South Africa: Mental wellness and medical cover

31 July 2014: Mental illnesses are often spoken about in passing, but it is important to know how they should be managed and how your medical scheme can help should you ever be diagnosed with one.

“There are many reasons behind the increasing numbers of people being diagnosed with mental disorders,” says Executive Principal Officer of Liberty Medical Scheme, Andrew Edwards. “In some cases it can be attributed to science, technology and medical treatments advancing rapidly so more is known about these types of illness and how to diagnose and treat them.” But he adds in other cases mental illness results from people living longer, more stressful lives and having diminishing community support.

Edwards says while medical schemes are required to cover the costs of some mental illnesses, such as bipolar mood disorder and schizophrenia under the Prescribed Minimum Benefits (PMB), there are a range of other illnesses that may also require psychiatric treatment.

“It’s a misnomer to think that mental illness cannot be as life changing as physical illnesses,” says Edwards. “Some mental disorders can negatively affect a person’s quality of life, their ability to work and in extreme cases, can lead to suicide. It’s important that medical scheme members know their rights when it comes to mental illness as well as their medical aid benefits so that they are as prepared as possible should they be diagnosed with such an illness.”

Edwards also encourages scheme members to find out whether their scheme covers the cost of both in- and out-of-hospital treatments. “If you’re on a chronic medication, make sure you register this with your medical scheme and sign up for any health management programmes available from your scheme.”

Children and teenagers

Mental illness knows no age limits and some mental illnesses can start to develop in early childhood. These include illnesses such as anxiety disorders, mood disorders and schizophrenia.

“Some of these conditions can be successfully treated through a combination of medication and psychotherapy out of hospital,” says Edwards. “Find out how many visits are covered and what type of medication is funded from your Savings account or general risk when it comes to psychiatric illnesses.”

With increasing social pressures on teenagers, disorders such as anorexia nervosa and bulimia are more common.  Since it is a condition listed under the PMBs, the Scheme must cover costs related to the diagnosis, treatment and care related to the disease. Schemes should cover hospital-based management up to 3 weeks per year or a minimum of 15 out-patient contacts per year.

“We also live in a time where some young people are battling with issues such as substance abuse and require admission to drug or alcohol rehabilitation centres,” says Edwards. “These programmes can be very costly in the private sector costing anywhere up to about R21 000 depending on the programme.”

Many schemes will only fund this type of rehabilitative treatment subject to pre-authorisation and if the programme is completed. It is also likely that second admissions within the same year, in the event of a related relapse, will be excluded. 


Edwards says mental illnesses such as panic disorder; depression; bipolar mood disorder; post-traumatic stress disorder; and schizophrenia are often only diagnosed in adulthood. Many of these require medical treatment, sometimes in hospital.

“Mental illnesses such as these can render someone disabled in the sense that they may not be able to take care of their responsibilities such as looking after children or holding down a job,” says Edwards. “Substance abuse is also a major problem in this age category.” 

The Elderly

Dementia is a collective term used to describe the problems that people with various underlying brain disorders or damage can have with their memory, language and thinking. Alzheimer’s disease is the best known and most common disorder under the umbrella of dementia, but signs of Parkinson’s and Huntington’s disease can also set in, often after the age of 65.

“These types of diseases can have devastating effects on families, but very few schemes cover treatment for them,” explains Edwards. “It’s therefore important for elderly members to have other insurance and cover in place so as not to put financial pressure on their loved ones,” says Edwards.

The Scheme has made provision to cover the management of Alzheimer’s as a chronic condition in two of its option choices, including Traditional Ultimate and Complete Plus. 

5 Questions to ask your medical scheme when it comes to mental wellness

– Are the in- and out-of-hospital treatments for a particular illness covered and at what tariff?

– Is the condition part of the Prescribed Minimum Benefits?

– Is there a managed care programme you can join to better manage your condition with the help of your medical scheme?

– What is the annual limit per family for mental wellness benefits?

– Are there any exclusions and is pre-authorisation for treatment required?