit only. Discovery and Medihelp do not publish a hard external limb rand limit, so no comparable figure is shown for them below.

External Prosthetic Limb Standard Benefit (Rand)
GEMS Onyx
R72,489
Bonitas Std
R57,630 (combined)
GEMS Ruby
R53,663
Bestmed Pace 1
R28,998 (ext.)
Momentum Inc.
R29,400
Fedhealth Exec
R19,300
Discovery
No Hard Limits Published
Medihelp
No Hard Limits Published

⚠️ A basic below-knee prosthetic system (socket + liner + foot) costs approximately R80,000–R150,000. A microprocessor knee runs R200,000–R400,000+. Standard benefits cover a fraction of actual costs. The PMB pathway and alternative funding are therefore not optional extras — for most amputees, they are the primary route.

Other Funding

Medical aid is often just one piece of the puzzle. Here are all the alternative funding routes available to South African amputees.

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Road Accident Fund (RAF)

If your amputation resulted from a road accident (motor vehicle, pedestrian, cyclist), you may have a claim against the RAF. The RAF covers past medical expenses, future prosthetic costs, loss of income, and general damages. Once settled, the RAF issues an undertaking letter for future prosthetics — typically one replacement every 5 years. Using an experienced personal injury attorney significantly improves outcomes.

📞 0800 23 52 23 · www.raf.co.za
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COIDA / Workmen's Compensation (WCA)

For amputations resulting from workplace accidents or occupational disease. Your employer must report the injury immediately. Once a WCA case number is issued, your prosthetist can apply for authorisation directly. Note: COIDA tariffs typically only fund basic components — for more advanced devices, you may need to supplement through medical aid or other means.

📞 0860 105 350 · www.labour.gov.za
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FEM — Construction Industry

The Federal Employer's Mutual Assurance Company administers COIDA cover specifically for the construction sector. The same claim process as WCA applies. Contact FEM directly if your employer operates in construction.

📞 011 359 4300 · www.fem.co.za
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Rand Mutual Assurance (RMA)

Covers workers in the mining sector and iron, steel, and metal industries. Report the injury to your employer within 7 days. Your employer submits to RMA. Once you have a claim number, your prosthetist can apply for pre-authorisation.

📞 011 359 4300 · www.randmutual.co.za
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Medical Negligence Claims

If your amputation was avoidable and resulted from medical negligence — misdiagnosis, infection mismanagement, surgical error — you may have a civil claim against the facility or practitioner. These cases are complex and often difficult to prove. Consult a specialist medical negligence attorney to assess viability before proceeding.

Consult a medical negligence attorney
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Personal Injury Claims

Covers amputations caused by general public negligence — gunshot wounds, dog bites, assault, slipping injuries in commercial premises, and similar incidents. A claim is made against the liable party's insurance. Consult a personal injury attorney. Metrorail and Transnet accidents have a specific legal pathway.

Consult a personal injury attorney
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Ex Gratia — Scheme Discretion

Most schemes have an Ex Gratia committee that can approve funding beyond your standard benefit limit on compassionate grounds. This is especially relevant for children, for cases where the prosthetic benefit is exhausted, and for high-cost microprocessor devices. Submit a detailed motivation with clinical reports. Ex gratia is not guaranteed and is entirely at the scheme's discretion — but it is worth applying for.

Contact your scheme's managed care or PMB department
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Gap Cover

Gap cover products can help bridge the shortfall between what your medical scheme pays and the actual cost of your prosthetic care — particularly co-payments and sub-limit overruns. If you have gap cover, check whether it extends to prosthetic appliances. If you don't currently have gap cover, this is worth investigating for future cycles.

Check with your current gap cover provider or broker
A note on the South African public health system: State hospitals technically provide prosthetic services, but capacity is severely limited. Only a handful of dedicated O&P (orthotics and prosthetics) facilities exist in the public sector — one centre in the Western Cape and three government-subsidised hospitals in the Eastern Cape. Wait times are measured in years, not months. Devices provided are typically basic functional units. The public system is a last resort and should not be relied upon for timely or advanced prosthetic care. If you do not have medical aid, prioritise RAF or COIDA claims if they apply, and explore NPO support and fundraising in parallel.

Medical Scheme Appeals / Complaints

What to do if your PMB claim is refused, and how to escalate it.

1

Appeal internally, with your scheme, first

The Council for Medical Schemes (CMS) requires you to exhaust your scheme's internal dispute process before they'll accept a complaint. Submit your appeal in writing, citing the PMB regulations, with a signed, completed appeal form (from your scheme's PMB/appeals department), supporting clinical documentation and motivation from your doctor/prosthetist, and detailed invoices and referral letters. Most schemes resolve internal appeals within ~30 days. Most denials are procedural (missing documentation, wrong codes) rather than valid refusals — a properly-motivated appeal usually succeeds at this stage.

2

Escalate to the Council for Medical Schemes (CMS)

If your scheme's internal appeal doesn't resolve it, or you disagree with the outcome, escalate to CMS — the independent statutory regulator. Submit via email (complaints@medicalschemes.co.za), post (The Council for Medical Schemes: Complaints Adjudication Unit, Private Bag X34, Hatfield, 0028), or in person at CMS offices. You'll need: the completed CMS complaint form, a detailed account of the facts and what you want resolved, proof you already escalated internally, and any clinical reports/statements.

3

What happens after you submit

Within 6 working days: written acknowledgement, reference number, and assigned contact person. Within 4 working days of that: your complaint is analysed and referred to your scheme. Within 30 days: your scheme must respond in writing. Within 120 calendar days total: CMS aims to resolve the matter.

Key Contacts
CMS Phone0861 123 267
CMS Phone (alt)+27 12 431 0500
CMS Emailcomplaints@medicalschemes.co.za
HoursMon–Fri, 8:00–16:30

Support / Key Contacts

You are not navigating this alone. Community, professional support, and official contacts.

Community & Personal Support

Christiaan Olivier is a South African counsellor, psychotherapist, and left through-knee amputee since 2004. His YouTube channel and personal site offer real-world perspective on life with limb loss — from someone who has been living it for over two decades. He is available to amputees seeking professional support, guidance, and community.

▶ The Amped Life with Chris on You Tube 🌐 Integrated Life Counselling and Therapy

Key Contacts

Council for Medical Schemes (CMS)0861 123 267
complaints@medicalschemes.co.za
Road Accident Fund (RAF)0800 23 52 23
COIDA / Workmen's Comp0860 105 350
GEMS Enquiries0860 00 4367
Discovery Health PMB0860 99 8877
Bonitas0860 103 493
Medihelp0860 100 030
Momentum Health0860 117 859
Fedhealth0860 002 153
Bestmed PMB0860 002 378
pmb@bestmed.co.za