What does GEMS not pay for?

All medical schemes have a list of medicines, treatments and procedures that they do not pay for. This is because funds that are available for healthcare are not unlimited.

All Scheme exclusions are listed in detail in Rule 16 and Annexure E of the Scheme Rules. 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 and you will be responsible for paying those costs.

Examples of exclusions (items that GEMS does not pay for)

• All costs for operations, medicines, treatments and procedures for cosmetic purposes (cosmetic refers to procedures such as liposuction).
• Holidays taken for recovery.
• Medicines not registered with the South African Health Products Regulatory Authority.
• Toiletries, beauty products, slimming products, homemade remedies and alternative medicines.
• Household products such as disinfectants, soaps, food and nutritional supplements.
• Treatments by a healthcare provider who is not registered with a recognised professional body or any healthcare facility that is not registered in terms of the law.
• Any medicine, procedure or treatment that is not in line with evidence-based medicine principles and not supported by the Scheme's Rules and managed care guidelines.
• Penalties that members incur and must pay to a healthcare provider because they did not keep an appointment.

Remember that even if a treatment is not a Scheme exclusion and is approved or authorised, if it exceeds the Scheme Rate/ Tariff and benefit limits it will still not be paid or not be paid in full. Items may also be declined if they do not comply with managed care rules. 

Exclusions versus PMBs
Exclusions may not apply to 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 does not matter how you got the condition.